2023 - MOD 1 - HESI-SAUNDERS
A nurse notes documentation in the medical record that a woman in labor is at +1 station. Based on this finding, what does the nurse determine is the presenting part of the fetus? 1 cm below the ischial spines 1 cm above the ischial spines At the level of the ischial spines Above the level of the ischial spines
1 cm below the ischial spines RATIONALE: Station is the relationship of the presenting part of the fetus to an imaginary line drawn between the maternal ischial spines. It is a measure of the degree of descent of the presenting part of the fetus through the birth canal. Station is expressed in centimeters above or below the spines. When the presenting part is 1 cm below the ischial spines, the station is noted as +1. When the presenting part is 1 cm above the ischial spines, the station is noted as -1. When the presenting part is at the level of the ischial spines, the station is noted as zero.
A non-stress test is performed on a pregnant woman, and the woman is told by the obstetrician that the results are nonreactive. Based on this test result, what determination does the nurse make? Fetal well-being has been established. A contraction stress test will be scheduled. Placental function and oxygenation are adequate. The results are inadequate and the non-stress test must be repeated.
A contraction stress test will be scheduled. RATIONALE: A nonreactive stress test indicates a nonreassuring or abnormal finding. A contraction stress test may be performed if non stress test findings are nonreactive. The contraction stress test records the response of the fetal heart rate to stress induced by uterine contractions, identifying the fetus whose oxygen reserves are insufficient to tolerate the recurrent mild hypoxia of uterine contractions. On the basis of the data in the question, the other options are incorrect.
A sexually active single female client is discussing methods of contraception with the family planning nurse. The client tells the nurse that her primary concern is avoiding contracting sexually transmitted infections (STIs). In responding to the client, which method of protection does the nurse say provides the best protection against many STIs? A diaphragm A cervical cap A latex condom An intrauterine device (IUD)
A latex condom RATIONALE: Latex condoms provide the best protection available (other than abstinence) against many STIs. A diaphragm and a cervical cap provide a mechanical barrier to prevent the passage of sperm into the uterus but do not provide protection against STIs. An IUD, which is inserted into the uterus, provides no protection against STIs.
Which priority action would the nurse take after attaching an external electronic fetal monitor to a pregnant client? Checking the fetal heart rate Discussing the labor process with the client Assessing the frequency of the contractions Documenting the time that the monitor was attached
Checking the fetal heart rate RATIONALE: Assessing the fetal heart rate is the priority action after an electronic fetal monitor is attached to a pregnant client. Although assessment of the frequency of contractions is important, it is not the priority. Likewise, documenting and discussing the labor process with the client are components of the plan of care but are not the priority.
A nurse monitoring the fetal heart rate (FHR) pattern of a woman in the first stage of labor whose cervix is dilated 6 cm notes the presence of early decelerations. Based on this finding, what action should the nurse take? Contacting the nurse-midwife Continuing to monitor the FHR pattern Administering oxygen at 10 L by face mask Preparing the woman for immediate delivery
Continuing to monitor the FHR pattern RATIONALE: Early deceleration of FHR is a visually apparent gradual decrease and return to baseline FHR that occurs in response to fetal head compression during a contraction. It is a normal and benign finding, and therefore no intervention is necessary.
A client attending prenatal birthing class asks the nurse how long it takes for an egg to implant in the uterus once it has been fertilized. Which response should the nurse give? 4 days 10 days 14 days 21 days
10 days RATIONALE: Fertilization occurs when one spermatozoon enters the ovum and the two nuclei containing the parents' chromosomes merge. Once the ovum is fertilized, implantation gradually occurs from the sixth through the 10th day. Implantation is complete on the 10th day.
A middle-aged couple comes to the family planning center to discuss methods of contraception and asks about sterilization. As a means of determining whether this method of sterilization is appropriate, which question should the nurse ask the couple? "Has either of you ever had surgery?" "Do you plan to have any other children?" "Does either of you have diabetes mellitus?" "Does either of you have problems with high blood pressure?"
"Do you plan to have any other children?" RATIONALE: Sterilization is a method of contraception for couples who have completed their families. It should always be considered a permanent end to fertility, because reversal surgery is difficult and expensive and may not be covered by insurance. Additionally, reversal surgery is not always successful, and it increases the risk of ectopic pregnancy. Therefore the nurse would ask the couple about plans for having children in the future to help determine the correct method of contraception. The assessment questions noted in the other options may be appropriate to ask a client who may be undergoing surgery, but they are not specifically related to sterilization.
Which statements by Joanna reflect a need for further information? "He's too young to get cavities." "I will use the car seat every time we drive somewhere." "He will probably swallow gum instead of just chewing it." "He can eat most foods as long as I cut them into round pieces." "I will apply sunscreen if we are outside for more than an hour." "We need to make sure that our cleaning supplies are in a locked cabinet."
"He's too young to get cavities." "He can eat most foods as long as I cut them into round pieces." "I will apply sunscreen if we are outside for more than an hour." RATIONALE: Cavities can occur in teeth of a person of any age, and parents of toddlers should be taught how to care for a toddler's teeth, and be provided with information about foods that are highly likely to cause cavities. Toddlers are at a very high risk for poisoning, and a major cause is improper storage of harmful items. Therefore, locking cleaning supplies and other toxic items is essential, along with constant vigilance in supervising the toddler. Toddlers can chew, but may have problems with large pieces of food. Food should be cut into small pieces; round pieces may be easily aspirated and are choking hazards. It takes practice for a toddler to learn how to chew gum, but not to swallow it. Sunscreen should be applied before any exposure to sunlight. Parents should always use a care safety seat, even if the trip is short.
A nurse provides information to a female client about the use of a diaphragm. Which statement by the client indicates a need for further information? "I need to use spermicidal cream with the diaphragm." "I shouldn't leave the diaphragm in for more than 24 hours." "I have to insert the diaphragm immediately before intercourse." "The diaphragm should stay in place for at least 6 hours after intercourse."
"I have to insert the diaphragm immediately before intercourse." RATIONALE: When in place over the cervical os, the diaphragm blocks access of sperm to the cervix. Because the device does not fit tightly enough to completely block penetration of sperm, however, it must be filled with spermicidal jelly or cream before insertion. (Spermicide must be reapplied with repeated intercourse.) It may be inserted as long as 6 hours before intercourse. The diaphragm must remain in place for at least 6 hours after intercourse, but, because of the risk of toxic shock syndrome, it should not be left in place for more than 24 hours.
The nurse is assessing Mrs. Valenti's nutritional status. Which statements by Mrs. Valenti indicate a risk for malnutrition? Select all that apply. "Sometimes I have to make myself eat." "My weight stays about the same each week." "Food just doesn't taste the same as it used to." "I have to wear my dentures to chew my food." "Sometimes I have trouble swallowing my food." "I try to eat fruits and vegetables with each meal."
