oB/peds test 3

A toddler with otitis media is prescribed amoxicillin clavulanate 250 mg/5 mL three times daily by mouth for 10 days. What should the nurse teach the mother about this medication? A) "It is OK to stop the antibiotic if the child begins to have side effects." B) "Give the antibiotic for the full 10 days as prescribed." C) "It is important to measure the prescribed dose in a household teaspoon." D) "Be sure to administer a loading dose of the medication when you get home."

B) Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria. A loading dose was not ordered. A household teaspoon could contain less than 5 mL, and the full dose must be given. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms.

The nurse is planning care for a 4-year-old child newly diagnosed with type 1 diabetes mellitus. The child's mother appears unconcerned with the diagnosis and is complaining about the cost of medication, as three additional children in the family have needs. On which nursing diagnoses should the nurse focus when planning this client's care? Select all that apply. A) Chronic Pain B) Deficient Knowledge C) Compromised Family Coping D) Risk for Unstable Blood Glucose Level E) Disturbed Body Image

B) Because the child is only 4 years old, the mother will need to learn how to provide the insulin injections; however, the mother is unconcerned with the diagnosis, likely due to Deficient Knowledge. The mother's complaint about the cost of medication and lack of concern about the diagnosis would cause the client to have a Risk for Unstable Blood Glucose Level, as it is unknown whether the mother is going to ensure the child has the required medication. The family has a total of four children and the mother is concerned with money for medication, as there are three additional children with needs. This could lead to Compromised Family Coping. There is no evidence to support the diagnoses of Chronic Pain or Disturbed Body Image with this client.

Which term is commonly used by clients to describe conjunctivitis? A) Stye B) Pink eye C) Red eye D) Retinitis

B) Clients commonly refer to conjunctivitis as "pink eye," not red eye. Retinitis is a disease related to the retina, not the conjunctiva of the eye. Retinitis causes vision loss, not inflammation, redness, and discharge. A stye is a pimple-like infected oil gland on or near the edge of the eyelid.

The nurse is caring for an adult client who was diagnosed with a congenital heart defect as a child, which was later repaired with surgery. Which common complication of a heart defect should the nurse monitor that the client may still be at risk for? A) Deep vein thrombosis B) Endocarditis C) Atherosclerosis D) Shock

B) Common complications of congenital heart defects that develop during adulthood include dysrhythmias, endocarditis, stroke, heart failure, pulmonary hypertension, and heart valve problems. Congenital heart defects do not normally cause deep vein thrombosis, atherosclerosis, or shock

Which best describes how congenital defects are categorized? A) By the severity of defect B) By the pathophysiology and hemodynamics of defect C) By the location of defect D) By the infant's age when the defect was diagnosed

B) Congenital heart defects are categorized by their pathophysiology and hemodynamics. They are not categorized by the severity of the defect, location of the defect, or the infant's age when the defect is diagnosed.

Health promotion and prevention related to type 1 diabetes should include A) teaching clients at high risk how to prevent type 1 diabetes. B) teaching clients with type 1 diabetes how to prevent complications. C) providing clients with vaccinations against viruses that cause type 1 diabetes. D) referring clients to a nutritionist and exercise therapist.

B) Currently, there is no known way to prevent type 1 diabetes. Therefore, prevention related to type 1 diabetes is related to preventing the short- and long-term complications of the disease process. Although vaccinations are available against some viruses that may trigger type 1 diabetes, vaccinations against all viruses are not available, and many other triggers exist that may cause type 1 diabetes in susceptible individuals. Nurses may refer clients to a nutritionist or exercise therapist after diagnosis, but proper nutrition or exercise will not prevent type 1 diabetes.

A baby will be having surgery to correct a congenital heart defect. On which topic should the parents be instructed regarding the care of the child before surgery? A) Restricting immunizations until after the surgery B) Preventing exposure to infection C) Implementing no particular precautions D) Restricting fluids for a week before the surgery

B) Preoperative care of a baby having surgery to correct a congenital heart defect should include prevention from infection with good hand washing. There are precautions that the parents should take to ensure the child is in optimal health prior to the surgery. Immunizations should be continued. The parents may be instructed to withhold food and fluids several hours before the surgery. Fluids would not be restricted for a week before surgery.

The nurse is providing discharge instructions for a client who has acute conjunctivitis from Staphylococcus. Which should the nurse include when teaching this client? Select all that apply. A) "It is OK to share makeup once the infection has resolved." B) "Do not share towels, makeup, or contact lenses with anyone else, as this can spread the infection." C) "You can soak your eyelids with a warm cloth to soften crusts and exudates that may form." D) "Wash your hands before cleansing the eye and administering eye drops." E) "You may go back to sharing towels when the infection is gone."

B) Sharing supplies, such as towels, make-up, or contact lenses, is never a good idea even after the infection is cleared, due to potential for cross-contamination. Handwashing (hand hygiene) will minimize the risk of bringing in other organisms to an already infected eye. Soaking the lids with a warm cloth will soften the crusts from exudates that accompany the Staphylococcus infection. The action of rubbing one's eyes can traumatize the eyes further and increase the risk of cross-contamination.

The nurse provides discharge instructions to the parents of a child recovering from surgery to repair a congenital heart defect. What statement indicates that teaching has been effective? A) "Our child should be restricted in play and activity for at least 6 months." B) "Our child will need to take antibiotics prior to having dental surgery." C) "Fluids should be restricted to maximize lung function." D) "Our child should not return to normal activities for at least 2 years."

B) Since the child is at risk for infective endocarditis, prophylactic antibiotics are indicated for invasive procedures. The child should be encouraged to gradually return to normal activities, including play. The child's activity should not be restricted for 6 months to 2 years. The child should not restrict fluids.

The nurse is caring for a 15-year-old pregnant adolescent during the labor and delivery process. The client has no support person with her, and she plans to give up her baby for adoption. What nursing intervention can the nurse implement to facilitate the grieving process for this client? A) Encourage the client to avoid seeing and holding the baby. B) Encourage the client to see and hold the baby. C) Encourage the client to have the adoptive parents present for the birth. D) Encourage the client to sign the adoption papers as soon as possible after the birth.

B) The adolescent who is planning to give up her baby for adoption should be given the option of seeing and holding her baby. This facilitates the grieving process. However, seeing or holding the newborn should be her choice. The nurse should not discourage the adolescent from seeing her baby and should not encourage the adolescent to sign adoption papers as soon as possible after the birth. Because of privacy concerns, the nurse should not encourage the adolescent to have the adoptive parents present for the birth except for special circumstances as determined by the client, not the nurse.

The nurse is caring for a client who refuses treatment for otitis media. The nurse correctly teaches the client that she is at increased risk for developing which condition? A) External otitis B) Meningitis C) Pneumonia D) Influenza

B) The bacterial infection from otitis media may migrate internally, leading to the development of bacterial meningitis. Otitis media is not known to cause external otitis. Otitis media does not cause pneumonia or influenza.

The destruction of which types of cells in the islets of Langerhans cause type 1 diabetes mellitus? A) Alpha cells B) Beta cells C) Delta cells D) Gamma cells

B) The beta cells of the islets of Langerhans in the pancreas are the only cells in the body that produce insulin. Destruction of these cells cause type 1 diabetes mellitus. Alpha cells are responsible for the production of glucagon, and delta cells produce somatostatin. Gamma cells produce pancreatic polypeptide.

The body structure that provides a route by which infections organisms can enter the middle ear to cause otitis media is the A) nasopharynx. B) eustachian tube. C) tympanic membrane. D) sinus cavity.

B) The eustachian tube connects the middle ear with the nasopharynx, and this tube provides a route through which infectious organisms can enter the middle ear from the nose and throat. The nasopharynx and sinus cavity are structures in the nose and throat. They do not directly connect to the middle ear. The tympanic membrane separates the middle ear from the external auditory canal. It protects the middle ear from infectious organisms when it is intact.

The nurse is instructing a pregnant client on how the baby's condition is evaluated during labor. Which client statement indicates appropriate understanding of the information presented? A) "During labor, the nurse will verify that my contractions are strong but not too close together." B) "During labor, the nurse will look at the color and amount of bloody show that I have." C) "During labor, the nurse will assess the baby's heart rate with a Doppler ultrasound." D) "During labor, the nurse will regularly check my cervix by doing a pelvic exam."

C) During labor, the nurse will assess the baby's heart rate with a Doppler ultrasound unless complications are present. This is the statement the client should make to prove that education was successful. The nurse will also monitor contractions, bloody show, and the cervix, but these assessments do not monitor the baby's condition.

A client has completed the full course of antibiotics prescribed to treat otitis media. Which primary manifestation of the disorder will be relieved as evidence that treatment has been effective? A) Impaired hearing B) Dizziness C) Pain D) Nausea and vomiting

C) Ear pain is the most common symptom of otitis media that motivates the client to seek healthcare. Secondary symptoms associated with the disease include dizziness, impaired hearing, and nausea and vomiting.

The nurse is planning care for a client admitted with diabetic ketoacidosis (DKA). On what should the nurse focus for this client's care? Select all that apply. A) Administration of oral glucose B) Monitoring for fluid volume overload C) Frequent blood glucose monitoring D) Intravenous fluid infusions E) Insulin infusion

C) For the client experiencing diabetic ketoacidosis, frequent blood sugar monitoring, IV fluids, and insulin drips for treatment mandate that the client be cared for in an intensive care environment until stabilized. The client will be dehydrated and most likely will not need treatment for fluid volume overload. Oral glucose should not be administered to the client with diabetic ketoacidosis.

