Practice Questions 2:
Which information would the nurse include as part of the teaching plan for an anxious client about to have her first routine Papanicolaou (Pap) smear? - past statistics on the incidence of cervical cancer - description of the early symptoms of cervical cancer - explanation of why there is a small risk for cervical cancer - information on how a Pap smear screens for precancerous and cancerous cells of the cervix
- information on how a Pap smear screens for precancerous and cancerous cells of the cervix rationale: Providing verbal information about what a Pap smear is used for decreases fear and fosters further communication. Current, not past statistics on the incidence of cervical cancer should be used. Cervical cancer is asymptomatic in the early stages. Explanation of why there is a small risk for cervical cancer offers false reassurance.
A client has just given birth to an infant with Down syndrome. The mother is crying and asks the nurse what she is supposed to do now. Which response would the nurse give? - "tell me what you know about Down syndrome" - I would just continue to rest and recover from your delivery" - "You really need to pull yourself together for your baby" - "Should I call in a chaplain or social worker for you?"
- "tell me what you know about Down syndrome" rationale: Asking the client what she knows about Down syndrome is an open-ended question that will facilitate teaching and open dialogue. Telling the client to just recover is not addressing the client's emotional adjustment. Chastising the client for emotional expression will block further dialogue. A chaplain or social worker is not needed at this moment but could potentially be used later.
Which nursing intervention is the priority during the first 2 hours after a cesarean birth? - evaluating fluid needs to maintain optimum hydration - monitoring the incision to help prevent the onset of infection - encouraging bonding to promote mother-infant interaction - assessing the lochia to identify the complication of hemorrhage
- assessing the lochia to identify the complication of hemorrhage rationale: The amount and character of the lochia must be checked after a cesarean birth just as they are after a vaginal birth. Although it is important to maintain hydration, preventing hemorrhage is the priority. Although the area of the incision is monitored, it is too early for evidence of infection. Encouraging bonding is very important, but the mother's health and safety would be the priority.
A client at 36 weeks' gestation presents with severe abdominal pain, heavy vaginal bleeding, a drop in blood pressure, and an increased pulse rate. Which complication of pregnancy is suggested by these signs and symptoms? - Hydatidiform mole - vena cava syndrome - marginal placenta previa - complete abruptio placentae
- complete abruptio placentae rationale: Severe pain accompanied by bleeding at term or close to it is symptomatic of complete premature detachment of the placenta (abruptio placentae). A hydatidiform mole is diagnosed before 36 weeks' gestation; it is not accompanied by severe pain. There is no bleeding with vena cava syndrome. Bleeding caused by placenta previa should not be painful.
A client who recently gave birth is transferred to the postpartum unit by the nurse. Which nursing action would the nurse perform to prevent a charge of client abandonment? - assess the client's condition - document the client's condition and the transfer - orient the client to the room and explain unit routines - report the clients condition to the responsible staff member assuming her care
- report the client's condition to the responsible staff member assuming her care rationale: Because the nurse is responsible for the client's care until another nurse assumes that responsibility, the nurse would report directly to the client's primary nurse. Safe handoffs of clients at the time of transfer are an essential element of client safety. Making an assessment of the client's condition is not enough. Although documentation is important, it is insufficient. Orienting the client to the room and explaining unit routines is insufficient. Although the nurse would carry out these activities, the safe handoff of client care is the essential action at this time.
While teaching a new mother ways to decrease the risk of infection for the newborn, which type of immunity would the nurse explain was transferred to her baby through the placenta? - active natural - passive natural - active artificial - passive artificial
-passive natural rationale: Passive natural immunity is developed from an antigen-antibody response in the mother that is transmitted to the fetus. Active natural immunity is acquired by an individual in response to a disease or an infection. Active artificial immunity is acquired by an individual in response to small amounts of antigenic material (e.g., vaccination). Passive artificial immunity is conferred by the injection of antibodies prepared in another host.
