Combined Class- Maternity Evolve- Part 2

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The nurse is preparing a client for epidural anesthesia. Which client statement would cause the nurse to stop the placement of the epidural catheter?

"I'm not exactly sure how an epidural works."

Vitamin K 0.5 mg is prescribed for a newborn. The vial on hand is labeled "1 mL = 2 mg." How many milliliters should the nurse administer? Include a leading zero if applicable. Record your answer using two decimal places. _____ mL

0.25

After a difficult birth, a neonate has an Apgar score of 8 after 5 minutes. Which signs met the criteria of 2 points? (Select all that apply.) 1 . Reflex irritability: cry 2 . Respiratory rate: good cry 3 . Heart rate: 110 beats/min 4 . Color: body pink, extremities blue 5 . Muscle tone: some flexion of extremities

1 . Reflex irritability: cry 2 . Respiratory rate: good cry 3 . Heart rate: 110 beats/min **A cry for reflex irritability rates a score of 2. A good cry for respiratory rate scores a 2. A heart rate of 100 beats/min or more rates a 2. A pink body with blue extremities rates a 1. Some flexion of extremities rates a 1 for muscle tone.

A client who just gave birth has three young children at home. She comments to the nursery nurse that she must prop the baby during feedings when she returns home because she has too much to do and, anyway, holding babies during feedings spoils them. What is the nurse's best response? 1"You seem concerned about time. Let's talk about it." 2"That's up to you; you have to do what works for you." 3"Holding the baby when feeding is important for development." 4"It's not safe to prop a bottle. The baby could aspirate the fluid."

1"You seem concerned about time. Let's talk about it."

A client consents to have her newborn son circumcised. Which statement indicates to the nurse that the mother needs additional discharge instructions? 1. "I'll put an ice bag on his penis so it won't swell." 2. "I need to change the dressing four times each day." 3. "I'll call my doctor if I notice any bleeding from the penis." 4. "I need to keep the diaper loose so it won't rub on the penis."

1. "I'll put an ice bag on his penis so it won't swell."

On the first postpartum day, a client whose infant is rooming in asks the nurse to return her baby to the nursery and bring the baby to her only at feeding times. How should the nurse respond? 1. "It seems that you've changed your mind about rooming in." 2. "I think you're having difficulty caring for the baby." 3. "All right. I'll inform the other nurses of your decision." 4. "You must be tired. I'll bring the baby back at feeding time."

1. "It seems that you've changed your mind about rooming in."

A pregnant client in the third trimester tells the nurse in the prenatal clinic that she has heartburn after every meal. What explanation should the nurse give about the cause of the heartburn? 1. "The cardiac sphincter relaxes and allows acid to be regurgitated." 2. "In pregnancy, gastric motility increases, causing a burning sensation." 3. "In pregnancy, gastric pH increases, causing acid to enter the esophagus." 4. "In pregnancy, the pyloric sphincter relaxes, allowing acid to enter the intestine."

1. "The cardiac sphincter relaxes and allows acid to be regurgitated."

A client who just gave birth has three young children at home. She comments to the nursery nurse that she must prop the baby during feedings when she returns home because she has too much to do and, anyway, holding babies during feedings spoils them. What is the nurse's best response? 1. "You seem concerned about time. Let's talk about it." 2. "That's up to you; you have to do what works for you." 3. "Holding the baby when feeding is important for development." 4. "It's not safe to prop a bottle. The baby could aspirate the fluid."

1. "You seem concerned about time. Let's talk about it."

A client is to undergo amniocentesis at 38 weeks' gestation to determine fetal lung maturity. What lecithin/sphingomyelin ratio (L/S ratio) is adequate for the nurse to conclude that the fetus' lungs are mature enough to sustain extrauterine life? 1. 2:1 2. 1:1 3. 1:4 4. 3:4

1. 2:1 **The lecithin concentration increases abruptly at 35 weeks, reaching a level that is twice the amount of sphingomyelin, which decreases concurrently. At 30 to 32 weeks' gestation, the amounts of lecithin and sphingomyelin are equal, indicating lung immaturity. A ratio of 1:4 does not reflect fetal lung maturity; nor does a ratio of 3:4.

Four days after a vaginal hysterectomy a client calls the follow-up service and tells the nurse that she has a yellowish-green vaginal discharge. The nurse advises the client to return to the clinic for an evaluation. Which symptoms are suggestive of a vaginal infection? (Select all that apply.) 1. Abdominal pain 2. Urinary frequency 3. Rising temperature 4. Decreased pulse rate 5. Decreased blood pressure

1. Abdominal pain 3. Rising temperature

A client in her 10th week of pregnancy exhibits presumptive signs of pregnancy that the nurse may detect. (Select all that apply.) 1. Amenorrhea 2. Breast changes 3. Urinary frequency 4. Abdominal enlargement 5. Positive urine pregnancy test

1. Amenorrhea 2. Breast changes 3. Urinary frequency

What is the best nursing intervention to minimize perineal edema after an episiotomy? 1. Applying ice packs 2. Offering warm sitz baths 3. Administering aspirin prn 4. Elevating the hips on a pillow

1. Applying ice packs **Cold causes vasoconstriction and reduces edema by lessening the accumulation of blood and lymph at the episiotomy site; cold also deadens nerve endings and lessens the pain.

After reading that nutrition during pregnancy is important for optimal growth and development of a baby, a pregnant woman asks the nurse what foods she should be eating. The nurse begins the teaching/learning process by: 1. Asking the client what she usually eats at each meal 2. Explaining to the client why spicy foods should be avoided 3. Instructing the client to add calories while continuing to eat a healthy diet 4. Providing the client with a list of foods for reference when planning meals

1. Asking the client what she usually eats at each meal

What characteristic does the nurse anticipate in an infant born at 32 weeks' gestation? 1. Barely visible areolae and nipples 2. Ear pinnae that spring back when folded 3. Definite creases of the infant's palms and soles 4. A zero-degree angle on the square window sign

1. Barely visible areolae and nipples

A client seeking family planning information asks the nurse during which phase of the menstrual cycle an intrauterine device (IUD) should be inserted. Before responding the nurse recalls that the insertion usually is done: 1. Between the first and fourth days of the cycle 2. Between fifth and 11th days 3. Between the 14th and 16th days 4. Between the 25th and 28th days

1. Between the first and fourth days of the cycle **An IUD should be inserted during menstruation because the cervical os is slightly dilated at this time; also, there is little chance of the woman's being pregnant.

A primigravida who is at 38 weeks' gestation is undergoing a nonstress test. The nurse determines that the baseline fetal heart rate is 130 to 140 beats/min. It rises to 160 on two occasions and 157 once during a 20-minute period. Each of the episodes in which the heart rate is increased lasts 20 seconds. What action should the nurse take? 1. Discontinuing the test because the pattern is reassuring 2. Encouraging the client to drink more fluids to decrease the fetal heart rate 3. Notifying the primary health care provider and preparing for an emergency birth 4. Recording this nonreassuring pattern and continuing the test for further evaluation

1. Discontinuing the test because the pattern is reassuring

During a male newborn's first encounter with his mother the nurse encourages her to undress him. The mother strokes him with her whole hand and while looking at him intently says, "He feels so velvety, and he is going to be just as good looking as his daddy." The baby is alert and responsive while gazing at his mother. What is the nurse's assessment of this first mother-infant encounter? 1. Early parenting behavior 2. Neonatal attachment behavior 3. Newborn consummatory behavior 4. Overprotective parenting behavior

1. Early parenting behavior

A client is concerned about gaining weight during pregnancy. What should the nurse tell the client is the cause of the greatest weight gain during pregnancy? 1. Fetal growth 2. Fluid retention 3. Metabolic alterations 4. Increased blood volume

1. Fetal growth

A client is admitted in active labor to the birthing center. She is 100% effaced, dilated 3 cm, and at +1 station. What stage of labor does the nurse identify? 1. First 2. Latent 3. Second 4. Transitional

1. First

In the second hour after the client gives birth her uterus is firm, above the level of the umbilicus, and to the right of midline. What is the most appropriate nursing action? 1. Having the client empty her bladder 2. Watching for signs of retained secundines 3. Massaging the uterus vigorously to prevent hemorrhage 4. Explaining to the client that this is a sign of uterine stabilization

1. Having the client empty her bladder **A full bladder elevates the uterus and displaces it to the right. Even though the uterus feels firm, it may relax enough to foster bleeding.

A nurse is caring for a pregnant client with thrombophlebitis. Which anticoagulant medication may be prescribed? (Select all that apply.) 1. Heparin (Hep-Lock) 2. Clopidogrel (Plavix) 3. Warfarin (Coumadin) 4. Enoxaparin (Lovenox) 5. Acetylsalicylic acid (Acuprin)

1. Heparin (Hep-Lock) 4. Enoxaparin (Lovenox) **Heparin (Hep-Lock) may be used during pregnancy because it does not cross the placental barrier and will not cause hemorrhage in the fetus. Enoxaparin (Lovenox) does not cross the placental barrier; its classification for pregnancy is B.

A nurse suspects that a newborn has toxoplasmosis, one of the TORCH infections. How and when may it have been transmitted to the newborn? 1. In utero through the placenta 2. In the postpartum period through breast milk 3. During birth through contact with the maternal vagina 4. After the birth through a blood transfusion given to the mother

1. In utero through the placenta

The nurse is counseling a pregnant client with type 1 diabetes about medication changes as pregnancy progresses. Which medication will be needed in increased dosages during the second half of her pregnancy? 1. Insulin 2. Antihypertensives 3. Pancreatic enzymes 4. Estrogenic hormones

1. Insulin

A client has a modified radical mastectomy because of a malignant tumor of the breast. What does the nurse plan to teach the client during the early postoperative period? 1. Keep the arm in an elevated position. 2. Observe the incision site for redness and bleeding. 3. Maintain a high Fowler position with the affected arm on a pillow. 4. Perform range-of-motion exercises, including flexion and abduction of the affected arm.

1. Keep the arm in an elevated position.

A client is scheduled to have a contraction stress test (CST) to determine fetal well-being. Which type of fetal heart rate (FHR) decelerations constitutes a nonreassuring outcome? 1. Late 2. Early 3. Baseline 4. Variable

1. Late

A client in preterm labor is to receive a tocolytic medication, and bedrest is prescribed. Which position should the nurse suggest that the client maintain while on bedrest? 1. Lateral 2. Supine 3. Fowler 4. Semi-Fowler

1. Lateral **The lateral position relieves pressure on the vena cava, thereby promoting venous return and increasing placental perfusion.

At 37 weeks' gestation a client's membranes spontaneously rupture but she does not have contractions. What action is most important in the nursing plan of care for this client? 1. Monitoring for the presence of fever 2. Monitoring for signs of preeclampsia 3. Monitoring for heavy vaginal bleeding 4. Making preparations for fetal scalp pH sampling

1. Monitoring for the presence of fever

n specific situations gloves are used to handle newborns whether or not they are HIV positive. When is it unnecessary for the nurse to wear gloves while caring for a newborn? 1. Offering a feeding 2. Changing the diaper 3. Giving an admission bath 4. Suctioning the nasopharynx

1. Offering a feeding

A client with severe preeclampsia in the high-risk unit is receiving an infusion of magnesium sulfate. If eclampsia were to occur, what action would the nurse take first? 1. Prevent injury 2. Assess fetal heart tones 3. Maintain an open airway 4. Increase the infusion rate

1. Prevent injury

What are the indicators of nutritional risk in pregnancy in a client who is of normal weight? (Select all that apply.) 1. Smoker 2. Twin gestation 3. Hemoglobin of 12 g/dL 4. Term delivery 2 years ago 5. Caffeine intake of 180 mg/day 6. Fasting blood sugar of 80 mg/dL

1. Smoker 2. Twin gestation

A nurse is observing the newborn of a known opioid user for signs of withdrawal. What clinical manifestations does the nurse expect to identify? (Select all that apply.) 1. Sneezing 2. Hyperactivity 3. High-pitched cry 4. Exaggerated Moro reflex 5. Reduced deep tendon reflexes

1. Sneezing 2. Hyperactivity 3. High-pitched cry

What does the nurse teach a client to do when performing breast self-examination? 1. Squeeze the nipples to examine for discharge 2. Use the right hand to examine the right breast 3. Place a pillow under the shoulder opposite the examined breast to raise it 4. Compress breast tissue to the chest wall with the palm to palpate for lumps

1. Squeeze the nipples to examine for discharge

A pregnant woman at 6 week's gestation tells the nurse at her first prenatal visit that she uses an over-the-counter herbal product as a health supplement that has been approved by the Food and Drug Administration. What should the nurse recommend to the client? (Select all that apply.) 1. Stop taking the supplement immediately. 2. Discuss the use of the supplement with the practitioner. 3. Increase the dosage of the supplement as pregnancy progresses. 4. Ask the pharmacist whether the supplement is safe for use during pregnancy. 5. Discuss the use of any over-the-counter products with the practitioner.

1. Stop taking the supplement immediately. 2. Discuss the use of the supplement with the practitioner. 5. Discuss the use of any over-the-counter products with the practitioner.

Immediately after the third stage of labor a nurse administers the prescribed oxytocin (Pitocin) infusion. Why is this medication administered? 1. To help the uterus contract 2. To lessen uterine discomfort 3. To aid in the separation of the placenta 4. For the stimulation of breast milk production

1. To help the uterus contract

What instruction should a nurse include when teaching about the correct use of a female condom 1."Remove the condom before standing up." 2."Insert the condom within 1 hour before intercourse." 3."Have your partner wear a male condom at the same time." 4."Cleanse the condom with warm water when preparing it for future use."

1."Remove the condom before standing up."

The nurse discusses fetal weight gain with a pregnant client. When does it usually show a marked increase? 1.During the third trimester 2.During the second trimester 3.At the end of the first trimester 4.No difference is observed

1.During the third trimester

A client who is pregnant for the first time and carrying twins is scheduled for a cesarean birth. What should preoperative teaching include? 1.Frequent ambulation is begun within 24 hours. 2.Discharge from the hospital occurs in 5 to 7 days. 3.Enemas are required for effective bowel movements. 4.Sponge baths are taken until incisional healing is complete

1.Frequent ambulation is begun within 24 hours.

When a mother sees her newborn son assume a fencing position as she turns his head, she becomes concerned. What should the nurse explain about this reflex? 1.It is expected in the healthy newborn. 2.It should disappear around 2 months of age. 3.This is suspicious and the practitioner will be notified. 4.This may indicate a minor neurological problem and will be monitored.

1.It is expected in the healthy newborn

What must the LPN observe first when planning to promote mother-infant attachment? 1.Mother-infant interaction 2.Mother-father interaction 3.The infant's physical status 4.The mother's ability to care for her infant

1.Mother-infant interaction

A nurse is caring for several new mothers in the birthing unit, all in the taking-in phase of the postpartum period. What information is most appropriate for these clients at this time? 1.Perineal care 2.Infant feeding 3.Infant hygiene 4.Family planning

1.Perineal care

On a routine prenatal visit the sign or symptom that a healthy primigravida at 20 weeks' gestation will most likely report for the first time is: 1.Quickening 2.Palpitations 3.Pedal edema 4.Vaginal spotting

1.Quickening

A woman questions the nurse about the effectiveness of oral contraceptives. What most important factor about the effectiveness of oral contraceptives should be included in the reply to this question? 1.User motivation 2.Simplicity of use 3.Reliability record 4.Identified risk factors

1.User motivation

What does a nurse expect to find when checking the vital signs of a client in the early postpartum period? 1Bradycardia with no change in respirations 2Tachycardia with a decrease in respirations 3Increased basal temperature with a decrease in respirations 4Decreased basal temperature with an increase in respirations

1Bradycardia with no change in respirations

A client at 35 weeks' gestation calls the prenatal clinic, concerned that she has "not felt the baby move as much as usual." The most appropriate recommendation by the nurse is to have the client call the clinic with the results after she has: 1Drunk a glass of orange juice and timed 10 fetal movements 2Sat in a tub filled with warm water and then timed 30 fetal movements 3Taken a nap and counted the number of fetal movements for 20 minutes 4Walked for 15 minutes and checked to see whether the fetus moved more frequently

1Drunk a glass of orange juice and timed 10 fetal movements

A client is concerned about gaining weight during pregnancy. What should the nurse tell the client is the cause of the greatest weight gain during pregnancy? 1Fetal growth 2Fluid retention 3Metabolic alterations 4Increased blood volume

1Fetal growth

A client in labor begins to experience contractions 2 to 3 minutes apart and lasting about 45 seconds. Between contractions the nurse identifies a fetal heart rate (FHR) of 100 beats/min on the internal fetal monitor. What is the next nursing action? 1Notifying the health care provider 2Resuming continuous fetal heart monitoring 3Continuing to monitor the maternal vital signs 4Documenting the fetal heart rate as an expected response to contractions

1Notifying the health care provider

Examination of a client in active labor reveals fetal heart sounds in the right lower quadrant. The head is in the anterior position, is well flexed, and is at the level of the ischial spines. What fetal position should the nurse document? 1ROA, 0 station 2LOP, -2 station 33ROP, - station 4LOA, +1 station

1ROA, 0 station

A nurse caring for a client who gave birth to a healthy neonate evaluates the client's uterine tone 8 hours later. How does the nurse determine that the uterus is demonstrating appropriate involution? 1The amount of lochia rubra is moderate. 2Numerous clots are being passed vaginally. 3Bleeding from the episiotomy has stopped. 4Uterine cramps are absent during breastfeeding

1The amount of lochia rubra is moderate.

During labor a client who has been receiving epidural anesthesia has a sudden episode of severe nausea, and her skin becomes pale and clammy. What is the nurse's immediate reaction? 1Turning the client on her side 2Notifying the health care provider 3Checking the vaginal area for bleeding 4Checking the fetal heart rate every 3 minutes

1Turning the client on her side

A nurse is assessing a newborn with suspected retention of a fetal structure that will result in a congenital heart defect. Which fetal structures should undergo change after birth? (Select all that apply.) 1 . Mitral valve 2 . Foramen ovale 3 . Pulmonary veins 4 . Ductus arteriosus 5 . Pulmonary arteries

2 . Foramen ovale 4 . Ductus arteriosus **If the foramen ovale fails to close, the infant will have an atrial septal defect. If the ductus arteriosus fails to close, the pressure in the lungs and heart will be abnormal, resulting in chronic heart disease. The mitral valve, pulmonary veins, and pulmonary arteries do not change after birth.

A client has a child with Tay-Sachs disease and wants to become pregnant again. She tells the nurse, "I'm worried it will happen again." How should the nurse respond? 1. "Did you discuss this with your physician?" 2. "Have you considered the option of genetic counseling?" 3. "Can you remember if Tay-Sachs occurred before in your family?" 4. "It is a rare disease that is statistically improbable to happen again."

2. "Have you considered the option of genetic counseling?"

After a mastectomy or a hysterectomy a client may feel incomplete as a woman. What statement should alert the nurse to this feeling in a client who has undergone total hysterectomy? 1. "I can't wait to see all my friends again." 2. "I feel washed out; there isn't much left." 3. "I'm planning to recuperate at my daughter's home." 4. "I can't wait to get home; I so want to see my grandchild."

2. "I feel washed out; there isn't much left."

A 2-day-old infant who weighs 6 lb (2722 g) is fed formula every 4 hours. Newborns need about 73 mL of fluid per pound of body weight each day. In light of this information, approximately how much formula should the infant receive at each feeding? 1. 1 to 2 oz 2. 2 to 3 oz 3. 3 to 4 oz 4. 4 to 5 oz

2. 2 to 3 oz

The school nurse is teaching a group of 16-year-old girls about the female reproductive system. One student asks how long after ovulation it is possible for conception to occur. The most accurate response by the nurse is based on the knowledge that an ovum is no longer viable after: 1.12 hours 2.24 hours 3.48 hours 4.72 hours

2. 24 hours

A newborn of 30 weeks' gestation has a heart rate of 86 beats/min and slow, irregular respirations. The infant grimaces in response to suctioning, is cyanotic, and has flaccid muscle tone. What Apgar score should the nurse assign to this neonate? 1. 2 2. 3 3. 4 4. 5

2. 3 **A heart rate of less than 100 beats/min = 1; slow and irregular respirations = 1; grimaces in response to suctioning = 1; flaccid muscle tone = 0; and cyanosis = 0. This infant's Apgar score is 3. A score of 2 is too low. A score of 4 is too high, as is a score of 5.

A mother is breastfeeding her newborn. She asks when she may switch the baby to a cup. The nurse concludes that the mother understands the teaching about feeding when she says she will start to introduce a cup after the baby reaches: 1. 4 months 2. 6 months 3. 12 months 4. 16 months

2. 6 months **Around 6 months of age infants are able to swallow independently of sucking, and a cup may be introduced. Introducing a cup at 4 months is inappropriate because the infant does not have the ability to swallow independently of sucking at this age.

The nurse instructs a pregnant client in the sources of protein that can be used to meet the increased daily requirement during pregnancy. How many grams of protein should the client eat each day? 1. 65 g 2. 60 g 3. 55 g 4. 50 g

2. 60 g **The Food and Nutrition Board of the National Academy of Sciences recommends that a pregnant woman consume 60 g of protein daily to meet the needs of pregnancy. The recommended daily intake of protein for a breastfeeding (lactating) woman is 65 g.

The nurse is caring for a group of postpartum clients. Which one should the nurse monitor most closely? 1. A primipara who had an 8-lb newborn 2. A grand multipara who just had her sixth child 3. A primipara who received 50 mcg of IV fentanyl during her labor 4. A multipara whose placenta was expelled 15 minutes after the birth

2. A grand multipara who just had her sixth child **A grand multipara is a woman who has had at least 6 births . Multiparity contributes to an increased incidence of uterine atony because the uterine muscle may not contract effectively, leading to postpartum hemorrhage

During a pelvic examination of a 24-year-old woman, the nurse suspects a vaginal infection because of the presence of a white curdlike vaginal discharge. What other assessment supports a fungal vaginal infection? 1. A foul odor 2. An itchy perineum 3. An ischemic cervix 4. A forgotten tampon

2. An itchy perineum

What should a nurse teach a non-nursing mother to help relieve the discomfort of engorgement? 1. Empty the breasts manually once a day. 2. Apply cold packs to the breasts frequently. 3. Ask the practitioner to prescribe a medication for pain. 4. Loosen the brassiere until the breast swelling has subsided.

2. Apply cold packs to the breasts frequently.

The nurse is caring for a newborn with caput succedaneum. The nurse is able to differentiate caput succedaneum from cephalhematoma because caput succedaneum features scalp edema that: 1. Becomes ecchymotic 2. Crosses the suture line 3. Increases after several hours 4. Is tender in the surrounding area

2. Crosses the suture line

What is the primary outcome for client care in the third stage of labor? 1. Absence of discomfort 2. Firmly contracted uterine fundus 3. Efficient fetal heart beat-to-beat variability 4. Maternal respiratory rate within the expected range

2. Firmly contracted uterine fundus

The clinic nurse is providing home care instructions for a client with pelvic inflammatory disease. What resting position should be recommended by the nurse? 1. Sims 2. Fowler 3. Supine with knees flexed 4. Lithotomy with head elevated

2. Fowler **The Fowler position facilitates localization of the infection by pooling exudate in the lower pelvis.

A pregnant client with an infection tells the nurse that she has taken tetracycline (Tetracyn) for infections on other occasions and prefers to take it now. The nurse tells the client that tetracycline is avoided in the treatment of infections in pregnant women because it: 1. Affects breastfeeding adversely 2. Influences the fetus's teeth buds 3. Causes fetal allergies to the medication 4. Increases the fetus's tolerance to the medication

2. Influences the fetus's teeth buds

A newborn who is born at 36 weeks' gestation weighs 8 lb 13 oz (3997 g). How should the nurse document this finding? 1. Large for gestational age (LGA) and term 2. LGA and preterm 3. Appropriate for gestational age (AGA) and term 4. AGA and preterm

2. LGA and preterm

A client with cervical cancer is to undergo a course of internal radiation. The client returns to her lead-lined room on the oncology unit with an indwelling urinary catheter and a vaginal applicator in place. Once the practitioner has loaded the applicator with the radiation source, the nurse's plan of care should include: 1. Changing linens several times a day 2. Leaving the urinary catheter undisturbed 3. Cleansing the perineal area with a mild antiseptic twice daily 4. Removing equipment from the room immediately after it is used

2. Leaving the urinary catheter undisturbed

A client starting her second trimester asks a nurse in the prenatal clinic whether she can safely take an over-the-counter (OTC) medicine now that she is past the first 3 months of pregnancy. The nurse explains why she should consult with her health care provider before taking any oral medications. What physiological alteration associated with pregnancy may change the client's response to medication? 1. Decreased glomerular filtration rate 2. Longer gastrointestinal emptying time 3. Increased secretion of hydrochloric acid 4. Development of fetal-placental circulation

2. Longer gastrointestinal emptying time **Gastrointestinal motility is reduced during pregnancy because of the high level of placental progesterone and displacement of the stomach superiorly and the intestines laterally and posteriorly; absorption of some drugs, vitamins, and minerals may be increased because of their slow passage through the gastrointestinal tract.

A client at 39 weeks' gestation arrives in the birthing suite reporting that she is having regular contractions. A vaginal examination reveals that the presentation is a double-footling breech. The practitioner decides to proceed to a cesarean birth under regional anesthesia. What is an important intervention to help prevent postoperative maternal complications? 1. Providing scrupulous skin care 2. Maintaining adequate hydration 3. Monitoring the vital signs frequently 4. Teaching how to use an incentive spirometer

2. Maintaining adequate hydration

A nurse who is caring for a mother and her newborn infant reviews their record. In light of the data the record contains, what nursing intervention is required? 1. Neonatal blood transfusion 2. Maternal rubella vaccination 3. Maternal RhoGAM injection 4. Neonatal 50% glucose infusion

2. Maternal rubella vaccination

A nurse helps a client to the bathroom to void several times during the first stage of labor. This is done because a full bladder: 1. Is often injured during labor 2. May inhibit the progress of labor 3. Jeopardizes the status of the fetus 4. Predisposes the client to urinary infection

2. May inhibit the progress of labor

A nurse teaches a pregnant woman about the need to increase her intake of complete proteins. Which foods identified by the client indicate that the teaching is effective? (Select all that apply.) 1. Nuts 2. Milk 3. Eggs 4. Bread 5. Beans 6. Cheese

2. Milk 3. Eggs 6. Cheese

While auscultating the lungs of a client admitted with severe preeclampsia, the nurse identifies crackles. What inference does the nurse make when considering the presence of crackles in the lungs? 1. Seizure activity is imminent. 2. Pulmonary edema has developed. 3. Bronchial constriction was precipitated by the stress of pregnancy. 4. Impaired diaphragmatic function was caused by the enlarged uterus.

2. Pulmonary edema has developed.

A nurse is counseling a client with type 1 diabetes who has requested contraceptive information. On which method of contraception should the nurse place the most emphasis? 1.Rhythm 2.Diaphragm 3.Oral contraceptive 4.Intrauterine device

2.Diaphragm

A nurse plans to evaluate a postpartum client's uterine fundus for involution. What should the nurse ask the client to do before this assessment? 1.Drink fluids. 2.Empty her bladder. 3.Perform the Valsalva maneuver. 4.Assume the semi-Fowler position.