During an assessment, the nurse notes the client in the fourth stage of labor is experiencing intense shaking and chills. Based on this data, which conclusion by the nurse is appropriate? A) This is evidence of incomplete expulsion of the placenta. B) The client has a full bladder. C) This is a normal reaction to the ending of the physical exertion of labor. D) The client has a fever from a postpartum infection.

C) Many clients experience a shaking chill in the fourth stage of labor, which is thought to be associated with the ending of the physical exertion of labor. The nurse would need to assess the client's temperature to determine the presence of a fever. Indications of a full bladder would most likely be a displaced uterus. Shaking chills after delivery is not evidence of incomplete expulsion of the placenta.

The nurse is providing care to a client in labor who experiences spontaneous rupture of membranes. The fetus is in the vertex position. The nurse notes that the amniotic fluid is meconium stained. Based on this data, which is the priority action by the nurse? A) Notifying the healthcare provider that birth is imminent B) Changing the client's position in bed C) Beginning continuous fetal heart rate monitoring D) Administering oxygen at 2 liters per minute

C) Meconium-stained amniotic fluid is an abnormal fetal finding and is an indication for continuous fetal monitoring. Changing the client's position is not indicated. Meconium-stained amniotic fluid does not indicate that birth is imminent. Oxygen administration is not indicated.

The nurse is analyzing data collected after assessing a child with a congenital heart defect that decreases pulmonary blood flow. Which nursing diagnosis would be applicable for this client? A) Acute Pain B) Ineffective Breathing Pattern C) Decreased Cardiac Output D) Excess Fluid Volume

C) Nursing diagnoses for clients with congenital heart defects that decrease pulmonary blood flow include Decreased Cardiac Output, Risk for Infection, Caregiver Role Strain, and Activity Intolerance. Acute Pain and Ineffective Breathing Pattern are appropriate nursing diagnoses for a child following cardiac surgery. Excess Fluid Volume is a nursing diagnosis seen in the care of a client with a congenital heart defect that increases pulmonary blood flow.

The nurse is teaching the parents of an infant who is diagnosed with acute otitis media. Which is the priority teaching point for these parents? A) Administer a decongestant for nasal congestion. B) Keep the baby in a flat position during sleep. C) Administer acetaminophen to relieve pain and decrease fever. D) Place the baby to sleep with a pacifier.

C) Parents are taught to administer acetaminophen to relieve the discomfort and decrease fever associated with acute otitis media. Decongestants are not recommended for treatment of acute otitis media. A flat position could exacerbate the discomfort. Elevating the head slightly is recommended. Placing infants to sleep with a pacifier can increase the incidence of otitis media.

The nurse is counseling a couple who is planning a pregnancy. The woman was diagnosed with type 1 diabetes when she was 14 years old. She is now 27. Which examination should the nurse prepare the woman to have before, during, and after the pregnancy? A) Gastrointestinal examination for gastric hypotony B) Neural examination for diabetic peripheral neuropathy C) Eye examination for diabetic retinopathy D) Renal examination for urinary incontinence

C) Pregnant women with type 1 diabetes are at an increased risk for diabetic retinopathy. Women with type 1 diabetes who are planning a pregnancy should have eye examinations before the pregnancy, during each trimester, and for 1 year postpartum. Older adults, not pregnant women, are at increased risk for gastric hypotony and urinary incontinence related to type 1 diabetes. Pregnant women with type 1 diabetes are not at increased risk for diabetic peripheral neuropathy compared to other clients with type 1 diabetes.

The nurse walks into an examination room and sees a young child demonstrate a specific behavior. (See image.) The nurse recognizes this behavior is most characteristic of which health problem? A) Sore throat B) Hunger C) Otitis media D) Head cold

C) Pulling at the ear is a characteristic sign of otitis media in a young child. Pulling at the ear does not indicate a sore throat, hunger, or a head cold.

A client who is newly diagnosed with type 1 diabetes has smoked for 30 years. When teaching the client on ways to optimize health outcomes, what should the nurse explain about the effects of smoking and diabetes? A) Smoking is a major factor in the development of diabetic neuropathy. B) Smoking increases insulin resistance. C) Smoking accelerates atherosclerotic changes in blood vessels. D) Smoking promotes weight gain.

C) Smoking is especially unhealthy for diabetic clients because smoking accelerates the atherosclerotic effects that occur in blood vessels from elevated levels of blood glucose. Smoking is not associated with weight gain; in fact, people use weight gain as an excuse not to quit smoking. Poor glycemic control in diabetics is associated with the development of complications including diabetic neuropathy. Smoking does not affect insulin resistance.

The nurse is teaching the mother of an infant with otitis media to manage the associated fever and pain. Which instruction by the nurse is correct? A) Swaddle the baby in blankets. B) Feed the baby solid foods. C) Administer acetaminophen. D) Bathe the baby with cool water.

C) Swaddling the baby with blankets is not going to reduce the fever or help the pain. The baby may not be of the age to take solid foods. Acetaminophen will help reduce the child's fever and reduce the pain. Bathing with cool water is not an appropriate intervention to reduce the fever of a baby.

The nurse is teaching a mother how to administer optical antibiotics to her child who has conjunctivitis. Which statement made by the mother indicates teaching has been effective? A) "I will drop the medication onto the eyeball." B) "I will wait 10 seconds between drops." C) "I will wash my hands before instilling the medication." D) "I will rub the eye with a cotton ball after I administer the medication."

C) Teach the client to wash hands thoroughly before and after instilling eye medications. Handwashing is the single most important means of preventing transmission of infection. Medication is dropped into the lower conjunctival sac and should not be rubbed after instillation. The time between drops is 1 to 5 minutes, depending on the type of medication.

The nurse is assessing a client who presents with purulent drainage and crusting of the eye. The nurse should recognize that these findings are most consistent with which type of infection? A) Viral conjunctivitis B) Allergic conjunctivitis C) Bacterial conjunctivitis D) Fungal conjunctivitis

C) The major difference between bacterial and viral conjunctivitis is that bacterial conjunctivitis has a purulent discharge that may result in crusting, whereas the discharge from viral conjunctivitis is serous (watery). Allergic conjunctivitis produces watery to thick drainage and is characterized by itching. Fungi do not cause conjunctivitis.

The nurse is providing care to the client during the second stage of labor. Which nursing action is appropriate? A) Assessing maternal temperature every 1-2 hours after amniotic membranes have ruptured B) Encouraging the client to void every 1-2 hours C) Assessing fetal heart rate every 5 minutes D) Administering antibiotics for a positive group beta strep

C) The second stage of labor is reached when the cervix is completely dilated. At this time, it is appropriate for the nurse to assess fetal heart rate every 5 minutes or after every contraction. Assessing temperature every 1 to 2 hours after amniotic membranes have ruptured, encouraging the client to void, and administering antibiotics are all nursing actions that are appropriate during the first stage of labor.

Which type of infection has been implicated in destruction of pancreatic beta cells and thus causes type 1 diabetes? A) Fungal B) Parasitic C) Viral D) Bacterial

C) Triggers for the development of type 1 diabetes include genetic predisposition, environmental factors, viral infections, or chemical toxins. Fungal, parasitic, and bacterial infections have not been linked to the development of type 1 diabetes.

The nurse is planning for several women who are pregnant for the first time who are in the labor and delivery process. Which woman has the highest risk of labor and delivery complications? A) A healthy 38-year-old woman B) A 24-year-old woman with asthma C) A 36-year-old woman with diabetes D) A 31-year-old woman with hypertension

C) Women over the age of 35 have an increased risk for complications during labor and delivery, especially when the woman already has preexisting medical conditions such as hypertension or diabetes. However, risks are much lower for women under the age of 35 or women over the age of 35 who do not have preexisting medication conditions.

The nulliparous client states, "I have been in labor for 4 hours and I am still only 2 cm dilated. Why is this happening? I feel like I should be ready to push by now." Which is the best response by the nurse? A) "When your perineal body thins out, your cervix will begin to dilate much faster than it is now." B) "The hormones that cause labor to begin are just getting to the levels that will change your cervix." C) "What did you expect? You've only had contractions for a few hours. Labor takes time." D) "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress."

D) Cervical effacement must be nearly complete before cervical dilation takes place in primiparas. This is why the labor and birth of a first baby usually take much more time than for subsequent labor and births. The perineal body thinning primarily occurs during the second stage of labor; it is not expected early in labor. The reply "what did you expect" is not therapeutic. Although it is true that this client has only been in early labor for a short time, and it is true that labor for a nullipara averages 12-24 hours, the nurse must always be therapeutic in all communication. The hormones that cause labor contractions do not directly cause cervical change; the contractions cause the cervix to change.

The nurse correctly explains to a young mother that bottle-feeding an infant in the upright position may help to prevent which infectious health problem? A) Choking B) Aspiration C) Sinus infection D) Otitis media

D) Infants and small children who are bottle-fed in a supine position have a greater probability of developing otitis media because the eustachian tube opens when the child sucks, and the horizontal angle provides easy access to the middle ear. Children are not prone to sinus infection during infancy as the result of feeding position. Although choking and aspiration can occur due to an improper position during bottle-feeding, they are not infectious health problems.

A client in the fourth stage of labor is experiencing perineal trauma. Which nursing diagnosis is the priority at this time? A) Health-Seeking Behaviors B) Fear C) Anxiety D) Acute Pain

D) Many clients experience perineal trauma during the childbirth process, which causes acute pain in the fourth stage of labor. Therefore, Acute Pain is a more appropriate nursing diagnosis related to this condition than Fear or Anxiety. The diagnosis of Health-Seeking Behaviors does not address the client experiencing perineal trauma during labor.