"Sometimes I have to make myself eat." "Food just doesn't taste the same as it used to." "Sometimes I have trouble swallowing my food." RATIONALE: Several factors including dysphagia, decreased enjoyment of food because of a diminished sense of taste, and a lower motivation to eat may increase the risk of malnutrition in an older adult. Many older adults require dentures to eat, but this is only a problem if they are ill fitting. A stable weight and consumption of several servings of fruits and vegetables every day are signs/symptoms of good nutrition.
A nurse is planning to determine the presentation and position of the fetus, using the Leopold maneuvers. Prioritize and number the nursing actions in the order in which they would be performed. (The number 1 would indicate the first action and the number 6 represents the last action.) Explain the procedure to the woman. Ask the woman to empty her bladder. Wash hands and don gloves. Palpate the uterine fundus to determine the fetal part felt. Palpate the sides of the uterus to determine the location of the fetal back. Palpate the suprapubic area to determine whether the presenting part is engaged.
1 - Explain the procedure to the woman. 2 - Ask the woman to empty her bladder. 3 - Wash hands and don gloves. 4 - Palpate the uterine fundus to determine the fetal part felt. 5 - Palpate the sides of the uterus to determine the location of the fetal back. 6 - Palpate the suprapubic area to determine whether the presenting part is engaged. RATIONALE: The Leopold maneuvers are performed to determine the presentation and position of the fetus and to aid in the location of fetal heart sounds. The nurse first explains the procedure to the woman and then asks her to empty her bladder. Once this has been done, the nurse washes his or her hands, dons gloves, and positions the woman on her back, with her knees flexed slightly and a small pillow or folded towel under one hip. The nurse then begins the maneuvers. The first maneuver involves palpating the uterine fundus to determine the fetal part felt. The second maneuver involves palpating the sides of the uterus to determine the location of the fetal back. In the third, the nurse palpates the suprapubic area to determine whether the presenting part is engaged. The fourth maneuver, performed only in cephalic presentations, is done to determine whether the fetal head is flexed.
Mrs. Frances Valenti, 85 years old, lives in a residential home for older adults. She visits the clinic and tells the nurse that she is having persistent diarrhea. During the physical assessment, the nurse notes that Mrs. Valenti appears weak when walking, that she is intermittently confused, and that her skin is dry. Her temperature is 101° F; 38.3° C, her apical pulse is 92 beats/min and irregular, her respiratory rate is 28 breaths/min, and her blood pressure is 108/70 mm Hg. Mrs. Valenti tells the nurse that she has been able to eat and drink small amounts but that the diarrhea will not stop. The nurse suspects that Mrs. Valenti is dehydrated. The nurse developing a plan of care for Mrs. Valenti will prioritize the following concerns from the highest priority (1) to the lowest (4). Loss of fluid volume Potentially damaged skin Possible injury Confusion
1 Loss of fluid volume 2 Confusion 3 Possible injury 4 Potentially damaged skin RATIONALE: The most appropriate (highest priority) concern for the client who is dehydrated is loss of fluid volume. Possible injury and confusion compete for second priority. Because confusion is an actual client problem and could place the client at risk for an injury, confusion is the second priority and possible injury is the third priority. The possibility of damaged skin is the fourth priority.
A pediatric nurse is developing nursing care plans on the basis of Erik Erikson's stages of psychosocial development. Using Erikson's stages of psychosocial development, number the psychosocial crises in order of occurrence on the basis of developmental stage, from birth (1) to 20 years of age (5). Trust versus mistrust Autonomy versus shame and doubt Initiative versus guilt Industry versus inferiority Identity versus role confusion
1 Trust versus mistrust 2 Autonomy versus shame and doubt 3 Initiative versus guilt 4 Industry versus inferiority 5 Identity versus role confusion RATIONALE: Erikson describes the human life cycle as a series of eight ego-developmental stages, from birth to death. Each stage presents a psychosocial crisis and focuses on psychosocial tasks that are accomplished. These orderly stages and associated psychosocial crises are: trust vs. mistrust (infancy), autonomy versus shame and doubt (toddler), initiative versus guilt (preschooler), industry vs. inferiority (school-age), and identity versus role confusion (adolescent). Erikson also identifies intimacy versus isolation for early adulthood, generativity versus stagnation for middle adulthood, and integrity versus despair for later adulthood (older adult).
Penny Martin, age 29, has been admitted to the birthing center with contractions, which, she reports, have been 3 minutes apart and regular for 2 hours. This is the first pregnancy for Penny and her husband, Gilbert, and they tell the nurse that they have eagerly looked forward to the baby's arrival after 4 years of trying to conceive. Examination reveals that Penny is 100% effaced and dilated to 4 cm. The membranes are bulging but intact. Penny exclaims, "I can't wait to get this over with! We've looked forward to this for so long!" Her vital signs: blood pressure 122/78 mm Hg; pulse 78 beats/min, respirations (between contractions) 16 breaths/min, temperature 98.2° F (36.8° C). Penny is admitted to the labor room in the first stage of labor. Which breathing pattern should the labor room nurse teach Gilbert so that he may coach Penny? Pushing in short bursts when the urge is very strong Exhaling small amounts of air through an open glottis during pushing A deep inspiration and expiration at the beginning and end of each contraction Taking a cleansing breath at the beginning of a contraction, holding her breath, then pushing as hard as she can for as long as possible
A deep inspiration and expiration at the beginning and end of each contraction RATIONALE: Breathing exercises provide a focus during contractions, interfering with the transmission of pain sensation. During the first stage of labor, the client uses cleansing breaths (a deep inspiration and expiration at the beginning and end of each contraction), slow-paced breathing, modified-paced breathing, pattern-paced breathing, and breathing to prevent pushing. If the woman pushes strenuously before the cervix is completely dilated, she risks injury to the cervix and fetal head.
Joanna Burns has brought her 2-year-old son, Joel, to the well-baby clinic for a scheduled visit. She expresses concern to the nurse about her son's behavior, telling the nurse that she has a great deal of difficulty getting Joel to bed at night. Joel throws temper tantrums to postpone the event, she reports. Joanna also tells the nurse that because of this behavior she is worried about being able to toilet-train Joel. Joanna asks the nurse about strategies to deal with Joel's behavior. Joanna asks the nurse about toilet-training Joel. She is not sure whether he is ready and anticipates that he will throw temper tantrums if she begins to toilet-train him. The nurse tells Joanna to watch for certain signs of readiness to toilet-train. What are they? Select all that apply. Ability to remove clothing Refusal to sit on the toilet Impatience with a wet or soiled diaper. An increased number of wet diapers during the day A dry diaper when the child wakes from a nap
Ability to remove clothing Impatience with a wet or soiled diaper. A dry diaper when the child wakes from a nap RATIONALE: Signs of readiness for toilet training include the ability to stay dry for 2 hours; waking dry from a nap; the ability to sit, squat, and walk; the ability to remove clothing; the ability to recognize the urge to defecate or urinate; the ability to sit on the toilet for 5 to 10 minutes without fussing or getting off; impatience with a wet or soiled diaper; and willingness to please the parent.
