Nursing Adaptive Quiz 1

The nurse teaches a client about the increased need for vitamin A to meet the demands imposed by rapid fetal tissue growth during pregnancy. Which foods should the nurse encourage the client to ingest to meet this increased need? Select all that apply. a. Carrots b. Citrus Fruits c. Fat-free milk d. Cantaloupes e. Extra Egg Whites

A. Carrots D. Cantaloupes

The nurse has completed a prenatal class for women who are all expectant with their first child. Which statement by a pregnant woman indicates the need for additional teaching? a. "During pregnancy it's safe for me to use my regular herbal remedies." b. "My doctor will tell me if it's safe for me to take my allergy medications." c. "I should avoid all x-rays unless absolutely necessary and tell the technician that I'm pregnant." d. "I'm only 18 weeks pregnant, so it's safe for me to go through the airport security check when I go on vacation next month."

a. "During pregnancy it's safe for me to use my regular herbal remedies." Herbal remedies can be harmful to the fetus. All medications, including allergy medications, should be cleared through the healthcare provider. Radiation from x-rays can be harmful to the fetus. However, the amount of radiation encountered in airport security over the course of a single trip would not pose a risk to the fetus.

A 20-year-old developmentally challenged woman is a resident in a group home. She has had four abortions in the past 2 years, and the agency supervisor recommends that she be sterilized. It is obvious that the client is unable to exercise informed consent for sterilization. The nurse understands that the procedure cannot be performed without legal consent from whom? a. Next of Kin b. Court-appointed individual or group c. Agency designated to perform abortion d. Organization or agency licensed to administer the group home

b. Court-appointed individual or group In the United States each state has its own restrictions; the approval of a court-appointed individual or group is required to give legal consent. The other options do not meet the legal requirements for consent. The states have an obligation to oversee the best interests of the mentally disabled, and the court must be involved.

A nurse is discussing immunizations needed to confer active immunity with a pregnant client during her first visit to the prenatal clinic. What information should the nurse consider including to ensure that the client understands the process of active immunity? a. Protein antigens are formed in the blood to fight invading antibodies. b. Protein substances are formed by the body to destroy or neutralize antigens. c. Blood antigens are aided by phagocytes in defending the body against pathogens. d. Sensitized lymphocytes from an immune donor act as antibodies against invading pathogens.

b. Protein substances are formed by the body to destroy or neutralize antigens. Active immunity occurs when the individual's cells produce antibodies in response to an agent or its products; these antibodies will destroy the foreign agent (antigen) should it enter the body again. Antigens do not fight antibodies; they trigger the formation of antibodies that in turn attack the antigen. Sensitized lymphocytes do not act as antibodies.

A pregnant woman tells a nurse, "I think I can feel the baby move now. It feels like butterflies in my stomach. My friend calls it feeling life." What term should the nurse include when discussing fetal movement with the woman? a. Lightening b. Quickening c. Engagement d. Ballotement

b. Quickening The word quickening originates from the Middle English word quik, which means "alive." Lightening is the descent of the fetus into the birth canal toward the end of pregnancy. Engagement occurs when the presenting part is at the level of the ischial spines. Ballottement refers to the technique that causes the fetus to rebound in the amniotic fluid after pressure has been exerted against the fetus. Test-Taking Tip: Being emotionally prepared for an examination is key to your success. Proper use of resources over an extended period of time ensures your understanding and increases your confidence about your nursing knowledge. Your lifelong dream of becoming a nurse is now within your reach! You are excited, yet anxious. This feeling is normal. A little anxiety can be good because it increases awareness of reality; but excessive anxiety has the opposite effect, acting as a barrier and keeping you from reaching your goal. Your attitude about yourself and your goals will help keep you focused, adding to your strength and inner conviction to achieve success.

A client at 7 weeks' gestation elects to undergo an induced abortion. After receiving oral mifepristone, she returns to the clinic 2 days later to have misoprostol inserted vaginally. How long after the procedure should the nurse have the client return for a follow-up visit? a. 4 hours b. 8 to 24 hours c. 4 to 8 days d. 2 weeks

c. 4 to 8 days Research has demonstrated that oral mifepristone followed by vaginal insertion of misoprostol is an effective regimen for medical abortion with fewer side effects. A follow-up visit should occur in 4 to 8 days for examination or ultrasound to confirm that termination has occurred. A return visit in 4 to 24 hours is too soon, whereas 2 weeks is too long.