2.Empty her bladder

A nurse discusses the type of anesthesia that will be used for a vaginal birth with a client who has class I cardiac disease. Which type of block is most appropriate for this client? 1.Spinal 2.Epidural 3.Pudendal 4.Inhalation

2.Epidural

A client with a benign ovarian tumor undergoes laparoscopic surgery. What should the nurse include in the postoperative teaching? 1.Resume usual activities after 12 hours. 2.Expect shoulder pain for 12 to 24 hours. 3.Douche with povidone-iodine twice a day. 4.Report vaginal spotting that occurs during the first 3 days after the surgery.

2.Expect shoulder pain for 12 to 24 hours.

A nurse evaluates that a client who is taking oral contraceptives understands the related dietary teaching when the client states, "While I'm taking birth control pills I should increase my intake of foods containing: 1.Calcium." 2.Folic acid." 3.Vitamin A." 4.Vitamin D."

2.Folic acid."

A client at 10 weeks' gestation phones the prenatal clinic to report that she is experiencing some vaginal bleeding and abdominal cramping. The nurse arranges for her to go to the local hospital. The vaginal examination reveals that her cervix is dilated 2 cm. What diagnosis should the nurse expect? 1.Septic abortion 2.Inevitable abortion 3.Threatened abortion 4.Incomplete abortion

2.Inevitable abortion

A client who is at 10 weeks' gestation returns for her second prenatal visit. She asks why she has to urinate so often. The nurse tells her that urinary frequency in the first trimester is: 1.Caused by the descent of the baby's head into the uterus 2.Influenced by the enlarging uterus, which is still within the pelvis 3.Caused by maternal renal filtration of waste products excreted by the growing fetus 4.Mostly a psychological phenomenon that results from the knowledge that one is pregnant

2.Influenced by the enlarging uterus, which is still within the pelvis

A pregnant client with an infection tells the nurse that she has taken tetracycline (Tetracyn) for infections on other occasions and prefers to take it now. The nurse tells the client that tetracycline is avoided in the treatment of infections in pregnant women because it: 1.Affects breastfeeding adversely 2.Influences the fetus's teeth buds 3.Causes fetal allergies to the medication 4.Increases the fetus's tolerance to the medication

2.Influences the fetus's teeth buds

A couple, married for 5 years, want to start a family. When talking with the nurse the husband says, "Well, I guess we're going to have to jump into bed three or four times a day, every day, until it works." What is the nurse's best response? 1.Telling them to continue intercourse as usual until conception occurs 2.Instructing them in the frequency and timing of intercourse to promote conception 3.Discouraging this because sperm production decreases with frequent sexual intercourse 4.Agreeing that the frequency of intercourse must increase but twice daily is sufficient to promote conception

2.Instructing them in the frequency and timing of intercourse to promote conception

A client gives birth to a baby weighing 7 lb 2 oz and decides to breastfeed. The nurse is instructing the client regarding breastfeeding. What should the nurse tell the client to expect? 1.Weight loss will occur rapidly. 2.Lochial flow will be increased. 3.Uterine involution will be delayed. 4.Cold compresses will promote lactation.

2.Lochial flow will be increased.

Thirty minutes after a client gives birth, the nurse palpates the client's uterus. It is relaxed and the lochia is excessive. What is the nurse's initial action? 1.Check vital signs 2.Massage the uterus 3.Notify the practitioner 4.Elevate the foot of the bed

2.Massage the uterus

A nurse is planning a childbirth education class about maternal psychological and physiological changes as pregnancy nears term. Which problems and concerns should the nurse include in the presentation? (Select all that apply.) 1.Food cravings increase. 2.Nesting needs increase. 3.Dependency needs decrease. 4.Anxiety about childbirth increases. 5.Gastrointestinal motility decreases

2.Nesting needs increase. 4.Anxiety about childbirth increases. 5.Gastrointestinal motility decreases

At a client's first visit to the prenatal clinic, the nurse asks the client when she had her last menstrual period so the estimated date of birth (EDB) can be determined. The client responds, "January 21." According to Nägele's rule, what is the month and day of the client's EDB? 1.October 21 2.October 28 3.November 21 4.November 28

2.October 28

Methods of relieving back pain are explained during a childbirth class. What activities identified by the client permit the nurse to conclude that the teaching has been understood? (Select all that apply.) 1.Tailor sitting 2.Pelvic rocking 3.Forward tilting 4 .Sacral pressure 5.Kegel exercises

2.Pelvic rocking 3.Forward tilting 4 .Sacral pressure

A client who is in preterm labor at 34 weeks' gestation is receiving intravenous tocolytic therapy. The frequency of her contractions increases to every 10 minutes, and her cervix dilates to 4 cm. The infusion is discontinued. Toward what outcome should the priority nursing care be directed at this time? 1.Reduction of anxiety associated with preterm labor 2.Promotion of maternal and fetal well-being during labor 3.Supportive communication with the client and her partner 4.Helping the family cope with the impending preterm birth

2.Promotion of maternal and fetal well-being during labor

Rho(D) immune globulin (RhoGAM) is prescribed for an Rh-negative client who has just given birth. Before giving the medication, the nurse verifies the newborn's Rh factor and reaction to the Coombs test. Which combination of newborn Rh factor and Coombs test result confirms the need to give Rho(D) immune globulin ? 1.Rh positive with a positive Coombs result 2.Rh positive with a negative Coombs result 3.Rh negative with a positive Coombs result 4.Rh negative with a negative Coombs result

2.Rh positive with a negative Coombs result

A woman arrives at the prenatal clinic stating that her pregnancy test is positive. She asks the nurse for information about an abortion. After verifying that the woman is at 8 weeks' gestation, the nurse counsels her that having an abortion is controversial and that many women have long-lasting feelings of guilt after an abortion. What is the nurse's legal responsibility? 1.To share her own thoughts on abortion with the client 2.To provide the client with correct, unbiased information 3.To ask why the client wants information about abortion 4.To notify the health care provider because this is beyond the scope of nursing practice

2.To provide the client with correct, unbiased information

A client arrives at the prenatal clinic and tells the nurse that she thinks that she is pregnant. The first day of the client's last menstrual period (LMP) was September 14, 2013. Using Naegele's Rule, what date in June 2014 is the client's estimated date of birth (EDB)? Record your answer as a whole number. ________

A 30-year-old client with a 35-day menstrual cycle is trying to become pregnant. The nurse counsels the client and her partner about the optimal timing of intercourse during the cycle. The nurse determines that the counseling has been effective when the couple state that they should have intercourse on the:

21st day of the cycle

A primigravida with type 1 diabetes is having her first prenatal visit. While discussing changes in insulin needs during pregnancy and after birth, the nurse explains that in light of the client's blood glucose readings she should expect to increase her insulin dosage. Between which weeks of gestation is this expected to occur?

24th and 28th weeks of gestation

On her first prenatal visit a client says to the nurse, "I guess I'll be having an internal examination today." What is the nurse's best response? 1"Yes, an internal exam is done at the mother's first visit." 2"Are you worried about having an internal examination?" 3"Have you ever had an internal examination done before?" 4"Yes, a slightly uncomfortable internal exam must be done."

3"Have you ever had an internal examination done before?"

A negative home pregnancy test may result if the woman performs the test: 1. By saturating the test strip 2.On the first void of the morning 3. 10 days after intercourse took place 4. While taking a prescribed tranquilizer

3. 10 days after intercourse took place

A registered nurse (RN) on the postpartum unit is providing care to four maternal/infant couplets and is running behind. Which nursing action is best delegated to a licensed practical nurse/licensed vocational nurse (LPN/LVN) who also works on the unit? 1. Discharge teaching for a client who delivered her third infant girl 2 days ago 2. Delivering a clear-liquid dietary tray to a client who had a cesarean section 4 hours ago 3. Administering 2 tablets of acetaminophen and oxycodone (Percocet) to a client who rates her pain as 7 of 10 4. The initial assessment of a client who just delivered an 8 lb 12 oz (3970 g) infant over an intact perineum

3. Administering 2 tablets of acetaminophen and oxycodone (Percocet) to a client who rates her pain as 7 of 10

An estrogen-progestin oral contraceptive is prescribed for a client. Which adverse effects should the nurse teach the client to report to the health care provider? (Select all that apply.) 1. Lethargy 2 .Dizziness 3. Chest pain 4. Constipation 5. Breast soreness 6. Calf tenderness

3. Chest pain 5. Breast soreness 6. Calf tenderness

List the mechanisms of labor in the correct sequence: 1. Flexion 2. Extension 3. Engagement 4. Descent 5. Expulsion 6. Restitution 7. Internal rotation 8. External rotation

3. Engagement 4. Descent 1. Flexion 7. Internal rotation 2. Extension 6. Restitution 8. External rotation 5. Expulsion

A 15-year-old emancipated minor gave birth to a boy 36 hours ago and has requested a circumcision. What is the nurse's priority? 1. Getting a physician's prescription for a lidocaine injection 2. Educating the new mother about the circumcision procedure 3. Getting an informed consent signed by the mother of the baby 4. Getting an informed consent signed by the grandmother of the baby

3. Getting an informed consent signed by the mother of the baby **As an emancipated minor , the mother of the baby has the right to make the decision regarding the circumcision and is responsible for signing the informed consent.

On the third postpartum day a mother visits the clinic and asks why her newborn's skin has begun to appear yellow. The nurse explains that the change in her infant's skin tone is the result of: 1. Breast milk ingestion 2. Inadequate fluid intake 3. Immaturity of the vascular system 4. Breakdown of fetal red blood cells

3. Immaturity of the vascular system

A client comes to the fertility clinic for hysterosalpingography using radiopaque contrast material to determine whether her fallopian tubes are patent. When preparing for the test, the nurse explains to the client that she: 1. Will receive a local anesthetic and the pain will lessen 2. Will have to rest in bed for 8 hours after the test is completed 3. May have some persistent shoulder pain for 14 hours after the test 4. May become nauseated during the test, but the nausea will subside

3. May have some persistent shoulder pain for 14 hours after the test

What is the focus of the nurse's anticipatory guidance during the first trimester of pregnancy? 1. Birthing process 2. Signs of complications 3. Physical changes of pregnancy 4. Role transition into parenthood

3. Physical changes of pregnancy

e nurse in the postpartum unit is teaching self-care to a group of new mothers. What color does the nurse teach them that the lochial discharge will be on the fourth postpartum day? 1. Dark red 2. Deep brown 3. Pinkish brown 4. Yellowish white

3. Pinkish brown

An 18-year-old primigravida at 36 weeks' gestation is admitted with a diagnosis of mild preeclampsia. What is the nurse's most important goal for this client? 1. Easing her anxiety 2. Limiting the bleeding 3. Reducing her blood pressure 4. Decreasing the circulating blood volume

3. Reducing her blood pressure

A nurse is teaching a primigravida about how she can identify the onset of labor. What clinical indicator of labor would necessitate the client to call her health care provider? 1. Bloody show and back pressure occurring with no contractions 2. Irregular contractions coming 10 minutes apart 3. Rupture of membranes or contractions 5 minutes apart 4. Contractions 12 minutes apart and lasting about 30 seconds

3. Rupture of membranes or contractions 5 minutes apart

A nurse is teaching a woman how to perform breast self-examination. Which statement indicates that the client needs further education? 1."I examine my breasts about a week after my period starts." 2."I've been looking for dimpling and checking for lumps." 3."My breasts are so tender right before my period that I hate doing it." 4."My grandmother examines her breasts on the first Monday of each month."

3."My breasts are so tender right before my period that I hate doing it."

A nurse is preparing a client with a ruptured tubal pregnancy for immediate surgery. What type of surgery should the informed consent include? 1.Myomectomy 2.Hysterectomy 3.Salpingectomy 4.Oophorectomy

3.Salpingectomy

A breastfeeding mother asks the nurse what she can do to ease the discomfort caused by a cracked nipple. What should the nurse instruct the client to do? 1.Stop nursing for a few days and allow the nipple to heal 2.Manually express milk and feed it to the baby in a bottle 3.Start feedings on the unaffected breast until the affected breast heals 4.Use a breast shield to keep the baby from making direct contact with the nipple

3.Start feedings on the unaffected breast until the affected breast heals

A 36-year-old multigravida who is at 14 weeks' gestation is scheduled for an α-fetoprotein test. She asks the nurse, "What does this test do?" The nurse bases the response on the knowledge that this test can reveal: 1Kidney defects 2Cardiac anomalies 3Neural tube defects 4Urinary tract anomalies

3Neural tube defects

A nurse is teaching a client to care for her episiotomy after discharge. What priority instruction should the nurse include? 1Rest with legs elevated at least two times a day. 2Avoid stair climbing for several days after discharge. 3Perform perineal care after toileting until healing occurs. 4Continue sitz baths three times a day if they provide comfort.

3Perform perineal care after toileting until healing occurs.

The transmission of which microorganism that causes maternal mastitis is minimized by frequent handwashing by nursing staff members? 1Escherichia coli 2Group B Streptococcus 3Staphylococcus aureus 4Chlamydia trachomatis

3Staphylococcus aureus

The nurse is caring for a client whose labor is to be induced. What is the nurse's responsibility when a client's labor is being stimulated with an oxytocin (Pitocin) infusion? 1Flushing the IV tubing if the flow slows 2Checking the fetal heart rate every 2 hours 3Stopping the infusion if contractions become hypertonic 4Decreasing the infusion rate if hypertonic contractions continue for 15 minutes

3Stopping the infusion if contractions become hypertonic

A nurse is caring for a client during the transition phase of labor. The nurse determines that the client has entered the second stage of labor when: 1There is restlessness and thrashing about 2There are complaints of sudden and intense back pain 3The client reports that she feels the urge to move her bowels 4The client asks for medication to relieve pain from the strong contractions

3The client reports that she feels the urge to move her bowels

A nitrazine test strip that turns deep blue indicates that the fluid being tested has a pH of: 1 4.5 2 5.5 3 6.5 4 7.5

4 7.5

A mother asks the neonatal nurse why her infant must be monitored for hypoglycemia when her type 1 diabetes was in excellent control during her pregnancy. How should the nurse respond? 1. "A newborn's glucose level drops after birth, so we're being especially cautious with your baby because of your diabetes." 2. "A newborn's pancreas produces an increased amount of insulin during the first day of birth, so we're checking to see whether hypoglycemia has occurred." 3. "Babies of mothers with diabetes do not have large stores of glucose at birth, so it's difficult for them to maintain the blood glucose level within an acceptable range." 4. "Babies of mothers with diabetes have a higher-than-average insulin level because of the excess glucose received from the mothers during pregnancy, so the glucose level may drop."

4. "Babies of mothers with diabetes have a higher-than-average insulin level because of the excess glucose received from the mothers during pregnancy, so the glucose level may drop."

A client in active labor is rushed from the emergency department to the labor and birth suite screaming, "Knock me out!" Examination reveals that her cervix is dilated 9 cm. What should the nurse say while trying to calm the client? 1. "I'll rub your back—that will help ease your pain." 2. "You'll get a shot when you reach the birthing room." 3. "I'm sure you're in pain, but try to bear with it for the baby's sake." 4. "Medication may interfere with the baby's first breaths; keep breathing."

4. "Medication may interfere with the baby's first breaths; keep breathing."

What should be included in the plan of care for a client with class I cardiac disease during the last weeks of pregnancy? 1. Administering penicillin, promoting periods of rest, and daily testing of urine for protein 2. Maintaining bedrest, administering oxygen and penicillin, and monitoring for cardiac decompensation 3. Instituting seizure precautions and instructing the client to report dyspnea, coughing, palpitations, and increased fatigue 4. Advising the client to limit stress, promoting rest after meals, and educating the client about the analgesia and anesthesia used during labor

4. Advising the client to limit stress, promoting rest after meals, and educating the client about the analgesia and anesthesia used during labor

A nurse determines that a newborn has a cephalhematoma. What did the nurse note? 1. Ridges where the cranial bones overlap 2. Edema involving the scalp over the occipital area 3. Pulsation of the cerebral arteries in the anterior and posterior fontanels 4. Bleeding between the parietal bone and periosteum confined within the suture line

4. Bleeding between the parietal bone and periosteum confined within the suture line

A client who is visiting the family planning clinic is prescribed an oral contraceptive. As part of teaching, the nurse plans to inform the client of the possibility of: 1. Cervicitis 2. Ovarian cysts 3. Fibrocystic disease 4. Breakthrough bleeding

4. Breakthrough bleeding

A nurse is caring for a client with tertiary syphilis. Which body system should the nurse monitor most closely? 1. Respiratory 2. Reproductive 3. Integumentary 4. Cardiovascular

4. Cardiovascular **Syphilis is primarily a vascular disease; aortitis, valvular insufficiency, and aortic aneurysms are the most prevalent problems in tertiary syphilis.

A client has chosen not to have her son circumcised. What instruction should be included in discharge teaching for the care of an uncircumcised neonate? 1. Assess the penis daily for signs of bleeding. 2. Apply petroleum jelly to the penis for 1 week. 3. Pull the foreskin back once a day for 1 month. 4. Clean the penis with warm water at each diaper change

4. Clean the penis with warm water at each diaper change

What is the safest and most reliable birth control method for the nurse to recommend to a client with type 1 diabetes? 1. Vaginal sponge 2. Oral contraceptive 3. Rhythm method with a condom 4. Diaphragm with a spermicidal gel

4. Diaphragm with a spermicidal gel

At 30 weeks' gestation a client with class II cardiac disease expresses concern about her labor and asks the nurse what to expect. What does the nurse tell the client to expect if cardiac decompensation occurs? 1. Elective cesarean birth 2. Artificial rupture of the membranes 3. Induction of labor with an oxytocin infusion 4. Epidural anesthesia with a vacuum extraction birth

4. Epidural anesthesia with a vacuum extraction birth

A nurse is planning for the discharge of a crack-addicted 17-year-old mother and her newborn. What is the most appropriate referral to meet the mother's and infant's needs? 1. Legal aid 2. Family court 3. Foster parent care 4. Home health nurse

4. Home health nurse

A nurse is caring for a client in labor who is receiving epidural anesthesia. For which common side effect of this route of anesthesia should the client be monitored? 1. Sinus tachycardia 2. Urinary frequency 3. Respiratory distress 4. Hypotensive episodes

4. Hypotensive episodes

A woman who had a home birth brings the infant to the well-baby clinic on the third day after the birth, and the infant weighs 5% less than at birth. What does the nurse suspect as the cause of this weight loss? 1. Viral or bacterial infection 2. Obstructive gastrointestinal anomaly 3. Generalized muscle response to stimulation 4. Imbalance between nutrient intake and fluid loss

4. Imbalance between nutrient intake and fluid loss

What nursing action best promotes parent-infant attachment behaviors? 1. Restricting visitors on the postpartum unit 2. Supporting rooming-in with parent-infant care 3. Encouraging the mother to choose breastfeeding 4. Keeping the new family together immediately after the birth

4. Keeping the new family together immediately after the birth

What factor identified by the nurse in a client's history places the client at increased risk for breast cancer? 1. Early menopause 2. Low-income background 3. Delayed onset of menarche 4. Late beginning of childbearing

4. Late beginning of childbearing

Where is the best area for the nurse to determine adequate tissue oxygenation in a neonate born of black parents? 1. Heels and buttocks 2. Upper tips of the ears 3. Nail beds on the hands and feet 4. Mucous membranes of the mouth

4. Mucous membranes of the mouth

A nurse is evaluating the rate of involution of a client's uterus on the second postpartum day. Where does the nurse expect the fundus to be located? 1. At the level of the umbilicus 2. One fingerbreadth above the umbilicus 3. Above and to the right of the umbilicus 4. One or two fingerbreadths below the umbilicus

4. One or two fingerbreadths below the umbilicus

The practice of separating parents from their newborn immediately after birth and limiting their time with the infant during the first few days after delivery contradicts studies of: 1. Early rooming-in 2. Taking-in behaviors 3. Taking-hold behaviors 4. Parent-child attachment

4. Parent-child attachment

A postpartum client is being prepared for discharge. The laboratory report indicates that she has a white blood cell (WBC) count of 16,000/dL. What is the next nursing action? 1. Checking with the nurse manager to see whether the client may go home 2. Reassessing the client for signs of infection by taking her vital signs 3. Delaying the client's discharge until the practitioner has conducted a complete examination 4. Placing the report in the client's record because this is an expected postpartum finding

4. Placing the report in the client's record because this is an expected postpartum finding **Leukocytosis (15,000-20,000 mm3 WBC) typically occurs during the postpartum period as a compensatory defense mechanism. There is no need for further intervention, because the client is exhibiting an expected postpartum leukocytosis.

Before the administration of Rho(D) immune globulin (RhoGAM) the nurse reviews the laboratory data of a pregnant client. Which blood type and Coombs test result must a pregnant woman have to receive RhoGAM after giving birth? 1. Rh-positive and Coombs positive 2. Rh-negative and Coombs positive 3. Rh-positive and Coombs negative 4. Rh-negative and Coombs negative

4. Rh-negative and Coombs negative **Rho(D) immune globulin (RhoGAM) is given to an Rh-negative mother after birth if the infant is Rh positive and the Coombs test reveals that the mother was not previously sensitized (negative).

A nurse assesses a new mother who is breastfeeding. The client asks how to care for her nipples. What should the nurse recommend? 1. Putting lanolin cream on the nipples after breastfeeding 2. Applying vitamin E gel to the nipples before breastfeeding 3. Using soap and water to clean the breasts and nipples at least once a day 4. Spreading breast milk on the nipples after the feeding and allowing them to air dry

4. Spreading breast milk on the nipples after the feeding and allowing them to air dry

A couple who recently immigrated from Israel tell a nurse in the prenatal clinic that they are concerned about a genetic disease that is prevalent among Jewish people. Which genetic screening should the nurse expect the health care provider to recommend to determine the possibility of the couple's child's inheriting the disease? 1. Cystic fibrosis 2. Phenylketonuria 3. Turner syndrome 4. Tay-Sachs disease

4. Tay-Sachs disease **Tay-Sachs disease is a genetic disorder transmitted as an autosomal recessive trait that occurs primarily among Ashkenazi Jews. Cystic fibrosis, Phenylketonuria, and Turner syndrome do not have a higher prevalence in the Jewish population.

A male born at 28 weeks' gestation weighs 2 lb 12 oz. What characteristic does the nurse expect to observe? 1. Staring eyes 2. Absence of lanugo 3. Descended testicles 4. Transparent red skin

4. Transparent red skin

A preterm infant is started on digoxin (Lanoxin) and furosemide (Lasix) for persistent patent ductus arteriosus. Which clinical finding provides the best indication of the effectiveness of the furosemide? 1. Pedal edema is reduced. 2. Digoxin toxicity is avoided. 3. Fontanels appear depressed. 4. Urine output exceeds fluid intake

4. Urine output exceeds fluid intake

A nurse is caring for a client who is being given intravenous magnesium sulfate to treat preeclampsia. Which adverse side effect alerts the nurse to notify the health care provider? 1. Respiratory rate of 18 breaths/min 2. 2+ patellar reflex response 3. Magnesium blood level of 5 mEq/L 4. Urine output of less than 100 mL in 4 hours

4. Urine output of less than 100 mL in 4 hours

A client is admitted to the birthing room in active labor. The nurse determines that the fetus is in the left occiput posterior (LOP) position. At what point can the fetal heart be heard? 1. right side above the umbilicus A 2. left side above the umbilicus B 3. right side below the umbilicus C 4. left side below the umbilicus D

4. left side below the umbilicus D

The nurse is caring for a group of postpartum clients. Which factor puts a client at increased risk for postpartum hemorrhage? 1.Breastfeeding in the birthing room 2.Receiving a pudendal block for the birth 3.Having a third stage of labor that lasts 10 minutes 4.Giving birth to a baby weighing 9 lb 8 oz

4.Giving birth to a baby weighing 9 lb 8 oz

A primigravida at 12 weeks' gestation complains of nausea and vomiting during a visit to the prenatal clinic. Which pregnancy hormone should the nurse explain is thought to be responsible for nausea and vomiting during the first trimester? 1.Estrogen 2.Progesterone 3.Human placental lactogen (hPL) 4.Human chorionic gonadotropin (hCG)

4.Human chorionic gonadotropin (hCG)

A woman in the family planning clinic has decided to use the diaphragm for contraception. What should the nurse teach her about using a diaphragm? 1.Completely cover the outside of the diaphragm with spermicidal jelly or cream. 2.Douche within 1 hour of intercourse to enhance the effectiveness of the diaphragm. 3.Correct placement of the diaphragm leaves an inch between the diaphragm and the vaginal wall. 4.Insert the diaphragm before intercourse and leave it in at least 6 hours after intercourse to kill all the sperm

4.Insert the diaphragm before intercourse and leave it in at least 6 hours after intercourse to kill all the sperm

A pregnant couple is attending preparation-for-childbirth classes. Which exercise should the nurse teach the mother to increase the tone of the muscles of the pelvic floor? 1.Pelvic tilt 2.Half sit-ups 3.Pelvic rocking 4.Kegel exercises

4.Kegel exercises

A 28-year-old woman is scheduled to undergo a laparoscopic bilateral salpingo-oophorectomy. What does a nurse expect to be the client's priority concern? 1.Acute pain 2.Risk for hemorrhage 3.Fear of chronic illness 4.Loss of childbearing potential

4.Loss of childbearing potential

A pregnant client is experiencing nausea and vomiting. The nurse determines that this discomfort: 1.Is always present during early pregnancy 2.Will disappear when lightening occurs 3.Is a common response to an unwanted pregnancy 4.May be related to an increased human chorionic gonadotropin level

4.May be related to an increased human chorionic gonadotropin level

A nurse is planning care with a client for the recovery period after a laparoscopic hysterectomy and bilateral salpingo-oophorectomy. What should be included among the changes that the client should expect after surgery? 1.Depression 2.Weight gain 3.Urine retention 4.Surgical menopause

4.Surgical menopause

A client who has had recurrent infections before and during pregnancy should be instructed to eat a nutrient-rich diet as a means of supporting the body's natural defense mechanisms. What should the nurse encourage the client to include in her diet? 1.Fat-soluble vitamins 2.Dietary fiber and oat bran 3.Low-fat foods with essential fatty acids 4.Vitamins A, C, and E and selenium

4.Vitamins A, C, and E and selenium

One minute after birth a nurse assesses a newborn and auscultates a heart rate of 90 beats/min. The newborn has a strong, loud cry; moves all extremities well; and has acrocyanosis but is otherwise pink. What is this neonate's Apgar score?

Getting an informed consent signed by the mother of the baby

A 15-year-old emancipated minor gave birth to a boy 36 hours ago and has requested a circumcision. What is the nurse's priority?

"Insulin dosage and dietary needs will be adjusted in accordance with the results of blood glucose monitoring."

A 24-year-old client who has had type 1 diabetes for 6 years is concerned about how her pregnancy will affect her diet and insulin needs. How should the nurse respond?

Compression by the enlarging uterus

A client at 11 weeks' gestation reports having to urinate more often. The nurse explains that urinary frequency often occurs because bladder capacity during pregnancy is diminished by:

"A beta-adrenergic."