Which child has a risk factor for developing otitis media? A) A 10-year-old child who plays baseball and soccer B) A 14-year-old child who lives on a farm C) A 5-year-old child who stays with her grandmother during summer break D) An 18-month-old child who attends daycare while his parents work

D) Risk factors for developing otitis media include being younger than age 2, participating in group care settings, having seasonal allergies, or being exposed to poor air quality. The 18-month-old child has two risk factors for developing otitis media. None of the other children have any of these risk factors.

The nurse is providing teaching to the parents of a child born with tetralogy of Fallot (TOF). Which statement should the nurse include in her teaching regarding this defect? A) "Increased pulmonary blood flow causes symptoms with this disease." B) "This disease consists of pulmonic stenosis, left ventricular hypertrophy, ventricular septal defect, and an overriding aorta." C) "Your child has a decreased amount of red blood cells because of this disease." D) "This disease consists of pulmonic stenosis, right ventricular hypertrophy, ventricular septal defect, and an overriding aorta."

D) TOF consists of four defects—pulmonic stenosis, right ventricular hypertrophy, ventricular septal defect, and an overriding aorta. This disease is also characterized by decreased pulmonary blood flow and polycythemia (increased red blood cells due to hypoxia).

The nurse is assessing a college student who presents with red, swollen eyes; photophobia; and yellowish drainage from the conjunctiva. Which question should the nurse ask the client first? A) "Have you had extra caffeine this week?" B) "Did you get sand in your eye recently?" C) "Have you been exposed to HIV?" D) "Have any of your friends experienced these symptoms?"

D) The client is exhibiting signs and symptoms of conjunctivitis. The nurse should explore ways in which the client may have been exposed. Most cases of conjunctivitis are spread by hand to eye contact. Exposure to HIV, sand in the eye, and caffeine are not known causes of conjunctivitis and would not be appropriate questions to ask this client to determine the cause of the symptoms.

During the fourth stage of labor, a client's blood pressure is 110/60 mmHg, pulse 90, and the fundus is firm, midline, and halfway between the symphysis pubis and the umbilicus. Based on this data, which is the primary action by the nurse? A) Massage the fundus. B) Turn the client onto the left side. C) Place the bed in the Trendelenburg position. D) Continue to monitor.

D) The client's assessment data are normal for the fourth stage of labor, so monitoring is the only action necessary. During the fourth stage of labor, the mother experiences a slight drop in blood pressure and a slightly increased pulse. A left lateral position is not necessary with a BP of 110/60 and a pulse of 90. The Trendelenburg position is not necessary with a BP of 110/60 and a pulse of 90. The uterus should be midline and firm; massage is not necessary.

The nurse is caring for a pregnant woman with congenital heart disease. The woman asks if she will be able to have a vaginal delivery. Which answer by the nurse is correct? A) A Cesarean section is preferred because you will lose less blood than with a vaginal birth. B) A Cesarean section is preferred because there is a lower risk of infection than with a vaginal birth. C) A vaginal birth is preferred over a Cesarean section for women who have aortic stenosis. D) A vaginal birth is preferred because there is a lower risk of thrombophlebitis than with a Cesarean section.

D) Vaginal delivery is preferable to Cesarean section for most clients with congenital heart defects because they will likely lose less blood with vaginal birth. Risk of wound infection and thrombophlebitis are also concerns with Cesarean birth. Dilated aorta, pulmonary hypertension, and aortic stenosis are contraindications for vaginal delivery.

During a vaginal examination, the nurse palpates fetal buttocks that are facing the left posterior and are 1 cm above the ischial spines. Which of the following is consistent with this assessment? 1. LOA −1 station. 2. LSP −1 station. 3. LMP +1 station. 4. LSA +1 station

The LOA position refers to a fetus whose occiput (O) is facing toward the mother's left anterior (LA) and a presenting part at −1 station is 1 cm above the ischial spines. 2. The LSP position is the correct answer. The fetal buttocks (S or sacrum) are facing toward the mother's left posterior (LP) and buttocks at −1 station are 1 cm above the ischial spines. 3. The LMP position refers to a fetus whose face (M or mentum) is facing toward the mother's LP and a presenting part at +1 is 1 cm below the ischial spines. 4. The LSA position refers to a fetus whose buttocks (S) are facing toward the mother's LA and a presenting part at +1 station is 1 cm below the ischial spines. TEST-TAKING TIP: If the test taker understands the definition of station, he or she could easily eliminate two of the four responses in this question. When the presenting part of the fetus is at zero (0) station, the part is at the same level as an imaginary line between the mother's ischial spines. When the presenting part is above the spines, the station is negative (-). When the presenting part has moved past the spines, the station is defined as positive (+). Because the question states that the nurse palpated the buttocks above the spines, the station is negative. This effectively eliminates the two answer options that include a positive sta

When performing Leopold maneuvers, the nurse notes that the fetus is in the left occiput anterior position. Which is the best position for the nurse to place a fetoscope to hear the fetal heartbeat? 1. Left upper quadrant. 2. Right upper quadrant. 3. Left lower quadrant. 4. Right lower quadrant.

The left upper quadrant would be the appropriate place to place a fetoscope to hear the fetal heartbeat if the baby were in the LSA position, not the LOA position. The right upper quadrant would be appropriate if the baby were in the RSA position. The right lower quadrant would be appropriate if the baby were in the ROA position. TEST-TAKING TIP: The fetal heart is best heard through the fetal back. Because, as determined by doing Leopold maneuvers, the baby is LOA, the fetal back (and, hence, the fetal heart) is in the left lower quadrant.

When during the latent phase of labor should the nurse assess the fetal heart pattern of a low-risk woman, G1 P0000? Select all that apply. 1. After vaginal examinations. 2. Before administration of analgesics. 3. Periodically at the end of a contraction. 4. Every ten minutes. 5. Before ambulating.

1, 2, 3, and 5 are correct. 1. The nurse should assess the fetal heart after all vaginal examinations. 2. The nurse should assess the fetal heart before giving the mother any analgesics. 3. The fetal heart should be assessed periodically at the end of a contraction. 5. The nurse should assess the fetal heart before the woman ambulates. The fetal heart pattern should be assessed every hour during the latent phase of a low-risk labor. It is not standard protocol to assess every 10 minutes. TEST-TAKING TIP: Except for invasive procedures, assessment of the fetal heart pattern is the only way to evaluate the well-being of a fetus during labor. The fetal heart pattern should, therefore, be assessed whenever there is a potential for injury to the baby or to the umbilical cord. At each of the times noted in the scenario—vaginal examination, analgesic administration, contraction, and ambulation—either the cord could be compressed or the baby could be compromised.

A nurse is caring for a laboring woman who is in transition. Which of the following signs/symptoms would indicate that the woman is progressing into the second stage of labor? Select all that apply. 1. Bulging perineum. 2. Increased bloody show. 3. Spontaneous rupture of the membranes. 4. Uncontrollable urge to push. 5. Inability to breathe through contractions.

1, 2, and 4 are correct. As the fetal head descends through a fully dilated cervix, the perineum begins to bulge, the bloody show increases, and the laboring woman usually feels a strong urge to. A bulging perineum indicates progression to the second stage of labor. The bloody show increases as a woman enters the second stage of labor. With a fully dilated cervix and bulging perineum, laboring women usually feel a strong urge to push. The gravida's ability to work with her labor is more dependent on her level of pain and her preparation for labor than on the phases and/ or stages of labor. TEST-TAKING TIP: It is important that the test taker clearly understands the difference between the three phases of the first stage of labor and the three stages of labor. The three phases of the first stage of labor—latent, active, and transition—are related to changes in cervical dilation and maternal behaviors. The three stages of labor are defined by specific labor progressions—cervical change to full dilation (stage 1), full dilation to birth of the baby (stage 2), birth of the baby to birth of the placenta (stage 3)

A nurse is educating a pregnant woman regarding the moves a fetus makes during the birthing process. Please place the following cardinal movements of labor in the order the nurse should inform the client that the fetus will make: 1. Descent. 2. Expulsion. 3. Extension. 4. External rotation. 5. Internal rotation.

1, 5, 3, 4, 2. The correct order of the movements listed is: 1. Descent. 5. Internal rotation. 3. Extension. 4. External rotation. 2. Expulsion. TEST-TAKING TIP: The test taker must review the cardinal moves of labor. There are a couple of tricks to help the test taker to remember the sequence of the moves of labor. First, descent and flexion must occur. If the baby does not descend into the birth canal and the baby does not flex the head so that his or her chin is on the chest, the baby simply will not be able to traverse through the bony pelvis. Second, internal rotation (rotation of the fetal body when the fetal head is still inside the mother's pelvis) must occur before external rotation (rotation of the fetal body after the fetal head is outside the mother). In between the rotational moves is extension, the delivery of the head. And, finally, expulsion must be last because the delivery of the baby's body is simply the last movement.

A client enters the labor and delivery suite stating that she thinks she is in labor. Which of the following information about the woman should the nurse note from the woman's prenatal record before proceeding with the physical assessment? Select all that apply. 1. Weight gain. 2. Ethnicity and religion. 3. Age. 4. Type of insurance. 5. Gravidity and parity.

1,2,3,5 1. Before proceeding with a physical assessment, the nurse should check the client's weight gain reported in her prenatal record. 2.The client's ethnicity and religion should be noted before physical assessment. This allows the nurse to proceed in a culturally sensitive manner. 3.The client's age should also be noted before the physical assessment is begun. 5. The client's gravidity and parity—how many times she has been pregnant and how many times she has given birth—should also be noted before a physical assessment is begun

A woman has decided to hire a doula to work with her during labor and delivery. Which of the following actions would be appropriate for the nurse to delegate to the doula? Select all that apply. 1. Give the woman a back rub. 2. Assist the woman with her breathing. 3. Assess the fetal heart rate. 4. Check the woman's blood pressure. 5. Regulate the woman's intravenous infusion rate.

