3302-Exam 1

State nurse practice acts define the legal scope of nursing practice. How can the policies of an institution influence nursing practice? The institution: (Select all that apply) 1. Can restrict nurses from performing acts that are allowed by the state nurse practice act 2. Cannot develop policies that expand the scope of nursing practice beyond the state nurse practice act 3. Can either restrict or expand the scope of nursing practice beyond the state nurse practice act 4. Can either restrict or expand the limits of the practice act 5. Cannot restrict nurses from performing acts that are allowed by the state nurse practice act

1. Can restrict nurses from performing acts that are allowed by the state nurse practice act 2. Cannot develop policies that expand the scope of nursing practice beyond the state nurse practice act

Which of the following is a function of the amniotic sac? 1. Provides a medium for fetal movement 2. Assists in the development of the respiratory and digestive tracts 3. Assists in the maintaining hormonal balance throughout the pregnancy 4. Supplies metabolic and nutritional support to the developing fetus

1. Provides a medium for fetal movement

Which of the following are changes that occur in a woman postpartum, who is breastfeeding? (select all that apply) 1. Increased prolactin 2. Increased hunger 3. Increased urine output 4. Increased progesterone production 5. Increased blood volume

1. Increased prolactin 2. Increased hunger 3. Increased urine output Rational: Postpartum with the delivery of the placenta progesterone and estrogen levels decrease, dieresis occurs, prolactin increase. Women typically have increased hunger after birth.

When teaching an adolescent about ovulation the nurse would include that ovulation is initiated by a surge in which of the following? 1. LH 2. Progesterone 3. FSH 4. Estrogen

1. LH Rationale: A surge in luteinizing hormone initiates ovulation.

The nurse is planning care for a patient, from a different culture, who does not speak or understand English. What should the nurse do to ensure culturally competent care is provided to the patient? (Select all that apply). 1. Secure the services of an interpreter 2. Assist the patient by scheduling English language lessons 3. Ask a family member to interpret for the patient 4. Make sure consent forms are in the patient's native language 5. Make sure instructions are written in the patient's native language

1. Secure the services of an interpreter 4. Make sure consent forms are in the patient's native language 5. Make sure instructions are written in the patient's native language

What are the positive/diagnostic signs of pregnancy? (Select all that apply) 1. Visualization of the fetus by U.S. 2. The fetal heart is audible 3. Chadwick's signs 4. Ballottment 5. Linea negra 6. The examiner palpates fetal movement

1. Visualization of the fetus by U.S. 2. The fetal heart is audible 6. The examiner palpates fetal movement

The nurse is providing instructions to a postpartum patient who has been diagnosed with mastitis. Which statement made by the patient indicates a need for further teaching? 1 "I need to wear a supportive bra to relieve the discomfort." 2 "I need to stop breastfeeding until this condition resolves." 3 "I can use analgesics to alleviate some of the discomfort." 4 "I need to take antibiotics, and I should begin to feel better in 24 to 48 hours."

2 "I need to stop breastfeeding until this condition resolves."

A 16-year-old is seen at her 10-weeks gestation visit. She tells the nurse that she felt the baby move that morning. What response by the nurse is appropriate? 1. "That is very exciting. The baby must be very healthy." 2. "Would you please describe what you felt for me?" 3. "Would you please let me see whether I can feel the baby?" 4. "That is impossible at this stage. The baby is not big enough yet."

2. "Would you please describe what you felt for me?"

The rubella vaccine has been prescribed for a new mother. Which statement should the postpartum nurse make when providing information about the vaccine to the client? 1. "You should avoid sexual intercourse for 2 weeks after administration of the vaccine." 2. "You should not become pregnant for 2 to 3 months after administration of the vaccine." 3. "You should avoid heat and extreme temperature changes for 1 week after administration of the vaccine." 4."You must sign an informed consent because anaphylactic reactions can occur with the administration of this vaccine."

2. "You should not become pregnant for 2 to 3 months after administration of the vaccine."

The nurse is caring for a postpartum patient of Vietnamese descent who immigrated to the United States 5 years ago. The patient asks for the regular hospital menu because, she says, American food tastes best. The nurse assesses this response to be related to which of the following cultural concepts? 1. Paternalism 2. Acculturation 3. Ethnocentrism 4. Cultural competence

2. Acculturation

Which vital sign observed by the nurse would be of concern in the postpartum phase because it could be a sign of hemorrhage 1. A body temperature of 100.4º F 2. An increase in pulse from 90 to 108 bpm 3. An increase in respiratory rate from 18 to 22 4. A blood pressure change from 130/88 to 120/80

2. An increase in pulse from 90 to 110 beats/min

The nurse is preparing to perform a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment? 1. Ask the client to turn on her side. 2. Ask the client to urinate and empty her bladder. 3. Massage the fundus gently before determining the level of the fundus. 4. Ask the client to lie flat on her back, with her knees and legs flat and straight.