A 16-year-old client arrives at the clinic complaining of increased vaginal discharge, intermittent vaginal bleeding, excessive bleeding during menstruation, and pain in the lower abdomen. She relates an active sexual history with multiple partners. Which disease does the nurse suspect the client has? a. Herpes b. Syphilis c. Gonorrhea d. Toxoplasmosis

c. Gonorrhea The client has signs and symptoms indicative of pelvic inflammatory disease, which is a complication of gonorrhea. Herpes is noted for its painful genital lesions; there are no data to indicate the presence of these lesions. The client does not have the signs and symptoms associated with syphilis or those associated with toxoplasmosis. STUDY TIP: Begin studying by setting goals. Make sure they are realistic. A goal of scoring 100% on all exams is not realistic, but scoring an 85% may be a more realistic and attainable goal.

The nurse teaches a client who is scheduled for an elective cesarean birth several exercises that may be performed on the first postoperative day. The nurse concludes that further teaching is necessary when the client states that one of the exercises is what? a. Leg bends b. Foot circles c. Pelvic rocking d. Shoulder circles

c. Pelvic rocking Pelvic rocking on the first postoperative day could be very painful and might traumatize the wound site. Leg bends promote circulation in the lower extremities and help alleviate gas pains. Foot circles promote circulation in the lower extremities. Shoulder circles relieve neck stiffness and tension that may be present in the postpartum period. Test-Taking Tip: Once you have decided on an answer, look at the stem again. Does your choice answer the question that was asked? If the question stem asks "why," be sure the response you have chosen is a reason. If the question stem is singular, then be sure the option is singular, and the same for plural stems and plural responses. Many times, checking to make sure that the choice makes sense in relation to the stem will reveal the correct answer.

On her first visit to the prenatal clinic, a woman is to have a pelvic examination. What information should the nurse include when discussing the examination? a. She should direct her questions to the HCP b. She should relax during the examination to prevent discomfort c. A douche will be necessary before the examination for the biopsy d. A rectal exam may be performed after the pelvic exam

d. A rectal exam may be performed after the pelvic exam A rectal examination is usually conducted to palpate any masses or detect abnormalities in the rectum; it is performed after the vaginal examination to avoid contamination. Gloves are changed between vaginal and rectal examinations. The client should be encouraged to ask questions of both the healthcare provider and the nurse so that nursing care and treatment plans based on client needs can be developed. The client may be unable to relax and will feel powerless if told that she must do so. Douching or vaginal irrigation is contraindicated unless specifically prescribed; there are no data to indicate that there will be a biopsy. Test-Taking Tip: Read carefully and answer the question asked; pay attention to specific details in the question.

A client who has missed two menstrual periods tells a nurse at the prenatal clinic that the home pregnancy test was positive. Her last menstrual period began on June 18. According to Nägele's rule, what is the estimated date of birth (EDB)? a. March 8 b. March 11 c. March 1 d. March 25

d. March 25 March 25 is the EDB. Using Nägele's rule, take the first day of the last menstrual period (June 18), subtract 3 months, and then add 7 days. March 8, March 11, and March 1 are incorrect calculations according to Nägele's rule

A client is trying to become pregnant. The nurse should teach the client that a postcoital test to evaluate fertility should be performed at what time? a. 1 week after ovulation b. Immediately after menses c. Just before the next menstrual period d. Within 1 to 2 days of presumed ovulation

d. Within 1 to 2 days of presumed ovulation Because of an increased estrogen level, the cervical mucus is abundant within 1 to 2 days of ovulation, and its quality changes in such a way as to optimize sperm survival time. Cervical mucus 1 week after ovulation is no longer receptive to spermatozoa. Cervical mucus is destructive to spermatozoa and sperm penetration immediately after the menses. The cervical mucus is not yet receptive to spermatozoa just before the next menstrual period.