1. An appropriate action by the doula is giving the woman a back massage. 2. An appropriate action by the doula is to assist the laboring woman with her breathing. The nurse, not the doula, should assess the fetal heart. The nurse, not the doula, should assess the blood pressure. The nurse, not the doula, should regulate the IV. TEST-TAKING TIP: Even if the test taker were unfamiliar with the role of the doula, he or she could deduce the answers to this question. Three of the responses involve physiological assessments or interventions, while two of the responses deal with providing supportive care—the role of the doula.

On examination of a full-term primipara, a labor nurse notes: active labor, right occipitoanterior (ROA), 7 cm dilated, and +3 station. Which of the following should the nurse report to the physician? 1. Descent is progressing well. 2. Fetal head is not yet engaged. 3. Vaginal delivery is imminent. 4. External rotation is complete.

1. Descent is progressing well. The presenting part is 3 centimeters below the ischial spines. The fetal head is well past engagement. Engagement is defined as 0 station. The woman, a primipara, is only 7 centimeters dilated. Delivery is likely to be many hours away. External rotation does not occur until after delivery of the fetal head TEST-TAKING TIP: This question includes a number of concepts. Descent and station are discussed in answer options 1 and 2. The dilation of the cervix, which is related to the fact that the woman is a primigravida, is discussed in choice 3. And one of the cardinal moves of labor— external rotation—is included in choice 4. The test taker must be prepared to answer questions that are complex and that include diverse information. In a 7 cm dilated primipara with a baby at +3 station, vaginal delivery is not imminent, but the fetal head is well past engagement and descent is progressing well. External rotation has not yet occurred because the baby's head has not yet been birthed.

The labor and delivery nurse performs Leopold maneuvers. A soft round mass is felt in the fundal region. A flat object is noted on the left and small objects are noted on the right of the uterus. A hard round mass is noted above the symphysis. Which of the following positions is consistent with these findings? 1. Left occipital anterior (LOA). 2. Left sacral posterior (LSP). 3. Right mentum anterior (RMA). 4. Right sacral posterior (RSP).

1. The nurse's findings upon performing Leopold maneuvers indicate that the fetus is in the left occiput anterior (LOA) position—that is, the fetal back is felt on the mother's left side, the small parts are felt on her right side, the buttocks are felt in the fundal region, and the head is felt above her symphysis. The findings after the nurse performs Leopold maneuvers do not indicate that the fetus is in the left sacral posterior (LSP) position; in that position, the fetus's buttocks (S or sacrum) are facing toward the mother's left posterior (LP), a hard round mass is felt in the fundal region, and a soft round mass is felt above the symphysis. The findings after the nurse performs Leopold maneuvers do not indicate that the fetus is in the right mentum anterior (RMA) position; in that position, the fetus's face (M or mentum) is facing toward the mother's right anterior (RA) and small objects are felt on the right of the mother's abdomen with a flat area felt on the mother's left side. The findings after the nurse performs Leopold maneuvers do not indicate that the fetus is in the right sacral posterior (RSP) position; in that position, the fetus's sacrum (S) is facing the mother's right posterior (RP) and a hard round mass is felt in the fundal region while a soft round mass is felt above the symphysis. TEST-TAKING TIP: The test taker must review fetal positioning. This is an especially difficult concept to understand. The best way to learn the three- dimensional concept of fetal position is to look at the pictures in a text. Using a doll, the nurse can then imitate the pictures by placing the doll into each of the positions.

A midwife advises a mother that her obstetric conjugate is of average size. How should the nurse interpret that information for the mother? 1. The anterior to posterior diameter of the pelvis will accommodate a fetus with an average-sized head. 2. The fetal head is flexed so that it is of average diameter. 3. The mother's cervix is of average dilation for the start of labor. 4. The distance between the mother's physiological retraction ring and the fetal head is of average dimensions

1. The obstetric conjugate is the shortest anterior to posterior diameter of the pelvis. When it is of average size, it will accommodate an average-sized fetal head. When the fetal head is flexed, the diameter of the head is minimized. This is not, however, the obstetric conjugate. There is no average dilation for the beginning of labor. The physiological retraction ring is the area of the uterus that forms as a result of cervical effacement. It is not related to the obstetric conjugate. TEST-TAKING TIP: The obstetric conjugate is measured by the healthcare practitioner to estimate the potential for the fetal head to fit through the anterior-posterior diameter of the maternal pelvis. It is the internal distance between the sacral promontory and the symphysis pubis.

While evaluating the fetal heart monitor tracing on a client in labor, the nurse notes that there are fetal heart decelerations present. Which of the following assessments must the nurse make at this time? 1. The relationship between the decelerations and the labor contractions. 2. The maternal blood pressure. 3. The gestational age of the fetus. 4. The placement of the fetal heart electrode in relation to the fetal position

1. The relationship between the decelerations and the contractions will determine the type of deceleration pattern. The maternal blood pressure is not related to the scenario in the question. Although some fetuses are at higher risk for fetal distress, the nurse must first determine which type of deceleration is present. If the nurse is able to identify that a deceleration is present, the electrode placement is adequate. TEST-TAKING TIP: Decelerations are defined by their relationship to the contraction pattern. It is essential that the nurse determine which of the three types of decelerations is present. Early decelerations mirror contractions, late decelerations develop at the peak of contractions and return to baseline well after contractions are over, and variable decelerations can occur at anytime and are often unrelated to contractions.

While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing shows average short-term and long-term variability with a baseline of 142 beats per minute (bpm). What should the nurse do? 1. Provide caring labor support. 2. Administer oxygen via face mask. 3. Change the client's position. 4. Speed up the client's intravenous.

1. The tracing is showing a normal fetal heart tracing. No intervention is needed. There is no need to administer oxygen at this time. The tracing is normal. If the client is comfortable, there is no need to change her position.There is no need to speed up the intravenous at this time. TEST-TAKING TIP: The baseline fetal heart variability is the most important fetal heart assessment that the nurse makes. If the baby's heart rate shows average variability, the nurse can assume that the baby is not hypoxic or acidotic. In addition, the normal heart rate of 142 is reassuring.

The nurse auscultates a fetal heart rate of 152 on a client in early labor. Which of the following actions by the nurse is appropriate? 1. Inform the mother that the rate is normal. 2. Reassess in 5 minutes to verify the results. 3. Immediately report the rate to the healthcare practitioner. 4. Place the client on her left side and apply oxygen by face mask.

1. This is the correct response. A fetal heart rate of 152 is normal. This woman is in early labor. The fetal heart does not need to be assessed every 5 minutes. The rate is normal. There is no need to report the rate to the healthcare practitioner. The rate is normal. There is no need to institute emergency measures. TEST-TAKING TIP: It is essential that the test taker know the normal physiological responses of women and their fetuses in labor. The normal fetal heart rate is 110 to 160 bpm. A rate of 152, therefore, is within normal limits. No further action is needed at this time.

The childbirth education nurse is evaluating the learning of four women, 38 to 40 weeks' gestation, regarding when they should go to the hospital. The nurse determines that the teaching was successful when a client makes which of the following statements? Select all that apply. 1. The client who says, "If I feel a pain in my back and lower abdomen every 5 minutes." 2. The client who says, "When I feel a gush of clear fluid from my vagina." 3. The client who says, "When I go to the bathroom and see the mucous plug on the toilet tissue." 4. The client who says, "If I ever notice a greenish discharge from my vagina." 5. The client who says, "When I have felt cramping in my abdomen for 4 hours or more."

1. True labor contractions often begin in the back and, when the frequency of the contractions is q 5 minutes or less, it is usually appropriate for the client to proceed to the hospital. 2. Even if the woman is not having labor contractions, rupture of membranes is a reason to go to the hospital to be assessed. 4. Greenish liquid is likely meconium- stained fluid. The client needs to be assessed. Expelling the mucous plug is not sufficient reason to go to the hospital to be assessed The latent phase of labor can last up to a full day. In addition, Braxton Hicks contractions can last for quite a while. Even though a woman may feel cramping for 4 hours or more, she may not be in true labor. TEST-TAKING TIP: The mucous plug protects the uterine cavity from bacterial invasion. It is expelled before or during the early phase of labor. In fact, it may be hours, days, or even a week after the mucous plug is expelled before true labor begins

In addition to breathing with contractions, the nurse should encourage women in the first stage of labor to perform which of the following therapeutic actions? 1. Lying in the lithotomy position. 2. Performing effleurage. 3. Practicing Kegel exercises. 4. Pushing with each contraction.

2. Effleurage is a light massage that can soothe the mother during labor. The lithotomy position is not physiologically supportive of labor and birth. Practicing Kegel exercises can help to build up the muscles of the perineum but will not help the woman to work with her labor. Pushing is not performed until the second stage of labor. TEST-TAKING TIP: There are a number of actions that mothers can take that can support their breathing during labor. Walking, swaying, and rocking can all help a woman during the process. Effleurage, the light massaging of the abdomen or thighs, is often soothing for laboring mothers.

The nurse is assessing a client who states, "I think I'm in labor." Which of the following findings would positively confirm the client's belief? 1. She is contracting q 5 min × 60 sec. 2. Her cervix has dilated from 2 to 4 cm. 3. Her membranes have ruptured. 4. The fetal head is engaged.