Mrs. Frances Valenti, 85 years old, lives in a residential home for older adults. She visits the clinic and tells the nurse that she is having persistent diarrhea. During the physical assessment, the nurse notes that Mrs. Valenti appears weak when walking, that she is intermittently confused, and that her skin is dry. Her temperature is 101° F; 38.3° C, her apical pulse is 92 beats/min and irregular, her respiratory rate is 28 breaths/min, and her blood pressure is 108/70 mm Hg. Mrs. Valenti tells the nurse that she has been able to eat and drink small amounts but that the diarrhea will not stop. The nurse suspects that Mrs. Valenti is dehydrated. Which action should the nurse implement first to treat the dehydration? Administering oral Pedialyte Instituting NPO (nothing-by-mouth) status Encouraging Mrs. Valenti to drink sips of water Starting an intravenous (IV) line and administer IV fluids
Administering oral Pedialyte RATIONALE: Oral hydration is the first approach to the treatment of dehydration if the client is able to ingest fluids. Sport drinks, though high in sugar, are often recommended over tap water because they are easily absorbed by the stomach, are generally palatable to clients, and will more quickly correct the dehydration. Pedialyte and other commercial fluid and electrolyte solutions are also available. The administration of IV fluids is a last-resort approach. There is no reason to maintain Mrs. Valenti on NPO status; in fact, this could worsen the dehydration.
Three months later, Marilyn visits the primary health care provider's office because of ear pain. The primary health care provider's assessment and prescription are shown in Marilyn's health record (refer "Chart" below). Based on these prescriptions, what should the nurse teach Marilyn at this time? Vital Signs and Focused Physical AssessmentTemperature: 100.9° F (oral)Pulse: 88 beats/minRespiratory rate: 10 breaths/minBlood pressure: 110/72 mm HgClient complains of left ear pain and severe sinus congestion of 2 days's duration. Came to the office today Current MedicationsDaily women's vitaminOrtho-Cyclen, oral contraception New PrescriptionsPseudoephredine (Sudafed) 30 mg every 4 hours as needed for nasal congestionAmpicillin (Omnipen) 500 mg orally every 6 hours for 7 days. Normal saline nasal rinse as needed The vitamins should not be taken while taking the antibiotic. The oral contraceptive should be stopped until the antibiotic prescription is finished. The oral contraception should be stopped while taking the pseudoephedrine for nasal congestion. An alternate form of birth control will be needed while taking the ampicillin and for at least 1 month afterward.
An alternate form of birth control will be needed while taking the ampicillin and for at least 1 month afterward. RATIONALE: Several medications, including penicillin antibiotics, can reduce the effectiveness of oral contraceptives, which may in turn result in unintended pregnancy. Marilyn should use an alternate form of birth control while taking the ampicillin and for at least 1 month afterward, but the oral contraceptive should not be stopped. Vitamins and pseudoephedrine do not interact with oral contraceptives.
Oral contraceptive therapy has been prescribed for a client with a history of seizures who is taking phenytoin. Which information should the nurse provide to the client after reviewing the new prescription? An increased dosage of the oral contraceptive must be prescribed because phenytoin reduces the effectiveness of oral contraceptives. An increased dosage of the phenytoin must be prescribed because phenytoin reduces the effectiveness of the oral contraceptive. The primary health care provider will need to increase the dosage of the phenytoin. The effect of the phenytoin will be magnified while the client is taking the oral contraceptive.
An increased dosage of the oral contraceptive must be prescribed because phenytoin reduces the effectiveness of oral contraceptives. RATIONALE: Phenytoin is an anticonvulsant that reduces the effectiveness of oral contraceptives. When a client is taking a medication that diminishes the effectiveness of oral contraceptives, an increased dosage of the oral contraceptive may be required. An increased dosage of the phenytoin would not be necessary; additionally, this could be harmful to the client and lead to phenytoin toxicity. The effect of the phenytoin is not magnified while the client is taking the oral contraceptive.
After 2 days Mrs. Valenti is feeling better, and the discharge planner begins arranging for her to be sent back to the residential home. The nurse gives report to the nurse at the home, and Mrs. Valenti arrives there late in the afternoon. Which measures should the nurse at the residential home implement to prevent recurrence of dehydration? Select all that apply. Assessing urine output Offering fluids with meals only Offering fluids other than water, such as coffee and iced tea Monitoring her pulse and respiratory rates, and blood pressure Find out what fluids she prefers besides water and offer those
Assessing urine output Monitoring her pulse and respiratory rates, and blood pressure Find out what fluids she prefers besides water and offer those RATIONALE: Measures to help prevent dehydration in older adults include monitoring pulse rate and respiration for increases and the blood pressure for a decrease, all of which may indicate dehydration. In addition, urine output should be monitored, because decreased urine output may indicate dehydration. Fluids should be offered every hour, including with the evening snack, and the nurse should find out what fluids are preferred and offer those, with the exception of drinks containing caffeine (e.g., coffee and iced tea), which acts as a diuretic.
A nurse preparing a woman in the third trimester of pregnancy for a physical examination assists the woman into the supine position on the examining table. While waiting for the obstetrician to arrive, the woman suddenly complains of feeling lightheaded and dizzy. Which immediate action should the nurse take? Checking the woman's blood pressure Calling the obstetrician to the examining room Placing a cool cloth on the woman's forehead Assisting the client into a lateral recumbent position
Assisting the client into a lateral recumbent position RATIONALE: When a pregnant woman is in the supine position, particularly during the second and third trimesters, the weight of the gravid uterus partially occludes the vena cava and descending aorta. The occlusion impedes return of blood from the lower extremities and consequently reduces cardiac return, cardiac output, and blood pressure. This is known as supine hypotensive syndrome. Signs/symptoms include faintness, lightheadedness, dizziness, and agitation. A lateral recumbent position alleviates the pressure on the blood vessels and quickly corrects supine hypotension. Although the nurse may take the woman's blood pressure, this is not the action to take immediately. It is not necessary to call the obstetrician to the examining room. Placing a cool cloth on the woman's forehead will not alleviate the problem.