Which nursing action would the nurse perform to enhance the beginning of the mother-infant relationship? - suggesting that the mother choose breast-feeding instead of formula-feeding - advising the mother to engage in rooming-in with the newborn at the bedside - encouraging the mother to help out with simple aspects of her newborn's care - observing the mother-infant interaction unobtrusively to evaluate the relationship
- encouraging the mother to heliport with simple aspects her newborn's care rationale: Holding, touching, and interacting with the newborn while providing basic care promotes attachment. The nurse's infant feeding preference should not be forced upon the mother. Although rooming-in helps promote attachment, not all women have the physical or emotional ability to provide 24-hour care to the newborn so early in the postpartum period. Early observation is not adequate; full evaluation of the relationship can be achieved only by allowing the mother ample time to interact with her baby.
A plan of care is created for a term small-for-gestational-age (SGA) neonate who has been admitted to the neonatal intensive care unit (NICU). The newborn did not reach the goal for weight gain for a specified date. Which would the next step be in care planning for this infant? - increase the daily number of calories - change the goal to a more realistic number - evaluate the problem before altering the plan - postpone the evaluation date after another month
- evaluate the problem before altering the plan rationale: Before further intervention is undertaken, the reason for the inadequate weight gain should be evaluated. Evaluation should take place before the plan is changed or the goal altered to identify any barriers to achieving the goal. Increasing the daily number of calories or changing the goal to a more realistic number is premature. Postponing the evaluation date for another month is unsafe; the reason for the lack of goal attainment must be identified.
Which is the initial nursing action when a multipara requests something for pain? - examining the clients cervix for dilation and effacement - determining the clients options by assessing the prescriptions in the chart - asking her whether she prefers an epidural or something in her intravenous line - evaluating the fetal monitoring strip to determine the frequency and duration of contractions
- examining the client's cervix for dilation and effacement rationale: Evaluating the client's cervical dilation and effacement determines her progress in labor and reveals whether it is safe to administer analgesia or anesthesia. Assessment is the initial step of the nursing process. Options for pain management would be determined after dilation has been assessed. The client may be asked about her preferred method of analgesia, but that should be done after her degree of dilation has been determined. The stem of the question indicated that the client is in active labor; information on the fetal monitoring strip regarding contractions will not add to the assessment data.
A client at 7 weeks' gestation tells the nurse in the prenatal clinic that she has been bothered by episodes of nausea throughout the day. Which interventions would the nurse recommend? Select all that apply. One, some, or all responses may be correct. - focus on and repeat a rhythmic chant - sit upright for 30 minutes after meals - take low-sodium antacids after meals - drink carbonated beverages with meals - eat small, frequent meals and eat dry crackers in between
- focus on and repeat a rhythmic chant - eat small, frequent meals and eat dry crackers in-between rationale: Focusing helps mitigate odors, tastes, and thoughts that may cause nausea. Avoiding an empty stomach decreases the occurrence of nausea associated with pregnancy. Sitting upright after meals will help ease heartburn but will have little effect on nausea. Prescribed low-sodium antacids may be taken between meals later in pregnancy to promote relief from heartburn. Carbonated beverages may or may not help; however, women should be advised to consume fluids between, not with, meals.
Which behavior would the nurse assess first when evaluating mother-infant attachment? - mother-infant interaction - mother-father interaction - the infant's wake and sleep cycles - the mother's ability to care for infant
- mother-infant interaction rationale: The extent and quality of the mother-infant interaction is believed to be a predictor of positive or negative attachment behavior. Mother-father interaction, the infant's wake and sleep cycles, and the mother's ability to care for her infant are also assessed but are not as significant as mother-infant interaction.
Which clinical finding would the nurse evaluate before continuing the administration of intravenous (IV) magnesium sulfate therapy? - temperature and respirations - patellar reflexes and urinary output - urinary glucose and specific gravity - level of consciousness and funduscopic appearance
- patellar reflexes and urinary output rationale: Adequate urinary output, an indicator of effective renal function, is necessary to prevent toxicity, because magnesium sulfate is excreted by the kidneys. Signs of magnesium sulfate toxicity include an absence of patellar reflexes and slowed respiration; therefore, these assessments are essential. Although slowed respiration may indicate magnesium sulfate toxicity, deviations in temperature are not relevant. Urinary glucose and specific gravity are urine tests; they are not relevant to magnesium sulfate therapy. The client's level of consciousness and funduscopic appearance are assessments that may indicate worsening preeclampsia; they are not determinants of the response to magnesium sulfate therapy.