2. Once the cervix begins to dilate, a client is in true labor. Women may contract without being in true labor. Membranes can rupture before true labor begins. Engagement can occur before true labor begins. TEST-TAKING TIP: Although laboring women experience contractions, contractions alone are not an indicator of true labor. Only when the cervix dilates is the client in true labor. False labor contractions are usually irregular and mild, but, in some situations, they can appear to be regular and can be quite uncomfortable.

The nurse is assessing the fetal station during a vaginal examination. Which of the following structures should the nurse palpate? 1. Sacral promontory. 2. Ischial spines. 3. Cervix. 4. Symphysis pubis.

2. Station is assessed by palpating the ischial spines. Palpating the sacral promontory assesses the obstetric conjugate, not the fetal station.Palpating the cervix assesses dilation and effacement, not fetal station. Palpating the symphysis pubis assesses the obstetric conjugate, not the fetal station. TEST-TAKING TIP: The test taker must be thoroughly familiar with the anatomy of the female reproductive system and the measurements taken during pregnancy and labor. Station is determined by creating an imaginary line between the ischial spines. The descent of the presenting part of the fetus is then compared with the level of that "line."

A low-risk 38-week gestation woman calls the labor unit and says, "I have to come to the hospital right now. I just saw pink streaks on the toilet tissue when I went to the bathroom. I'm bleeding." Which of the following responses should the nurse make first? 1. "Does it burn when you void?" 2. "You sound frightened." 3. "That is just the mucous plug." 4. "How much blood is there?"

2. The nurse is using reflection to acknowledge the client's concerns. The client may have a urinary tract infection with blood in the urine. First, however, the nurse should acknowledge the client's concerns. Although the woman's statement is consistent with the expulsion of the mucous plug, this response ignores the fact that the client is frightened by what she has seen. The nurse will want to clarify that the woman isn't actually bleeding, but the question should follow an acknowledgment of the woman's concerns TEST-TAKING TIP: Pregnant women are very protective of themselves and of the babies they are carrying. Any time a change that might portend a problem occurs, a pregnant woman is likely to become concerned and frightened. Certainly, seeing any kind of blood loss from the vagina can be scary. The nurse must acknowledge that fear before asking other questions or making other comments.

A client in labor, G2 P1001, was admitted 1 hour ago at 2 cm dilated and 50% effaced. She was talkative and excited at that time. During the past 10 minutes she has become serious, closing her eyes and breathing rapidly with each contraction. Which of the following is an accurate nursing assessment of the situation? 1. The client had poor childbirth education prior to labor. 2. The client is exhibiting an expected behavior for labor. 3. The client is becoming hypoxic and hypercapnic. 4. The client needs her alpha-fetoprotein levels checked.

2. The woman is showing expected signs of the active phase of labor. There is no indication that this woman has had poor preparation for childbirth. There is no indication that this woman is showing signs of hypoxia and/or hypercapnia. The alpha-fetoprotein assessment is a test to screen for Down syndrome and neural tube defects in the fetus. It is done during pregnancy. TEST-TAKING TIP: The test taker must be familiar with the different phases of the first stage of labor: latent, active, and transition. The multiparous woman in the scenario entered the labor suite in the latent phase of labor when being talkative and excited is normal, but after 1 hour she has progressed into the active phase of labor in which being serious and breathing rapidly with contractions are expected behaviors

A client is in the second stage of labor. She falls asleep immediately after a contraction. Which of the following actions should the nurse perform at this time? 1. Awaken the woman and remind her to push. 2. Cover the woman's perineum with a sheet. 3. Assess the woman's blood pressure and pulse. 4. Administer oxygen to the woman via face mask.

2. The woman's privacy should be maintained while she is resting. The woman should not push until the next contraction. She should be allowed to sleep at this time. The woman is in no apparent distress. Vital sign assessment is not indicated. The woman is in no apparent distress. Oxygen is not indicated. TEST-TAKING TIP: Because the woman is in second stage, she is pushing with contractions. If she is very tired, she is likely to fall asleep immediately following a contraction. It is important for the nurse to maintain the woman's privacy by covering her perineum with a sheet between contractions. It would also be appropriate to awaken the woman at the beginning of the next contraction.

A client who is 7 cm dilated and 100% effaced is breathing at a rate of 50 breaths per minute during contractions. Immediately after a contraction, she complains of tingling in her fingers and some light-headedness. Which of the following actions should the nurse take at this time? 1. Assess the blood pressure. 2. Have the woman breathe into a bag. 3. Turn the woman onto her side. 4. Check the fetal heart rate.

2. This client is showing signs of hyperventilation. The symptoms will likely subside if she rebreathes her exhalations. Although this client is light-headed, her problem is unlikely related to her blood pressure. It is unnecessary for this client to be moved to her side. The baby is not in jeopardy at this time. TEST-TAKING TIP: It is essential that the test taker attend to the clues in the question and not assume that other issues may be occurring. This client is light- headed as a result of being tachypneic during contractions. Hyperventilation, which can result from tachypnea, is characterized by tingling and light- headedness. Rebreathing her air should rectify the problem.

A gravid client, G3 P2002, was examined 5 minutes ago. Her cervix was 8 cm dilated and 90% effaced. She now states that she needs to move her bowels. Which of the following actions should the nurse perform first? 1. Offer the client the bedpan. 2. Evaluate the progress of labor. 3. Notify the physician. 4. Encourage the patient to push.

2.The nurse should first assess the progress of labor to see if the client has moved into the second stage of labor. This client has probably moved into the second stage of labor. Providing a bedpan is not the first action. It is too early to notify the physician. It is too early to advise the mother to push. TEST-TAKING TIP: The average length of transition in multiparas is 10 minutes. This client is therefore likely to have moved into the second stage of labor. The nurse's first action, therefore, is to assess the progress of labor. If she is in second stage, the physician will be notified and the client will be encouraged to push. If she is not yet in second stage, she should continue breathing with her contractions.

A nurse has just performed a vaginal examination on a client in labor. The nurse palpates the baby's buttocks as facing the mother's right side. Where should the nurse place the external fetal monitor electrode? 1. Left upper quadrant (LUQ). 2. Left lower quadrant (LLQ). 3. Right upper quadrant (RUQ). 4. Right lower quadrant (RLQ).

3. Because the baby's back is facing the mother's right side and the sacrum is presenting, the fetal monitor should be placed in her RUQ. Because the baby's back is facing the mother's right side, the fetal monitor should not be placed in the LUQ. Because the baby's back is facing the mother's right side, the fetal monitor should not be placed LLQ. The monitor electrode should have been placed in the RLQ if the nurse had assessed a vertex presentation. TEST-TAKING TIP: Although the question does not tell the test taker whether the sacrum is facing anteriorly or posteriorly, it does provide the information that the sacrum is felt toward the mother's right. Because this baby is in the sacral presentation and the back is toward the right, the best location for the fetal monitor is in the RUQ, at the level of the fetal back

An obstetrician is performing an amniotomy on a gravid woman in transition. Which of the following assessments must the nurse make immediately following the procedure? 1. Maternal blood pressure. 2. Maternal pulse. 3. Fetal heart rate. 4. Fetal fibronectin level.

3. It is essential to assess the fetal heart rate immediately after an amniotomy. The maternal blood pressure is not the priority assessment after an amniotomy. the maternal pulse is not the priority assessment after an amniotomy. Fetal fibronectin is assessed during pregnancy. It is not assessed once a woman enters labor. TEST TAKING TIP: Amniotomy, as the word implies, is the artificial rupture of the amniotic sac. During the procedure, there is a risk that the umbilical cord may become compressed. Because there is no direct way to assess cord compression, the nurse must assess the fetal heart rate for any adverse changes.

The Lamaze childbirth educator is teaching a class of pregnant couples the breathing technique that is most appropriate during the second stage of labor. Which of the following techniques did the nurse teach the women to do? 1. Alternately pant and blow. 2. Take rhythmic, shallow breaths. 3. Push down with an open glottis. 4. Do slow chest breathing

3. Open glottal pushing is used during stage 2 of labor. The alternate pant-blow technique is used during stage 1 of labor. Rhythmic, shallow breaths are used during stage 1 of labor. Slow chest breathing is used during stage 1. TEST-TAKING TIP: Because the laboring client is in stage 2, the woman will change from using breathing techniques during contractions to pushing during contractions to birth the baby. Open glottal pushing is recommended because pushing against a closed glottis can decrease the mother's oxygen saturation

The nurse knows that which of the following responses is the primary rationale for the inclusion of the information taught in childbirth education classes? 1. Mothers who are performing breathing exercises during labor refrain from yelling. 2. Breathing and relaxation exercises are less exhausting than crying and moaning. 3. Knowledge learned at childbirth education classes helps to break the fear-tension- pain cycle. 4. Childbirth education classes help to promote positive maternal-newborn bonding.

3. Some of the techniques learned at childbirth education classes are meant to break the fear-tension-pain cycle. Childbirth educators are not concerned with the possible verbalizations that laboring women might make. Breathing exercises can be quite tiring. Simply being in labor is tiring. The goal of childbirth education, however, is not related to minimizing the energy demands of labor. Although childbirth educators discuss maternal-newborn bonding, it is not a priority goal of childbirth education classes. EST-TAKING TIP: When a frightened woman enters the labor suite, she is likely to be very tense. It is known that pain is often worse when tensed muscles are stressed. Once the woman feels pain, she may become even more frightened and tense. This process becomes a vicious cycle. The information and skills learned at childbirth education classes are designed to break the cycle.