Laboratory tests are performed on a woman in the first trimester of pregnancy, and the results indicate that she is negative for Rh factor. Which explanation of this finding should the nurse provide to the woman? The result of the Rh factor screen is normal. Because the Rh factor is not present, no additional testing is necessary. Because the Rh factor is not present, the newborn infant will need to receive immunization immediately after birth. Because the Rh factor is not present, the client will need to receive Rh immune globulin at about 28 weeks' gestation.
Because the Rh factor is not present, the client will need to receive Rh immune globulin at about 28 weeks' gestation. RATIONALE: If the client is Rh negative and the result of an antibody screen is negative, she will need repeat antibody screens and should receive Rh immune globulin around 28 weeks' gestation to prevent the formation of anti-Rh antibodies. An Rh-negative woman should also receive Rh immune globulin within 72 hours of delivery if her newborn is Rh-positive. On the basis of the data provided in the question, the other options are incorrect.
A nurse in a daycare center is planning play activities for a group of toddlers. Which choices are the most appropriate play materials for these children? Videos, compact disc player, board games Rattles, stuffed animals, squeaky dolls, soft mobiles Cards, Monopoly game, sewing kits, paint-by-number kits Blocks, rocking horse, finger paints, wooden puzzles, thick crayons, paper
Blocks, rocking horse, finger paints, wooden puzzles, thick crayons, paper RATIONALE: The toddler engages in parallel play. Appropriate toys promote increased locomotive skills, meet the need for tactile play, and are safe. Blocks, a rocking horse, finger paints, wooden puzzles, thick crayons, and paper are all appropriate toys for a toddler. Videos, a compact disc player, board games, sewing kits, and paint-by-number kits are more appropriate for a school-age child. Rattles, stuffed animals, squeaky dolls, and soft mobiles are more appropriate for an infant.
A subarachnoid (spinal) block is administered to a woman before a cesarean section. During the immediate postpartum period, which vital sign does the nurse check most closely as part of monitoring for adverse effects of the block? Temperature Apical pulse Respirations Blood pressure
Blood pressure RATIONALE: The injection site for a subarachnoid block is in the spinal subarachnoid space at L3-L5. This type of anesthesia, administered just before birth, relieves uterine and perineal pain and numbs the vagina, perineum, and lower extremities. The adverse effects of a subarachnoid block are maternal hypotension, bladder distention, and postural puncture headache. Although the nurse would monitor the woman's temperature, pulse, and respirations, the blood pressure must be monitored most closely.
A nurse assists an obstetrician in performing an amniotomy on a woman admitted to the labor unit. Which action should the nurse take immediately after the procedure? Helping the woman walk Checking the fetal heart rate Assisting the woman in bathing Checking the woman's temperature
Checking the fetal heart rate RATIONALE: Amniotomy is the artificial rupture of membranes that is performed by the primary health care provider to stimulate labor. The primary risk associated with amniotomy is that the umbilical cord will slip down in the gush of fluid and become compressed between the fetal presenting part and the woman's pelvis, obstructing blood flow to and from the placenta and reducing gas exchange. Therefore the nurse's action immediately after the procedure would be to check the fetal heart rate. Although the nurse would monitor the woman's temperature and help the woman bathe, these are not immediately necessary actions. The woman would not be allowed to walk unless this has specifically been prescribed.
Which findings are normal age-related physiological changes? Select all that apply. Increased heart rate Diminished visual acuity Decline in long-term memory Increased susceptibility to urinary tract infections Increased incidence of awakening after onset of sleep
Diminished visual acuity Increased susceptibility to urinary tract infections Increased incidence of awakening after onset of sleep RATIONALE: Anatomic changes in the eye affect the older individual's visual ability acuity, sometimes leading to problems in carrying out activities of daily living. Light adaptation is diminished and visual fields reduced. The heart rate slows and the heart valves thicken. Age-related changes that affect the urinary tract increase an older client's susceptibility to urinary tract infections. Short-term memory may decline with age, but long-term memory is usually maintained. Sleep pattern changes are common with increasing age. Older persons generally experience an increased incidence of awakening after sleep onset.
A nurse checking the vital signs of an older client notes that the client's resting heart rate is 60 beats per minute. Which action should the nurse take on the basis of this finding? Document the finding. Recheck the heart rate in 30 minutes. Assess the client for signs/symptoms of infection. Contact the primary health care provider to report the heart rate.
Document the finding. RATIONALE: In an adult client, a heart rate slower than 60 beats per minute indicates bradycardia and a heart rate faster than 100 beats per minute indicates tachycardia. The heart rate decreases with age, so a rate of 60 beats per minute is within the normal parameters. Therefore, because the rate presented in the question constitutes a normal finding, the nurse would document the heart rate. On the basis of the data in the question, the other options are unnecessary.
A nurse is obtaining an obstetric history from a client who is pregnant. The client tells the nurse that she gave birth to twins at 36 weeks' gestation and had a stillbirth at 24 weeks. The client also reports that she experienced a spontaneous abortion at 12 weeks' gestation. How should the nurse document the woman's pregnancies? Gravida 2, para 4 Gravida 3, para 5 Gravida 4, para 2 Gravida 5, para 3
Gravida 4, para 2 RATIONALE: Gravida refers to the number of pregnancies, of any length, that the woman has had. Para (parity) refers to the number of pregnancies that have progressed past 20 weeks at delivery. Because the client is pregnant and was pregnant with twins, pregnant before the stillbirth at 24 weeks, and pregnant before experiencing a spontaneous abortion at 12 weeks' gestation, she is referred to as gravida 4. Because only two of the pregnancies progressed past 20 weeks, she is para 2. Therefore the client is gravida 4, para 2.
A home-care nurse is providing information to an older client about measures to prevent constipation. Which action should the nurse tell the client to take? Take an oral laxative daily. Include bran in the daily diet. Eat less fresh fruit each day. Keep fluid intake to 1000 mL per day.
Include bran in the daily diet. RATIONALE: Diet is a common cause of constipation in older adults. Usually a lack of certain foods, rather than the consumption of certain foods, leads to the problem. Fresh fruits and vegetables contain natural laxatives and should be included in the daily diet. Another dietary cause of constipation is the lack of fiber or bulk and reduced fluid intake. Therefore the client should include fiber, such as bran, in the diet and should drink 2000 mL of fluid daily unless it is contraindicated because of a medical condition. Constipation may be caused by overuse or improper use of laxatives stemming from the client's excessive concern about the frequency of bowel movements. The client would not be instructed to take a laxative on a daily basis.