A client at 31 weeks' gestation is admitted in preterm labor. She asks the nurse whether there is any medication that can stop the contractions. What is the nurse's response?

A decrease in frequency and duration of contractions

A client at 32 weeks' gestation is admitted to the prenatal unit in preterm labor. An infusion of magnesium sulfate is started. What physiological response indicates to the nurse that the magnesium sulfate is having a therapeutic effect?

Dyspnea

A client at 36 hours' postpartum is being treated with subcutaneous enoxaparin (Lovenox) for deep vein thrombosis of the left calf. Which client adaptation is of most concern to the nurse who is monitoring the client?

Providing a dark, quiet room with minimal stimuli

The ribcage is not compressed, then released during birth.

A client has a cesarean birth. The nurse monitors the newborn's respiration because infants subjected to cesarean birth are more prone to atelectasis. Why does this occur?

Preparing for a cesarean birth

A client is admitted in active labor at 39 weeks' gestation. During the initial examination the nurse identifies multiple red blister-like lesions on the edges of the client's vaginal orifice. Once the nurse has spoken to the practitioner and receive prescriptions, the priority nursing action is:

Discuss why bedrest is necessary

A client is found to have preeclampsia, and bedrest at home is prescribed. It is doubtful that this client will be able to comply because she has two preschool children. What should be included in the plan of care that may help the client follow the prescribed regimen?

Urine retention

A client is receiving an epidural anesthetic during labor. For which side effect should the nurse monitor the client?

ABO incompatibility

A client who has type O Rh-positive blood gives birth. The neonate has type B Rh-negative blood. Eleven hours after birth, the infant's skin appears yellow. What is the most likely cause?

High level of chorionic gonadotropin

"Nurse at least every 3 hours for at least 10 minutes on each breast."

A client who is breastfeeding tells a nurse that her breasts are swollen and painful. What can the nurse teach her to do to limit engorgement?

Placenta previa

A client with frank vaginal bleeding is admitted to the birthing unit at 30 weeks' gestation. The admission data include blood pressure of 110/70 mm Hg, pulse of 90 beats/min, respiratory rate of 22 breaths/min, fetal heart rate of 132 beats/min. The uterus is nontender, the client is reporting no contractions, and the membranes are intact. In light of this information, what problem does the nurse suspect?

Side-lying

A client with mild preeclampsia is being treated on an outpatient basis. Three days of bedrest is prescribed. What position should the nurse encourage the client to maintain while in bed?

Prevent injury

A client with severe preeclampsia in the high-risk unit is receiving an infusion of magnesium sulfate. If eclampsia were to occur, what action would the nurse take first?

Central nervous system depressant that blocks neuromuscular transmissions

A client with severe preeclampsia is receiving an IV infusion of magnesium sulfate. The nurse remembers that magnesium sulfate is a:

The fetus may be compromised in utero.

A client's membranes rupture spontaneously during the latent phase of the first stage of labor, and the fluid is greenish brown. What does the nurse conclude?

Tay-Sachs disease

A nurse decides on a teaching plan for a new mother and her infant. What should the plan include?

A demonstration and explanation of infant care

Nonreassuring fetal signs, indicating prolapse of the cord

A health care provider determines that a fetus is in a breech presentation. For which complication should the nurse monitor the client?

Staying with her after bringing the infant to help her verbalize her feelings.

A health care provider tells a mother that her newborn has multiple visible birth defects. The mother seems composed and asks to see her baby. What nursing action will be most helpful in easing the mother's stress when she sees her child for the first time?

Selecting a focal point and beginning breathing techniques

A laboring client has asked the nurse help her to use a nonpharmacological strategy for pain management. Name the sensory simulation strategy.

Decreased blood pressure

A local anesthetic (pudendal block) is administered to a client as second-stage labor begins. For what side effect does the nurse monitor for the client?

6 months

An injury to the brachial plexus during birth

A newborn has a diagnosis of Erb palsy (Erb-Duchenne paralysis). What does a nurse identify as the cause of this complication?

Start resuscitation

A newborn has an Apgar score of 3 at 1 minute after birth. What is the immediate nursing action in response to this Apgar score?

The amount of lochia rubra is moderate.

A demonstration and explanation of infant care

A nurse decides on a teaching plan for a new mother and her infant. What should the plan include?

Documenting the heart rate

A nurse determines that a 1-day-old newborn has a heart rate of 138 beats/min. What is the best nursing action at this time?

Developing a safety plan with the client

Jaundice that develops in the first 12 to 24 hours

A nurse is assessing a newborn for signs of hyperbilirubinemia (pathological jaundice). What clinical finding confirms this complication?

Ductus arteriosus Foramen ovale

Calcium gluconate

A nurse is caring for a client with preeclampsia who is receiving intravenous magnesium sulfate therapy. What antidote should the nurse have readily available?

Absence of the knee-jerk reflex Respiratory rate of 11 breaths/min

A nurse is caring for a client with severe preeclampsia who is receiving magnesium sulfate. What side effects indicate that the serum magnesium level may be excessive? (Select all that apply.)

An audible click on abduction

A nurse is performing the Ortolani test on a newborn. Which finding indicates a positive result?

Preterm infant Small-for-gestational-age infant Large-for-gestational-age infant

A nurse is testing a newborn's heel blood for the level of glucose. Which newborn does the nurse anticipate will experience hypoglycemia? (Select all that apply.)

Straw-colored, clear, and containing little white specks

A nurse observes a laboring client's amniotic fluid and decides that it is the expected color. What finding supports this conclusion?

LOA

A nurse performs Leopold's maneuvers on a newly admitted client in labor. Palpation reveals a soft, firm mass in the fundus; a firm, smooth mass on the mother's left side; several knobs and protrusions on the mother's right side; and a hard, round, movable mass in the pubic area with the brow on the right. On the basis of these findings, the nurse determines that the fetal position is:

The probability of tonic-clonic seizures is reduced.

A nurse places a newly admitted client with worsening preeclampsia in a private room. Why is it important for this client to be in a nonstimulating environment?

A newborn's intestinal tract does not synthesize it for several days after birth.

A nurse prepares to administer vitamin K to a newborn. Why is vitamin K given specifically to newborns?

Amino acids PKU is an inborn error of metabolism involving an inability to metabolize phenylalanine, an essential amino acid. Lactose, glucose, and fatty acids are all metabolized by people with PKU.

A nurse provides a list of foods for a breastfeeding client with phenylketonuria (PKU) to avoid. Which nutrient is included on the list?

Extra circulating glucose causes the fetus to acquire fatty deposits.

A nurse teaching a prenatal class is asked why infants of diabetic mothers are larger than those born to women who do not have diabetes. On what information about pregnant women with diabetes should the nurse base the response?

Mother should be reunited with her infant as soon as possible to enhance adjustment

Infection

A nurse who is admitting a newborn to the nursery observes a fetal scalp monitor site on the scalp. For what complication should the nurse monitor this newborn?

Continue to monitor the blood glucose level per policy.

A nurse who is monitoring the blood glucose level of the term infant of a diabetic mother (IDM) identifies a blood glucose level of 48 mg/dL. What should the nurse do?

Gastric acidity is low and does not provide bacteriostatic protection.

A parent of a newborn asks, "Why do I have to scrub my baby's formula bottles?" What information about a newborn should the nurse consider before replying in language that the parent will understand?

Decreased blood pH

A preterm infant with respiratory distress syndrome (RDS) has blood drawn for an arterial blood gas analysis. What test result should the nurse anticipate for this infant?

24th and 28th weeks of gestation

Hypoglycemia

A small-for-gestational-age (SGA) newborn who has just been admitted to the nursery has a high-pitched cry, appears jittery, and exhibits irregular respirations. What complication does the nurse suspect?

Administration of antibiotics before delivery

A woman in active labor arrives at the birthing unit. She tells the nurse that she was found to have a chlamydial infection the last time she visited the clinic but that she stopped taking the antibiotic after 3 days because she "felt better." What would the nurse anticipate as part of the plan of care, in light of this history?

Call an ambulance to go to the emergency department.

A woman who was discharged recently from the hospital after undergoing a hysterectomy calls the clinic and states that she has tenderness, redness, and swelling in her right calf. What should the nurse instruct the client to do?

Leg lifts and sit-ups

A woman with an active lifestyle is in her 30th week of pregnancy. Which activity will the nurse discourage?

A 16-year-old primigravida who appears to be at or close to term arrives at the emergency department stating that she is in labor and complaining of pain continuing between contractions. The nurse palpates the abdomen, which is firm and shows no sign of relaxation. What problem does the nurse conclude that the client is experiencing?

Abruptio placentae

Administering 2 tablets of acetaminophen and oxycodone (Percocet) to a client who rates her pain as 7 of 10

Call for assistance and don sterile gloves Insert two fingers into the vagina and exert upward pressure against the fetal presenting part Put a rolled towel under one hip and place in the modified Sims position Administer oxygen to the mother and monitor fetal heart tones

After a client's membranes rupture spontaneously, the nurse sees the umbilical cord protruding from the vagina. Place the nursing interventions in order of priority.

Reflex irritability: cry Respiratory rate: good cry Heart rate: 110 beats/min

After a difficult birth, a neonate has an Apgar score of 8 after 5 minutes. Which signs met the criteria of 2 points? (Select all that apply.)

Below the umbilicus on the right side

After performing Leopold maneuvers on a laboring client, a nurse determines that the fetus is in the right occiput posterior (ROP) position. Where should the Doppler ultrasound transducer be placed to best auscultate fetal heart tones?

A client in her 10th week of pregnancy exhibits presumptive signs of pregnancy that the nurse may detect. (Select all that apply.)

Amenorrhea Breast changes Urinary frequency

Reducing her blood pressure

An 18-year-old primigravida at 36 weeks' gestation is admitted with a diagnosis of mild preeclampsia. What is the nurse's most important goal for this client?

Occiput posterior

An expectant couple asks the nurse about the cause of low back pain during labor. The nurse replies that this pain occurs most often when the fetus is positioned:

Bulging fontanels

An infant has surgery for repair of a myelomeningocele. For which early sign of impending hydrocephalus should the nurse monitor the infant?

A client who has just begun breastfeeding complains that her nipples feel very sore. What should the nurse encourage the mother to do? (Select all that apply.)

Apply cool packs to her breasts to reduce the discomfort Take the analgesic medication prescribed to limit the discomfort Assume a different position when breastfeeding to adjust the infant's sucking

A newborn male is being discharged 4 hours after having had a circumcision. What should the nurse instruct the mother to do?

Apply the diaper loosely for several days

What is the best nursing intervention to minimize perineal edema after an episiotomy?

Applying ice packs

An infant born at 40 weeks' gestation weighs 6 lb 13 oz (3090 g). What category describes this neonate?

Appropriate for gestational age (AGA) and term

Suctioning the mouth

At 10 hours of age a newborn has a large amount of mucus in the nasopharynx and becomes cyanotic. What is the nurse's initial action?

"It's understandable for you to be worried that you won't be able to carry this pregnancy to term. You've had a difficult time."

At 12 weeks' gestation a client with a history of frequent spontaneous abortions says to the nurse, "Every day I wonder whether I'll be able to have this baby." How should the nurse respond?

Epidural anesthesia with a vacuum extraction birth

A client at 35 weeks' gestation is experiencing contractions. Her cervix is dilated 2 cm. The nurse teaches the client that sexual activity, particularly intercourse, should be:

Avoided to limit the onset of labor

Below the umbilicus on the right side

A nurse is caring for a postpartum client who had abruptio placentae. Which finding indicates that disseminated intravascular coagulation (DIC) is occurring?

Bleeding at the venipuncture site

A client in the birthing suite has spontaneous rupture of the membranes, after which a prolapsed cord is identified. The nurse calls for help and with a sterile gloved hand moves the fetal head off the cord. What should the nurse anticipate?

Cesarean birth

Shortly after birth the nurse instills erythromycin ophthalmic ointment in the newborn's eyes. The father asks why an antibiotic is needed because the mother does not have an infection. The nurse explains that it protects the newborn from:

Chlamydia and gonorrhea

A nurse in the clinic determines that a 4-day-old neonate who was born at home has a purulent discharge from the eyes. What condition does the nurse suspect?

Chlamydia trachomatis infection

Which risk factors are associated with the future development of osteoporosis in women? (Select all that apply.)

Cigarette smoking Familial predisposition Inadequate intake of dietary calcium

A client in active labor is admitted to the birthing room. A vaginal examination reveals that the cervix is dilated 6 to 7 cm. In light of this finding, the nurse expects that the:

Client's contractions will become longer and more frequent

Comparing the identification bands of mother and infant

A client at 11 weeks' gestation reports having to urinate more often. The nurse explains that urinary frequency often occurs because bladder capacity during pregnancy is diminished by:

Compression by the enlarging uterus

One hour after a birth a nurse palpates a client's fundus to determine whether involution is taking place. The fundus is firm, in the midline, and two fingerbreadths below the umbilicus. What should the nurse do next?

Continue periodic evaluations and record the findings

Decrease caffeine intake

A pregnant woman who was admitted to the high-risk maternity unit for severe hyperemesis gravidarum is receiving total parenteral nutrition (TPN). Intralipids are not being administered. For what potential complication should the nurse monitor the client?

Dehydration

An infant is born with a bilateral cleft palate. Plans are made to begin reconstruction immediately. What nursing intervention should be included to promote parent-infant attachment?

Demonstrating positive acceptance of the infant

Discontinuing the test because the pattern is reassuring

Ensuring that the client's diet is nutritionally adequate

During a prenatal interview at 20 weeks' gestation, the nurse determines that the client has a history of pica. What is the most appropriate nursing action?

Hypocalcemia; increase her intake of milk

During a routine prenatal visit, a client tells a nurse that she gets leg cramps. What condition does the nurse suspect, and what suggestion is made to correct the problem?

"The heart rate is usually rapid, and this one is in the expected range."

During a routine visit to the prenatal clinic a client listens to the fetal heartbeat for the first time. The client, commenting on how rapid it is, appears frightened and asks whether this is normal. The nurse should explain:

Suctioning the airway

During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn?

A client in her 37th week of gestation calls a nurse in the prenatal clinic and reports, "My ankles are swollen." What should the nurse recommend?

Elevating her legs more frequently during the day

ROA, 0 station

A client is admitted in active labor to the birthing center. She is 100% effaced, dilated 3 cm, and at +1 station. What stage of labor does the nurse identify?

First

After being transported to the hospital by the ambulance, a pregnant woman is brought into the emergency department on a stretcher. The nurse notes that the fetus' head has emerged. How should the nurse assist the mother in the birth of the fetus' anterior shoulder?

Gently guiding the head downward

A primigravida is admitted to the birthing unit in active labor. The fetus is in a breech presentation. What physiological response does the nurse expect during this client's labor?

Greenish-tinged amniotic fluid

To help the uterus contract

Immediately after the third stage of labor a nurse administers the prescribed oxytocin (Pitocin) infusion. Why is this medication administered?

Offering a feeding

In specific situations gloves are used to handle newborns whether or not they are HIV positive. When is it unnecessary for the nurse to wear gloves while caring for a newborn?

A client making her first visit to the prenatal clinic asks which immunization can be administered safely to a pregnant woman. What should the nurse tell her?

Inactive influenza

A neonate has phenylketonuria (PKU). What information should the nurse include in a discussion with the parents when explaining what caused their infant's problem?

Inborn error of metabolism

A 26-year-old primigravida experiencing severe abdominal pain is brought to the emergency department by ambulance with a suspected ruptured tubal pregnancy. What should the nurse do first?

Insert an intravenous catheter

A multigravida in active phase of labor says, "I feel all wet. I think I urinated." What should the nurse do first?

Inspect her perineal area

Since giving birth six months ago, a woman has breastfed her infant. The woman becomes hysterical after learning that her husband has been seriously injured in an automobile accident. Culturally this woman believes that emotional stress while breastfeeding can "sour the milk," and she indicates that she must wean her infant immediately. What should the nurse do?

Instruct the mother about formula feeding

A thin older adult client is found to have osteoporosis. What should the nurse include in the discharge plan for this client?

Instructions relative to diet and exercise

What is a common problem that affects the client in labor when an external fetal monitor has been applied to her abdomen?

Intrusion on movement

A nurse is writing a teaching plan about osteoporosis. How should the nurse explain what osteoporosis is?

It involves a decrease in bone substance.

What is an important nursing intervention when a client is receiving intravenous (IV) magnesium sulfate for preeclampsia?

Maintaining a quiet, darkened environment

A nurse who is caring for a 32-week appropriate-for-gestational-age (AGA) neonate develops a plan of potential interventions for the neonate. What is the priority intervention?

Maintaining respirations

One hour postpartum a nurse evaluates the amount of vaginal bleeding and determines that a client's uterus has become relaxed and boggy. What should the nurse do next?

Massage the uterus until firm

After a cesarean birth a nurse performs fundal checks every 15 minutes. The nurse determines that the fundus is soft and boggy. What is the priority nursing action at this time?

Massaging the client's fundus

A 42-year-old client undergoes amniocentesis during the 16th week of gestation because of concern about Down syndrome. What additional information about the fetus will examination of the amniotic fluid reveal at this time?

Neural tube defect

A client at 40 weeks' gestation is admitted to the birthing unit in early active labor. She tells the nurse that her membranes ruptured 26 hours ago. Assessments of the fetal heart rate range between 168 and 174 beats/min. What is the priority nursing action?

Obtaining maternal vital signs

A 28-year-old woman seeks advice about oral contraceptives from the nurse in her company health office. What should the nurse tell her if she is a smoker

Oral contraceptives can cause thrombophlebitis.

What actions are part of nursing care during the fourth stage of labor for the client with a fourth-degree laceration? (Select all that apply.)

Pain management with oral analgesics Assessment of the site every 15 minutes Application of an ice pack for 20-minute intervals

During labor the nurse encourages the client to void periodically. The nurse knows that an over distended urinary bladder during labor can:

Predispose the client to uterine hemorrhage after birth

The nurse administers the prescribed vitamin K intramuscularly to a newborn immediately after birth to:

Promote the synthesis of prothrombin

What antidote to the side effects of terbutaline (Brethine) should a nurse have available?

Propranolol (Inderal)

A client's membranes rupture during the transition phase of labor, and the amniotic fluid appears pale green. What priority intervention for the infant can the nurse anticipate implementing upon delivery?

Providing for suctioning of the oropharynx as the head emerges

A client is scheduled for amniocentesis. What should the nurse do before the procedure?

Remind the client to empty her bladder

During the second reactive period a newborn becomes more alert and responsive and there is an increase in mucus production and gagging. What should the nurse do first?

Remove secretions from the pharynx

A fetal monitor is applied to a client in labor. The nurse should take action in response to a fetal heart rate that:

Repeatedly drops abruptly to 90 beats/min unrelated to contractions

An increased Paco 2 of 55 mm Hg

Respiratory acidosis is confirmed in a neonate with respiratory distress syndrome when the laboratory report reveals:

A laboring client has asked the nurse help her to use a nonpharmacological strategy for pain management. Name the sensory simulation strategy

Selecting a focal point and beginning breathing techniques

Stop taking the supplement immediately. Discuss the use of the supplement with the practitioner Discuss the use of any over-the-counter products with the practitioner.

On the second day of life, minutes after drinking 2½ ounces of formula, a newborn regurgitates about half an ounce. The mother remarks, "My baby spits up after every feeding." What should the nurse do next?

Suggest that she hold her baby upright for 30 minutes after feeding

Verifying oxygen saturation frequently to adjust flow on the basis of need

Supplemental oxygen is ordered for a preterm neonate with respiratory distress syndrome (RDS). What action does the nurse take to reduce the possibility of retinopathy of prematurity?

The amount of lochia rubra is moderate

Taking-in

The gravida 1 now para 1 woman delivered a 7-lb 6 oz female infant at 11 pm yesterday after a labor of 14 hours. After breakfast the nursery staff brings the baby to the new mother. The mother smiles at the baby, then asks that the nurse take the baby back to the nursery because she has not had a shower yet. One hour later the nurse returns with the infant. Again the mother smiles at the baby; then she holds her, kisses her, and feeds her a bottle. Immediately after feeding the baby, the mother calls the nursery and asks that the baby be picked up so she can take a nap. What behavior is the new mother demonstrating?

"The health care provider will tell you how your baby's pain will be controlled."

The mother of a newborn son tells the nurse that she is concerned about circumcision because of the pain involved. What is the nurse's best response?

Position of the fetus and the placenta

The nurse teaches a client who is to undergo amniocentesis that ultrasonography will be performed just before the procedure to determine the:

The cause is an increased intravascular pressure during birth.

The parents of a newborn are concerned about red pinpoint dots on their infant's face and neck. How should the nurse explain the finding?

Buccal smear

The parents of a newborn are told that their neonate may have Down syndrome and that additional diagnostic studies will be done to confirm this diagnosis. What procedure does the nurse expect to be performed?

Most important is the institution of a corrective formula soon after birth.

The parents of a newborn with phenylketonuria (PKU) ask a nurse how to prevent future problems. What must the nurse consider before responding?

Low-lying

The practitioner diagnoses placenta previa. What does this indicate to the nurse about the condition of the placenta?

Staphylococcus aureus

The transmission of which microorganism that causes maternal mastitis is minimized by frequent handwashing by nursing staff members?

A woman who is 28 weeks pregnant calls the clinic to report that she is frightened because she is leaking breast milk. The best response is to tell her that:

This can be a normal occurrence during pregnancy

A newborn's total body response to noise or movement is often distressing to the parents. What should the nurse explain about this response?

This reflexive response is an expected part of development.

Immature liver function

Three days after birth, a breastfeeding newborn becomes jaundiced. The parents bring the infant to the clinic and blood is drawn for an indirect serum bilirubin determination, which reveals a concentration of 12 mg/dL. The nurse explains that what the infant has is physiological jaundice, a benign condition, caused by:

A vaginal examination reveals that a client in labor is dilated 7 cm. Soon afterward she becomes nauseated and has the hiccups, and bloody show increases. What phase of labor does the nurse determine the client is entering?

Transition

A client has a diagnosis of an unruptured tubal pregnancy. Which findings correlate with this diagnosis? (Select all that apply.)

Unilateral abdominal pain History of a sexually transmitted infection

A practitioner prescribes penicillin G benzathine suspension (Bicillin L-A) 2.45 million units for a client with a sexually transmitted infection (STI). The medication is available in a multidose vial of 10 mL in which 1 mL = 300,000 units. How many milliliters should the nurse administer? Record your answer using one decimal place. ____ mL.

Use ratio and proportion: 2, 450,000 units : 300,000 units = x mL : 1 mL 300,000x = 2,450,000 x = 8.2 mL

What complication should a nurse be alert for in a client receiving an oxytocin (Pitocin) infusion to induce labor?

Uterine tetany

A nurse instructs a client who is taking oral contraceptives to increase her intake of dietary supplements. Which supplement should be increased? Calcium Vitamin C Vitamin E Potassium

Vitamin C

Restricting visitors Maintaining a quiet environment

What are the primary nursing interventions when a client is receiving an infusion of magnesium sulfate for severe preeclampsia? (Select all that apply.)

Barely visible areolae and nipples

What characteristic does the nurse anticipate in an infant born at 32 weeks' gestation?

Will be encouraged to participate in his care as much as possible

Preterm labor Multiple gestation Chromosomal anomalies Bleeding in the first trimester

Women who become pregnant for the first time at a later reproductive age (35 years or older) are at risk for what complications? (Select all that apply.)

The partner of a woman experiencing back pain in labor asks what he can do to help. The nurse demonstrates how to apply counterpressure to his partner's back. Where on the image should counterpressure be applied?

Antibiotic

something with cardiac...mitral valve stenosis

A client in active labor becomes very uncomfortable and asks a nurse for pain medication. Nalbuphine (Nubain) is prescribed. How does this medication relieve pain?

By acting on opioid receptors to reduce pain

How should the nurse assess a newborn's grasp reflex?

By pressing the examining fingers against the palms of the newborn's hands

A 7-lb, 4-oz (3290-g) boy is admitted to the nursery and placed in a warm crib. The neonate begins to choke on mucus. How should the nurse suction him with a bulb syringe?

By suctioning the mouth before the nostrils

The nurse visualizes and palpates a generalized, soft, edematous area of the scalp on the occiput of a newborn. What does the nurse suspect?

Caput succedaneum

A couple interested in family planning ask the nurse about the cervical mucus method of family planning. The nurse explains that with this method the couple must avoid intercourse when and a few days after the cervical mucus is:

Clear and stretchable

These findings indicate that the infant may have a pneumothorax, and the health care provider should be contacted immediately.

Continuous positive-pressure ventilation therapy by way of an endotracheal tube is started in a newborn with respiratory distress syndrome (RDS). The nurse determines that the infant's breath sounds on the right side are diminished and that the point of maximum impulse (PMI) of the heartbeat is in the left axillary line. How should the nurse interpret these data?

A nurse determines that a 1-day-old newborn has a heart rate of 138 beats/min. What is the best nursing action at this time?

Documenting the heart rate

A client at 16 weeks' gestation arrives at the prenatal clinic for a routine visit. During the examination the nurse notes bruises on the client's face and abdomen. There are no bruises on her legs and arms. Further assessment is required to confirm:

Domestic abuse

A primigravida asks when she will be able to hear the fetal heartbeat for the first time. The nurse should explain that the heartbeat can be heard with:

Doppler ultrasound at 10 to 12 weeks

"Because you need salt to maintain body water Balance; it is not restricted. Just eat a well-balanced diet."

Early parenting behavior

Three vessels: one vein and two arteries

During a newborn assessment the nurse counts the infant's cord vessels. What does the nurse expect to observe in a healthy newborn?

Breathe into her cupped hands

During labor a client begins to experience dizziness and tingling of her hands. What should the nurse instruct the client to do?

Predispose the client to uterine hemorrhage after birth

During labor the nurse encourages the client to void periodically. The nurse knows that an over distended urinary bladder during labor can:

Cervix effaces and dilates during true labor.

During prenatal classes the nurse teaches the difference between true labor and false labor. How does the nurse explain the difference?

Cephalhematoma

During the discharge examination of a 2-day-old newborn, the nurse observes an edematous area confined to the right side of the scalp. How should the nurse document this condition?

A nurse is teaching a childbirth class to a group of pregnant women. One of the women asks the nurse at what point during the pregnancy the embryo becomes a fetus. How should the nurse respond

During the eighth week of the pregnancy

Remove secretions from the pharynx

During the second reactive period a newborn becomes more alert and responsive and there is an increase in mucus production and gagging. What should the nurse do first?

Family history of genetic abnormalities

During their first visit to the prenatal clinic a couple asks the nurse whether the woman should have an amniocentesis for genetic studies. Which factor indicates that an amniocentesis should be performed?

Dyspnea

A nurse plans to evaluate a postpartum client's uterine fundus for involution. What should the nurse ask the client to do before this assessment?

Empty her bladder

Encourage the family to bring in special foods preferred in their culture

A client with a history of endometriosis has abdominal surgery to remove adhesions. What should this client's postoperative plan of care include?

Encouraging the client to ambulate in the hallway

At 9 pm visiting hours are officially over, but the sister of a newly admitted postpartum client remains at the bedside. What is the most appropriate nursing intervention?