A gravid client at term called the labor suite at 7:00 p.m. questioning whether she was in labor. The nurse determined that the client was likely in labor after the client stated: 1. "At 5:00 p.m., the contractions were about 5 minutes apart. Now they're about 7 minutes apart." 2. "I took a walk at 5:00 p.m., and now I talk through my contractions easier than I could then." 3. "I took a shower about a half hour ago. The contractions hurt more than they did before." 4. "I had some tightening in my belly late this afternoon, and I still feel it after waking up from my nap."

3. This response indicates that the labor contractions are increasing in intensity. The frequency of labor contractions decreases. It does not increase. Labor contractions increase in intensity. They do not become milder. This client has slept through the "tightening" and there is no increase in intensity. It is unlikely that she is in true labor. TEST-TAKING TIP: The test taker should review the labor contraction definitions of frequency, duration, and intensity. As labor progresses, the frequency of contractions decreases but the duration and the intensity, or the length and strength, of the contractions increase. The nurse notes the change in intensity when he or she palpates the fundus of the uterus, and the client subjectively complains of increasing pain.

A nurse is teaching childbirth education classes to a group of pregnant teens. Which of the following strategies would promote learning by the young women? 1. Avoiding the discussion of uncomfortable procedures like vaginal examinations and blood tests. 2. Focusing the discussion on baby care rather than on labor and delivery. 3. Utilizing visual aids like movies and posters during the classes. 4. Having the classes at a location other than high school to reduce their embarrassment.

3. Using visual aids can help to foster learning in teens as well as adults. It is important to include all relevant information in the childbirth class. Baby care should be included, but it is also important to include information about labor and delivery. Having the classes conveniently located in the school setting often enhances teens' attendance. TEST-TAKING TIP: Because of their classroom experiences, adolescents are accustomed to learning in groups. The school setting is comfortable for them and, because of its location and its familiarity, is an ideal setting for childbirth education programs. In addition, educators often use visual aids to promote learning and because teens are frequent theatergoers, showing movies is an especially attractive way to convey information to them.

A client is complaining of severe back labor. Which of the following nursing interventions would be most effective? 1. Assist mother with childbirth breathing. 2. Encourage mother to have an epidural. 3. Provide direct sacral pressure. 4. Move the woman to a hydrotherapy tub.

3. When direct sacral pressure is applied, the nurse is providing a counteraction to the pressure being exerted by the fetal head. Breathing will help with contraction pain but is not as effective when a client is experiencing back labor. It is inappropriate automatically to encourage mothers to have anesthesia or analgesia in labor. There are other methods of providing pain relief. Hydrotherapy is very soothing but will not provide direct relief. TEST-TAKING TIP: Whenever a laboring woman complains of severe back labor, it is very likely that the baby is lying in the occiput posterior position. Every time the woman has a contraction, the head is pushed into the coccyx. When direct pressure is applied to the sacral area, the nurse is providing counteraction to the pressure being exerted by the fetal head.

While performing Leopold maneuvers on a woman in labor, the nurse palpates a hard round mass in the fundal area, a flat surface on the left side, small objects on the right side, and a soft round mass just above the symphysis. Which of the following is a reasonable conclusion by the nurse? 1. The fetal position is transverse. 2. The fetal presentation is vertex. 3. The fetal lie is vertical. 4. The fetal attitude is flexed.

3. With the findings of a hard round mass in the fundal area and soft round mass above the symphysis, the nurse can conclude that the fetal lie is vertical. With the palpation findings of a hard round mass in the fundal area and soft round mass above the symphysis, the nurse can conclude that the fetal position in not transverse. The findings on palpation also indicate that the presentation is not vertex.The attitude is difficult to determine when performing Leopold maneuvers. TEST-TAKING TIP: Many obstetric assessments have a component that is sensual and a component that is an interpretation or concept. Leopold maneuvers are good examples. The nurse palpates specific areas of the pregnant abdomen but then must interpret or translate what he or she is feeling into a concept. For example, in the scenario presented, the nurse palpates a hard round mass in the fundal area of the uterus and must interpret that feeling as the fetal head. Similarly, the nurse palpates a soft round mass above the symphysis and must interpret that feeling as the fetal buttocks. With these findings and interpretations, the nurse will then realize that the fetal lie is vertical.

The nurse is caring for a nulliparous client who attended Lamaze childbirth education classes. Which of the following techniques should the nurse include in her plan of care? Select all that apply. 1. Hypnotic suggestion. 2. Rhythmic chanting. 3. Muscle relaxation. 4. Pelvic rocking. 5. Abdominal massage

3.Muscle relaxation is an integral part of Lamaze childbirth education. 4. Pelvic rocking is taught in Lamaze classes as a way of easing back pain during pregnancy and labor. 5.Abdominal massage, called effleurage, is also an integral part of Lamaze childbirth education Hypnotic suggestion is usually not included in childbirth education based on the Lamaze method. Rhythmic chanting is usually not included in childbirth education based on the Lamaze method. TEST-TAKING TIP: The test taker may have expected to find breathing techniques included in the question related to Lamaze childbirth education. Although breathing techniques are taught, there are a number of other techniques and principles that couples learn in Lamaze classes. The test taker should be familiar with all aspects of childbirth education.

A nurse determines that a client is carrying a fetus in the vertical lie. The nurse's judgment should be questioned if the fetal presenting part is which of the following? 1. Sacrum. 2. Occiput. 3. Mentum. 4. Scapula.

4. A fetus in a scapular presentation is in a horizontal lie. A fetus in a sacral presentation is in a vertical lie. A fetus in an occipital presentation is in a vertical lie. A fetus in a mentum presentation is in a vertical lie. TEST-TAKING TIP: Lie is concerned with the relationship between the fetal spine and the maternal spine. When the spines are parallel, the lie is vertical (or longitudinal). When the spines are perpendicular, the lie is horizontal (or transverse). It is physiologically impossible for a baby in the horizontal lie to be delivered vaginally.

A woman who states that she "thinks" she is in labor enters the labor suite. Which of the following assessments will provide the nurse with the most valuable information regarding the client's labor status? 1. Leopold maneuvers. 2. Fundal contractility. 3. Fetal heart assessment. 4. Vaginal examination.

4. A vaginal examination will provide the nurse with the best information about the status of labor. Leopold maneuvers, although performed on a woman in labor, assess for fetal position, not the progress of labor. Fundal contractility will assess for uterine contractions, but this is not the most valuable information. Assessment of the fetal heart is critically important in relation to fetal well-being, but it will not determine the progress of labor. TEST-TAKING TIP: Each of the assessments listed is performed on a woman who enters the labor suite for assessment. However, the only assessment that will determine whether or not a woman is in true labor is a vaginal examination. Only when there is cervical change—dilation and/or effacement—is it determined that a woman is in true labor.

The nurse documents in a laboring woman's chart that the fetal heart is being "assessed via intermittent auscultation." To be consistent with this statement, the nurse, using a Doppler electrode, should assess the fetal heart at which of the following times? 1. After every contraction. 2. For 10 minutes every half hour. 3. Only during the peak of contractions. 4. For 1 minute immediately after contractions.

4. Intermittent auscultation should be performed for 1 full minute after contractions end The frequency of intermittent auscultation is determined by which stage of labor the woman is in. The frequency of intermittent auscultation is determined by which stage of labor the woman is in. The fetal heart rate should be assessed before, during and after contractions. TEST-TAKING TIP: Although most babies are monitored via electronic fetal monitoring in labor, there is a great deal of evidence to show that intermittent auscultation (AI) is as effective a method of monitoring the fetal heart. When performing AI, it is essential, however, that the fetal heart be monitored using a strict protocol: nurse caring for only one patient at a time who assesses the fetal heart before, during, and for at least 30 to 60 seconds immediately after contractions to monitor for the presence of any late or variable decelerations (see the Guideline for Fetal Heart Monitoring in Labor and Delivery (2012) published by the Northern New England Perinatal Quality Improvement Network)

Upon examination, a nurse notes that a woman is 10 cm dilated, 100% effaced, and −3 station. Which of the following actions should the nurse perform during the next contraction? 1. Encourage the woman to push. 2. Provide firm fundal pressure. 3. Move the client into a squat. 4. Monitor for signs of rectal pressure.

4. Monitoring for rectal pressure is appropriate at this time. This client is fully dilated and effaced, but the baby is not yet engaged. Until the baby descends and stimulates rectal pressure, it is inappropriate for the client to begin to push. Fundal pressure is inappropriate. Many women push in the squatting position, but it is too early to push at this time. TEST-TAKING TIP: Although the test taker may see in practice that women are encouraged to begin to push as soon as they become fully dilated, it is best practice to wait until the woman exhibits signs of rectal pressure. Pushing a baby who is not yet engaged may result in an overly fatigued woman or, more significantly, a prolapsed cord

The nurse sees the fetal head through the vaginal introitus when a woman pushes. The nurse, interpreting this finding, tells the client, "You are pushing very well." In addition, the nurse could also state which of the following? 1. "The baby's head is engaged." 2. "The baby is floating." 3. "The baby is at the ischial spines." 4. "The baby is almost crowning.

4. The baby's head is almost crowning Engagement is equal to 0 station. This fetus well past 0 station. A baby who is floating is in negative station. When the presenting part is at the ischial spines, the baby is engaged or at 0 station. TEST-TAKING TIP: A baby is crowning when the mother's perineal tissues are stretched around the fetal head at the same location where a crown would sit. The station at this time is past +5 station (or 5 cm past the ischial spines).

One hour ago, a multipara was examined with the following results: 8 cm, 50% effaced, and +1 station. She is now pushing with contractions and the fetal head is seen at the vaginal introitus. The nurse concludes that the client is now: 1. 9 cm dilated, 70% effaced, and +2 station. 2. 9 cm dilated, 80% effaced, and +3 station. 3. 10 cm dilated, 90% effaced, and +4 station. 4. 10 cm dilated, 100% effaced, and +5 station.