As Penny's labor progresses, the obstetrician performs another examination and concludes that Penny is in the second stage of labor. Which of these assessment findings should the nurse expect to note at this stage of labor? Select all that apply. Descent of 1 to 2 cm Pink to bloody mucus Increase in bloody show Increased urge to bear down Cervical dilation of 10 cm with 100% effacement Contractions 2 minutes apart, 90 seconds in duration
Increase in bloody show Increased urge to bear down Contractions 2 minutes apart, 90 seconds in duration Cervical dilation of 10 cm with 100% effacement RATIONALE: The second stage of labor is the stage during which the infant is born. The stage begins with cervical dilation of 10 cm and complete (100%) cervical effacement. The increase in bloody show, increased urge to bear down, and increased duration and frequency of contractions are part of the descent, or active pushing, phase of the second stage of labor. Mucus that is pink to bloody and descent of 1 to 2 cm are findings that are characteristic of the first stage of labor.
A nurse is providing information to the parents of a 5-month-old infant about introducing solid foods to the infant. Which of the following instructions should the nurse give to the parents? Cheese should not be used as a subsitute for Introduce one new food at a time at intervals of 4 to 7 days. Mix soft solid food with formula if the infant refuses to eat. Start with fruits and vegetables; if these are tolerated, add cereal to the diet.
Introduce one new food at a time at intervals of 4 to 7 days. RATIONALE: Solids may be added to feedings when the infant is 5 to 6 months old. Rice cereal is introduced first because of its low allergenic potential. The recommended sequence after the introduction of rice is weekly introduction of fruits, followed by vegetables and then meat. Cheese may be used as a substitute for meat or as a finger food. Parents are instructed to introduce one food at a time, usually at intervals of 4 to 7 days, as a means of identifying food allergies. Foods are never mixed with formula in the bottle.
A nurse has provided information to a 16-year-old girl about adequate nutritional intake. Which statement by the girl indicates a need for additional information? It is all right to eat pizza for breakfast once in a while. It is important to eat at least two servings of fruit per day. It is acceptable to eat an occasional hamburger and fries at a fast-food restaurant. It is acceptable to replace the daily milk requirement with a protein food such as a cheeseburger.
It is acceptable to replace the daily milk requirement with a protein food such as a cheeseburger. RATIONALE: According to the MyPlate food plan, three servings per day should be consumed from the dairy group. Protein foods are not acceptable substitutes for this food group. The other statements are accurate
A client discussing family planning methods with the nurse tells the nurse that she uses the calendar method because her menstrual periods are regular. Which information about the reliability of this method should the nurse provide to the client? It is unreliable. It is extremely reliable if menstrual periods are regular. If it has prevented pregnancy so far, it is a reliable method. It is very reliable if the basal body temperature method is also used.
It is unreliable. RATIONALE: The calendar method is based on the fact that ovulation occurs approximately 14 days before the onset of menses. It is unreliable because many factors, such as illness or stress, can affect the time of ovulation. In the basal body temperature method, the woman charts her temperature each morning before getting out of bed. The basal body temperature may decrease slightly before ovulation and then increase slightly with ovulation. This method, which is not reliable because errors are frequent, is often used along with other methods. Therefore the other options are incorrect.
Penny's labor is progressing slowly because her contractions are inadequate, so the obstetrician prescribes intravenous oxytocin to augment labor. While the oxytocin is being administered, the nurse monitoring Penny closely, notes that her contractions are occurring every 3 minutes and are lasting 60 seconds. Which action should the nurse take? Contact the obstetrician Stop the oxytocin infusion Transport Penny to the delivery room Maintain the current dosage of oxytocin
Maintain the current dosage of oxytocin RATIONALE: Oxytocin, a hormone naturally produced by the posterior pituitary gland, stimulates uterine contractions and may be used to induce labor or to augment a labor that is progressing slowly because of inadequate uterine contractions. The nurse monitors the client closely and maintains the dosage if the intensity of contractions results in intrauterine pressure of 40 to 90 mm Hg (as shown by an internal monitor), if the duration of contractions is 40 to 90 seconds, if the contractions come at 2- to 3-minute intervals, or if cervical dilation of 1 cm/hr occurs in the active stage. Oxytocin is stopped if uterine hyperstimulation or a non-reassuring pattern of fetal heart rate occurs. There is no need to contact the obstetrician at this time or to transport Penny to the delivery room, because she is still progressing through the first stage of labor.
A nurse has completed a family assessment and is documenting the information obtained during the interview. The household comprises a father, a mother, one son, and two daughters. What family type should the nurse document? Nuclear Blended Extended Multi-adult
NUCLEAR RATIONALE: A nuclear family consists of two partners, heterosexual or homosexual, and perhaps one or more children. A blended family is formed when parents bring unrelated children from prior or foster-parenting relationships into a new joint-living situation. An extended family includes relatives such as aunts, uncles, grandparents, and cousins in addition to the nuclear family. A multi-adult family is one in which more than one adult is living in a household.
Penny's labor continues, and she is now at 9 cm of dilation. During contractions, the fetal heart monitor shows the patterns depicted on the graph. What does the nurse determine? No action is required The oxytocin infusion must be stopped Penny should be moved into a side-lying position Oxygen, at a rate of 8 to 10 L/min by way of a face mask, needs to be administered
No action is required RATIONALE: Early deceleration of the fetal heart rate (FHR) is an obvious gradual decrease and then return to baseline that is associated with uterine contractions. Early decelerations are considered benign, and nursing interventions are not required. Moving the mother into a side-lying position, administering oxygen, and stopping the oxytocin infusion are interventions that would be needed for late or variable decelerations of the FHR, which may indicate fetal distress.
A pregnant woman expresses concern to the nurse about how her 10-year-old daughter will adapt to a newborn's introduction into the home. Which response should the nurse make to the woman? Most children resent a "newcomer" to the home. An only child always has difficulty when a new baby arrives. You must provide a great deal of attention to the 10-year-old to help prevent resentment on the older child's part. Older school-age children often enjoy taking responsibility for the care of a younger sibling.
Older school-age children often enjoy taking responsibility for the care of a younger sibling. RATIONALE: Older school-age children often enjoy taking responsibility for the care of a younger sibling. The nurse would appropriately teach the pregnant woman measures to deal with adaptation to a new infant. The information in the other options is inaccurate.
Which instruction should the nurse provide to the mother? Place the child in the back seat of the car in a booster seat Place the child in the back seat in a forward-facing convertible seat with a harness Restrain the child in the passenger side of the front seat as long as an air bag is in place Place the child in the back seat of the car in a forward-facing position using the car seat belts
Place the child in the back seat in a forward-facing convertible seat with a harness RATIONALE: The convertible restraint is used for toddlers and preschoolers. It is best that the child ride in a rear-facing position for as long as possible, to the highest height and weight allowed by the manufacturer of their convertible seat. Once a child has outgrown the rear-facing seat, a forward-facing seat with a full harness should be used for as long as the child fits. Booster seats are for older children who have outgrown their forward-facing car safety seats. Air bags can be harmful or even lethal to small children.