2. Ask the client to urinate and empty her bladder.

The nurse is assisting a multiparous woman to the bathroom for the first time since her delivery 3 hours ago. When the patient stands up, blood runs down her legs and pools on the floor. The patient becomes pale and states she is dizzy. The first action of the nurse is to: 1. Assist the patient back to the bathroom to empty her bladder 2. Assist the patient back to the bed and check the fundus 3. Immediately assess her blood pressure and pulse 4. Increase her IV fluids and elevate her legs

2. Assist the patient back to the bed and check the fundus

The postpartum client asks the nurse about the occurrence of afterpains. The nurse informs the client that afterpains will be especially noticeable during which activity? 1. Ambulating 2. Breast-feeding 3. Taking sitz baths 4. Arriving home and activities are increased

2. Breast-feeding Afterpains are a normal occurrence and result from contractions of the uterus as it reduces in size during involution. Afterpains may be especially noticeable during breast-feeding because oxytocin is released in response to the infant's sucking. The other options are incorrect.

The purpose of initiating contractions in a contraction stress test (CST) is to: 1. Determine the degree of fetal activity during a contraction 2. Evaluate the effect of a stressful stimulus of the fetus 3. Identify fetal acceleration patterns in response to fetal movement 4. Increase placental blood flow to the fetus

2. Evaluate the effect of a stressful stimulus of the fetus Rationale: Contraction stress test is to test the fetus that shows compromises when stress is added (ex. Nipple stimulation or pitocin)

A nurse teaches newly pregnant clients that if an ovum is fertilized and implants in the endometrium, the hormone the fertilized egg begins to secrete is which of the following? 1. Estrogen 2. Human chorionic gonadotropin (hCG) 3. Progesterone 4. Luteinizing hormone

2. Human chorionic gonadotropin (hCG) Rationale: If the ovum is fertilized and implants in the endometrium, the fertilized egg begins to secrete human chorionic gonadotropin (hCG), which is needed to maintain the corpus luteum.

A patient experiences a postpartum hemorrhage and refuses a blood transfusion. The physician disregards the patient's wishes and administers the transfusion as he considers the potential danger to the patient's life. The decision is based on the principal: 1. Nonmaleficence 2. Paternalism 3. Respect for Authenticity 4. Beneficence

2. Paternalism Rationale: Paternalism is a decision made by a physician or often caregiver that dictates what is best for the patient without considering the patient's own beliefs and value system.

The primary reason for evaluating alpha-fetoprotein (AFP) levels in maternal serum is to: 1. Screen for RH compatibility 2. Screen for neural tube defect 3. Evaluate fetal lung maturity 4. Diagnose a genetic abnormality

2. Screen for neural tube defect

A client 2 months pregnant with her first child. During a routine prenatal visit, she tells the nurse that she is not sure she is ready to have a baby, even though this is a planned pregnancy. What is the nurse's best response? 1. You may want to discuss these concerns with a therapist 2. You are feeling ambivalence, which is normal in the first trimester 3. You may want to consider having an abortion before it is too late 4. You need to share these feelings with your partner

2. You are feeling ambivalence, which is normal in the first trimester

A woman who is 32 weeks pregnant is informed by the nurse that a danger sign of pregnancy could be: 1. constipation 2. alteration in the pattern of fetal movement 3. heart palpitations 4. edema in the ankles and feet at the end of the day

2. alteration in the pattern of fetal movement

Painful intercourse due to a decrease in estrogen levels is called 1. ovulation 2. dyspareunia 3. diuresis 4. preeclampsia

2. dyspareunia

The nurse teaches a client trying to conceive that fertilization of the ovum usually occurs: 1. before ovulation 2. in the distal third of the fallopian tube 3. in the upper portion of the uterus 4. on the first day of the menstrual cycle

2. in the distal third of the fallopian tube

The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action is to: 1. place her on a bedpan to empty her bladder. 2. massage her fundus. 3. call the physician. 4. administer Methergine, 0.2 mg IM, which has been ordered prn.