4. The cervix is fully dilated and fully effaced and the baby is low enough to be seen through the vaginal introitus. This client is still in stage 1 (the cervix is not fully effaced or fully dilated) and the station is high. This client is still in stage 1 (the cervix is not fully effaced or fully dilated) and the station is high.Although this client is fully dilated, the cervix is not fully effaced and the baby has not descended far enough. TEST-TAKING TIP: To answer this question, the test taker must methodically evaluate each of the given responses. Once the nurse determines that a woman is not yet fully dilated or effaced, it can be determined that the woman is still in stage 1 of labor. Choice 3 does show a woman who is fully dilated but who is yet to efface fully and whose baby is still above the vaginal introitus. Only choice 4 meets all criteria set forth in the question.

A nurse describes a client's contraction pattern as: frequency every 3 min and duration 60 sec. Which of the following responses corresponds to this description? 1. Contractions lasting 60 seconds followed by a 1-minute rest period. 2. Contractions lasting 120 seconds followed by a 2-minute rest period. 3. Contractions lasting 2 minutes followed by a 60-second rest period. 4. Contractions lasting 1 minute followed by a 120-second rest period.

4. The frequency and duration of this contraction pattern is every 3 minutes lasting 60 seconds. The frequency and duration of this contraction pattern is every 2 minutes lasting 60 seconds. The frequency and duration of this contraction pattern is every 4 minutes lasting 120 seconds. The frequency and duration of this contraction pattern is every 3 minutes lasting 120 seconds. TEST-TAKING TIP: The test taker must recall that frequency is defined as the time from the beginning of one contraction to the beginning of the next, while duration is defined as the beginning of the increment of a contraction to the end of the decrement. The only choices that include a frequency of 3 minutes are choices 3 and 4. Of these, the only choice with a duration of 60 seconds is choice 4.

A nurse is teaching a class of pregnant couples the most therapeutic Lamaze breathing technique for the latent phase of labor. Which of the following techniques did the nurse teach? 1. Alternately panting and blowing. 2. Rapid, deep breathing. 3. Grunting and pushing with contractions. 4. Slow chest breathing.

4.Most women find slow chest breathing effective during the latent phase. The pant-blow breathing technique is usually used during the transition phase of labor. Rapid, deep breathing is rarely used in labor. Grunting and pushing, characteristic of open glottal pushing, is the method that women instinctively use during the second stage of labor. It is also the safest method of pushing. TEST-TAKING TIP: Because the latent phase is the first phase of the first stage of labor, the contractions are usually mild and they rarely last longer than 30 seconds. A slow chest breathing technique, therefore, is effective and does not tire the woman out for the remainder of her labor. It is important to note that couples who have learned the Bradley method of childbirthing are encouraged to perform relaxed breathing throughout their labors.

A woman, 40 weeks' gestation, calls the labor unit to see whether or not she should go to the hospital to be evaluated. Which of the following statements by the woman indicates that she is probably in labor and should proceed to the hospital? 1. "The contractions are 5 to 20 minutes apart." 2. "I saw a pink discharge on the toilet tissue when I went to the bathroom." 3. "I have had cramping for the past 3 or 4 hours." 4. "The contractions are about a minute long and I am unable to talk through them."

4.This client is exhibiting clear signs of true labor. Not only are the contractions lasting a full minute but she is stating that they are so uncomfortable that she is unable to speak through them. She should be seen. This client may be in the latent phase of labor or may be experiencing false labor contractions. Either way, unless she is having other symptoms, there is no need to be seen by a healthcare practitioner. This client is having some bloody show with the expulsion of the mucous plug, but pink streaks are normal and can be seen hours to a few days before true labor begins. This client may be in the latent phase of labor, but there is no need to go to the hospital with "cramping." TEST-TAKING TIP: Nurses interpret the comments made by gravid women who are close to term. Clients, especially primiparas, are often anxious about the labor process and have difficulty interpreting what they are feeling. Only when the woman is experiencing contractions that are increasing in intensity and duration and decreasing in frequency, or when the woman has ruptured membranes, should she be encouraged to go to the hospital for an evaluation.

A woman, G2 P0101, 5 cm dilated, and 30% effaced, is doing first-level Lamaze breathing with contractions. The nurse detects that the woman's shoulder and face muscles are beginning to tense during the contractions. Which of the following interventions should the nurse perform first? 1. Encourage the woman to have an epidural. 2. Encourage the woman to accept intravenous analgesia. 3. Encourage the woman to change her position. 4. Encourage the woman to perform the next level breathing

4.This woman is in the active phase of labor. The first phase breathing is probably no longer effective. Encouraging her to shift to the next level of breathing is appropriate at this time. It is inappropriate to encourage her to have an epidural at this time. It is inappropriate to encourage her to have an IV analgesic at this time. A change of position might help but will probably not be completely effective. TEST-TAKING TIP: If a woman has learned Lamaze breathing, it is important to support her actions. Encouraging her to take pain-relieving medications may undermine her resolve and make her feel like she has failed. The initial response by the nurse should be to support her by encouraging her to use her breathing techniques.

The nurse enters a laboring client's room. The client is complaining of intense back pain with each contraction. The nurse concludes that the fetus is likely in which of the following positions? 1. Mentum anterior. 2. Sacrum posterior. 3. Occiput posterior. 4. Scapula anterior.

A fetus in the mentum anterior position is unlikely to elicit severe back pain in the mother. A fetus in the sacral posterior position is unlikely to elicit severe back pain in the mother. When a fetus is in the occiput posterior position, mothers frequently complain of severe back pain. A fetus in the scapula anterior position is unlikely to elicit severe back pain in the mother. TEST-TAKING TIP: If the test taker were to view a picture of a baby in the occiput posterior position, he or she would note that the occiput of the baby lies adjacent to the coccyx of the mother. During each contraction, the occiput, therefore, is forced backward into the coccyx. This action is very painful.

A client who uses extended-wear contact lenses should be taught measures for reducing the risk of which of the following conditions? A) Conjunctivitis B) Cataracts C) Glaucoma D) Macular degeneration

A) Individuals who use extended-wear contact lenses are at higher risk of developing conjunctivitis. Therefore, client teaching should include prevention of eye infections. These individuals are not at specific risk for other types of eye conditions, such as cataracts, glaucoma, or macular degeneration.

The nurse is caring for a premature infant diagnosed with patent ductus arteriosus (PDA). Which medication should the nurse anticipate administering to this client? A) Indomethacin B) Propranolol C) Antibiotics D) Prostaglandin E1

A) Intravenous indomethacin often stimulates the closure of the PDA in premature infants. Prophylactic antibiotics are used in some clients with a congenital heart defect, but this is not common for infants with PDA. Propranolol is used to treat tetralogy of Fallot. Prostaglandin E1 is used with some congenital heart defects to maintain a PDA, not help close the PDA.

The mother of a baby born with a congenital heart defect is upset, as no one else in the family has been born with this condition. To determine the cause of the defect, which question is appropriate for the nurse to ask the mother? A) "Did you consume any alcohol before you knew you were pregnant?" B) "Is there a history of diabetes in your family?" C) "Was the baby's father exposed to any toxins in the work environment?" D) "Do you have a history of hypertension?"

A) Most congenital heart defects occur during the first 8 weeks of pregnancy and are a combination of environmental and genetic factors. Fetal exposure to alcohol is one of the greatest factors for the development of these defects. Asking the mother if she consumed alcohol before she was aware that she was pregnant is an appropriate question when determining the cause of the heart defect. A history of hypertension will not cause a fetus to develop a congenital heart defect. The father's exposure to toxins in the work environment is not known to cause congenital heart defects of children. Maternal diabetes can impair fetal heart development, but a family history of diabetes is not known to cause congenital heart defects.

The nurse is planning care for a pediatric client recovering from surgery to repair a congenital heart defect. Which intervention should the nurse include to support the client's fluid status? A) Encourage oral intake of fluids when permitted. B) Limit oral and intravenous intake of fluids. C) Continue normal saline administration even after oral intake is normal. D) Convert the intravenous line to a saline lock immediately after surgery.

A) The child should be encouraged to begin oral fluids and nutrition when permitted. Although oral fluids are rarely limited, intake and output should be carefully assessed. Fluids and antibiotics should be provided as ordered until the child's oral intake is normal. Once normal, the line can be converted to a heparin or saline lock.

The laboring client's fetal heart rate baseline is 120 beats per minute (bpm). Accelerations are present to 135 bpm. During contractions, the fetal heart rate gradually slows to 110 bpm and is at 120 bpm by the end of the contraction. Which nursing action is appropriate? A) Documenting the fetal heart rate B) Preparing for imminent delivery C) Applying oxygen via mask at 10 liters per minute D) Assisting the client into the Fowler position

A) The described fetal heart rate has a normal baseline, the presence of accelerations indicates adequate fetal oxygenation, and early decelerations are normal. No intervention is necessary. The fetal heart rate tracing is normal; oxygen is not indicated. There is no indication that delivery will be occurring soon. The client does not need to be assisted into the Fowler position.

The client with diabetes mellitus reports having difficulty trimming the toenails because they are thick and ingrown. What should the nurse recommend to this client? A) Make an appointment with a podiatrist. B) Offer to file the tops of the nails to reduce thickness after cutting. C) Cut the nails straight across with a clipper after the bath. D) Make an appointment with a nail shop for a pedicure.