Joanna Burns has brought her 2-year-old son, Joel, to the well-baby clinic for a scheduled visit. She expresses concern to the nurse about her son's behavior, telling the nurse that she has a great deal of difficulty getting Joel to bed at night. Joel throws temper tantrums to postpone the event, she reports. Joanna also tells the nurse that because of this behavior she is worried about being able to toilet-train Joel. Joanna asks the nurse about strategies to deal with Joel's behavior. What should the nurse tell Joanna? Avoid letting Joel take any daytime naps Provide a quiet activity for 30 minutes before bedtime Provide a high-carbohydrate snack before bedtime to promote sleep Allow the stalling tactics for 30 minutes, then tell Joel that he must go to be
Provide a quiet activity for 30 minutes before bedtime RATIONALE: Toddlers often resist going to bed by stalling or even throwing temper tantrums to postpone the event. Firm, consistent limits are needed when toddlers try stalling tactics. Warning the child a few minutes before it is time for bed may reduce bedtime protests. Winding down with a quiet activity for 30 minutes before bedtime also helps the toddler prepare for sleep. Bedtime rituals are important and should be followed consistently. Daytime naps do not need to be avoided; a balance of activity, rest, and sleep is important. Avoiding high-carbohydrate snacks and excitement before bedtime promotes relaxation.
A nurse teaches a pregnant woman how to perform Kegel exercises to help maintain bladder control. Which instruction should the nurse provide? Select all that apply. Perform the exercise while urinating. Perform the exercise once only after urinating. Repeat the contraction-relaxation cycle 30 times a day. Contract the muscles around the vagina and hold for 10 seconds, then relax the muscles for 10 seconds. Continuously contract and relax the muscles around the vagina at least 30 times and perform the exercise three times a day.
Repeat the contraction-relaxation cycle 30 times a day. Contract the muscles around the vagina and hold for 10 seconds, then relax the muscles for 10 seconds. RATIONALE: Kegel exercises improve tone of the muscles of the pelvic floor and help maintain bladder control. They are not performed during urination, because urine retention increases the risk of urinary tract infection. The woman is taught to contract the muscles around the vagina and hold for 10 seconds, then relax the muscles for 10 seconds. The contraction-relaxation cycle is repeated 30 times a day.
Joanna Burns has brought her 2-year-old son, Joel, to the well-baby clinic for a scheduled visit. She expresses concern to the nurse about her son's behavior, telling the nurse that she has a great deal of difficulty getting Joel to bed at night. Joel throws temper tantrums to postpone the event, she reports. Joanna also tells the nurse that because of this behavior she is worried about being able to toilet-train Joel. Joanna asks the nurse about strategies to deal with Joel's behavior. Joanna asks the nurse how to deal with Joel's bedtime temper tantrums. Which strategy should the nurse recommend to Joanna? Safely isolating Joel and ignoring the temper tantrum Giving in to Joel's demand and allowing him to stay up a little longer Telling Joel that he will be punished if the temper tantrum continues Telling Joel that a favorite toy will be taken away if the temper tantrum doesn't stop
Safely isolating Joel and ignoring the temper tantrum RATIONALE: Temper tantrums, a common toddler response to anger and frustration, are often a result of thwarted attempts at exerting mastery and autonomy. Generally the most effective method of handling a tantrum is to safely isolate and ignore the child. The child should learn that nothing, not even attention, is gained from a tantrum. Giving in to the child's demands or scolding and punishing the child will only worsen the behavior. Toddlers stop using tantrums when they do not achieve their goals and as their verbal skills increase.
Janice comes to the clinic for her 39-week visit. (Refer to Janice's record by refering "Chart" below.) Based on the data recorded (refer to medical record), the nurse concludes that one condition may be a problem. What is it? Vital SignsBlood pressure 162/110 mm HgTemperature: 98.4° FPulse 92 beats/minRespirations 14 breaths/min Subjective Data"I've had a headache for the last few days.""My vision seems blurry lately.""I've had to take off my rings because my fingers are swollen." Objective DataUrine dipstick: proteinuria +2; glucose negativeBilateral ankle edema, +2; Edema of face and fingers. Fundal height 38.5 cm. Fetal heart tones (FHTs): 140 beats/min .Deep tendon reflexes: 2+ Eclampsia Mild preeclampsia Severe preeclampsia Chronic hypertension
Severe preeclampsia RATIONALE: A client experiencing severe preeclampsia will have a blood pressure of 160/110 mm Hg or higher on two separate occasions and will have 2+ to 3+ proteinuria on dipstick testing. Headaches, blurred vision, and facial and finger edema may also be present. Chronic hypertension would have been detected before pregnancy or before 20 weeks of gestation. Mild preeclampsia presents with a blood pressure of 140/90 mm Hg, minimal or no headache, no vision problems, and proteinuria of less than 2+ on dipstick testing. Eclampsia is an emergency that is characterized by seizure activity and sometimes coma.
During a conversation with a nurse, an older client states, "I'm so dissatisfied with my life; it's just been one disappointment after another." Using Erik Erikson's theory of psychosocial development, which interpretation of the client's statement does the nurse make? The client has fulfilled his life's goals. The client is looking back over his life and accepting what has occurred. The client is demonstrating unsuccessful resolution of the crisis associated with this developmental stage. The client is demonstrating successful resolution of the crisis associated with the developmental stage by verbalizing what has occurred during his life.
The client is demonstrating unsuccessful resolution of the crisis associated with this developmental stage. RATIONALE: According to Erikson, all individuals pass through eight psychosocial stages over the course of a lifetime. Each stage represents a crisis in which the goal is to integrate physical, maturation, and psychosocial demands. In later adulthood, the psychosocial crisis is integrity versus despair. The task during this stage is to look back over one's life and accept its meaning. A sense of integrity and fulfillment indicates successful resolution of the crisis. Dissatisfaction with life indicates unsuccessful resolution of the crisis.
A nurse is developing a plan of care for an older client that addresses interventions to prevent cold discomfort and the development of accidental hypothermia. Which outcomes are desired and should be selected by the nurse for the plan of care? Select all that apply. The client is not shivering. The client's body temperature is 98° F (36.7°C). The client's fingers and toes are cool to touch. The client remains in a fetal position when in bed. The client complains of coolness in the hands and feet only.
The client is not shivering. The client's body temperature is 98° F (36.7°C). RATIONALE: Desired outcomes for nursing interventions to prevent cold discomfort and the development of accidental hypothermia include warm hands and feet; relaxed, uncurled body; body temperature higher than 97° F; absence of shivering; and no complaints of feeling cold.
A pregnant client has been scheduled for amniocentesis, and the nurse is providing information to her about the procedure. What should the nurse tell the woman? The procedure will take about 2 hours. The obstetrician will locate the fetus with the use of the Leopold's maneuvers. The client may feel pressure as the needle is inserted and mild cramping as the needle enters the uterine muscle. Several serious risks are associated with the procedure, and several informed consent forms will have to be signed.