2. massage her fundus. rationale: A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action is to massage the fundus until firm

Infant gets an immunological benefit of breastfeeding by getting ______ from the mother and colostrum 1. active immunity 2. passive antibodies 3. prolactin 4. full immunity

2. passive antibodies

The patient delivered her first child vaginally 7 hours ago. She has no complaints, has been up out of bed once, and has not voided since delivery. She has an IV of Lactated Ringer's solution at 100 ml/hr. Her fundus is firm, one fingerbreadth above the uterus, to the right of midline. The best nursing action is to: 1. Document your findings 2. Increase the rate of the IV 3. Assist the patient to the bathroom 4. Assess the patient's pain level

3. Assist the patient to the bathroom

A student nurse is assessing a registered nurse in the care of a postpartum patient who is 48 hours post cesarean section. The nearest completes her assessment and states the patient is at risk for thrombophlebitis. What nursing interventions will help decrease her risk? 1. Maintain bedrest with position changes and leg exercises every two hours 2. Provide a heat pack if the affected limb is pale and cool to the touch 3. Encourage ambulation 4. Begin a prophylactic heparin therapy

3. Encourage ambulation

On assessment of a client who is 30 minutes into the fourth stage of labor, the nurse finds the client's perineal pad saturated in blood and blood soaked into the bed linen under the client's buttocks. Which is the nurse's initial action? 1. Call the health care provider. 2. Assess the client's vital signs. 3. Gently massage the uterine fundus. 4. Administer a 300-mL bolus of a 20 units/L oxytocin (Pitocin) solution.

3. Gently massage the uterine fundus

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action would be most appropriate? 1. Raise the head of the client's bed. 2. Obtain hemoglobin and hematocrit levels. 3. Instruct the client to request help when getting out of bed. 4. Inform the nursery room nurse to avoid bringing the newborn to the client until the mother's symptoms have subsided.

3. Instruct the client to request help when getting out of bed. Rationale: Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that caution the nurse to focus interventions on the client's safety. The nurse should advise the client to get help the first few times she gets out of bed. Option 1 is not a helpful action in this situation and would not relieve the symptoms. Option 2 requires a health care provider's prescription. Option 4 is unnecessary.

Chelsea is a 28-year-old, G3P3 who delivered a 9 pound, 12 ounce baby following a Pitocin augmented labor. She had an epidural. When she experienced difficulty pushing, she was given a midline episiotomy and the baby's head was delivered by vacuum extractor. She developed a temperature of 100.2 two hours following her delivery. Which statement lists precipitating factors for postpartum hemorrhage? 1. Age, large baby, Pitocin augmented labor, delivery with vacuum extractor 2. Large baby, epidural, Pitocin augmented labor, temperature of 100.2 3. Large baby, epidural, Pitocin augmented labor, delivery with vacuum extractor 4. Epidural, Pitocin augmented labor, episiotomy, temperature of 100.2

3. Large baby, epidural, Pitocin augmented labor, delivery with vacuum extractor

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? 1. Record the findings. 2. Massage the fundus. 3. Notify the health care provider 4. Place the client in Trendelenburg's position.

3. Notify the health care provider Rationale: If bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm would not assist in controlling the bleeding. Trendelenburg's position should be avoided because it may interfere with cardiac and respiratory function. Although the nurse would record the findings, the initial nursing action would be to notify the HCP.

The nurse is creating a handout on reproduction for teen clients. Which piece of information should the nurse include in this handout? 1. The fertilized ovum is called a gamete. 2. Prior to fertilization, the sperm are zygotes. 3. Ova survive 12-24 hours in the fallopian tube if not fertilized. 4. Sperm survive in the female reproductive tract up to a week.

3. Ova survive 12-24 hours in the fallopian tube if not fertilized.

The nurse advises an alcoholic patient to stop consuming alcohol during pregnancy. What could be the reason for this? To prevent: 1. Angiomas in the fetus 2. Urinary infections in the patient 3. Teratogenic effect in the fetus 4. Gastrocnemius spasm in the patient

3. Teratogenic effect in the fetus

A woman is menstruating. If hormonal studies were to be done at this time, which of the following hormonal levels would the nurse expect to see? 1. Both estrogen and progesterone are high 2. Estrogen is high and progesterone is low 3. Estrogen is low and progesterone is high 4. Both estrogen and progesterone are low

4. Both estrogen and progesterone are low

Which of the following are false statements regarding the infant mortality rate? (Select all that apply). 1. The infant mortality rate is the number of deaths of infants under the age of 1 year per 1000 live births. 2. The U.S. infant mortality rate varies widely based on the race of the mother. 3. The infant mortality rate is the number of deaths of children under the age of 2 years per 100,000 live births. 4. The U.S. infant mortality rate is calculated based on the number of preterm births per year

3. The infant mortality rate is the number of deaths of children under the age of 2 years per 100,000 live births. 4. The U.S. infant mortality rate is calculated based on the number of preterm births per year

Postpartum __________ may be due to the transient increase in cardiac output 1. dyspnea 2. dyspareunia 3. bradycardia 4. baby blues

3. bradycardia

During the first trimester, the pregnant woman is most motivated to learn about: 1. fetal development. 2. impact of a new baby on family members. 3. measures to reduce nausea and fatigue so she can feel better. 4. location of childbirth preparation and breastfeeding classes.