Encouraging the sister to participate in care as much as the client wishes

Enlarging area of caput with each contraction

A client is taking a progesterone oral contraceptive (minipill). The nurse instructs the client to take one pill daily during the:

Entire menstrual cycle

After a spontaneous vaginal delivery the client expresses concern because the newborn has a red rash with small papules on the face, chest, and back. What condition does the nurse recognize?

Erythema toxicum

Hydramnios is diagnosed in a primigravida at 35 weeks' gestation. What condition of the newborn is associated with hydramnios?

Esophageal atresia

A nurse teaches a new mother about neonatal weight loss in the first 3 days of life. What does the nurse explain is the cause of this weight loss?

Excretion of accumulated excess fluids

A breastfeeding mother asks the nurse how human milk compares with cow's milk. How should the nurse respond

Fat in human milk is easier to digest and absorb than the fat in cow's milk

What findings occur with supine hypotensive syndrome? (Select all that apply.)

Feeling of faintness Increased venous pressure Decreased systolic pressure

An infant born with hydrocephalus is to be discharged after insertion of a ventriculoperitoneal shunt. Which common complication should the nurse instruct the parents to report if it occurs at home?

Fever accompanied by decreased responsiveness

Five minutes after being born, a newborn is pale; has irregular, slow respirations; has a heart rate of 120 beats/min; displays minimal flexion of the extremities; and has minimal reflex responses. What is this newborn's Apgar score?

"What is the baby's daily schedule?"

Four weeks after giving birth, a client is agitated and tells the clinic nurse, "The baby cries all the time, and I don't know what to do." What question should the nurse ask before planning nursing care?

While a client is being interviewed on her first prenatal visit she states that she has a 4-year-old son who was born at 41 weeks' gestation and a 3-year-old daughter who was born at 35 weeks' gestation and lost one pregnancy at 9 weeks and another at 18 weeks. Using the GTPAL system, how would you record this information?

G5 T1 P1 A2 L2

A pregnant client is making her first antepartum visit. She has a 2-year-old son born at 40 weeks, a 5-year-old daughter born at 38 weeks, and 7-year-old twin daughters born at 35 weeks. She had a spontaneous abortion 3 years ago at 10 weeks. How does the nurse, using the GTPAL format, document the client's obstetric history?

G5 T2 P1 A1 L4

Absence or weakness of which of the following reflexes during the newborn assessment should the nurse report to the health care provider?

Gag

What does the nurse conclude is related directly to an infant's survival in the neonatal period?

Gestational age and birth weight

Gestational age and birthweight

A 15-year-old emancipated minor gave birth to a boy 36 hours ago and has requested a circumcision. What is the nurse's priority?

Getting an informed consent signed by the mother of the baby

\In the second hour after the client gives birth her uterus is firm, above the level of the umbilicus, and to the right of midline. What is the most appropriate nursing action?

Having the client empty her bladder

Because of the high discomfort level during the transition phase of labor, nursing care should be directed toward:

Helping the client maintain control

How should a nurse direct care for a client in the transition phase of the first stage of labor?

Helping the client maintain control

A primipara delivered 12 hours ago. Although an ice bag has been applied to her perineal area, the client continues to complain of rectal pressure resulting in excruciating pain in the area of the episiotomy that is not relieved with analgesics. What does the nurse conclude is the cause of the client's pain?

Hematoma in the perineal area

High level of chorionic gonadotropin

Stroke the extremities Flick the soles of the feet

How does the nurse perform tactile stimulation to initiate respiration in a newborn? Select all that apply.

Testing heel blood with the use of a glucose-oxidase strip

How should a nurse screen the newborn of a diabetic mother for hypoglycemia?

A client gives birth to a full-term male with an 8/9 Apgar score. What should the immediate nursing care of this newborn include?

Identifying the infant, assessing respirations, and keeping him warm

A woman in the family planning clinic has decided to use the diaphragm for contraception. What should the nurse teach her about using a diaphragm?

Insert the diaphragm before intercourse and leave it in at least 6 hours after intercourse to kill all the sperm.

The nurse is caring for a client in her third trimester who is to undergo amniocentesis. What should the nurse do to prepare the client for this test?

Instruct her to void immediately before the test

The physiological destruction of fetal red blood cells

Jaundice develops in a newborn 72 hours after birth. What should the nurse tell the parents is the probable cause of the jaundice?

Type A or B

Laboratory studies reveal that a pregnant client's blood type is O and she is Rh-positive. Problems related to incompatibility may develop in her infant if the infant is:

What does the nursing care for an infant with necrotizing enterocolitis (NEC) include?

Measuring abdominal girth every 2 hours

What type of lochia should the nurse expect to observe on a client's pad on the fourth day after a vaginal delivery?

Moderate serosa

When calculating an Apgar score for a newborn, what is given a score in addition to the heart rate?

Muscle tone

"The test won't be done until your baby has had enough milk for the results to be accurate."

On her first postpartum day, a client asks the nurse whether her baby has had a test for phenylketonuria (PKU) yet. How should the nurse reply?

"Have you ever had an internal examination done before?"

On her first prenatal visit a client says to the nurse, "I guess I'll be having an internal examination today." What is the nurse's best response?

Iron Folic acid

On her first visit to the prenatal clinic a client with rheumatic heart disease asks the nurse whether she has special nutritional needs. What supplements in addition to the regular pregnancy diet and prenatal vitamin and minerals will she need? (Select all that apply.)

A perfect score is 10; 1 point is deducted for lessened muscle tone (the baby's arms do not flex) and 1 point for acrocyanosis, which is manifested by bluish hands and feet.

One minute after birth a nurse notes that a newborn is crying, has a heart rate of 140 beats/min, is acrocyanotic, resists the suction catheter, and keeps the arms extended. What Apgar score should the nurse assign to the newborn? Record your answer using a whole number. ___

A left modified radical mastectomy is performed on a client with breast cancer. What is the most important measure to be included in the care plan for the first postoperative day?

Placing the client in the semi-Fowler position with the left arm and hand elevated

The nurse is reassessing a newborn who had an axillary temperature of 97° F (36° C) and was placed skin to skin with the mother. The newborn's axillary temperature is still 97° F (36° C) after 1 hour of skin-to-skin contact. Which intervention should the nurse implement next?

Placing the newborn under a radiant warmer in the nursery

A postpartum client is being prepared for discharge. The laboratory report indicates that she has a white blood cell (WBC) count of 16,000/dL. What is the next nursing action?

Placing the report in the client's record because this is an expected postpartum finding

What is the most important parameter for the nurse to monitor during the first 24 hours after the birth of an infant at 36 weeks' gestation?

Respiratory distress

While a client at 30 weeks' gestation is being examined in the prenatal clinic, the nurse identifies a respiratory rate of 26/min, blood pressure of 100/60, and diaphragmatic tenderness, and the client reports increased urinary output. Which finding indicates that the client may be experiencing a complication

Respiratory rate

When a preterm newborn requires oxygen, the nurse in the neonatal intensive care unit monitors and adjusts the oxygen concentration. What complication do these adjustments attempt to prevent?

Retinopathy of prematurity

A newborn has congenital cataracts, microcephaly, deafness, and cardiac anomalies. Which infection does the nurse suspect that the newborn's mother contracted during her pregnancy?

Rubella

What should the nurse tell a new mother will be delayed until her newborn is 36 to 48 hours old?

Screening for phenylketonuria

A woman visits the prenatal clinic because an over-the-counter pregnancy test has rendered a positive result. After the initial examination verifies the pregnancy, the nurse explains some of the metabolic changes that occur during the first trimester of pregnancy. (Select all that apply.)

Sleep needs increase. Fluid retention increases. Calcium requirements increase

What are the indicators of nutritional risk in pregnancy in a client who is of normal weight? (Select all that apply.)

Smoker Twin gestation

During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn?

Suctioning the airway

A nurse is assessing a primigravida who was admitted in early labor after her membranes ruptured. She is at 41 weeks' gestation. Her contractions are irregular and her cervix is dilated 3 cm. The fetal head is at station 0 and the fetal heart rate tracing is reactive. How can the nurse help the client facilitate labor?

Take a walk around the unit with her

Telling the mother, "I'm sorry, but I need to ask you to stay in the waiting area."

A nurse is teaching a childbirth preparation class about the discomfort of labor. What is the greatest influence on the perception of pain for a woman in labor?

Tension of the client

Test the leaking fluid with nitrazine paper

"The progression is slow, so people with myasthenia will spend their younger life with few problems."

The family of a pregnant client with myasthenia gravis asks the nurse whether the client will be an invalid. What is the best response by the nurse?

Below the ischial spines

The fetus of a woman in labor is at +1 station. At what place in the pelvic area does the nurse conclude that the presenting part is located?

Gynecoid A gynecoid pelvis is considered most favorable for a vaginal birth because the inlet allows the fetus room to pass. The gynecoid pelvis is considered the typical female pelvis. An android pelvis, which has a heart shape, is considered a male pelvis. The fetus often gets stuck. The anthropoid pelvis is elongated, with a roomy anterior posterior dimension and a narrower transverse diameter than the gynecoid pelvis. Although delivery is possible with this type of pelvis, it is less likely to be successful. The platypelloid pelvis is flat, with a compressed oval shape as the middle opening, instead of an open circle like the gynecoid pelvis. This is a rare type of pelvis.

The four essential components of labor are powers, passageway, passenger, and psyche. Passageway refers to the bony pelvis. What type of pelvis is considered the most favorable for a vaginal delivery?

Dry and provide skin-to-skin contact with the mother

The health care provider hands a neonate to a nurse immediately after birth. What should the nurse do next for the newborn?

Tongue thrust

The mother of a neonate with Down syndrome visits the clinic 1 week after delivery. She explains to the nurse that she is having problems feeding her baby. What is the probable cause of these feeding difficulties?

Voids six or more times a day

Instruct her to void immediately before the test

The nurse is caring for a client in her third trimester who is to undergo amniocentesis. What should the nurse do to prepare the client for this test?

Stopping the infusion if contractions become hypertonic

The nurse is caring for a client whose labor is to be induced. What is the nurse's responsibility when a client's labor is being stimulated with an oxytocin (Pitocin) infusion?

"This is the time when the baby is likely to be most responsive to you."

The nurse is caring for a couple after the birth of their first child. What should the nurse tell the family to do when their infant is exhibiting the behavior demonstrated in the picture?

The mouth covers most of the areolar surface.

The nurse is helping a mother breastfeed her newborn. What is the best indication that the newborn has achieved an effective attachment to the breast?

"I'm not exactly sure how an epidural works."

The nurse is preparing a client for epidural anesthesia. Which client statement would cause the nurse to stop the placement of the epidural catheter?

At least 15 ejaculations to clear the tract of sperm must occur before the semen is checked.

The nurse is teaching a client who is scheduling a vasectomy. What information is essential that the nurse explain to the client?

Opiate withdrawal syndrome

The nurse observes that 12 hours after birth the neonate is hyperactive and jittery, sneezes frequently, has a high-pitched cry, and is having difficulty suckling. Further assessment reveals increased deep tendon reflexes and a diminished Moro reflex. What problem does the nurse suspect?

A contraction stress test (CST) is performed on a client at 40 weeks' gestation. The findings are interpreted as negative. What does the nurse conclude from this interpretation?

There will be weekly retesting because, at this time, the fetus has oxygen reserves.

Tongue thrust

After her baby's birth a client wishes to begin breastfeeding. How can the nurse assist the client at this time?

Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex

A thin 24-year-old woman who runs 10 miles each week asks the nurse for advice about preventing osteoporosis. Which vitamin and other dietary supplement should the nurse recommend?

Vitamin D and calcium citrate

What is the nurse's initial action immediately after assisting with a precipitous birth in the triage area of the emergency department?

Warming the newborn

A client in labor is receiving an oxytocin (Pitocin) infusion. For which adverse reaction resulting from prolonged administration should the nurse monitor the client?

Water intoxication

A client with endometriosis asks the nurse what side effects to expect from leuprolide (Lupron). What should the nurse include in the response?

Weight gain

Protruding tongue Epicanthal eye folds One transverse palmar crease

What characteristics cause the nurse to suspect that a newborn has Down syndrome? (Select all that apply.)

Protruding tongue Hypotonic muscle tone Broad nose with a depressed bridge

What clinical findings does the nurse expect to observe in a newborn with trisomy 21 (Down syndrome)? (Select all that apply.)

Sudden onset of knifelike pain in one of the lower quadrants

What clinical manifestation requires immediate intervention in a woman with a probable ruptured tubal pregnancy?

Uterine tetany

What complication should a nurse be alert for in a client receiving an oxytocin (Pitocin) infusion to induce labor?

Bradycardia with no change in respirations

What does a nurse expect to find when checking the vital signs of a client in the early postpartum period?

They have a tendency to collapse with each breath.

What does the nurse expect concerning the alveoli in the lungs of a 28-week-gestation neonate?

Diminished cardiac output

What is a nurse's most important concern when caring for a client with a ruptured tubal pregnancy?

Maintaining a quiet, darkened environment

What is an important nursing intervention when a client is receiving intravenous (IV) magnesium sulfate for preeclampsia?

Warming the newborn

What is the nurse's initial action immediately after assisting with a precipitous birth in the triage area of the emergency department?

Monitoring for signs of uterine contractions

What is the priority nursing care after an amniocentesis?

Trendelenburg

What is the safest position for a woman in labor when the nurse notes a prolapsed cord?

Mother-infant interaction

What must the LPN observe first when planning to promote mother-infant attachment?

Keeping the infant in a warm environment

What nursing care is most important for a newborn with respiratory distress syndrome (RDS)?

Elevate the lower extremities.

What recommendation should a nurse give to a client with fluid retention during pregnancy?

A sharp, sudden decrease

What should a nurse anticipate about the insulin requirements of a client with diabetes on her first postpartum day?

Apply cold packs to the breasts frequently.

What should a nurse teach a non-nursing mother to help relieve the discomfort of engorgement?

Protecting the skin surrounding the exposed bladder

What should be included in the teaching plan for the mother of a newborn with exstrophy of the bladder?

Learning specific behaviors involving states of wakefulness to promote positive interactions

What should the nurse discuss with new parents to help them prepare for infant care?

Help the parents stimulate their awake baby through touch, sound, and sight

What should the nurse do to enhance a neonate's behavioral development?

Use tactile stimuli on the chest or extremities

What should the nurse do when an apnea monitor sounds an alarm 10 seconds after cessation of respirations?

Maintenance dosages of cardiac medications will probably be increased

What should the nurse explain to a newly pregnant client with cardiac disease?

Expected movements and behaviors

What should the nurse's initial discussion include to best help new parents understand the unique characteristics of a newborn?

Irritability and muscle tremors

What signs and symptoms of withdrawal does the nurse identify in a postpartum client with a history of opioid abuse?

Moderate serosa

What type of lochia should the nurse expect to observe on a client's pad on the fourth day after a vaginal delivery?

Avoid squeezing them and don't try to wash them off.

When a nurse brings a newborn to a mother, the mother comments about the milia on her infant's face. What information should the nurse include when responding?

Having the visitor step outside the room

When a nurse who is carrying a newborn to the mother enters the room, a visitor asks to hold the infant. The visitor is sneezing and coughing. What is the most important measure for the nurse to take?

Mucous membranes of the mouth

Where is the best area for the nurse to determine adequate tissue oxygenation in a neonate born of black parents?

Increasing fatigue

Which adaptation does the nurse suspect is the result of early decompensation in a pregnant woman with cardiac problems?

Small breast buds Wrinkled thin skin Pinnae that remain flat when folded

Which characteristics should alert the nurse to conclude that a male newborn is a preterm infant? (Select all that apply.)

One who gives birth to an infant weighing 9 lb 8 oz

Which client should a nurse suspect is at increased risk for postpartum hemorrhage?

Face Trunk Buttocks

Which parts of a newborn's body are usually affected by the rash erythema toxicum neonatorum? Select all that apply.

Numerous superficial veins

Which sign indicates to the nurse that a neonate is preterm?

Respiratory rate The increased respiratory rate is one sign of cardiac decompensation ; cardiac output and blood volume peak during the second trimester, and signs and symptoms of cardiac disease become prominent at this time. Oliguria (not increased urine output), accompanied by edema of the face, legs, and fingers, is a sign of cardiac complications. The client's blood pressure is within the expected range for a pregnant woman. Diaphragmatic tenderness is a vague symptom that is not related to heart disease.

Pulmonary edema has developed.

While auscultating the lungs of a client admitted with severe preeclampsia, the nurse identifies crackles. What inference does the nurse make when considering the presence of crackles in the lungs?

Record the fetal response to contractions and continue to monitor the heart rate

While caring for a client in labor, a nurse notes that during a contraction there is a 15-beat/min acceleration of the fetal heart rate above the baseline. What is the nurse's next action?

"Infants' feet appear flat because the arch is covered with a fat pad."

While inspecting her newborn a mother asks the nurse whether her baby has flat feet. How should the nurse respond?

Warm the environment

While observing a newborn, the nurse notes that the skin is mottled. What should the nurse do first?

Down syndrome

While reviewing laboratory results of clients seen at a maternity clinic, the nurse notes that one client's maternal serum α-fetoprotein level is lower than is typical. The nurse recognizes that this may be associated with:

It contains exposed tissue and blood

While showing a new mother how to care for her infant's umbilical cord stump, the nurse explains that the stump is a potential source of infection because:

Different cultural groups favor different essential nutrients.

Why is it important for a nurse in the prenatal clinic to provide nutritional counseling to all newly pregnant women?

What is most important information to teach to a client who has had a mastectomy before she leaves the hospital?

Why self-examination of the remaining breast is important

While inspecting her newborn a mother asks the nurse whether her baby has flat feet. How should the nurse respond?

"Infants' feet appear flat because the arch is covered with a fat pad."

While waiting for his 39-year-old wife to change clothes after an amniocentesis, the husband says to the nurse, "I sure hope that they don't find anything wrong because of my wife's age. I don't know how we'd deal with a child with Down syndrome. We already have two small children at home." What is the nurse's best response?

"It must be difficult, worrying about whether your baby will be disabled."

During labor a client states that she does not want eyedrops or ointment placed in her baby's eyes immediately after birth. How should the nurse respond?

"Let's talk about why you don't want the medicine to be put into your baby's eyes."

A client receives spinal anesthesia during labor and birth. Twenty-four hours later, she tells a nurse that she has a headache. Which statements indicate to the nurse that the headache is a reaction to the anesthesia? (Select all that apply.)

"My ears are ringing." "It gets better when I lie down." "Bright lights really bother my eyes." "My head hurts more when I'm sitting watching TV."

A client who is breastfeeding tells a nurse that her breasts are swollen and painful. What can the nurse teach her to do to limit engorgement

"Nurse at least every 3 hours for at least 10 minutes on each breast."

A pregnant client in the third trimester tells the nurse in the prenatal clinic that she has heartburn after every meal. What explanation should the nurse give about the cause of the heartburn?

"The cardiac sphincter relaxes and allows acid to be regurgitated."

The mother of a newborn son tells the nurse that she is concerned about circumcision because of the pain involved. What is the nurse's best response?

"The health care provider will tell you how your baby's pain will be controlled."

"The heart rate is usually rapid, and this one is in the expected range."

During a childbirth class, several participants have questions about the elective induction of labor. One participant states that it is more convenient for a woman with a busy schedule. What evidenced-based information should the nurse provide to the participant?

"The widespread use of elective induction increases the risk of unfavorable outcomes."

A pregnant client has a positive group B Streptoccus (GBS) test at 36 weeks' gestation. What is the priority instruction that the nurse will include in the client's teaching plan?

"This information will be in your prenatal record, but please remind your labor and delivery nurse of this finding."

While a mother is inspecting her newborn she expresses concern that her baby's eyes are crossed. How should the nurse respond?

"This is expected. Your baby is trying to focus."

The nurse is caring for a couple after the birth of their first child. What should the nurse tell the family to do when their infant is exhibiting the behavior demonstrated in the picture?

"This is the time when the baby is likely to be most responsive to you."

A newborn with a severe bilateral cleft lip and palate is shown to the father first. The father says, "How could this happen to us? What's my wife going to do? It would've been better if she'd never gotten pregnant." How should the nurse respond?

"This must be very hard on you. I can go with you when your wife sees the baby."

During a routine 32-week prenatal visit, a client tells the nurse that she has had difficulty sleeping on her back at night. What should the nurse advise the client about her position when she sleeps?

"Turn from side to side."

An older female client tells the nurse in the clinic that she has a cystocele that was diagnosed a year ago. She has urinary frequency and burning on urination. The client asks, "The doctor wanted me to have surgery for the cystocele last year, but I can manage with peripads. It won't hurt not to have surgery, will it?" How should the nurse respond?

"Yes, you're risking kidney damage."

When a client who had a mastectomy sees her incision for the first time, she exclaims, "I look horrible! Will it ever look better?" What is the nurse's best response?

"You seem shocked by the way you look now."

The parents of a newborn tell the nurse that they do not want their infant's eyes treated with a prophylactic agent. How should the nurse respond?

"You'll have to sign an informed consent to refuse the treatment."

A new mother who wishes to breastfeed her infant asks a nurse whether she needs to alter her diet. How should the nurse respond?

"You'll need extra amounts of the same foods you've been eating, plus more fluids."

A new mother wishes to breastfeed her infant and asks the nurse whether she needs to alter her diet. How should the nurse respond?

"You'll need greater amounts of the same foods you've been eating and more fluids."

"You'll need to take it for 5 years, after which it will be discontinued."

During a counseling discussion of nutrition, a nurse explains to a pregnant client that she will need additional calcium during pregnancy and that the best source is milk. The client states, "I never drink milk or eat milk products. They turn my stomach." What is the nurse's best reply?

"Your practitioner can prescribe calcium supplements."

"Your weight is expected for someone at 23 weeks' gestation. Continue the pregnancy diet."

A pregnant client arrives at the prenatal clinic, and the nurse obtains her obstetrical history. The client has two children at home, one born at 38 weeks' gestation and the second born at 34 weeks' gestation. She has also had one miscarriage, at 18 weeks, and an elective abortion. Using the GTPAL system, record the client's obstetrical record. 1 G5 T1 P1 A2 L2 2 G4 T2 P2 A1 L4 3 G2 T3 P3 A2 L1 4 G3 T2 P1 A3 L3

1 G5 T1 P1 A2 L2

A client on her first prenatal clinic visit is at 6 weeks' gestation. She asks how long she may continue to work and when she should plan to quit. How should the nurse respond? 1"What activities does your job entail?" 2"How do you feel about continuing to work?" 3"Most women work throughout their pregnancies." 4"Usually women quit work at the start of their third trimester."

1"What activities does your job entail?"

After 18 months of unsuccessful attempts at conception by a client, primary infertility related to anovulatory cycles is diagnosed. Clomiphene citrate (Clomid) is prescribed. The nurse concludes that the client understands the teaching about the correct time to take the clomiphene when the she states: 1. "I'll start the pills on the fifth day of my cycle." 2. "I'll start the pills on the last day of my period." 3. "I'll start the pills on the third day after my period." 4. "I'll start the pills on the 16th day of my cycle."

1. "I'll start the pills on the fifth day of my cycle." **The objective is to stimulate ovulation near the 14th day of the menstrual cycle, and this is achieved by taking the medication on the fifth through the ninth days; there is an increase in two pituitary gonadotropins luteinizing hormone and follicle-stimulating hormone, with subsequent ovarian stimulation.

What instruction should a nurse include when teaching about the correct use of a female condom? 1. "Remove the condom before standing up." 2. "Insert the condom within 1 hour before intercourse." 3. "Have your partner wear a male condom at the same time." 4. "Cleanse the condom with warm water when preparing it for future use."

1. "Remove the condom before standing up." **Removing the condom before standing up keeps the semen in the female condom and prevents the inadvertent contact of semen with vaginal tissues.

A pregnant client uses a computer almost continuously during her working hours. This has implications for her plan of care during pregnancy. What should the nurse recommend? 1. "Try to walk around every few hours during the workday." 2. "Ask for time in the morning and afternoon to elevate your legs." 3. "Tell your boss that you won't be able to work beyond the second trimester." 4. "Ask for time in the morning and afternoon so you can go get something to eat."

1. "Try to walk around every few hours during the workday."

A 20-year-old woman is known to be heterozygous for the cystic fibrosis (CF) gene. Her husband's genotype is unknown at present and the couple is expecting their first child. What should the nurse tell the couple about the probability of their baby's having CF? 1. 25% or less 2. 50% or more 3. Extremely common 4. Unknown at this time

1. 25% or less **Males with cystic fibrosis are usually sterile; therefore the father does not have cystic fibrosis, but he could be a carrier. If both parents are heterozygous carriers, the chance of having a child with CF is 25%. When one parent is a heterozygous carrier and the other has two unaffected genes, the chance of having a child who has CF is 0% but the chance of having a child who is a carrier is 50%.

After an abdominal hysterectomy the client returns to the unit with an indwelling catheter. The nurse notes that the urine in the client's collection bag has become increasingly sanguineous. What complication does the nurse suspect? 1. An incisional nick in the bladder 2. A urinary infection from the catheter 3. Disseminated intravascular coagulopathy 4. Uterine relaxation with increased bleeding

1. An incisional nick in the bladder **During an abdominal hysterectomy the urinary bladder may be nicked accidentally.

A client who has just begun breastfeeding complains that her nipples feel very sore. What should the nurse encourage the mother to do? (Select all that apply.) 1. Apply cool packs to her breasts to reduce the discomfort 2. Take the analgesic medication prescribed to limit the discomfort 3. Remove the infant from the breast for a few days to rest the nipples 4. Never expose the nipples to air, only wear a tight fitting brassiere 5 . Assume a different position when breastfeeding to adjust the infant's sucking

1. Apply cool packs to her breasts to reduce the discomfort 2. Take the analgesic medication prescribed to limit the discomfort 5 . Assume a different position when breastfeeding to adjust the infant's sucking

A pregnant woman at 34 weeks' gestation is being seen at the clinic. The client's blood pressure is 166/100 mm Hg and her urine is +3 for protein. She states that she has a severe headache and occasional blurred vision. Her baseline blood pressure was 100/62 mm Hg. What is the priority nursing action? 1. Arranging transportation to the hospital 2. Obtaining a prescription for an antihypertensive 3. Rechecking the blood pressure within 30 minutes 4. Obtaining a prescription for acetaminophen to relieve the headache

1. Arranging transportation to the hospital

At her first prenatal clinic visit a primigravida has blood drawn for a rubella antibody screening test, and the results are positive. What intervention is important when the nurse discusses this finding with the client? 1. Asking her whether she has had German measles and when she had the disease 2. Arranging for her to receive the rubella booster vaccine after the birth 3. Planning for her to receive the rubella booster vaccine at her next visit 4. Informing her that the result was expected and that treatment will not be needed

1. Asking her whether she has had German measles and when she had the disease

A woman has made the decision to have breast augmentation surgery, and the procedure is to be performed on an outpatient basis. As part of the preoperative protocol, the nurse provides teaching regarding the discharge instructions. Which instructions apply to this type of surgery? (Select all that apply.) 1. Avoid taking aspirin or NSAIDs (e.g., ibuprofen [Advil]) for pain relief. 2. Sleep with your head and torso elevated for at least 1 week. 3. You may sleep on your back or sides but not on your stomach. 4. Begin slowly raising your arms over your head after the first week. 5 . Take your temperature daily and notify the clinic if it goes above 99.6° F

1. Avoid taking aspirin or NSAIDs (e.g., ibuprofen [Advil]) for pain relief. 2. Sleep with your head and torso elevated for at least 1 week. 5 . Take your temperature daily and notify the clinic if it goes above 99.6° F

What does a nurse expect to find when checking the vital signs of a client in the early postpartum period? 1. Bradycardia with no change in respirations 2. Tachycardia with a decrease in respirations 3. Increased basal temperature with a decrease in respirations 4. Decreased basal temperature with an increase in respirations

1. Bradycardia with no change in respirations

During labor a client begins to experience dizziness and tingling of her hands. What should the nurse instruct the client to do? 1. Breathe into her cupped hands 2. Pant during the next three contractions 3. Hold her breath with the next contraction 4. Use a fast, deep, or shallow breathing pattern

1. Breathe into her cupped hands

A 7-lb, 4-oz (3290-g) boy is admitted to the nursery and placed in a warm crib. The neonate begins to choke on mucus. How should the nurse suction him with a bulb syringe? 1. By suctioning the mouth before the nostrils 2. By starting the oxygen and then suctioning the pharynx 3. By positioning the bulb far into the throat before beginning suctioning 4. By placing the bulb in the mouth, compressing the bulb, and starting suctioning

1. By suctioning the mouth before the nostrils

Which behavior indicates to a nurse that a new mother is in the taking-hold phase? 1. Calling the baby by name 2. Talking about the labor and birth 3. Touching the baby with her fingertips 4. Being involved with the infant's need to eat and sleep

1. Calling the baby by name **The mother has moved into the taking-hold phase when she takes control and becomes actively involved with her infant and calls the infant by name

A client has just been told that she has cervical erosion. The nurse would expect to help explain that early treatment of the erosion can help prevent: 1. Cancer of the cervix 2. Pelvic inflammatory disease 3. Unexpected vaginal bleeding 4. Additional cervical erosions

1. Cancer of the cervix **Erosion of the cervix frequently occurs at the columnosquamous junction, the most common site for carcinoma of the cervix.