The client may feel pressure as the needle is inserted and mild cramping as the needle enters the uterine muscle. RATIONALE: Amniocentesis is a relatively simple and safe procedure that permits the diagnosis of many fetal anomalies and confirms fetal maturity. It is a relatively painless procedure that takes only a short amount of time. Ultrasonography is used to locate the fetus and placenta and identify the largest pockets of amniotic fluid that can safely be sampled. A small amount of local anesthetic may be injected into the skin. The woman may feel pressure as the needle is inserted and mild cramping as the needle enters the myometrium. Leopold's maneuvers are a common and systematic way to determine the position of a fetus inside the woman's uterus. Informed consent will need to be provided by the client before the procedure. Although risks are associated with the procedure, the need for several informed consents to be signed is not warranted.
A nurse is conducting a psychosocial assessment of a 40-year-old client. Which findings would the nurse recognize as a sign/symptom of emotional health in a person in middle adulthood? The client is establishing intimate bonds of love and friendship. The client provides guidance during interactions with his children. The client verbalizes readiness to assume parental responsibilities. The client is making decisions concerning career, marriage, and parenthood.
The client provides guidance during interactions with his children. RATIONALE: Middle adulthood is the period between the middle to late thirties and the middle sixties. According to Erikson's developmental theory, the psychosocial crisis of middle adulthood is generativity versus stagnation. The developmental task is to fulfill life's goals involving family, career, and society; successful resolution is demonstrated by the willingness to give to and care for others and to guide others. Middle adults can achieve generativity with their own children or the children of close friends or through other social interactions with the next generation. Making decisions about career, marriage, and parenthood; verbalizing readiness to assume parental responsibilities; and establishing intimate bonds of love and friendship are signs of emotional health in the early adult years.
A nurse teaches the husband of a woman who is in the active phase of stage 1 labor how to perform effleurage on his wife. Which observation by the nurse indicates that the spouse is performing the procedure correctly? The man lightly pushes on his wife's sacral area with his fist. The man exerts steady pressure on his wife's abdomen during a contraction. The man lightly strokes his wife's abdomen in rhythm with her breathing during a contraction. The man exerts light pressure with the heel of the hand over the area of the uterine fundus.
The man lightly strokes his wife's abdomen in rhythm with her breathing during a contraction. RATIONALE: Effleurage (light massage) and counter pressure are two methods that provide pain relief to a woman in the first stage of labor. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during a contraction. It is used to distract the woman from contraction pain. Counter pressure is steady pressure, applied to the sacral area with the fist or heel of the hand, that may help the woman cope with the sensations of internal pressure and pain in the lower back. Therefore the other options are incorrect.
A nurse reviewing the record of a client seen in the clinic notes that the nurse-midwife documented the presence of the Goodell sign during examination of the client. What conclusion does the nurse make on the basis of this finding? The client is definitely pregnant. The nurse-midwife noted softening of the cervix. The client exhibits a presumptive sign of pregnancy. The nurse-midwife noted a violet coloration of the cervix.
The nurse-midwife noted softening of the cervix. RATIONALE: In the early weeks of pregnancy, the cervix softens as a result of pelvic congestion (Goodell sign). Cervical softening is noted on physical examination. The presence of the Goodell sign is a probable indication of pregnancy. Another probable indication of pregnancy is the Chadwick sign, in which the cervix changes from pink to a violet color. Presumptive indications of pregnancy are also termed subjective changes because they are experienced and reported by the woman. Positive indications of pregnancy include auscultation of fetal heart sounds, fetal movement felt by the examiner, and visualization of the fetus on ultrasonography.
The nurse notes documentation in the record of a client in labor that the client is completely effaced. Based on this information, what conclusion should the nurse make? The cervical os is completely dilated. The client will require induction with the use of oxytocin. Enlargement of the cervical canal that occurs during the first stage of labor is complete. The shortening and thinning of the cervix that occurs during the first stage of labor is complete.
The shortening and thinning of the cervix that occurs during the first stage of labor is complete. RATIONALE: Effacement is the shortening and thinning of the cervix that occurs during the first stage of labor. Dilation is the enlargement of the cervical os and cervical canal during the first stage. When the cervical os is completely dilated, the client is prepared for the birth of the baby. Induction is the deliberate initiation of uterine contractions that stimulates labor. In this situation, induction is not necessary.
Joanna Burns has brought her 2-year-old son, Joel, to the well-baby clinic for a scheduled visit. She expresses concern to the nurse about her son's behavior, telling the nurse that she has a great deal of difficulty getting Joel to bed at night. Joel throws temper tantrums to postpone the event, she reports. Joanna also tells the nurse that because of this behavior she is worried about being able to toilet-train Joel. Joanna asks the nurse about strategies to deal with Joel's behavior. During the office visit, the nurse assesses Joel's developmental level, documents the findings, and reviews the data (refer "Chart" below). Which statement correctly describes the nurse's assessment of these findings? Physical Development Chest circumference exceeding head circumferenceLateral diameter of chest exceeding anteroposterior diameterHas 16 primary teeth Language Development Uses pronouns "I," "me," and "you"Refers to self by nameTalks incessantlyUnderstands directional commands. Socialization Development Does not tolerate separation from parentFears strangersBrief attention spanWilling to share toys All findings are appropriate for a 2-year-old child. The physical findings are not appropr
The socialization findings are not appropriate for a 2-year-old child. RATIONALE: By the age of 2 years, children should have a sustained attention span, exhibit increased independence from their parents, be less likely to fear strangers, and have an awareness of ownership, as expressed by phrases such as "my toy." The findings listed under the "Physical Development" and "Language Development" tabs are appropriate for Joel's age. **I don't agree with this answer. I think it should be physical findings...aren't head/chest circumference supposed to be equal by this age?
A nurse is providing information about the fetal circulation to a client who is pregnant for the first time. What should the nurse tell the client? The umbilical cord holds two veins and one artery. Fetal blood circulation takes place strictly in the placenta. The umbilical vein carries freshly oxygenated, nutrient-laden blood from the placenta to the fetus. The one umbilical artery carries freshly oxygenated, nutrient-laden blood from the placenta to the fetus.
The umbilical vein carries freshly oxygenated, nutrient-laden blood from the placenta to the fetus. RATIONALE: The course of fetal blood circulation runs from the fetal heart to the placenta for exchange of oxygen, nutrients, and waste products and then back to the fetus for delivery to fetal tissues. The fetal umbilical cord has two arteries and one vein. The arteries carry deoxygenated blood and waste products away from the fetus to the placenta, where these substances are transferred to the mother's circulation. The umbilical vein carries freshly oxygenated and nutrient-laden blood from the placenta back to the fetus.