3. measures to reduce nausea and fatigue so she can feel better

This steroid hormone released by the corpus luteum that stimulates the uterus to prepare for and maintain a pregnancy: 1. Relaxin 2. LH 3. progesterone 4. estrogen

3. progesterone

The nurse is preparing to care for four assigned clients. Which client is at highest risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago 2. A multiparous client who delivered 6 hours ago 3. A primiparous client who delivered 6 hours ago and had epidural anesthesia 4. A multiparous client who delivered a large baby after oxytocin (Pitocin) induction

4. A multiparous client who delivered a large baby after oxytocin (Pitocin) induction

The nurse performs an assessment on a client who is 4 hours postpartum. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. What immediate action should the nurse take? 1. Provide oral fluids and begin fundal massage. 2. Begin hourly pad counts and reassure the client. 3. Elevate the head of the bed and assess vital signs. 4. Assess for hypovolemia and notify the health care provider

4. Assess for hypovolemia and notify the health care provider

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing action? 1. Document the findings. 2. Retake the temperature in 15 minutes. 3. Notify the health care provider 4. Increase hydration by encouraging oral fluids.

4. Increase hydration by encouraging oral fluids. Rationale: The client's temperature should be taken every 4 hours while she is awake. Temperatures up to 100.4° F (38° C) in the first 24 hours after birth often are related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse also would document the findings, the appropriate action would be to increase hydration. Taking the temperature in another 15 minutes is an unnecessary action. Contacting the HCP is not necessary.

The legal concept that protects a patient's right to autonomy and self-determination by specifying that no action may be taken, nor procedure or treatment given, without that person's prior understanding and freely given permission is called: 1. Nonmaleficence 2. Patient Privacy 3. Paternalism 4. Informed consent

4. Informed consent

The nurse is caring for four 1-day postpartum clients. Which client would require further nursing action? 1. The client with mild afterpains 2. The client with a pulse rate of 60 beats/minute 3. The client with colostrum discharge from both breasts 4. The client with lochia that is red and has a foul-smelling odor

4. The client with lochia that is red and has a foul-smelling odor Rationale: Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor or an odor similar to menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. The other options are normal findings for a 1-day postpartum client

The nurse is helping prepare a patient for discharge after childbirth. During a teaching session, the nurse instructs the patient to do Kegel exercises. What is the purpose of these exercises? 1. To prevent urine retention 2. To provide relief of lower back pain 3. To tone the abdominal muscles 4. To strengthen the perineal muscles

4. To strengthen the perineal muscles

When the placenta detaches, _________ needs to take place in order to prevent the mother from bleeding out 1. vasodilation 2. fundal massage 3. cord clamping 4. vasoconstriction

4. vasoconstriction

Nursing Practice Act

Each state has one that defines the Scope of practice, Standards of Care, Standards for education programs, Licensure requirements, Grounds for disciplinary action

Ethnocentrism

Conviction that the values and beliefs of ones' own cultural group are the best or only acceptable ones

Taking Hold

Rubins stage that happens the first 2-3 days post partum; the mother becomes more independent and starts to attend to her own needs and the infant's needs

Scope of Practice

The range of services and care that may be provided by a nurse based on state requirements *Hospitals will have their own standards for nurses to follow that fall within the state's scope of practice

autonomy

agreement to respect another's right to self determine a course of action; support of independent decision making

A woman who is 24 weeks pregnant dies from a head injury after a car accident. Her death would be recorded as a maternal mortality statistic a. True b. False

b. False

May be a transient rise in __________ secondary to the return of blood flow back into the central circulation from the uteroplacental unit

blood pressure (or cardiac output)

A common theory for the mechanism of Sudden Infant Death Syndrome include: a. Sleeping in the supine position b. Excessive sucking related to pacifier use c. Excessive inhalation during sleep d. Rebreathing of expired gas

d. Rebreathing of expired gas

Elimination of physiological edema through ______ can relieve carpel tunnel syndrome brought on by pregnancy

diuresis