A nurse is teaching a prenatal class about the changes that occur during the second trimester of pregnancy. What cardiovascular changes should the nurse include? (Select all that apply.) 1. Cardiac output increases. 2. Blood pressure decreases. 3 . The heart is displaced upward. 4. The blood plasma volume peaks. 5 . The hematocrit level is lowered

1. Cardiac output increases. 2. Blood pressure decreases. 3 . The heart is displaced upward.

How does the nurse know that a client at 40 weeks' gestation is experiencing true labor? 1. Cervical dilation 2. Membrane rupture 3. Decreased fetal heart rate 4. Intensification of contractions

1. Cervical dilation

A new mother asks a nurse why medicine is being put in her baby's eyes. What infection should the nurse tell the mother it is given to prevent? 1. Chlamydia 2. Candidiasis 3. Streptococcus 4. Staphylococcus

1. Chlamydia

Which risk factors are associated with the future development of osteoporosis in women? (Select all that apply.) 1. Cigarette smoking 2. Moderate exercise 3. Use of street drugs 4. Familial predisposition 5 . Inadequate intake of dietary calcium

1. Cigarette smoking 4. Familial predisposition 5 . Inadequate intake of dietary calcium

A nurse assesses a healthy 8-lb 8-oz (3860-gm) newborn who was given Apgar scores of 9 at 1 minute and 10 at 5 minutes. Which category of the Apgar score received a 1 rating at one minute? 1. Color 2. Heart rate 3. Respirations 4. Reflex irritability

1. Color **Because of inadequate peripheral circulation at birth there is acrocyanosis (body pink, hands and feet blue), which merits 1 point for color . This is a common occurrence in a healthy newborn. The fetal heart rate ranges from 110 to 160 beats/min; a newborn heart rate of more than 100 beats/min is expected in a healthy newborn and merits 2 points. An adequate respiratory rate is evidenced by crying, which is expected in a healthy newborn and merits 2 points. Reflex irritability is represented by crying, which is expected in a healthy newborn and merits 2 points.

A client at 43 weeks' gestation has just given birth to an infant with typical postmaturity characteristics. Which postmature signs does the nurse identify? (Select all that apply.) 1. Cracked and peeling skin 2. Long scalp hair and fingernails 3. Red, puffy appearance of face and neck 4. Vernix caseosa covering the back and buttocks 5. Creases covering the neonate's full soles and palms

1. Cracked and peeling skin 2. Long scalp hair and fingernails 5. Creases covering the neonate's full soles and palms

A nurse in the clinic, during a routine prenatal visit, notes bruises on the client's upper arms. When questioned, the client responds that her boyfriend was upset and hit her. What is the priority nursing action? 1. Developing a safety plan with the client 2. Calling the nurse manager to inspect the bruises 3. Informing the client that her pregnancy is in danger 4. Notifying social services to monitor the home situation

1. Developing a safety plan with the client

A client at 35 weeks' gestation calls the prenatal clinic, concerned that she has "not felt the baby move as much as usual." The most appropriate recommendation by the nurse is to have the client call the clinic with the results after she has: 1. Drunk a glass of orange juice and timed 10 fetal movements 2. Sat in a tub filled with warm water and then timed 30 fetal movements 3. Taken a nap and counted the number of fetal movements for 20 minutes 4. Walked for 15 minutes and checked to see whether the fetus moved more frequently

1. Drunk a glass of orange juice and timed 10 fetal movements

On reporting to the labor and delivery area a primipara indicates to the nurse that her contractions are occurring every 5 minutes. Upon further inquiry the nurse learns that the client has not attended any childbirth classes, and a cervical assessment reveals that she is in labor. When is the best time for the nurse to include education on simple breathing and relaxation techniques? 1. During the latent phase of the first stage of labor 2. During the active phase of the first stage of labor 3. During the active phase of the second stage of labor 4. During the transition phase of the first stage of labor

1. During the latent phase of the first stage of labor

A client with a history of endometriosis has abdominal surgery to remove adhesions. What should this client's postoperative plan of care include? 1. Encouraging the client to ambulate in the hallway 2. Elevating the client's legs by gatching the bed 3. Helping the client dangle her legs over the side of the bed 4. Maintaining the client on bedrest until the dressings have been removed

1. Encouraging the client to ambulate in the hallway

While caring for a client during labor, the nurse remembers that the second stage of labor: 1. Ends at the time of birth 2. Ends as the placenta is expelled 3. Begins with the transition phase of labor 4. Begins with the onset of strong contractions

1. Ends at the time of birth

The nurse is caring for a pregnant client who is undergoing an ultrasound examination during the first trimester. The nurse explains that an ultrasound during the first trimester is used to: 1. Estimate fetal age 2. Detect hydrocephalus 3. Rule out congenital defects 4. Approximate fetal linear growth

1. Estimate fetal age

A client asks the nurse about the use of an intrauterine device (IUD) for contraception. What information should the nurse include in the response? (Select all that apply.) 1. Expulsion of the device 2. Occasional dyspareunia 3. Delay of return to fertility 4. Risk for perforation of the uterus 5. Increased number of vaginal infections

1. Expulsion of the device 2. Occasional dyspareunia 4. Risk for perforation of the uterus

In the second stage of labor the nurse should plan to discourage a client from holding her breath longer than 6 seconds while pushing with each contraction. What complication does this prevent? 1. Fetal hypoxia 2. Perineal lacerations 3. Carpopedal spasms 4. Maternal hypertension

1. Fetal hypoxia **Prolonged breath holding at this stage of labor can result in decreased placental/fetal oxygenation, which could lead to fetal hypoxia.

A nurse is observing a newborn of 33 weeks' gestation. Which sign alerts the nurse to notify the health care provider? 1. Flaring nares 2. Acrocyanosis 3. Heartbeat of 140 beats/min 4. Respirations of 40 beats/min

1. Flaring nares

A client at 7 weeks' gestation tells the nurse in the prenatal clinic that she has been bothered by episodes of nausea, but no vomiting, throughout the day. What should the nurse recommend? (Select all that apply.) 1. Focus on and repeat a rhythmic chant. 2. Sit upright for 30 minutes after meals. 3. Take low-sodium antacids after meals. 4. Drink carbonated beverages with meals. 5. Eat small, frequent meals and eat dry crackers in between.

1. Focus on and repeat a rhythmic chant. 5. Eat small, frequent meals and eat dry crackers in between.

A client is admitted to the birthing unit with uterine tenderness and minimal dark-red vaginal bleeding. She has a marginal abruptio placentae. The priority evaluation includes fetal status, vital signs, skin color, and urine output. What additional information is essential? 1. Fundal height 2. Obstetric history 3. Time of the last meal 4. Family history of bleeding disorders

1. Fundal height **It is vital that a baseline measurement be obtained, because increasing fundal height is a sign of concealed hemorrhage.

A pregnant client arrives at the prenatal clinic, and the nurse obtains her obstetrical history. The client has two children at home, one born at 38 weeks' gestation and the second born at 34 weeks' gestation. She has also had one miscarriage, at 18 weeks, and an elective abortion. Using the GTPAL system, record the client's obstetrical record. 1. G5 T1 P1 A2 L2 2. G4 T2 P2 A1 L4 3. G2 T3 P3 A2 L1 4. G3 T2 P1 A3 L3

1. G5 T1 P1 A2 L2 **G (gravida ) stands for the total number of pregnancies a client has had. Gravida 5 indicates that this is the client's fifth pregnancy. T (term) stands for the number of neonates born at the expected date of birth. The neonate born at 38 weeks' gestation was born at term. P (preterm) stands for the number of neonates born before the expected date of birth. The neonate born at 34 weeks' gestation was born preterm. A (abortion or miscarriage) stands for the birth of a fetus before 20 weeks' gestation. Both the miscarriage and elective abortion are considered abortions. L (living) stands for the number of living children at the time of assessment. The client has two living children.

What is a common problem that affects the client in labor when an external fetal monitor has been applied to her abdomen? 1. Intrusion on movement 2. Inability to take sedatives 3. Interference with breathing techniques 4. Increased frequency of vaginal examinations

1. Intrusion on movement **Because the client is attached to a machine and movement may alter the tracings, movement is discouraged.

A nurse notes that a client is voiding frequently in small amounts 8 hours after giving birth. What should the nurse conclude about this small output of urine during the early postpartum period? 1. It may indicate retention of urine with overflow. 2. It may be indicative of beginning glomerulonephritis. 3. This is common because less fluid is excreted after birth. 4. This is common because fluid intake diminishes after birth.

1. It may indicate retention of urine with overflow.

What nursing care is most important for a newborn with respiratory distress syndrome (RDS)? 1. Keeping the infant in a warm environment 2. Turning the infant frequently to prevent apnea 3. Tapping the infant's toes to stimulate deep breathing 4. Maintaining the infant's oxygen administration level at the same rate

1. Keeping the infant in a warm environment

During discharge teaching a client who just had a hysterectomy states, "After this surgery, I don't expect to be interested in sex anymore." What should the nurse consider before responding? 1. Many women incorrectly equate hysterectomy with loss of libido. 2. Surgically forced menopause usually results in a decreased sex drive. 3. The loss of estrogen that results from this surgery will cause most women to experience a decrease in libido. 4. Body image changes that occur after this surgery prevent many women from resuming sexual activity.

1. Many women incorrectly equate hysterectomy with loss of libido. **The uterus is often erroneously believed necessary for a satisfying sex life.

The nurse is caring for four clients on the postpartum unit. Which client will most likely state that she is having difficulty sleeping because of afterbirth pains? 1. Multipara who has vaginally delivered three children 2. Primipara whose newborn weighed 7 lb 3. Multipara with effectively controlled diabetes 4. Multipara whose second child was small for gestational age

1. Multipara who has vaginally delivered three children

A client in labor begins to experience contractions 2 to 3 minutes apart and lasting about 45 seconds. Between contractions the nurse identifies a fetal heart rate (FHR) of 100 beats/min on the internal fetal monitor. What is the next nursing action? 1. Notifying the health care provider 2. Resuming continuous fetal heart monitoring 3. Continuing to monitor the maternal vital signs 4. Documenting the fetal heart rate as an expected response to contractions

1. Notifying the health care provider

A client at 24 weeks' gestation arrives at the clinic for a routine examination. She tells the nurse, "I feel puffy all over." In light of this statement, what is most important? 1. Obtaining her blood pressure 2. Determining how much salt she uses 3. Asking the extent of her daily fluid intake 4. Reviewing her history for total weight gain

1. Obtaining her blood pressure

During a routine prenatal office visit at 26 weeks' gestation, a client states that she is getting fat all over and that she even needed to buy bigger shoes. What is the next nursing action? 1. Obtaining the client's weight and blood pressure 2. Reassuring the client that weight gain is expected 3. Supporting the client's decision to buy comfortable shoes 4. Teaching the client about the importance of limiting fatty foods and sweets

1. Obtaining the client's weight and blood pressure **The client's weight and blood pressure helps the nurse determine whether an unusual weight gain or an increase in blood pressure has occurred; both of these findings are early signs of preeclampsia.

What actions are part of nursing care during the fourth stage of labor for the client with a fourth-degree laceration? (Select all that apply.) 1. Pain management with oral analgesics 2. Continuous application of a warm pack 3. Assessment of the site every 15 minutes 4. Gentle cleansing with antibacterial cleanser 5. Application of an ice pack for 20-minute intervals 6. Instructing the client in how to promote normal bowel function

1. Pain management with oral analgesics 3. Assessment of the site every 15 minutes 5. Application of an ice pack for 20-minute intervals

The nurse is caring for a client who is in the taking-in phase of the postpartum period. The area of health teaching that the client will be most responsive to is: 1. Perineal care 2. Infant feeding 3. Infant hygiene 4. Family planning

1. Perineal care

At 5 am, 2 hours after a long labor and vaginal birth, a client is transferred to the postpartum unit. What is the nurse's priority when planning morning care for this client? 1. Planning nursing care activities that provide time for the client to rest and sleep 2. Preparing for the probability of hemorrhage by massaging the client's uterus frequently 3. Arranging an individual session in which the client can learn about successful breastfeeding 4. Anticipating safety needs by instructing the client to remain in bed and call for assistance whenever ambulating

1. Planning nursing care activities that provide time for the client to rest and sleep

A newborn has congenital cataracts, microcephaly, deafness, and cardiac anomalies. Which infection does the nurse suspect that the newborn's mother contracted during her pregnancy? 1. Rubella 2. Herpes virus type 2 3. Toxoplasmosis gondii 4. Chlamydia trachomatis

1. Rubella

A nurse is caring for a client who has severe preeclampsia. For which characteristic of eclampsia should the nurse monitor the client? 1. Seizures 2. Anasarca 3. Excessive weight gain 4. Increased blood pressure

1. Seizures

Which characteristics should alert the nurse to conclude that a male newborn is a preterm infant? (Select all that apply.) 1. Small breast buds 2. Wrinkled thin skin 3. Multiple sole creases Incorrect4. Presence of scrotal rugae 5. Pinnae that remain flat when folded

1. Small breast buds 2. Wrinkled thin skin 5. Pinnae that remain flat when folded

The nurse is teaching a sex education course to high school students. What should the nurse teach them about why gonorrhea is difficult to control? (Select all that apply.) 1. Symptoms of the disease are vague. 2. Screening blood tests are expensive. 3. The incubation period is relatively short. 4 . Causative organisms have become resistant to treatment. 5 . Diagnostic tests for the causative organism are not yet available.

1. Symptoms of the disease are vague. 3. The incubation period is relatively short. 5 . Diagnostic tests for the causative organism are not yet available.

After an emergency cesarean birth, the client tells the nurse that she was hoping for a "natural" childbirth but is glad that she and her baby are all right." Which postpartum phase of adjustment does this statement most closely typify? 1. Taking-in 2. Letting-go 3. Taking-hold 4. Working-through

1. Taking-in

After an unexpected emergency cesarean birth the client tells the nurse, "I failed natural childbirth." Which postpartum phase of adjustment does this statement most closely typify? 1. Taking-in 2. Letting-go 3. Taking-hold 4. Working-through

1. Taking-in **By discussing the experience, the client is bringing it into reality; this is characteristic of the taking-in phase .

A nurse caring for a pregnant client and her partner suspects domestic violence. Which observations support this suspicion? (Select all that apply.) 1. The woman has injuries to the breasts and abdomen. 2. The partner refuses to come into the examination room. 3. The partner answers questions that are asked of the woman. 4. The woman has visited the clinic several times in the last month. 5 . The partner is excessively attentive while the health history is being taken.

1. The woman has injuries to the breasts and abdomen. 3. The partner answers questions that are asked of the woman. 4. The woman has visited the clinic several times in the last month.

What does the nurse expect concerning the alveoli in the lungs of a 28-week-gestation neonate? 1. They have a tendency to collapse with each breath. 2. There usually is a sufficient supply of pulmonary surfactant. 3. Although apparently mature they cannot absorb adequate oxygen. 4. Oxygen is not released into the circulation because they overinflate

1. They have a tendency to collapse with each breath.

During labor a client who has been receiving epidural anesthesia has a sudden episode of severe nausea, and her skin becomes pale and clammy. What is the nurse's immediate reaction? 1. Turning the client on her side 2. Notifying the health care provider 3. Checking the vaginal area for bleeding 4. Checking the fetal heart rate every 3 minutes

1. Turning the client on her side

For what complication should the nurse specifically monitor a grand multipara who has just given birth? 1. Uterine atony 2. Bladder distention 3. Profuse diaphoresis 4. Hypertensive episodes

1. Uterine atony **Grand multiparas have diminished uterine muscle tone as a result of the repeated distentions of pregnancy; consequently, the uterine muscles may not contract effectively during the fourth stage of labor.

What is the nurse's initial action immediately after assisting with a precipitous birth in the triage area of the emergency department? 1. Warming the newborn 2. Clamping the umbilical cord 3. Assessing maternal bleeding 4. Monitoring expulsion of the placenta

1. Warming the newborn

A client with endometriosis asks the nurse what side effects to expect from leuprolide (Lupron). What should the nurse include in the response? 1. Weight gain 2. Increased libido 3. Frequent urination 4. Heavy menstrual bleeding

1. Weight gain **The nurse should teach the client that the side effects of leuprolide (Lupron) include edema, which causes an increase in weight.

A woman in labor hears the health care provider tell the nurse that the fetal lie is longitudinal. The mother asks the nurse what this means in relation to her labor and birth of the baby. How should the nurse respond? 1."A vaginal birth is possible." 2."We're anticipating a cesarean delivery." 3."It has no relevance to the labor and birth." 4."Labor probably will be long, and you might have back pain."

1."A vaginal birth is possible."

The nurse has completed a prenatal class for women who are expecting their first babies. Which statement by a pregnant woman indicates the need for additional teaching? 1."During pregnancy it's safe for me to use my regular herbal remedies." 2."My doctor will tell me if it's safe for me to take my allergy medications." 3."I should avoid all x-rays unless absolutely necessary and tell the technician that I'm pregnant." 4."I'm only 18 weeks pregnant, so it's safe for me to go through the airport security check when I go on vacation next month."

1."During pregnancy it's safe for me to use my regular herbal remedies."

A nurse is teaching a childbirth class to a group of pregnant women. One of the women asks the nurse at what point during the pregnancy the embryo becomes a fetus. How should the nurse respond? 1."During the eighth week of the pregnancy." 2."At the end of the second week of pregnancy." 3."When the fertilized egg becomes implanted." 4."When the products of conception are seen on the sonogram."

1."During the eighth week of the pregnancy."

After a client has a spontaneous abortion at 12 weeks' gestation, the nurse notes that she and her partner are visibly upset. The partner has tears in his eyes, and the client is sobbing quietly with her face turned to the wall. At this time, what is the nurse's most therapeutic statement? 1."I'll be here if you want to talk." 2."Try to relax — it'll speed the healing process." 3."With any luck you'll get pregnant again soon." 4."It's best that this happened early rather than having the baby die after it was born."

1."I'll be here if you want to talk."

The nurse is preparing a client for epidural anesthesia. Which client statement would cause the nurse to stop the placement of the epidural catheter? 1."I'm not exactly sure how an epidural works." 2."I understand that the epidural might or might not take my pain away." 3."I signed the consent form for an epidural at my last clinic appointment." 4."I'm aware that the epidural could cause my contractions to slow down."

1."I'm not exactly sure how an epidural works."

On the first postpartum day, a client whose infant is rooming in asks the nurse to return her baby to the nursery and bring the baby to her only at feeding times. How should the nurse respond? 1."It seems that you've changed your mind about rooming in." 2."I think you're having difficulty caring for the baby." 3."All right. I'll inform the other nurses of your decision." 4."You must be tired. I'll bring the baby back at feeding time."

1."It seems that you've changed your mind about rooming in."

A client with mild preeclampsia is told that she must remain on bedrest at home. The client starts to cry and tells the nurse that she has two small children at home who need her. How should the nurse respond? 1."Let's explore your available current support and opportunities for child care." 2."Are you worried about how you'll be able to handle this problem?" 3."You can get a neighbor to help out, and your husband can do the housework in the evening." 4."You can prepare light meals and the children can go to nursery school a few hours each day."

1."Let's explore your available current support and opportunities for child care."

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. What is the nurse's best response? 1."Tell me what you know about Down syndrome." 2."I would just continue to rest and recover from your delivery." 3."You really need to pull yourself together for your baby." 4."Should I call in a chaplain or social worker for you?"

1."Tell me what you know about Down syndrome."

As the nurse helps a postpartum client change her perineal pad, the client comments, "I wish you didn't have to look at the pad it's embarrassing for me." What is the best nursing response? 1."This seems to be uncomfortable for you, but I have to estimate the amount of blood loss to prevent any problems." 2."There can be more blood loss than you might realize. We can determine how much you've lost with a formula." 3."Examining the pad is a common practice that helps us keep you safe. It's a necessary part of the job, and I don't mind." 4."Looking at your pad is a procedure we follow to determine the extent of your bleeding so we can give you the necessary care."

1."This seems to be uncomfortable for you, but I have to estimate the amount of blood loss to prevent any problems."

A client who is scheduled to have an abdominal panhysterectomy asks how the surgery will affect her periods. How should the nurse respond? 1."You won't have any more periods." 2."Your periods will become more regular." 3."Your periods will become lighter and then disappear." 4."You'll notice that the time between periods will be longer."

1."You won't have any more periods."

A client in labor is admitted to the birthing room. The exam reveals that the fetus is at -1 station. Where is the presenting part? 1.1 cm above the ischial spines 2.1 cm below the ischial spines 3.Visible at the vaginal opening 4.At the level of the ischial spines

1.1 cm above the ischial spines

The nurse discusses the recommended weight gain during pregnancy with a newly pregnant client who is 5 feet 3 inches tall and weighs 125 lb. The nurse explains that with the recommended weight gain, at term the client should weigh about: 1.150 lb 2.140 lb 3.135 lb 4.130 lb

1.150 lb

What should a nurse include in the teaching plan for a couple seeking information about family planning? 1.A condom must be held in place by the rim when the penis is withdrawn from the vagina. 2.Diaphragms are effective even when the partners choose not to use a spermicidal cream. 3.When the coitus interruptus method is used, sperm cannot reach the ovum if the man withdraws before ejaculation. 4.When periodic abstinence is used, the woman should have intercourse on days when she has an increase in temperature

1.A condom must be held in place by the rim when the penis is withdrawn from the vagina.

Four days after a vaginal hysterectomy a client calls the follow-up service and tells the nurse that she has a yellowish-green vaginal discharge. The nurse advises the client to return to the clinic for an evaluation. Which symptoms are suggestive of a vaginal infection? (Select all that apply.) 1.Abdominal pain 2.Urinary frequency 3.Rising temperature 4.Decreased pulse rate 5.Decreased blood pressure

1.Abdominal pain 3.Rising temperature

At 12 weeks' gestation, a client who is Rh negative expels the total products of conception. What is the nursing action after it has been determined that she has not been previously sensitized? 1.Administering RhoGAM within 72 hours 2.Making certain that RhoGAM is administered at the first clinic visit 3.Withholding the RhoGAM because the gestation lasted only 12 weeks 4.Withholding the RhoGAM because it is not used after delivery of a stillborn

1.Administering RhoGAM within 72 hours

A client is scheduled for a modified radical mastectomy. What nursing intervention is most important in the client's preoperative plan of care? 1.Allowing her to express her feelings about surgery 2.Encouraging range-of-motion exercise of the arms 3.Increasing her knowledge about postoperative expectations 4.Arranging for a visit by a woman who has had a mastectomy

1.Allowing her to express her feelings about surgery

While monitoring the fetal heart rate (FHR) of a client in labor, the nurse identifies an increase of 15 beats more than the baseline rate of 135 beats/min that lasts 15 seconds. How should the nurse document this event? 1.An acceleration 2.An early increase 3.A sonographic motion 4.A tachycardic heart rate

1.An acceleration

After an abdominal hysterectomy the client returns to the unit with an indwelling catheter. The nurse notes that the urine in the client's collection bag has become increasingly sanguineous. What complication does the nurse suspect? 1.An incisional nick in the bladder 2.A urinary infection from the catheter 3.Disseminated intravascular coagulopathy 4.Uterine relaxation with increased bleeding

1.An incisional nick in the bladder

A nurse is reviewing a postmenopausal client's history, which reveals that the client previously received hormonal replacement therapy (HRT) as treatment for osteoporosis. For which problem does HRT increase the client's risk? 1.Breast cancer 2.Rapid weight loss 3.Accelerated bone loss 4.Vaginal tissue atrophy

1.Breast cancer

After a client's membranes rupture spontaneously, the nurse sees the umbilical cord protruding from the vagina. Place the nursing interventions in order of priority

1.Call for assistance and don sterile gloves 2.Insert two fingers into the vagina and exert upward pressure against the fetal presenting part 3.Put a rolled towel under one hip and place in the modified Sims position 4.Administer oxygen to the mother and monitor fetal heart tones

Which behavior indicates to a nurse that a new mother is in the taking-hold phase? 1.Calling the baby by name 2.Talking about the labor and birth 3.Touching the baby with her fingertips 4.Being involved with the infant's need to eat and sleep

1.Calling the baby by name

A nurse is teaching a prenatal class about the changes that occur during the second trimester of pregnancy. What cardiovascular changes should the nurse include? (Select all that apply.) 1.Cardiac output increases. 2.Blood pressure decreases. 3.The heart is displaced upward. 4.The blood plasma volume peaks. 5.The hematocrit level is lowered

1.Cardiac output increases. 2.Blood pressure decreases. 3.The heart is displaced upward.