A woman in the first trimester of pregnancy calls the nurse at her obstetrician's office and reports that brown patches have developed on her face. What should the nurse tell the client? She should cover the discoloration with makeup. She should come to the clinic immediately to be checked. This is a normal skin change, the result of the hormonal fluctuations that occur during pregnancy. She should monitor the discoloration and make an appointment with the obstetrician if the patches worsen.
This is a normal skin change, the result of the hormonal fluctuations that occur during pregnancy. RATIONALE: Increased skin pigmentation, a normal occurrence during pregnancy, may begin as early as the second month of pregnancy, when estrogen and progesterone cause the level of melanocyte-stimulating hormone to increase. Women with dark hair or skin exhibit more hyperpigmentation than do women with very light skin. Areas of pigmentation include brownish patches, called chloasma, that usually involve the forehead, cheeks, and bridge of the nose. This sign/symptom is commonly called the "mask of pregnancy." Covering the discoloration with makeup may diminish the appearance of the brown patches, but it is not the most appropriate option. It is not necessary for the client to come to the clinic immediately, nor is it necessary for the client to make an appointment if the patches worsen.
A pregnant woman at 20 weeks' gestation calls the nurse at the maternity clinic and reports that she has noticed a white fluid draining from her nipples. What should the nurse tell the client? She must come to the clinic to be checked. This is an expected occurrence during pregnancy. This is frequently the first sign of a breast infection. She should notify the nurse-midwife of this finding.
This is an expected occurrence during pregnancy. RATIONALE: Colostrum, the creamy white-to-yellowish-to-orange premilk fluid, may be expressed from the nipples as early as 16 weeks' gestation. This is an expected occurrence during pregnancy. It is not necessary for the client to notify the nurse-midwife or to report to the clinic to be checked. It is not a sign/symptom of infection.
A pregnant client who is taking a prescribed iron supplement calls the nurse in the obstetrician's office and reports that she has been constipated. What is the best response the nurse should give to the client? To increase her daily intake of high-fiber foods That this is a normal occurrence during pregnancy To take the iron supplement every other day instead of every day To start taking an oral laxative daily until the constipation resolves
To increase her daily intake of high-fiber foods RATIONALE: The best response is for the client to increase her daily intake of high-fiber foods. Constipation is common during pregnancy. It may be caused by decreased intestinal motility or pressure from the uterus or may be a result of iron supplementation. The client should not discontinue or change the frequency of administration of an iron supplement that has been prescribed. If constipation persists, the client would be instructed to consult with the primary health care provider or nurse-midwife regarding a prescription for a laxative; taking a laxative on a daily basis could be harmful. Although constipation is a normal occurrence during pregnancy, the nurse should teach the client measures, such as including additional fiber in the diet, to alleviate and prevent its occurrence.
A nurse, assigned to care for a hospitalized child who is 8 years old, plans care, taking into account Erik Erikson's theory of psychosocial development. According to this theory, which choice represents the primary developmental task of the child? To master useful skills and tools To gain independence from parents To develop a sense of trust in the world To develop a sense of control over self and body functions
To master useful skills and tools RATIONALE: According to Erikson's theory of psychosocial development, the school-age child's task is to master useful skills and tools of the culture (industry versus inferiority). Gaining independence from parents is the psychosocial task of the adolescent. Development of a sense of trust in the world is the psychosocial task of an infant. Development of a sense of control over self and body functions is the psychosocial task of the toddler.
Once the nurse has implemented treatment for Mrs. Valenti's dehydration, which occurrence indicates the best expected outcome the client could have? Thirst Dry mucous membranes Decrease in blood pressure Urine output greater than 30 mL/hr
Urine output greater than 30 mL/hr RATIONALE: The expected outcome for the client with deficient fluid volume is that adequate fluid volume and electrolyte balance will return, as evidenced by a urine output greater than 30 mL/hr. Other expected outcomes would also include normal blood pressure, decreasing heart rate, consistent weight, and normal skin turgor. Thirst, dry mucous membranes, and a decrease in blood pressure are defining characteristics of deficient fluid volume.
A nurse has just assisted in the delivery of a newborn infant and is preparing to help deliver the placenta. For which sign/symptom of placental separation does the nurse monitor the woman? A soft, boggy fundus Shortening of the umbilical cord Vaginal fullness on examination Assumption of a discoid shape by the uterus
Vaginal fullness on examination RATIONALE: Signs/symptoms of placental separation include a firmly contracting fundus; a change in the uterus from a discoid to a globular shape, which occurs as the placenta moves into the lower uterine segment; a sudden gush of dark blood from the introitus; apparent lengthening of the umbilical cord as the placenta descends to the introitus; the presence of vaginal fullness (placenta) on vaginal or rectal examination; and the presence of fetal membranes at the introitus.
Penny Martin, age 29, has been admitted to the birthing center with contractions, which, she reports, have been 3 minutes apart and regular for 2 hours. This is the first pregnancy for Penny and her husband, Gilbert, and they tell the nurse that they have eagerly looked forward to the baby's arrival after 4 years of trying to conceive. After checking Penny again, the obstetrician decides to perform rupture of the membranes (ROM). Penny is told that she will need to empty her bladder first and then remain in bed after the procedure. Which of these assessment findings after ROM indicate that the amniotic fluid is normal? Select all that apply. Strong odor Thick and cloudy Watery consistency Greenish-brown color Pale and straw colored
Watery consistency Pale and straw colored RATIONALE: Normal amniotic fluid is pale or straw-colored and of a watery consistency, without a strong odor. Thick, cloudy amniotic fluid or a strong odor might indicate an intrauterine infection. Greenish-brown fluid reflects the presence of meconium and may indicate that the fetus has had a hypoxic episode.
A client, pregnant for the first time, is being seen in the clinic for her first prenatal visit. The client asks the nurse when the baby's heart will begin to beat. During which gestational week does the nurse tell the client that the fetal heart begins to beat? Week 1 Week 5 Week 8 Week 9
Week 5 RATIONALE: By gestational week 5 the heart has partitioned into four chambers and has begun to beat. Therefore, the other options are incorrect.
A nurse is performing an ophthalmoscopic examination of an older client. Which age-related change would the nurse expect to note while viewing the retina? Clear fundus Red blood vessels Yellow-orange optic disc Yellow spots near the macula
Yellow spots near the macula RATIONALE: Age-related changes of the retina include narrowed and straightened blood vessels, opaque gray arteries, and gray or yellow spots of hyaline degeneration, called drusen, near the macula. Red blood vessels, a clear fundus, and a yellow-orange optic disc are all normal findings, not age-related changes.