A) The toenails of the client with diabetes require close care. If the nails are thick or ingrown, they require the attention of a podiatrist. Cutting the nails across after the bath is correct for toenails that do not demonstrate the complications listed. The client with diabetes is at an increased risk for infection and should avoid situations in which this risk is increased, such as the nail shop pedicure. The nurse should not file the client's toenails to reduce thickness.

A pregnant client presents to the emergency department reporting that she has started labor and is certain the baby is coming "any minute now." After assessing and monitoring the client, the healthcare team determines that the client is in "false" labor, and the nurse prepares her for discharge. Which observations support the conclusion of false labor? Select all that apply. A) The contractions do not have a regular pattern. B) Her cervix has dilated 2 cm over the 2 hours of observation. C) The frequency and intensity of the contractions have stayed about the same. D) Walking seems to increase the strength of the contractions. E) The contractions are mostly in her abdomen.

A, C, E) Signs and symptoms of "false" labor, in contrast to "true" labor, include a pattern of irregular contractions that do not increase in frequency or intensity, a lack of cervical dilation and effacement, discomfort that is felt mostly in the abdomen rather than in the back and radiating to the front, and the fact that activity does not increase contraction intensity.

A woman has just arrived at the labor and delivery suite. To report the client's status to her primary healthcare practitioner, which of the following assessments should the nurse perform? Select all that apply. 1. Fetal heart rate. 2. Contraction pattern. 3. Urinalysis. 4. Vital signs. 5. Biophysical profile.

1, 2 ,4 1.The nurse should assess the fetal heart before reporting the client's status to the healthcare provider. 2. The nurse should assess the contraction pattern before reporting the client's status. 3. A complete urinalysis would likely be ordered by the primary healthcare practitioner once the client has been officially admitted, but the test would not be performed during the initial assessment process. 4.The nurse should assess the woman's vital signs before reporting her status. TEST-TAKING TIP: The fetal heart, contraction pattern, and maternal vitals all should be assessed to provide the healthcare practitioner with a picture of the health status of the mother and fetus. In some institutions, the nurse may also do a vaginal examination to assess for cervical change

The nurse is providing care to a client who is receiving treatment for diabetic ketoacidosis (DKA). Which possible pathophysiologic cause should the nurse identify for the altered metabolism the client is experiencing? A) Insulin deficiency B) Decreased gluconeogenesis C) Excess production of bicarbonate D) Hypo-osmolarity

A) A client who is diagnosed with DKA will experience alterations in metabolism due to an insulin deficiency. Within the pathophysiology of diabetic ketoacidosis, the client will experience increased gluconeogenesis, a loss of bicarbonate, and hyperosmolarity.

The nurse is caring for an infant diagnosed with hypoplastic left heart syndrome. The client has recently been scheduled for surgery to repair the defect. Which procedure does the nurse anticipate needing to provide client teaching about to the client's family? A) Norwood procedure B) Jatene procedure C) Rastelli procedure D) Damus-Kaye-Stansel procedure

A) Hypoplastic left heart syndrome is repaired using the Norwood, Glenn, and Fontan procedures, depending on the child's age. The Jatene procedure and the Damus-Kaye-Stansel procedure surgically repair the Transposition of Great Arteries (TGA). The Rastelli procedure is used to repair TGA with ventricular septal defect and pulmonary stenosis.

During what period of gestation do congenital heart defects usually develop? A) First 8 weeks of gestation B) Second trimester C) Third trimester D) Last 4 weeks of gestation

A) Most congenital heart defects develop during the first 8 weeks of gestation. They are usually the result of combined genetic and environmental factors.

When planning care for a client with trachoma, which potential complication should the nurse consider? A) Scarring of the cornea B) Eye muscle weakness C) Damaged iris D) Retinal detachment

A) Trachoma is a chronic form of conjunctivitis that causes the formation of granulation tissue that is abraded by the lashes, leading to scarring of the cornea and eventual blindness. The other options are not potential complications to this type of conjunctivitis.

The nurse is assessing a toddler diagnosed with tetralogy of Fallot (TOF). Which clinical manifestations does the nurse anticipate during the physical assessment? Select all that apply. A) Palpable thrill in the pulmonic area B) Nail clubbing C) Cough D) Apneic periods E) Knee-chest position

A, B, E) Manifestations of TOF include a palpable thrill in the pulmonic area, clubbing of the fingers due to reduce oxygenation, and the knee-chest position, which the child will perform to decrease the return of systemic venous blood to the heart. A cough and apneic periods are not manifestations of this congenital heart defect.

The nurse is providing care for a pediatric client with bacterial conjunctivitis. Which interventions should the nurse use as part of the collaborative management of the client? Select all that apply. A) Recommending dark sunglasses B) Recommending removing contacts at night C) Contacting the client's school nurse D) Performing careful hand hygiene E) Administering antiviral therapy

A, C, D) Dark glasses will help to reduce the photophobia that many clients with conjunctivitis experience. It is often appropriate for the nurse to contact the client's school nurse to discuss increased prevention and student education. Careful hand hygiene is a standard method for managing the client with conjunctivitis. Antibiotics, not antiviral medications, are prescribed with conjunctivitis. Contacts should not be worn during conjunctivitis.

A pregnant woman at 41 weeks' gestation has a Bishop score of 5. What does this score indicate? A) The cervix is favorable for a normal vaginal delivery. B) The cervix is unfavorable and induction of labor may be necessary. C) The cervix is unfavorable and a cesarean section may be necessary. D) The cervix is favorable and labor has been successfully induced.

B) A Bishop score less than 6 indicates that the cervix is unfavorable. When a pregnant woman at or near term has an unfavorable cervix, induction of labor may be necessary for medical or obstetric reasons. A Bishop score less than 6 does not indicate that a cesarean section may be necessary.

Which instruction should the nurse provide to an adolescent client with otitis media with regard to pain? A) Apply a cold compress to the affected ear. B) Report abrupt relief of pain immediately. C) Continue plans for air travel. D) Report increased pain when moving the outer ear.

B) Abrupt relief of pain may mean that the tympanic membrane has perforated. Heat should be applied to dilate surrounding blood vessels and decrease swelling. The pain of otitis media is not aggravated by movement of the external ear. Drastic changes in barometric pressure can increase pain considerably, so clients are discouraged from traveling by air.

A labor and delivery nurse is providing care for a neonate in the first few minutes after birth. One action the nurse will take to promote eye health and prevent conjunctivitis in the infant is administration of A) oral tetracycline. B) erythromycin as an eye ointment. C) ceftriaxone as an eye drop. D) parenteral acyclovir.

B) Prevention of conjunctivitis in a newborn is provided by the administration of an antibiotic eye ointment, usually erythromycin. Tetracycline may be used instead of erythromycin immediately after birth, but it will be used as an eye ointment, not as an oral formulation. Ceftriaxone is only administered for a confirmed case of gonococcal conjunctivitis. Parenteral acyclovir is only administered for a confirmed case of conjunctivitis due to herpes simplex virus.

The nurse is finalizing a plan of care for a school-age client newly diagnosed with type 1 diabetes mellitus. Which areas should the plan prioritize to achieve the maximum outcomes for this client? Select all that apply. A) Ways to minimize the number of school days missed B) Identification and referral to community resources C) Physical activities that limit exposure to injuries D) Self-management of glucose monitoring and medications E) Signs and symptoms of hypoglycemia and actions to take

B, d, e) Planning should prepare the child and the family for self-management of glucose monitoring and medications, signs and symptoms of hypoglycemia, and actions to take. Before discharge, the child and the family should be linked to the resources in the community that will support care of the child with diabetes. Minimizing the number of school days missed and activities that limit exposure to injuries are not immediate priorities for this client's plan.

The nurse is caring for a child who has just been diagnosed with an atrial septal defect (ASD). Which manifestations would the nurse expect upon assessment? Select all that apply. A) Pulmonary artery hypotension B) Midsystolic murmur at lower right sternal border C) Mitral valve regurgitation with cleft on mitral valve D) S1 heart tone may be split due to forceful left ventricular contraction E) Congestive heart failure

C, E) ASD occurs when there is an opening in the atrial septum, permitting left-to-right shunting of blood. Midsystolic murmur may be auscultated at the lower left sternal border due to increased blood flow across the tricuspid valve. Mitral valve regurgitation may occur with a cleft on the mitral valve. S1 heart tones may be split due to forceful right ventricular contraction. Finally, pulmonary artery hypertension and congestive heart failure may occur.

A client newly diagnosed with type 1 diabetes mellitus tells the nurse that the diagnosis must be wrong because the client is not overweight, eats all of the time, and is thin. Which response by the nurse is most appropriate? A) "Thin people can be diabetic, too." B) "Your condition makes it impossible for you to gain weight." C) "Your lab tests indicate the presence of diabetes." D) "You are eating large quantities because your condition makes it difficult for your body to obtain energy from the foods taken in."

D) The diabetic client is unable to obtain the needed glucose for the body's cells due to the lack of insulin. Patients diagnosed with type 1 diabetes mellitus experience polyphagia and are often thin. While the statement about diabetics being thin is correct, it does not answer the client. It is not impossible for diabetics to gain weight. Although the laboratory tests might indicate the presence of diabetes, this does not meet the client's needs for teaching.

The nurse is preparing to teach a client who is newly diagnosed with type 1 diabetes mellitus on the preferred area to self-inject insulin. On which area should the nurse focus, based on insulin absorption rates? A) Deltoid B) Thigh C) Hip D) Abdomen

D) The rate of absorption and peak of action of insulin differ according to the site. The site that allows the most rapid absorption is the abdomen, followed by the deltoid muscle, then the thigh, and then the hip. Because of the rapid absorption, the abdomen is the recommended site.