The nurse teaches a client about the increased need for vitamin A to meet the demands imposed by rapid fetal tissue growth during pregnancy. Which foods should the nurse encourage the client to ingest to meet this increased need? (Select all that apply.) 1.Carrots 2.Citrus fruits 3.Fat-free milk 4.Sweet potatoes 5.Extra egg whites

1.Carrots 4.Sweet potatoes

At 6 weeks' gestation a client is found to have gonorrhea. What medication does a nurse expect the health care provider to prescribe? 1.Ceftriaxone (Rocephin) 2.Levofloxacin (Levaquin) 3.Sulfasalazine (Azulfidine) 4.Trimethoprim/sulfamethoxazole (Bactrim)

1.Ceftriaxone (Rocephin)

How does the nurse know that a client at 40 weeks' gestation is experiencing true labor? 1.Cervical dilation 2.Membrane rupture 3.Decreased fetal heart rate 4.Intensification of contractions

1.Cervical dilation

A nurse is teaching a class of expectant parents about changes that are to be expected during pregnancy. What changes does the nurse explain result from the melanocyte-stimulating hormone? (Select all that apply.) 1.Chloasma 2.Linea nigra 3.Effacement 4.Morning sickness 5.Cervical softening 6.Urinary frequency

1.Chloasma 2.Linea nigra

A client who has just had a cesarean birth is receiving IV fluids and has an indwelling catheter. The client's fluid intake will need to be increased when the nurse identifies: 1.Dark amber urine 2.Urinary suppression 3.Tinges of blood in the urine 4.Cloudiness of the urine

1.Dark amber urine

The nurse explains to a woman in her 24th week of pregnancy that absorption of medications taken orally during pregnancy may be altered as a result of: 1.Delayed gastrointestinal emptying 2.A reduced glomerular filtration rate 3.Developing fetal-placental circulation 4.Increasing secretion of hydrochloric acid

1.Delayed gastrointestinal emptying

A client undergoes anterior and posterior surgical repair of a cystocele and rectocele and returns from the postanesthesia care unit with an indwelling catheter in place. What should the nurse tell the client about the primary reasons for the catheter? (Select all that apply.) 1.Discomfort is minimized. 2.Bladder tone is maintained. 3.Retention of urine is prevented. 4.Pressure on the suture line is relieved. 5.Hourly urine output can be easily measured

1.Discomfort is minimized 3.Retention of urine is prevented. 4.Pressure on the suture line is relieved.

A client is receiving antibiotics and antifungal medications for the treatment of a recurring vaginal infection. What should the nurse encourage the client to do to compensate for the effect of these medications? 1.Eat yogurt daily 2.Avoid spicy foods 3.Drink more fruit juices 4.Take a multivitamin every day

1.Eat yogurt daily

A nurse in the fertility clinic is instructing a client who will be using progesterone gel vaginally in the treatment of luteal phase infertility. When discussing the side effects of progesterone, what should the nurse tell the client to expect? 1.Enlarged, tender breasts 2.Increased vaginal secretions 3.Additional facial and body hair 4.Decreased basal body temperature

1.Enlarged, tender breasts

A nurse is planning care for a client who gave birth to a preterm male infant. What most common response does the nurse anticipate that the mother may experience? 1.Feelings of failure and loss of control 2.Thoughts related to guilt and withdrawal 3.Fear of forming a healthy relationship with her son until he is out of danger 4.Need for increased attachment behaviors because of her son's life-threatening condition

1.Feelings of failure and loss of control

During the examination of a client in labor, the cervix is determined to be dilated 4 cm. What stage of labor does the nurse record? 1.First 2.Second 3.Prodromal 4.Transitional

1.First

A client is admitted with a diagnosis of stage 0 cervical cancer (carcinoma in situ). What does the nurse emphasize while helping the client understand her diagnosis and prognosis? 1.Five-year survival rates for this cancer are nearly 100% with early treatment. 2.Radiation therapy is as successful as surgery in the treatment of this type of cancer. 3.Cancer has probably extended into the vaginal wall and may require a radical hysterectomy. 4.Stage 0 indicates that the cancer is invasive and may require surgery in addition to radiation therapy

1.Five-year survival rates for this cancer are nearly 100% with early treatment.

A primigravida, unsure of the date of her last menstrual period, is told by the nurse that she appears to be at 22 weeks' gestation. What data support this conclusion? 1.Fundus at the umbilicus 2.Fundus just over the symphysis 3.Fundal height of 9 inches (18 cm) 4.Fundal height of 14 inches (28 cm)

1.Fundus at the umbilicus

After 2 weeks of radiation therapy for cancer of the breast a client experiences some erythema over the area being radiated. The area is sensitive but not painful. She states that she has been using tepid water and a soft washcloth when cleansing the area and applying an ice pack three times a day. What does the nurse conclude from this information? 1.Further teaching on skin care is necessary. 2.No other intervention is needed at this time. 3.The radiation team should be notified of this problem. 4.Health teaching on the side effects of radiation is needed.

1.Further teaching on skin care is necessary.

The husband of a woman who had her fourth child 3 weeks ago states she has been irritable and crying frequently since bringing her newborn home. He asks the nurse whether this is normal. The nurse tries to help him understand the situation by stating that: 1.Having four children is tiring and assistance may be needed. 2.His wife probably has the postpartum blues, but it will soon pass. 3.This behavior is common after birth, and he should not be too concerned. 4.Women often express themselves by crying, and he should allow her to continue.

1.Having four children is tiring and assistance may be needed.

The nurse is caring for a client in her third trimester who is to undergo amniocentesis. What should the nurse do to prepare the client for this test? 1.Instruct her to void immediately before the test 2.Tell her to assume the high Fowler position before the test 3.Encourage her to drink three glasses of water before the test 4.Advise her to take nothing by mouth for several hours before the test

1.Instruct her to void immediately before the test

1.Iron 3. Folic acid **Because pregnant women with heart disease are more likely to have anemia, there may be an additional need for iron and also for folic acid.

1.Lateral

A 30-year-old woman is to undergo total abdominal hysterectomy for noninvasive endometrial cancer. The nurse anticipates the client may have difficulty adjusting emotionally to this type of surgery. What is the most common reason for this difficulty? 1.Loss of femininity 2.Body image changes 3.Diminished sexual desire 4.Slow postmenopausal recovery

1.Loss of femininity

A nurse is caring for a client with vaginal bleeding caused by placenta previa. What is the best nursing intervention to delay the birth of the fetus? 1.Maintaining bed rest 2.Planning for an ultrasound test 3.Preparing for a nonstress test 4.Administering oxygen by way of a mask

1.Maintaining bed rest

What should be included in nursing care immediately after a sexual assault? 1.Obtaining the assault history from the client 2.Informing the police before the client is examined 3.Having the client void a clean-catch urine specimen 4.Testing the client's urine for seminal alkaline phosphatase

1.Obtaining the assault history from the client

Contraceptives that contain estrogen-like and/or progesterone-like compounds are prepared in a variety of forms. Which contraceptives should the nurse tell clients have a hormonal component? (Select all that apply.) 1.Oral drugs 2.Diaphragm 3.Cervical cap 4.Female condoms 5.Foam spermicide. 6.Transdermal agents

1.Oral drugs 6.Transdermal agents

A female client with Hodgkin's disease is to start chemotherapy. She and her husband have been trying to have a child and are quite concerned when they learn that sterility may result. On what information should the nurse base the reply? 1.Ova can be harvested and frozen for future use. 2.Chemotherapy is not radical enough to destroy ovarian function. 3.Ovarian function will be temporarily destroyed but will return in time. 4.Radiation can be substituted for chemotherapy to preserve ovarian function.

1.Ova can be harvested and frozen for future use.

The nurse presents a program on breast self-examination. After a return demonstration the nurse concludes that she needs to review certain aspects of the teaching program. Which behavior by one of the students supports this conclusion? 1.Palpating each breast while in the sitting position 2.Checking her breasts for any deviation from what is expected 3.Palpating each breast with the palmar surface of her extended fingers 4.Checking her breasts for symmetry while holding her arms above her head

1.Palpating each breast while in the sitting position

A nurse is caring for an adolescent in labor an hour after she was admitted to the birthing unit. The adolescent is anxious and tense. She cries during contractions and asks the nurse for epidural anesthesia. The nurse obtains the adolescent's current vital signs and reviews her history and admission information. What nursing interventions are essential before epidural anesthesia is administered? (Select all that apply.) 1.Performing a baseline vaginal examination 2.Telling the adolescent what to expect with each procedure 3.Identifying risk factors that contraindicate epidural anesthesia 4.Having the parents sign a consent form for the epidural anesthesia 5.Explaining the need to stay in one position while the epidural catheter is in place

1.Performing a baseline vaginal examination 2.Telling the adolescent what to expect with each procedure 3.Identifying risk factors that contraindicate epidural anesthesia

The nurse is caring for a client who is in the taking-in phase of the postpartum period. The area of health teaching that the client will be most responsive to is: 1.Perineal care 2.Infant feeding 3.Infant hygiene 4.Family planning

1.Perineal care

A pregnant client asks the nurse for information about toxoplasmosis during pregnancy. What should the nurse teach the client? 1.Pork and beef should be cooked thoroughly. 2.Toxoplasmosis is a disease that is most prevalent in foreign countries. 3.Raw shellfish are intermediary hosts and should be avoided during pregnancy. 4.Salad dressings made with mayonnaise should be avoided during the summer months

1.Pork and beef should be cooked thoroughly.

A pregnant client asks a nurse for information about toxoplasmosis during pregnancy. What should the nurse teach the client about how to prevent the transmission of toxoplasmosis? 1.Pork and beef should be cooked well before being eaten. 2.Salads with mayonnaise dressing should be avoided during the summer. 3.Raw shellfish are intermediary hosts and should be avoided during pregnancy. 4.Toxoplasmosis is a disease that is prevalent in underdeveloped countries, not in developed ones

1.Pork and beef should be cooked well before being eaten.

A 36-year-old client undergoes a modified radical mastectomy. The nurse determines that the client understands the schedule for self-examination of her remaining breast when she states that she will examine her breast: 1.Seven days after each menstrual period 2.Several days before an expected menstrual period 3.Halfway between menstrual periods, preferably after showering 4.On the same date every month, regardless of when menstruation occurs

1.Seven days after each menstrual period

An adolescent who gave birth one day ago confides to the nurse that she hopes that her baby will be good and sleep through the night. What should the nurse include in the plan of care to facilitate a realistic expectation of a nighttime newborn schedule? 1.Talk softly and cuddle the baby when crying occurs 2.Keep the baby awake for longer periods during the day 3.Ensure sleep by adding cereal to the baby's bedtime bottle 4.Put a soft, brightly colored toy next to the baby at bedtime

1.Talk softly and cuddle the baby when crying occurs

A client who is visiting the prenatal clinic for the first time has a serology test for toxoplasmosis. What information about the client's activities in the history indicates to the nurse that there is a need for this test? 1.The client takes care of a cat. 2.The client works as a dog trainer. 3.The client uses chemical cleaners. 4.The client consumes raw vegetables

1.The client takes care of a cat.

After a client undergoes a biopsy for suspected cervical cancer, the laboratory report reveals a stage 0 lesion. What does a nurse conclude about this client's stage of cancer? 1.The lesion is carcinoma in situ. 2.There is early stromal invasion. 3.There is parametrial involvement. 4.The cancer is confined to the cervix

1.The lesion is carcinoma in situ.

Laboratory studies reveal that a pregnant client's blood type is O, and she is Rh positive. The client asks whether her newborn will have a problem with blood incompatibility. Before responding, the nurse must remember that fetal problems may develop if the fetus is: 1.Type A or B 2.Born preterm 3.Type O and Rh positive 4.Born to a diabetic mother

1.Type A or B

A nurse is teaching a breastfeeding mother about cleansing her nipples. What technique should the nurse emphasize? 1.Wash the breasts and nipples with water when bathing. 2.Wipe the nipples with sterile water before each feeding. 3.Swab the nipples with an alcohol sponge after each feeding. 4.Rub the breasts and nipples with soapy water when showering.

1.Wash the breasts and nipples with water when bathing.

What should the nurse teach a formula-feeding mother about breast engorgement when it occurs? 1.Wear a tightly fitted brassiere. 2.Take two aspirin every 4 hours. 3.Cease drinking milk for 2 weeks. 4.Apply warm compresses to the breasts

1.Wear a tightly fitted brassiere.

What client behavior indicates to the nurse that a woman needs further teaching about breastfeeding her newborn? 1.When she leans forward to place her breast in the infant's mouth 2.If she holds the infant level with her breast while in a side-lying position 3.If she touches her nipple to the infant's cheek at the beginning of the feeding 4.When she puts her finger in the infant's mouth to break the suction after the feeding

1.When she leans forward to place her breast in the infant's mouth

When seeing her preterm infant son in the neonatal intensive care unit for the first time, a mother exclaims, "He's so little! How will I ever be able to take care of him?" The nurse explains to the mother that she: 1.Will be encouraged to participate in his care as much as possible 2.May watch his care to familiarize herself with the specific routines 3.Should find someone with preterm care training to help at home for the first week 4.Will be able to care for him in a special nursery for a few days before his discharge

1.Will be encouraged to participate in his care as much as possible

A client at 35 weeks' gestation is experiencing contractions. Her cervix is dilated 2 cm. The nurse teaches the client that sexual activity, particularly intercourse, should be: 1Avoided to limit the onset of labor 2Permitted if contractions are irregular 3Confined to the side-lying position 4Allowed if penile penetration is shallow

1Avoided to limit the onset of labor

During labor a client begins to experience dizziness and tingling of her hands. What should the nurse instruct the client to do? 1Breathe into her cupped hands 2Pant during the next three contractions 3Hold her breath with the next contraction 4Use a fast, deep, or shallow breathing pattern

1Breathe into her cupped hands

A primigravida client gave birth in a vaginal delivery 24 hours ago. Which findings would be considered normal? 1Fundus firm at the umbilicus; moderate lochia rubra; voiding quantity sufficient; colostrum present 2Fundus firm, one fingerbreadth above the umbilicus; scant lochia alba; voided twice, 500 mL, 400 mL; breasts heavy 3Fundus firm, two fingerbreadths above the umbilicus; moderate lochia serosa; voided once, 200 mL; colostrum present 4Fundus firm, 2 fingerbreadths below the umbilicus; moderate serosa alba; voiding quantity sufficient; breasts engorged

1Fundus firm at the umbilicus; moderate lochia rubra; voiding quantity sufficient; colostrum present

In the second hour after the client gives birth her uterus is firm, above the level of the umbilicus, and to the right of midline. What is the most appropriate nursing action? 1Having the client empty her bladder 2Watching for signs of retained secundines 3Massaging the uterus vigorously to prevent hemorrhage 4Explaining to the client that this is a sign of uterine stabilization

1Having the client empty her bladder

Because of the high discomfort level during the transition phase of labor, nursing care should be directed toward: 1Helping the client maintain control 2Decreasing the rate of intravenous fluid 3Administering the prescribed medication 4Having the client breathe in a uniform pattern

1Helping the client maintain control

What is a common problem that affects the client in labor when an external fetal monitor has been applied to her abdomen? 1Intrusion on movement 2Inability to take sedatives 3Interference with breathing techniques 4Increased frequency of vaginal examinations

1Intrusion on movement

A client at 42 weeks' gestation has a reactive nonstress test. The nurse determines that the client understands what she was taught about the results when she is overheard telling her husband that the test was: 1Normal because of an increase in fetal heart rate (FHR) with fetal movement 2Abnormal because of a decrease in FHR between contractions 3Abnormal because of variability in FHR with each contraction 4Normal because the FHR remained unchanged with maternal movement

1Normal because of an increase in fetal heart rate (FHR) with fetal movement

A nurse is instructing a client to cough and deep-breathe after an emergency cesarean birth. The client says, "Get out of here. Can't you see that I'm in pain?" Which response will be the most effective? 1. "I'm sure you're in pain. I'll come back later." 2. "If you can't cough, try taking six very deep breaths." 3. "Your pain is to be expected, but you must exercise your lungs." 4. "I'll give you something for your pain. We can start the coughing tomorrow."

2. "If you can't cough, try taking six very deep breaths." **Having the client take deep breaths is important because deep breathing promotes full expansion of the alveoli and prevents stasis of pulmonary secretions.

New parents are asked to sign the consent for their son to be circumcised. They ask for the nurse's opinion of the procedure. How should the nurse respond? 1. "You should talk to the health care provider about this if you have any questions." 2. "Let's talk about it, because there are advantages and disadvantages." 3. "It's a safe procedure, and it's best for male infants to be circumcised." 4. "Although it may be a somewhat painful experience for the baby, I would allow it if I were you."

2. "Let's talk about it, because there are advantages and disadvantages."

A couple arrives at the newborn nursery asking to take their newborn grandson to his mother's room. What is the best response by the nurse? 1. "I'll get your grandchild. You must be very excited." 2. "Please go on to see your daughter. I'll bring the baby to her room." 3. "Show me your identification. I need to see it before I can give you the baby." 4. "Only the mother can ask for the baby. Have her call us to bring the baby to her."

2. "Please go on to see your daughter. I'll bring the baby to her room."

A client who had a child with Tay-Sachs disease is pregnant and is to have an amniocentesis to determine whether the fetus has the disease. The nurse counsels her to plan for the procedure at the optimal time for the procedure at: 1. 6 to 8 weeks' gestation 2. 14 to 16 weeks' gestation 3. 18 to 20 weeks' gestation 4. 22 to 24 weeks' gestation

2. 14 to 16 weeks' gestation **An amniocentesis is done at this time because a therapeutic abortion may be legally and safely performed if desired by the parents.

2. 24 hours **The ovum is viable for about 24 hours after ovulation; if not fertilized before this time, it degenerates.

A nurse is checking the external fetal monitor of a client in active labor. Which fetal heart pattern indicates cord compression? 1. Smooth, flat baseline tracings of 135 beats/min 2. Abrupt decreases in fetal heart rate that are unrelated to the contractions 3. Accelerations in the fetal heart rate of 10 beats/min above baseline 4. Decelerations when a contraction begins that return to baseline when the contraction ends

2. Abrupt decreases in fetal heart rate that are unrelated to the contractions

A woman has just received the news that she is pregnant. She is ambivalent about the pregnancy because she had planned to go back to work when her youngest child started school next year. What developmental task of pregnancy must the woman accomplish in the first trimester of pregnancy? 1. Recognize her ambivalence 2. Accept that she is pregnant 3. Prepare for the birth of the baby 4. Recognize the fetus as an individual separate from the mother

2. Accept that she is pregnant

Although a client in labor is prepared and plans to participate in the labor and birth process, she states that she is in severe discomfort. The nurse administers the prescribed butorphanol (Stadol). Which phase of labor is the safest time for the nurse to administer this medication? 1. Early phase 2. Active phase 3. Transition phase 4. Expulsion phase

2. Active phase **Respiratory depression of the newborn will not occur if the medication is given during the active phase; it should not be given when birth is expected to occur within 2 hours.

A female client came to the clinic with suspected primary syphilis. What sign of primary syphilis does the nurse expect the client to exhibit? 1. Flat wartlike plaques around the vagina and anus 2. An indurated painless nodule on the vulva that is draining 3. Glistening patches in the mouth covered with a yellow exudate 4. A maculopapular rash on the palms of the hands and soles of the feet

2. An indurated painless nodule on the vulva that is draining **This is the description of a chancre, which is the initial sign of syphilis.

A husband sits in the waiting room while his wife is getting her infertility prescription refilled by the clinic pharmacist. As the nurse sits down beside him, he blurts, "It's like there are three of us in bed—my wife, me, and the doctor." What feeling is reflected by this statement? 1. Guilt 2. Anger 3. Depression 4. Unworthiness

2. Anger

A client at 9 weeks' gestation asks the nurse in the prenatal clinic whether she may have chorionic villi sampling (CVS) performed during this visit. What should the nurse keep in mind as the optimal time for CVS while formulating a response? 1. At 8 weeks but no later than 10 weeks 2. At 10 weeks but no later than 12 weeks 3. At 12 weeks but no later than 14 weeks 4. At 14 weeks but no later than 16 weeks

2. At 10 weeks but no later than 12 weeks

2. Buccal smear **The cells in the buccal smear provide a pictorial analysis of chromosomes and show chromosomal abnormalities such as the trisomy found in Down syndrome.

An infant has surgery for repair of a myelomeningocele. For which early sign of impending hydrocephalus should the nurse monitor the infant? 1. Frequent crying 2. Bulging fontanels 3. Change in vital signs 4. Difficulty with feeding

2. Bulging fontanels

During prenatal classes the nurse teaches the difference between true labor and false labor. How does the nurse explain the difference? 1. Bloody show is rare with false labor. 2. Cervix effaces and dilates during true labor. 3. Membranes rupture at the start of true labor. 4. Fetal movement slows and contractions accelerate with false labor.

2. Cervix effaces and dilates during true labor.

During the postpartum period a client tells a nurse that she has been having leg cramps. Which foods should the nurse encourage the client to eat? 1. Liver and raisins 2. Cheese and broccoli 3. Eggs and lean meats 4. Whole-wheat breads and cereals

2. Cheese and broccoli **The leg cramps may be related to low calcium intake; cheese and broccoli each have a high calcium content.

A client's temperature is 100.4° F 12 hours after a spontaneous vaginal birth. What does the nurse suspect is the cause of the increased temperature? 1. Mastitis 2. Dehydration 3. Puerperal infection 4. Urinary tract infection

2. Dehydration

Why is it important for a nurse in the prenatal clinic to provide nutritional counseling to all newly pregnant women? 1. Most weight gain is caused by fluid retention. 2. Different cultural groups favor different essential nutrients. 3. Dietary allowances should not increase throughout pregnancy. 4. Pregnant women must adhere to a specific pregnancy dietary regimen.

2. Different cultural groups favor different essential nutrients.

A nurse is preparing to counsel a client whose two previous pregnancies were uneventful, ending in term vaginal births of healthy children. What should the nurse consider about multiparas with previous uneventful pregnancies before beginning prenatal counseling? 1. Multiparas cope more successfully with pregnancy than do primigravidas. 2. Each pregnancy is a unique experience that is stressful despite multiparity. 3. This pregnancy will provoke a situational crisis because the client has two children at home. 4. Support people play a lesser role because the client has had two prior experiences with pregnancy.

2. Each pregnancy is a unique experience that is stressful despite multiparity.

A multigravida of Asian descent weighs 104 lb, having gained 14 pounds during the pregnancy. On her second postpartum day, the client's temperature is 99.2° F (37.3° C). She has had poor dietary intake since admission. What should the nurse do? 1. Ask the nursing supervisor to discuss this with the health care provider 2. Encourage the family to bring in special foods preferred in their culture 3. Order a high protein milkshake as a between-meal snack to stimulate her appetite 4. Explain to the family that the dietitian plans nutritious meals that the client should eat

2. Encourage the family to bring in special foods preferred in their culture

During a prenatal interview at 20 weeks' gestation, the nurse determines that the client has a history of pica. What is the most appropriate nursing action? 1. Seeking a psychological referral for the client 2. Ensuring that the client's diet is nutritionally adequate 3. Informing the client of the danger this poses to her fetus 4. Obtaining a prescription for a multivitamin supplement for the client

2. Ensuring that the client's diet is nutritionally adequate

A resident practitioner in the birthing unit asks the nurse to prepare for a vaginal examination on a client with a low-lying placenta who is in early labor. What is the priority nursing action? 1. Preparing an intravenous piggyback of oxytocin (Pitocin) 2. Explaining why a vaginal examination should not be performed 3. Obtaining an internal monitor to be applied during the examination 4. Having equipment ready for a fetal scalp pH after the examination

2. Explaining why a vaginal examination should not be performed

A pregnant client who is scheduled for a nonstress test (NST) asks a nurse how the test can show that "my baby is all right." The nurse explains that it is a way of evaluating the condition of the fetus by comparing the fetal heart rate (FHR) with: 1. Fetal gestational age 2. Fetal physical activity 3. Maternal blood pressure 4. Maternal uterine contractions

2. Fetal physical activity

How should a nurse direct care for a client in the transition phase of the first stage of labor? 1. Decreasing intravenous fluid intake 2. Helping the client maintain control 3. Reducing the client's discomfort with medications 4. Having the client use simple breathing patterns during contractions

2. Helping the client maintain control

During the fourth stage of labor, the assessment of a primipara who has had a vaginal birth reveals a moderate to large amount of lochia rubra, a firm fundus that is at the umbilicus and deviated to the right, and pain that she rates as a 3 on a scale of 1 to 10. What is the priority nursing action? 1. Massaging the fundus 2. Helping the client void 3. Increasing the rate of the oxytocin infusion 4. Administering the prescribed pain medication

2. Helping the client void **A fundus that is deviated to the right during the fourth stage of labor commonly is caused by a distended bladder ; if the bladder remains distended, involution will be inhibited, resulting in a boggy uterus that is prone to hemorrhage.

A woman's pregnancy has been uneventful, and she has gained 25 lb. At term her hemoglobin level is 10.6 g/dL and her hematocrit is 31%. What does the nurse identify as the reason for these hemoglobin and hematocrit levels? 1. Infection 2. Hemodilution 3. Nutritional deficits 4. Concealed bleeding

2. Hemodilution **Infection does not lead to a lower hematocrit. The increase in circulating blood volume during pregnancy is reflected in lower hemoglobin and hematocrit readings (physiological anemia of pregnancy). The history reveals no prenatal problems, and weight gain is adequate. In the absence of other significant signs and symptoms, concealed bleeding is unlikely.

A nurse is caring for a client who is receiving internal radiation for cancer of the cervix. For which adverse reactions to the radiotherapy should the client be monitored? (Select all that apply.) 1. Nausea 2. Hemorrhage 3. Restlessness 4. Vaginal discharge 5. Increased temperature

2. Hemorrhage 5. Increased temperature

2. Hypoglycemia **SGA infants may exhibit signs of hypoglycemia, especially during the first 2 days of life, because of depleted glycogen stores and inhibited gluconeogenesis.

A woman is admitted for a hysterectomy and bilateral salpingo-oophorectomy. The nurse reviews the client's gynecological history. What condition does the client have that causes the nurse to anticipate an abdominal, rather than a vaginal, hysterectomy? 1. Prolapsed uterus 2. Large uterine fibroids 3. Mild dysplasia of the cervical os 4. Urinary incontinence when coughing

2. Large uterine fibroids **Attempting to remove a uterus with large uterine fibroids vaginally can cause trauma, resulting in hemorrhage.

Methods of relieving back pain are explained during a childbirth class. What activities identified by the client permit the nurse to conclude that the teaching has been understood? (Select all that apply.) 1. Tailor sitting 2. Pelvic rocking 3. Forward tilting 4. Sacral pressure 5. Kegel exercises

2. Pelvic rocking 3. Forward tilting 4. Sacral pressure

A client in labor is admitted with a suspected breech presentation. For what occurrence should the nurse be prepared? 1. Uterine inertia 2. Prolapsed cord 3. Imminent birth 4. Precipitate labor

2. Prolapsed cord

A nurse is teaching a breastfeeding client about medications that are safe and unsafe for her to take. Which medication is contraindicated? 1. Heparin (Hep-Lock) 2. Propylthiouracil (PTU) 3. Gentamicin (Garamycin) 4. Diphenhydramine (Benadryl)

2. Propylthiouracil (PTU) **The concentration of propylthiouracil (PTU) excreted in breast milk is three to 12 times higher than its level in maternal serum; this may cause agranulocytosis or goiter in the infant.

A nurse is discussing immunizations needed to confer active immunity with a pregnant client during her first visit to the prenatal clinic. What information should the nurse consider including that the client will understand with regard to active immunity? 1. Protein antigens are formed in the blood to fight invading antibodies. 2. Protein substances are formed by the body to destroy or neutralize antigens. 3. Blood antigens are aided by phagocytes in defending the body against pathogens. 4. Sensitized lymphocytes from an immune donor act as antibodies against invading pathogens.

2. Protein substances are formed by the body to destroy or neutralize antigens.

A client at 36 weeks' gestation is admitted to the high-risk unit because she gained 5 lb in the previous week and there is a pronounced increase in blood pressure. What is the initial intervention in the client's plan of care? 1. Preparing for an imminent cesarean birth 2. Providing a dark, quiet room with minimal stimuli 3. Initiating intravenous furosemide to promote diuresis 4. Administering calcium gluconate to lower the blood pressure

2. Providing a dark, quiet room with minimal stimuli **Increasing cerebral edema may predispose the client to seizures; therefore stimuli of any kind should be minimized.

Identify the position of the fetus whose buttocks are in the fundus, whose fetal back is on the maternal right side between the midline, and lateral surface of the abdomen, and whose attitude is general flexion. 1. RSA 2. ROA 3. RMA 4. LOA

2. ROA **The fetus is in the ROA (right occiput anterior) position: occiput facing the front on the right side of the mother). It is a vertex delivery. In the RSA (right sacrum anterior) position the buttocks point anteriorly on the mother's right side. RMA (right mentoanterior) is a brow presentation. In LOA (left occiput anterior), another vertex position, the fetus' back is on the mother's left side.

A 16-year-old primigravida at 32 weeks' gestation is admitted to the high-risk unit. Her blood pressure is 170/110 mm Hg and she has 4+ proteinuria. She gained 50 lb during the pregnancy, and her face and extremities are edematous. What complication, which occurs in the latter part of pregnancy, does the nurse identify? 1. Eclampsia 2. Severe preeclampsia 3. Chronic hypertension 4. Gestational hypertension

2. Severe preeclampsia **With severe preeclampsia, arteriolar spasms cause hypertension and decreased arterial perfusion of the kidneys, which in turn cause an alteration in the glomeruli, resulting in oliguria and proteinuria, as well as retention of sodium and water, resulting in edema.

A nurse is being oriented to a prenatal clinic after graduation. The new nurse takes a course on several tests during pregnancy. Place the tests in the order in which they should be performed during pregnancy. 1. Fetal movement test 2. Sickle cell screening 3. Group B Streptococcus culture 4. Serum glucose for gestational diabetes 5. α-Fetoprotein (AFP) testing for neural tube defects

2. Sickle cell screening 5. α-Fetoprotein (AFP) testing for neural tube defects 4. Serum glucose for gestational diabetes 1. Fetal movement test 3. Group B Streptococcus culture

A nurse is caring for a client in active labor. What positions should the nurse encourage the client to assume to help promote comfort during back labor? (Select all that apply.) 1. Prone 2. Sitting 3. Supine 4. Lateral 5. Knee-chest

2. Sitting 4. Lateral 5. Knee-chest

A nurse determines that the husband of a client in the early phase of labor understands the teaching from childbirth classes when he helps his wife use the breathing pattern of: 1. Pant-blow 2. Slow-chest 3. Shallow-chest 4. Accelerate-decelerate

2. Slow-chest

A nurse observes a laboring client's amniotic fluid and decides that it is the expected color. What finding supports this conclusion? 1. Clear, dark amber colored, and containing shreds of mucus 2. Straw-colored, clear, and containing little white specks 3. Milky, greenish yellow, and containing shreds of mucus 4. Greenish yellow, cloudy, and containing little white specks

2. Straw-colored, clear, and containing little white specks

Which position does the nurse teach the client to avoid when she experiences back pain during labor? 1. Sims position 2. Supine position 3. Right lateral position 4. Left side-lying position

2. Supine position **Low back pain is aggravated when the mother is in the supine position because fetal pressure on the sacral nerves is increased.

A nurse is obtaining a health history from a client with newly diagnosed cervical cancer. What aspect of the client's life is most important for the nurse to explore at this time? 1. Sexual history 2. Support system 3. Obstetrical history 4. Elimination patterns

2. Support system

A primipara gives birth to an infant weighing 9 lb 15 oz (4508 g). During labor a midline episiotomy is performed and the client sustains a third-degree laceration. The client tells the nurse that her perineal area is very painful. What should the nurse consider before explaining the reason for the pain? 1. Perineal muscles have been cut. 2. The anal sphincter muscle has been injured. 3. The anterior wall of the rectum has been traumatized. 4. Structures superficial to muscles have been damaged.

2. The anal sphincter muscle has been injured. **A third-degree laceration extends through the perineal muscles and continues through the anal sphincter muscle.

Jaundice develops in a newborn 72 hours after birth. What should the nurse tell the parents is the probable cause of the jaundice? 1. An allergic response to the feedings 2. The physiological destruction of fetal red blood cells 3. A temporary bile duct obstruction commonly found in newborns 4. The seepage of maternal Rh-negative blood into the neonate's bloodstream

2. The physiological destruction of fetal red blood cells

A client is receiving an oxytocin (Pitocin) infusion for induction of labor. The uterine graph on the electronic monitor indicates no rest period between contractions, and this is confirmed on palpation. What should the nurse do first? 1. Evaluate the fetal heart rate 2. Turn the oxytocin infusion off 3. Place the client in the left-lateral position 4. Prepare the client for an emergency birth

2. Turn the oxytocin infusion off

Before a postpartum client is discharged, the nurse advises her about problems that should be reported and then asks her to recall these problems. Identification of which problem identified by the client indicates that the teaching has been effective? 1. Breast engorgement with feelings of fullness 2. Urgency, frequency, and burning on urination 3.Increased amount of lochia after physical activity 4. Dryness and tenderness when intercourse is first resumed

2. Urgency, frequency, and burning on urination **These clinical findings are indicative of a urinary tract infection and should be reported immediately. Engorgement is expected and should subside in a few days.

A client is receiving an epidural anesthetic during labor. For which side effect should the nurse monitor the client? 1. Hypertension 2. Urine retention 3. Subnormal temperature 4. Decreased level of consciousness

2. Urine retention

What complication should a nurse be alert for in a client receiving an oxytocin (Pitocin) infusion to induce labor? 1. Intense pain 2. Uterine tetany 3. Hypoglycemia 4. mbilical cord prolapse

2. Uterine tetany

At 38 weeks' gestation a client is admitted to the birthing unit in active labor, and an external fetal monitor is applied. Late fetal heart rate decelerations begin to appear when her cervix is dilated 6 cm and her contractions are occurring every 4 minutes and lasting 45 seconds. What does the nurse conclude is the cause of these late decelerations? 1. Imminent vaginal birth 2. Uteroplacental insufficiency 3. Pattern of nonprogressive labor 4. Reassuring response to contractions

2. Uteroplacental insufficiency

A nurse instructs a client who is taking oral contraceptives to increase her intake of dietary supplements. Which supplement should be increased? 1. Calcium 2. Vitamin C 3. Vitamin E 4. Potassium

2. Vitamin C **Oral contraceptives can affect the metabolism of certain vitamins, particularly vitamin C, and supplementation may be required.

The nurse assures a breastfeeding mother that one way she will know that her infant is getting an adequate supply of breast milk is if the infant gains weight. What behavior does the infant exhibit if an adequate amount of milk is being ingested? 1. Has several firm stools daily 2. Voids six or more times a day 3. Spits out a pacifier when offered 4. Awakens to feed about every four hours

2. Voids six or more times a day

During a client's first visit to the prenatal clinic, a nurse discusses a pregnancy diet. The client states that her mother told her that she should restrict her salt intake. What is the nurse's best response? 1."Your mother is always correct. You should use less salt to prevent swelling during pregnancy." 2."Because you need salt to maintain body water Balance; it is not restricted. Just eat a well-balanced diet." 3."Salt is an essential nutrient that is naturally reduced by the body's estrogen. There's no reason to restrict salt in your diet." 4."We no longer recommend that salt intake be as restricted as much as in the past, but you still shouldn't add salt to your food."

2."Because you need salt to maintain body water Balance; it is not restricted. Just eat a well-balanced diet."

After 8 postpartum hours the nurse determines that a client's fundus is 3 cm above the umbilicus and displaced to the right. Which statement is most significant in confirming the reason for the location of the uterus? 1."I've been so thirsty the past few hours." 2."I went to the bathroom, but I can't seem to urinate." 3."I've changed my pad once since I got to my room." 4."I've had a lot of contractions, especially while I was nursing."

2."I went to the bathroom, but I can't seem to urinate."

A client is admitted with a diagnosis of torsion of the testes. How should the nurse respond when the client asks, "Why do I have to have surgery right now?"? 1."There's no other way to control the pain." 2."Irreversible damage occurs after a few hours." 3."The extreme swelling can cause the testicle to rupture." 4."The reduction in testicular blood flow leads to rapid death of sperm."

2."Irreversible damage occurs after a few hours."

A client who underwent mastectomy because of breast cancer is now undergoing chemotherapy, which has caused hair loss. The client states, "I feel like I've lost my sense of power." What is the nurse's best response? 1."Hair does not empower a person." 2."Losing power seems important to you." 3."Knowledge is power; I'll give you some pamphlets to read." 4."Hair loss is common; it will grow back, so you shouldn't worry."

2."Losing power seems important to you."

A client at 16 weeks' gestation is being treated for Trichomonas vaginalis. Which statement best indicates to the nurse that the client has learned measures to prevent a recurrence? 1."After having sex I'll insert a vaginal suppository." 2."My partner has to get treated before we have sex again." 3."I need to urinate immediately after having sexual intercourse." 4."Douching immediately after sexual intercourse will help protect me."

2."My partner has to get treated before we have sex again."

Which statement made by a pregnant client to a nurse indicates that the client does not understand the teaching about fetal growth and development? 1."The baby is smaller if the mother smokes." 2."The baby gets food from the amniotic fluid." 3."The baby's oxygen is provided by the mother." 4."The baby's umbilical cord has two arteries and one vein."

2."The baby gets food from the amniotic fluid."

A 37-year-old woman is admitted to the unit with severe menorrhagia. During a conversation, the nurse learns that the client has a history of fibroids, menorrhagia, pelvic pain, and depression. The client has been undergoing hormone therapy in hopes of easing the symptoms and reducing fibroids' size, without success. The lab reports hemoglobin and hematocrit readings of 6.8 and 20.2, respectively. The client begins to sob and cries, "I don't know what to do — the doctor is recommending a hysterectomy, but I haven't had children yet!" What is the best response by the nurse? 1."There are so many orphans looking for a mother." 2."This must be so difficult for you. Children are really important to you?" 3."You really have no choice but to follow the recommendation; the doctor is right." 4."Believe me when I tell you that kids are so difficult to raise — you're better off without them."

2."This must be so difficult for you. Children are really important to you?"

A married couple has been using oral contraceptives to delay pregnancy. When the wife misses her regular menstrual period, she decides to find out whether she is pregnant. She tells the nurse that pregnancy may have occurred because she missed her contraceptive pills for 1 week when she had the flu. How should the nurse respond? 1."That's the trouble with using contraceptive pills. People frequently forget to take them." 2."You may be correct. The effect of contraceptive pills depends on their being taken on a regular schedule." 3."Let's find out whether you really are pregnant. If you are, you may want to consider having an abortion." 4."Contraceptive pills are unpredictable. You could have become pregnant even if you had taken them regularly."

2."You may be correct. The effect of contraceptive pills depends on their being taken on a regular schedule."

During the postpartum period a client with heart disease and type 2 diabetes asks a nurse, "Which contraceptives will I be able to use to prevent pregnancy in the near future?" How should the nurse respond? 1."You may use oral contraceptives — they're almost completely effective in preventing pregnancy." 2."You should use foam with a condom to prevent pregnancy — this is the safest method for women with your illnesses." 3."You'll find that the intrauterine device is best for you, because it prevents a fertilized ovum from implanting in the uterus." 4."You have little to worry about regarding becoming pregnant in the near future because women with your illnesses usually become infertile."

2."You should use foam with a condom to prevent pregnancy — this is the safest method for women with your illnesses."

A client who is scheduled to have a hysterectomy starts to sob and says, "I told my husband that after this operation, I'll be only half a woman. He told me not to worry, but I know that he was just putting up a front." How should the nurse respond? 1."It's frightening to think that your husband rejects you as a woman." 2."You think this operation will affect how your husband feels about you as his wife." 3."Try not to worry about it right now. The most important thing is for you to get well." 4."I'll try to have your surgery postponed. You both need time to adjust to the effects of a hysterectomy."

2."You think this operation will affect how your husband feels about you as his wife."

A client who menstruates regularly every 30 days asks a nurse on what day she is most likely to ovulate. Because the client's last menses started on January 1, the nurse should tell her that ovulation should occur on which day in January? 1.7 2.16 3.24 4.29

2.16

A primigravida in her seventh week of gestation asks the nurse when she can expect to feel her baby move. The nurse replies that quickening usually occurs in the: 1.24th week 2.20th week 3.16th week 4.12th week

2.20th week

2.60 g

Although a client in labor is prepared and plans to participate in the labor and birth process, she states that she is in severe discomfort. The nurse administers the prescribed butorphanol (Stadol). Which phase of labor is the safest time for the nurse to administer this medication? 1.Early phase 2.Active phase 3.Transition phase 4.Expulsion phase

2.Active phase

The clinic nurse is planning care for a client found to have chlamydia. Which treatment should the nurse plan to implement? 1.Administration of acyclovir (Zovirax) 250 mg orally in a single dose 2.Administration of azithromycin (Zithromax) 1 g orally in a single dose 3.Administration of ceftriaxone (Rocephin) 250 mg intramuscularly in a single dose 4.Administration of benzathine penicillin G 2.4 million units intramuscularly in a single dose

2.Administration of azithromycin (Zithromax) 1 g orally in a single dose

Twenty-four hours after an uncomplicated labor and birth a client's complete blood count reveals a white blood cell (WBC) count of 17,000/mm3. How should the nurse interpret this WBC count? 1.A normal decrease in WBCs 2.An expected response to the process of labor and birth 3.A sign of an acute sexually transmitted viral infection 4.A sign of a bacterial infection of the reproductive system

2.An expected response to the process of labor and birth

2.Anger

A client who is to undergo dilation and curettage, and conization of the cervix for cancer appears tense and anxious. What is the best approach for the nurse to support the client emotionally? 1.Explaining that these procedures are considered minor surgery 2.Asking whether something is troubling the client and whether she'd like to talk about it 3.Stating that the procedures are routine and asking what the client is really worried about 4.Explaining that everybody is fearful before the surgery even though there is little reason to worry

2.Asking whether something is troubling the client and whether she'd like to talk about it

When a client is being given an intravenous infusion of magnesium sulfate, the nurse should have its antidote readily available. Which of the following medications would the nurse administer if toxicity were to occur? 1.Protamine sulfate 2.Calcium gluconate 3.Sodium bicarbonate 4.Naloxone hydrochloride

2.Calcium gluconate

A practitioner orders doxycycline (Vibramycin) for a sexually active woman with a history of a mucopurulent discharge and bleeding associated with cervical dysplasia, dysuria, and dyspareunia. With which sexually transmitted infection are these clinical findings and medication therapy commonly associated? 1.Herpes simplex 2 2.Chlamydial infection 3.Treponema pallidum 4.Neisseria gonorrhoeae

2.Chlamydial infection

A nurse is preparing to counsel a client whose two previous pregnancies were uneventful, ending in term vaginal births of healthy children. What should the nurse consider about multiparas with previous uneventful pregnancies before beginning prenatal counseling? 1Multiparas cope more successfully with pregnancy than do primigravidas. 2.Each pregnancy is a unique experience that is stressful despite multiparity. 3.This pregnancy will provoke a situational crisis because the client has two children at home. 4.Support people play a lesser role because the client has had two prior experiences with pregnancy.

2.Each pregnancy is a unique experience that is stressful despite multiparity.

2.Expect shoulder pain for 12 to 24 hours.

The clinic nurse is providing home care instructions for a client with pelvic inflammatory disease. What resting position should be recommended by the nurse? 1.Sims 2.Fowler 3.Supine with knees flexed 4.Lithotomy with head elevated

2.Fowler

A nurse is caring for a client who is receiving internal radiation for cancer of the cervix. For which adverse reactions to the radiotherapy should the client be monitored? (Select all that apply.) 1.Nausea 2.Hemorrhage 3.Restlessness 4.Vaginal discharge 5.Increased temperature

2.Hemorrhage 5.Increased temperature

A client presents to the clinic with complaints of nausea and amenorrhea and reports that she obtained a positive result on a home pregnancy test. Which component of the history is most indicative of pregnancy? 1.Her menses is a week late. 2.Her urine immunoassay test is positive, 3.She reports that she has urinary frequency, 4.She complains that she has nausea every morning

2.Her urine immunoassay test is positive,

A hysterectomy is scheduled for a client with endometrial cancer. Before the surgery, what should the nurse prepare the client to expect? 1.Nasogastric tube 2.Indwelling urinary catheter 3.Vaginal packing for 10 days 4.Jackson-Pratt drain in the abdominal incision

2.Indwelling urinary catheter

After a mastectomy, a client returns from surgery with a closed suction drainage system in place and a dry sterile dressing covering the incision. What should the nurse do when observing this client for signs of bleeding? 1.Empty the output in the portable suction unit hourly 2.Inspect the bedclothes under the client's axillary area for signs of drainage 3.Turn the client on the affected side to look for blood that may flow backward 4.Reinforce the operative site with a pressure dressing if drainage appears on the dressing

2.Inspect the bedclothes under the client's axillary area for signs of drainage

A nurse is caring for a client in labor whose cervix is dilated 6 cm. The client is receiving epidural analgesia. What common response to regional anesthesia does the nurse anticipate? 1.Urticaria 2.Lightheadedness 3.Elevated temperature 4.Sensation of chilliness

2.Lightheadedness

After a cesarean birth a nurse performs fundal checks every 15 minutes. The nurse determines that the fundus is soft and boggy. What is the priority nursing action at this time? 1.Elevating the client's legs 2.Massaging the client's fundus 3.Increasing the client's oxytocin drip rate 4.Examining the client's perineum for bleeding

2.Massaging the client's fundus

The nurse is obtaining a health history from a client with endometriosis. What consequences can occur as a result of this disorder? (Select all that apply.) 1.Menopause 2.Metrorrhagia 3.Ovarian cancer 4.Bowel strictures 5.Voiding difficulties

2.Metrorrhagia 4.Bowel strictures 5.Voiding difficulties

A nurse in the family planning clinic reviews the health history of a sexually active 16-year-old girl whose chief concern is a thick, burning discharge accompanied by a burning sensation and lower abdominal pain. After an examination the girl is informed that she may have a sexually transmitted infection (STI) that requires treatment. The adolescent is concerned that her parents will discover that she has been sexually active and asks the nurse whether her parents will be contacted. The nurse explains that her parents will: 1.Need to know to sign a consent form for testing and treatment 2.Not be contacted, because treatment at the clinic is confidential 3.Be notified when the insurance company is billed for testing and treatment 4.Remain uninformed if the adolescent ensures that her sexual contacts will come for testing

2.Not be contacted, because treatment at the clinic is confidential

A histogram (hysterosalpingography [HSG]) is performed to determine whether a client has a tubal obstruction. The nurse explains to the client that infertility caused by a defect in the tube is most often related to: 1.A tubal injury 2.Past infection 3.A fibroid tumor 4.A congenital anomaly

2.Past infection

A nurse is teaching a class of expectant parents about nutritional needs during pregnancy. What information should the nurse include? 1.Carbohydrate needs decrease during pregnancy. 2.Protein needs increase to at least 70 g/day during pregnancy. 3.Phosphorus and calcium needs decrease gradually throughout pregnancy. 4.Caloric needs increase gradually up to 100 more kcal/day throughout pregnancy

2.Protein needs increase to at least 70 g/day during pregnancy.

A nurse is discussing immunizations needed to confer active immunity with a pregnant client during her first visit to the prenatal clinic. What information should the nurse consider including that the client will understand with regard to active immunity? 1.Protein antigens are formed in the blood to fight invading antibodies. 2.Protein substances are formed by the body to destroy or neutralize antigens. 3.Blood antigens are aided by phagocytes in defending the body against pathogens. 4.Sensitized lymphocytes from an immune donor act as antibodies against invading pathogens

2.Protein substances are formed by the body to destroy or neutralize antigens.

When teaching a client about using a diaphragm as a form of contraception, the nurse should tell her that the diaphragm: 1.May or may not be used with a spermicidal lubricant 2.Should remain in place for at least 6 hours after intercourse 3.Must be inserted with the dome facing down to be maximally effective 4.Often appears puckered but that this will not interfere with its effectiveness

2.Should remain in place for at least 6 hours after intercourse

A nurse is planning to teach a new mother about breastfeeding. What should the nurse consider before preparing the client to breastfeed? 1.Oxytocin stimulates milk production. 2.Suckling stimulates the release of oxytocin. 3.Estrogen stimulates the secretion of lactogenic hormones. 4.Placental separation stimulates the release of progesterone.

2.Suckling stimulates the release of oxytocin.

A nurse is obtaining a health history from a client with newly diagnosed cervical cancer. What aspect of the client's life is most important for the nurse to explore at this time? 1.Sexual history 2.Support system 3.Obstetrical history 4.Elimination patterns

2.Support system

A female client with Hodgkin disease is to start total nodal irradiation. She and her partner, who are planning a family, become concerned when they learn that the radiation therapy includes the pelvic area. Before responding what must the nurse consider? 1.Irradiation of the area will result in permanent sterilization. 2.The eggs in the ovaries can be removed and frozen for future use. 3.The radiation may be intense enough to cause sterilization of one ovary. 4.Ovarian function will be destroyed temporarily, but function will return after therapy

2.The eggs in the ovaries can be removed and frozen for future use.

A woman has just received the news that she is pregnant. She is ambivalent about the pregnancy because she had planned to go back to work when her youngest child started school next year. What developmental task of pregnancy must the woman accomplish in the first trimester of pregnancy? 1Recognize her ambivalence 2Accept that she is pregnant 3Prepare for the birth of the baby 4Recognize the fetus as an individual separate from the mother

2Accept that she is pregnant

During prenatal classes the nurse teaches the difference between true labor and false labor. How does the nurse explain the difference? 1Bloody show is rare with false labor. 2Cervix effaces and dilates during true labor. 3Membranes rupture at the start of true labor. 4Fetal movement slows and contractions accelerate with false labor

2Cervix effaces and dilates during true labor.

A client at 10 weeks' gestation tells the nurse in the maternity clinic that she is worried because she is voiding frequently. How should the nurse respond? 1Recommending that she inform her health care provider 2Explaining why this is expected in early pregnancy 3Telling the client not to worry because this is expected 4Collecting the client's urine for a culture and sensitivity test

2Explaining why this is expected in early pregnancy

A nurse helps a client to the bathroom to void several times during the first stage of labor. This is done because a full bladder: 1Is often injured during labor 2May inhibit the progress of labor 3Jeopardizes the status of the fetus 4Predisposes the client to urinary infection

2May inhibit the progress of labor

When a client at 39 weeks' gestation arrives at the birthing suite she says, "I've been having contractions for 3 hours, and I think my water broke." What will the nurse do to confirm that the membranes have ruptured? 1Take the client's oral temperature 2Test the leaking fluid with nitrazine paper 3Obtain a clean-catch urine specimen 4Inspect the perineum for leaking fluid

2Test the leaking fluid with nitrazine paper

A primipara gives birth to an infant weighing 9 lb 15 oz (4508 g). During labor a midline episiotomy is performed and the client sustains a third-degree laceration. The client tells the nurse that her perineal area is very painful. What should the nurse consider before explaining the reason for the pain? 1Perineal muscles have been cut. 2The anal sphincter muscle has been injured. 3The anterior wall of the rectum has been traumatized. 4Structures superficial to muscles have been damaged.

2The anal sphincter muscle has been injured.

A client is receiving an oxytocin (Pitocin) infusion for induction of labor. The uterine graph on the electronic monitor indicates no rest period between contractions, and this is confirmed on palpation. What should the nurse do first? 1Evaluate the fetal heart rate 2Turn the oxytocin infusion off 3Place the client in the left-lateral position 4Prepare the client for an emergency birth

2Turn the oxytocin infusion off

A client is receiving an epidural anesthetic during labor. For which side effect should the nurse monitor the client? 1Hypertension 2Urine retention 3Subnormal temperature 4Decreased level of consciousness

2Urine retention

At 38 weeks' gestation a client is admitted to the birthing unit in active labor, and an external fetal monitor is applied. Late fetal heart rate decelerations begin to appear when her cervix is dilated 6 cm and her contractions are occurring every 4 minutes and lasting 45 seconds. What does the nurse conclude is the cause of these late decelerations? 1Imminent vaginal birth 2Uteroplacental insufficiency 3Pattern of nonprogressive labor 4Reassuring response to contractions

2Uteroplacental insufficiency

A nurse on the postpartum unit discusses breast care with a client who is formula feeding her newborn. Which statement indicates to the nurse that more teaching is needed? 1. "The discomfort will be better after a couple of days." 2. "I need to ask my husband to bring me my new bra." 3. "Applying heat to my breasts will help ease the discomfort." 4. "Pain medication will help with the pain from engorgement."

3. "Applying heat to my breasts will help ease the discomfort."

A nurse is teaching a postpartum client the characteristics of lochia and any deviations that should be reported immediately. What client statement indicates that the teaching was effective? 1. "If I pass any clots, I'll notify the clinic." 2. "I'll call the clinic if my lochia changes from red to pink." 3. "I'll notify the clinic if my lochia starts to smell bad." 4. "If my vaginal discharge continues for three weeks, I'll call the clinic."

3. "I'll notify the clinic if my lochia starts to smell bad." **Lochia has a characteristic menstrual musky or fleshy smell. A foul-smelling discharge, along with fever and uterine tenderness, suggests an infection.

Which statements by a client with hyperemesis gravidarum would confirm that the client needs further teaching? (Select all that apply.) 1. "I'll start drinking protein shakes." 2. "I'll start drinking plenty of fluids." 3. "I'll start limiting my carbohydrates." 4. "I'll lie down for at least 2 hours after I eat." 5. "I'll be sure to schedule rest periods throughout the day so I won't get tired."

3. "I'll start limiting my carbohydrates." 4. "I'll lie down for at least 2 hours after I eat."

After the birth of her daughter, a mother tells the nurse, "I was told that my baby has to have an injection of vitamin K. She's so small to be getting a shot. Why does she have to have it?" How should the nurse respond? 1. "Your baby needs the injection to help her develop red blood cells." 2. "An injection of vitamin K will help keep your baby from becoming jaundiced." 3. "Newborns are deficient in vitamin K. This treatment will protect your baby from bleeding." 4. "A newborn's blood clots extremely rapidly. This injection will help decrease the clotting time."

3. "Newborns are deficient in vitamin K. This treatment will protect your baby from bleeding."

The family of a pregnant client with myasthenia gravis asks the nurse whether the client will be an invalid. What is the best response by the nurse? 1. "Medications will mask the signs of the disease." 2. "With continuous treatment, the progression of the disease can usually be controlled." 3. "The progression is slow, so people with myasthenia will spend their younger life with few problems." 4. "There will be periods when bedrest will be necessary and times when regular activity will be possible."

3. "The progression is slow, so people with myasthenia will spend their younger life with few problems."

A 63-year-old woman with the diagnosis of estrogen-receptor positive cancer of the breast undergoes lumpectomy and radiation therapy, and tamoxifen (Nolvadex) is prescribed. The client asks the nurse how long she will have to take the medication. The nurse responds: 1. "You'll have to take it for the rest of your life." 2. "You'll need to take it for 10 days, like an antibiotic." 3. "You'll need to take it for 5 years, after which it will be discontinued." 4. "You'll need to take it for several months, until the bone pain subsides."

3. "You'll need to take it for 5 years, after which it will be discontinued."

A negative home pregnancy test may result if the woman performs the test: 1. By saturating the test strip 2. On the first void of the morning 3. 10 days after intercourse took place 4. While taking a prescribed tranquilizer

3. 10 days after intercourse took place **The most common error made by women taking home pregnancy tests is to perform the test too early in the pregnancy.

A nurse who is monitoring a newborn 3 minutes after birth remembers that the heart rate of a healthy, alert neonate may range between: 1. 120 and 180 beats/min 2. 130 and 170 beats/min 3. 110 and 160 beats/min 4. 100 and 130 beats/min

3. 110 and 160 beats/min

A client is scheduled for a vacuum aspiration abortion to terminate an unwanted pregnancy. What information should the nurse's teaching plan include? 1. It is a lengthy procedure but will cause no pain. 2. Both she and the father must sign the consent form. 3. A temperature of 100.4° F (38° C) or higher should be reported immediately. 4. She will experience a heavy menstrual flow for 1 to 2 weeks after the procedure.

3. A temperature of 100.4° F (38° C) or higher should be reported immediately.

A pregnant woman who is in the third trimester arrives in the emergency department with vaginal bleeding. She states that she snorted cocaine approximately 2 hours ago. Which complication does the nurse suspect as the cause of the bleeding? 1. Placenta previa 2. tubal pregnancy 3. Abruptio placentae 4. Spontaneous abortion

3. Abruptio placentae

When working with a client who has spontaneously aborted a pregnancy, it is important for the nurse to first deal with his or her own feelings about abortion, death, and loss so that he or she may : 1. Maintain control of the situation 2. Share personal grief with the clients 3. Allow the clients to express their grief 4. Teach the clients how to cope effectively

3. Allow the clients to express their grief **The nurse can be more sensitive to the needs of the client by addressing personal emotions first. Control is not, and should not be, the goal of the nurse. The client's feelings, not the nurse's, should be the focus. A time of crisis is not the time to teach; the client is not ready to learn.

After a client gives birth, what physiological occurrence indicates to the nurse that the placenta is beginning to separate from the uterus and is ready to be expelled? 1. Relaxation of the uterus 2. Descent of the uterus in the abdomen 3. Appearance of a sudden gush of blood 4. Retraction of the umbilical cord into the vagina

3. Appearance of a sudden gush of blood **When the placenta separates from the uterine wall, it tears blood vessels, resulting in a gush of blood from the vagina.

A client in labor is experiencing discomfort because her fetus is in the occiput posterior position. What nursing action will help relieve this discomfort? 1. Positioning her on the left side 2. Using effleurage on her abdomen 3. Applying pressure against her sacrum 4. Placing her in the semi-Fowler position

3. Applying pressure against her sacrum

While caring for a client who gave birth 1day ago, the nurse determines that the client's uterine fundus is firm at one fingerbreath below the umbilicus, blood pressure is 110/70 mm Hg, pulse is 72 beats/min, and respirations are 16 breaths/min. The client's perineal pad is saturated with lochia rubra. What is the priority nursing action? 1. Recording these expected findings 2. Obtaining a prescription for an oxytocic medication 3. Asking the client when she last changed the perineal pad 4. Notifying the primary health care provider that the client may be hemorrhaging

3. Asking the client when she last changed the perineal pad **The amount of lochia would be excessive if the pad were saturated in 15 minutes; saturating the pad in 2 hours is considered heavy bleeding.

What is the best nursing action for a client in active labor whose cervix is dilated 4 cm and 100% effaced with the fetal head at 0 station? 1. Document the fetal heart rate every 5 minutes 2. Call the anesthesia department to alert the staff there of an imminent birth 3. Assist the client's coach in helping her with the use of breathing techniques 4. Suggest that the client accept the PRN medication for pain that has been prescribed

3. Assist the client's coach in helping her with the use of breathing techniques

When a nurse brings a newborn to a mother, the mother comments about the milia on her infant's face. What information should the nurse include when responding? 1. They are common and will disappear in 2 to 3 days. 2. They are birthmarks that will disappear in 3 to 4 months. 3. Avoid squeezing them and don't try to wash them off. 4. Proper handwashing technique is important because milia are infectious.

3. Avoid squeezing them and don't try to wash them off.

A primigravida tells the nurse that she has morning sickness. What suggestion should the nurse make to help relieve the nausea? 1. Eating three small meals a day 2. Increasing dietary calcium intake 3. Avoiding long periods without food 4. Drinking 2 quarts or more of fluid a day

3. Avoiding long periods without food **Fasting results in hypoglycemia, which can cause nausea; in addition, the developing fetus should not be deprived of nutrients for any length of time.

The fetus of a woman in labor is at +1 station. At what place in the pelvic area does the nurse conclude that the presenting part is located? 1. Not yet engaged 2. Entering the pelvic inlet 3. Below the ischial spines 4. Visible at the vaginal opening

3. Below the ischial spines **A +1 station indicates that the fetal presenting part is 1 cm below the ischial spines, which are the points of engagement. Entrance of the pelvic inlet is designated as 0 station or as a negative number. The head must be at +3 to +5 to be visible at the vaginal opening.

A nurse is estimating a newborn's gestational age. What parameters should the nurse evaluate? (Select all that apply.) 1. Weight 2. Length 3. Breast size 4. Tonic-neck reflex 5. Genital development

3. Breast size 5. Genital development

A primigravida at term is admitted to the birthing room in active labor. Later, when the client is dilated 8 cm, she tells the nurse that she has the urge to push. The nurse instructs her to pant-blow at this time because pushing can cause which of the following? 1. Prolapse the cord 2. Rupture the uterus 3. Cervical edema 4. Lead to a precipitous birth

3. Cervical edema

Three weeks after a client gives birth, a deep vein thrombophlebitis develops in her left leg and she is admitted to the hospital for bedrest and anticoagulant therapy. Which anticoagulant does the nurse expect to administer? 1. Clopidogrel (Plavix) 2. Warfarin (Coumadin) 3. Continuous infusion of heparin 4. Intermittent doses of a low molecular weight heparin

3. Continuous infusion of heparin

A pregnant client at 30 weeks' gestation begins to experience contractions every 5 to 7 minutes. She is admitted with a diagnosis of preterm labor. Although the client is being given tocolytic therapy her cervix continues to dilate, and it is determined that a preterm birth is inevitable. Which medication does the nurse expect the health care provider to prescribe? 1. Norgestrel 2. Aminophylline 3. Dexamethasone 4. Magnesium sulfate

3. Dexamethasone **Dexamethasone is a glucocorticoid that stimulates the production of fetal lung surfactants, which are needed for fetal lung maturity; administration is started 48 hours before the expected birth.

3. G5 T2 P1 A1 L4 **5 T2 P1 A1 L4 indicates that there the client has had five pregnancies (twins count as one pregnancy and the current pregnancy counts as one); two term births; one preterm birth (the twins); one abortion; and four living children.

A primigravida is admitted to the birthing unit in active labor. The fetus is in a breech presentation. What physiological response does the nurse expect during this client's labor? 1. Heavy vaginal bleeding 2. Fetal heart rate irregularities 3. Greenish-tinged amniotic fluid 4. Severe back pain with contractions

3. Greenish-tinged amniotic fluid

A client measuring at 18 weeks' gestation visits the prenatal clinic stating that she is still very nauseated and vomits frequently. Physical examination reveals a brown vaginal discharge and a blood pressure of 148/90 mm Hg. What condition does the nurse suspect the client is experiencing? 1. Dehydration 2. Choriocarcinoma 3. Hydatidiform mole 4. Threatened abortion

3. Hydatidiform mole

A nurse in the newborn nursery receives a call from the emergency department saying that a woman with active herpes virus lesions gave birth in a taxicab while coming to the hospital. What does the nurse consider about the transmission of the herpes virus? 1. Contact precautions are necessary. 2. It occurs during sexual intercourse. 3. It can be acquired during a vaginal birth. 4. Protection is provided by way of maternal immunity

3. It can be acquired during a vaginal birth.

A nurse is assessing a newborn for signs of hyperbilirubinemia (pathological jaundice). What clinical finding confirms this complication? 1. Muscle irritability within 1 hour of birth 2. Neurological signs during the first 24 hours 3. Jaundice that develops in the first 12 to 24 hours 4. Jaundice that develops between 48 and 72 hours after birth

3. Jaundice that develops in the first 12 to 24 hours

A pregnant client with a history of preterm labor is at home on bedrest. What instructions should a teaching plan for this client include? 1. Place blocks under the foot of the bed. 2. Sit upright with several pillows behind the back. 3. Lie on the side with the head raised on a small pillow. 4. Assume the knee-chest position at regular intervals throughout the day.

3. Lie on the side with the head raised on a small pillow.

A client at 22 weeks' gestation asks the nurse how to prevent back pain as her pregnancy progresses. What does the nurse suggest that she wear? 1. Maternity girdle 2. Support stockings 3. Low-heeled shoes 4. Loose-fitting clothing

3. Low-heeled shoes **Low-heeled supportive shoes help maintain the body's center of gravity over the hips, limiting arching of the back that compensates for the increased weight in the abdominal area.

A multipara is admitted to the birthing room in active labor. Her temperature is 98° F (36.7° C), pulse 70 beats/min, respirations 18 breaths/min, and blood pressure 126/76 mm Hg. A vaginal examination reveals a cervix that is 90% effaced and 7 cm dilated with the vertex presenting at 2+ station. The client is complaining of pain and asks for medication. Which medication should be avoided because it may cause respiratory depression in the newborn? 1. Naloxone (Narcan) 2. Lorazepam (Ativan) 3. Meperidine (Demerol) 4. Promethazine (Phenergan)

3. Meperidine (Demerol) **Meperidine (Demerol) is an opioid that can cause respiratory depression in the neonate if administered less than 4 hours before birth.

The nurse observes several dark round areas on a newborn's buttocks on a dark-skinned neonate. How should this observation be documented? 1. Stork bites 2. Forceps marks 3. Mongolian spots 4. Ecchymotic areas

3. Mongolian spots

A 36-year-old multigravida who is at 14 weeks' gestation is scheduled for an α-fetoprotein test. She asks the nurse, "What does this test do?" The nurse bases the response on the knowledge that this test can reveal: 1. Kidney defects 2. Cardiac anomalies 3. Neural tube defects 4. Urinary tract anomalies

3. Neural tube defects

A health care provider determines that a fetus is in a breech presentation. For which complication should the nurse monitor the client? 1. Rapid dilation of the cervix, indicating precipitate labor 2. Stronger contractions, indicating progression of the labor 3. Nonreassuring fetal signs, indicating prolapse of the cord 4. Cessation of contractions, indicating primary uterine inertia

3. Nonreassuring fetal signs, indicating prolapse of the cord

A nurse is teaching a client to care for her episiotomy after discharge. What priority instruction should the nurse include? 1. Rest with legs elevated at least two times a day. 2. Avoid stair climbing for several days after discharge. 3. Perform perineal care after toileting until healing occurs. 4. Continue sitz baths three times a day if they provide comfort.

3. Perform perineal care after toileting until healing occurs.

3. Placenta previa **A nontender uterus and bright-red bleeding are classic signs of placenta previa ; as the cervix dilates, the overlying placenta separates from the uterus and begins to bleed.

A client in her 30th week of gestation is in preterm labor, and the practitioner prescribes betamethasone (Celestone). The client asks the nurse why she is being given this drug. As a basis for the response the nurse takes into consideration that it: 1. Prevents chorioamnionitis 2. Increases uteroplacental exchange 3. Promotes neonatal pulmonary maturity 4. Is used to treat fetal respiratory distress syndrome

3. Promotes neonatal pulmonary maturity

What should be included in the teaching plan for the mother of a newborn with exstrophy of the bladder? 1. Maintaining sterility of the exposed bladder 2. Measuring output from the exposed bladder 3. Protecting the skin surrounding the exposed bladder 4. Applying a pressure dressing to the exposed bladder

3. Protecting the skin surrounding the exposed bladder

The transmission of which microorganism that causes maternal mastitis is minimized by frequent handwashing by nursing staff members? 1. Escherichia coli 2. Group B Streptococcus 3. Staphylococcus aureus 4. Chlamydia trachomatis

3. Staphylococcus aureus **Staphylococcus aureus is a resident organism of the skin; it is the causative agent of 95% of the infections that result in maternal mastitis.

The nurse is caring for a client whose labor is to be induced. What is the nurse's responsibility when a client's labor is being stimulated with an oxytocin (Pitocin) infusion? 1. Flushing the IV tubing if the flow slows 2. Checking the fetal heart rate every 2 hours 3. Stopping the infusion if contractions become hypertonic 4. Decreasing the infusion rate if hypertonic contractions continue for 15 minutes

3. Stopping the infusion if contractions become hypertonic

A nurse is evaluating a client's understanding regarding postoperative concerns after mastectomy. Which development near and around the incision noted by the client should be reported to her practitioner? 1. Persistent itching 2. Decreased sensation 3. Swelling with erythema 4. Irregular-appearing ski

3. Swelling with erythema **Swelling and erythema are signs of infection and should be reported to the health care provider. Itching is a sign of healing that is expected.

A nurse is teaching a childbirth preparation class about the discomfort of labor. What is the greatest influence on the perception of pain for a woman in labor? 1. Parity of the client 2. Duration of the labor 3. Tension of the client 4. Difficulty of the labor

3. Tension of the client

A nurse is caring for a client at 42 weeks' gestation who is having a contraction stress test (CST). What does a positive result indicate? 1. The placenta has stopped growing. 2. The fetal lungs have not yet matured. 3. The function of the placenta has diminished. 4. The amniotic fluid is stained with meconium

3. The function of the placenta has diminished. **During a CST uterine blood flow to the placenta decreases. When a decrease is too great, fetal hypoxia and late decelerations occur, reflecting diminished placental function.

A nurse places a newly admitted client with worsening preeclampsia in a private room. Why is it important for this client to be in a nonstimulating environment? 1. The number of respirations is increased. 2. The severity of frontal headaches is decreased. 3. The probability of tonic-clonic seizures is reduced. 4. The duration of action of hypotensive medications is prolonged.

3. The probability of tonic-clonic seizures is reduced.

A client who is taking an oral contraceptive calls the nurse with concerns about side effects of the medication. Which adverse effect of this medication should alert the nurse to inform the client to immediately stop the contraceptive and contact the health care provider? (Select all that apply.) 1 . Nausea 2 . Weight loss 3. Visual disturbances 4. Persistent headaches 5. Decreased blood pressure

3. Visual disturbances 4. Persistent headaches

A client in labor is receiving an oxytocin (Pitocin) infusion. For which adverse reaction resulting from prolonged administration should the nurse monitor the client? 1. Change in affect 2. Hyperventilation 3. Water intoxication 4. Increased temperature

3. Water intoxication **Oxytocin (Pitocin) has an antidiuretic effect, acting to reabsorb water from the glomerular filtrate.

When is it most important for a female client to know that a fetus may be structurally damaged by the ingestion of drugs? 1. During early adolescence 2. Throughout the entire pregnancy 3. When she is planning to become pregnant 4. At the beginning of the first trimester

3. When she is planning to become pregnant

A nurse at a women's health clinic confirms that client teaching regarding the use of an oral contraceptive is understood when the client states, "I: 1. Can stop the pill and try to get pregnant right away" 2. May miss two periods and not worry about being pregnant" 3. Will put a baby's picture on my bathroom mirror so I'll see it every morning" 4. Am so glad we won't have to use condoms even if I miss just one pill during the month"

3. Will put a baby's picture on my bathroom mirror so I'll see it every morning" **Putting a baby's picture on the bathroom mirror serves as a reminder that the oral contraceptive must be taken every day.

A nurse on the postpartum unit discusses breast care with a client who is formula feeding her newborn. Which statement indicates to the nurse that more teaching is needed? 1."The discomfort will be better after a couple of days." 2."I need to ask my husband to bring me my new bra." 3."Applying heat to my breasts will help ease the discomfort." 4."Pain medication will help with the pain from engorgement."

3."Applying heat to my breasts will help ease the discomfort."

A nurse teaches a client with asthma about her illness during pregnancy. Which statement by the client indicates that the nurse's teaching has been effective? 1."Prednisone is safe to use during pregnancy." 2."My asthma will get worse as my pregnancy progresses." 3."I can use my albuterol inhaler if it's absolutely necessary." 4."I'll have to have a cesarean to prevent a severe attack during labor."

3."I can use my albuterol inhaler if it's absolutely necessary."

A pregnant client whose first child has Down syndrome is about to undergo amniocentesis. The client tells the nurse that she does not know what she will do if this fetus has the same diagnosis. The client asks the nurse, "Do you think abortion is the same as killing?" How should the nurse respond? 1."Some people think that that's what an abortion is." 2."No, I don't think so, but it's your decision to make." 3."I really can't answer that question. Are you ambivalent about abortion?" 4."I don't want to answer that question at this time. How do you feel about it?"

3."I really can't answer that question. Are you ambivalent about abortion?"

The nurse determines that a young female client who is being treated for a sexually transmitted infection (STI) understands instructions regarding future sexual contacts. Which statement confirms the nurse's conclusion? 1."If I have sex, nothing I do will really prevent me from getting another STI." 2."If I get another STI I can take any antibiotic, because I'm not allergic to any of them." 3."I won't have unprotected sex again, and I'll tell my partners to be tested for STIs." 4."I have to ask my partners if they have an STI, and if they say no I'll know that I can have sex."

3."I won't have unprotected sex again, and I'll tell my partners to be tested for STIs."

A nurse from the pediatric clinic who is strongly opposed to any chemical or mechanical method of birth control is asked to work in the family planning clinic. What is the most professional response that this nurse could give to the requesting supervisor? 1."I will go, but it is against my beliefs and values." 2."I won't do it, because I do not believe in birth control at all." 3."I would prefer another assignment that is not contrary to my beliefs." 4."I will have to stress that the rhythm method is the method of choice."

3."I would prefer another assignment that is not contrary to my beliefs."

Which statements by a client with hyperemesis gravidarum would confirm that the client needs further teaching? (Select all that apply.) 1."I'll start drinking protein shakes." 2."I'll start drinking plenty of fluids." 3."I'll start limiting my carbohydrates." 4."I'll lie down for at least 2 hours after I eat." 5."I'll be sure to schedule rest periods throughout the day so I won't get tired."

3."I'll start limiting my carbohydrates." 4."I'll lie down for at least 2 hours after I eat."

A primigravida is admitted to the birthing suite at term with contractions occurring every 5 to 8 minutes and a bloody show. She and her partner attended childbirth preparation classes. Vaginal examination reveals that the cervix is dilated 3 cm and 75% effaced. The fetus is at +1 station in occiput anterior position, and the membranes are intact. The client is cheerful and relaxed and asks the nurse whether it is all right for her to walk around. In light of the nurse's observations regarding the contractions and the client's knowledge of the physiology and mechanism of labor, how should the nurse respond? 1."I can't make a decision on that; I'll have to ask your health care provider." 2."Please stay in bed; walking could interfere with effective uterine contractions." 3."It's all right for you to walk as long as you feel comfortable and your membranes are intact." 4."You may sit in a chair, because your contractions cannot be timed when you walk and I won't be able to listen to the baby's heart."

3."It's all right for you to walk as long as you feel comfortable and your membranes are intact."

A nurse is teaching a prenatal class about infant safety. After the class several of the students are heard discussing what they have learned. The nurse determines that the teaching has been effective when one of the future parents states: 1."My mother has already made the cutest pillowcases for the baby's pillows." 2."I just bought a new baby seat that can be strapped into the front seat of the car. 3."My mother can't believe that babies are supposed to sleep on their backs, not their stomachs." 4."At my shower I was given a baby tub that has a special safety strap that lets me leave the baby alone in it."

3."My mother can't believe that babies are supposed to sleep on their backs, not their stomachs."

A client who is breastfeeding tells a nurse that her breasts are swollen and painful. What can the nurse teach her to do to limit engorgement? 1."Breastfeed four times a day, then offer water if the baby cries." 2."Offer just one bottle a day when you're experiencing discomfort." 3."Nurse at least every 3 hours for at least 10 minutes on each breast." 4."Limit nursing to 4 to 6 minutes on each breast at least six times a day."

3."Nurse at least every 3 hours for at least 10 minutes on each breast."

A client has just been informed by the health care provider that she has cervical polyps. The client asks the nurse whether she should worry about them. How should the nurse respond? 1."They're often malignant, so they have to be removed." 2."Cervical polyps are usually precursors of uterine cancer." 3."They're usually benign, and a biopsy rules out a malignancy." 4."Cervical polyps don't cause bleeding unless they're malignant."

3."They're usually benign, and a biopsy rules out a malignancy."

A multipara who is admitted to the hospital for repair of a rectocele and cystocele asks a nurse why these problems happened to her. How should the nurse respond? 1."Did you have a bladder infection?" 2."You probably have a malformation of your uterus." 3."You have relaxation of the muscles in your lower pelvis." 4."Did you have problems when your episiotomy was healing?"

3."You have relaxation of the muscles in your lower pelvis."

A young woman has been using oral contraceptives. When she misses her regular menstrual period, she visits the women's health clinic and tells the nurse that she may be pregnant because she missed taking her contraceptive pills for 1 week when she had the flu. How should the nurse respond? 1."It's too late to worry about that now. You may want to consider having an abortion." 2."Contraceptive pills are unpredictable. You probably would've become pregnant even if you had taken them regularly." 3."You may be right. One of the reasons that an exact schedule is prescribed for birth control pills is that they have to be taken regularly to be effective." 4."That's the trouble with birth control pills. They're so effective that women tend to believe that they won't get pregnant even if they skip pills for a few days."

3."You may be right. One of the reasons that an exact schedule is prescribed for birth control pills is that they have to be taken regularly to be effective."

A 63-year-old woman with the diagnosis of estrogen-receptor positive cancer of the breast undergoes lumpectomy and radiation therapy, and tamoxifen (Nolvadex) is prescribed. The client asks the nurse how long she will have to take the medication. The nurse responds: 1."You'll have to take it for the rest of your life." 2."You'll need to take it for 10 days, like an antibiotic." 3."You'll need to take it for 5 years, after which it will be discontinued." 4."You'll need to take it for several months, until the bone pain subsides."

3."You'll need to take it for 5 years, after which it will be discontinued."

A nurse is caring for a postpartum client. Where does the nurse expect the fundus to be located if involution is progressing as expected 12 hours after birth? 1.2 cm below the umbilicus 2.3 cm above the umbilicus 3.1 cm above the umbilicus 4.3 cm below the umbilicus

3.1 cm above the umbilicus

A couple expresses a desire to use the rhythm method of birth control. The woman tells the nurse that she menstruates every 32 days. What should the nurse teach the couple about when the client's ovulation probably occurs? 1.On the 14th day of the cycle 2.10 days after the first day of bleeding 3.14 days before the start of the next menses 4.2 to 3 days after the last day of menstrual bleeding

3.14 days before the start of the next menses

3.21st day of the cycle

The nurse teaches a high school sex education class that herpes genitalis infection cannot be cured but that the disease is marked by remissions and exacerbations. What else should the students be taught about this infection? 1.A healthy lifestyle will prevent exacerbations. 2.Once the infection is effectively treated, exacerbations are rare. 3.Although exacerbations occur they are not as severe as the initial episode. 4.The most effective way to prevent exacerbations is to abstain from sexual activity

3.Although exacerbations occur they are not as severe as the initial episode.

On her second visit to the fertility clinic, a client whose temperature charts demonstrate an ovulatory pattern and a regular menstrual cycle requests fertility drugs. What is the nurse's best intervention? 1.Scheduling an endometrial biopsy 2.Making arrangements for a culdoscopy 3.Asking the client to have her partner's semen examined 4.Calling the health care provider to prescribe the fertility drug

3.Asking the client to have her partner's semen examined

A 16-year-old adolescent at 24 weeks' gestation visits the prenatal clinic for the first time. After the physical examination she tells the nurse, "I can't believe how big I am. Will I get much bigger?" What information about adolescent growth and development does the nurse need to know before responding? 1.Adolescents generally regain their figures 2 weeks after the birth, so size is of moderate concern. 2.Adolescents are in a high-risk category, so weight gain should be limited to prevent complications. 3.Body image is very important to adolescents, so pregnant teenagers are concerned about body size. 4.Physiological growth in adolescents is more rapid than in adults, so the gravid size is larger than that of an adult woman.

3.Body image is very important to adolescents, so pregnant teenagers are concerned about body size.

A nurse in the postpartum unit must complete several interventions before a client's discharge from the hospital. The nurse plans to delegate some of the tasks to the nursing assistant. Which activity must be performed by the nurse? 1.Taking the neonate's picture 2.Placing the infant car seat in the car 3.Comparing the identification bands of mother and infant 4.Preparing the discharge gift packages and distributing them to parents

3.Comparing the identification bands of mother and infant

How does the nurse know whether a client is in true labor? 1.Contractions occur every 10 minutes with no change in frequency over 2 hours, and the cervix is closed. 2.Contractions are not evident; the cervix is dilated 3 cm and 50% effaced, and there is no change after 4 hours of staying out of bed. 3.Contractions occur every 5 to 10 minutes; the cervix is dilated 2 cm and 75% effaced, and dilation has increased to 3 cm in 2 hours. 4.Contractions are irregular, occurring every 10 to 15 minutes; the cervix is dilated one fingertip and is 50% effaced, and there is no change with 4 hours of bedrest

3.Contractions occur every 5 to 10 minutes; the cervix is dilated 2 cm and 75% effaced, and dilation has increased to 3 cm in 2 hours.

A client in labor is receiving an oxytocin (Pitocin) infusion. What should the nurse do first when repetitive late decelerations of the fetal heart rate are observed? 1.Administer oxygen 2.Place the client on the left side 3.Discontinue the oxytocin infusion 4.Check the client's blood pressure

3.Discontinue the oxytocin infusion

The cervix of a client in labor is fully dilated and 100% effaced. The fetal head is at +3 station, the fetal heart rate ranges from 140 to 150 beats/min, and the contractions, lasting 60 seconds, are 2 minutes apart. What does the nurse expect to see when inspecting the perineum? 1 Small tears 2 Greenish-yellow amniotic fluid 3.Enlarging area of caput with each contraction 4.An increasing amount of amniotic fluid with each contraction

3.Enlarging area of caput with each contraction

What is the best nursing intervention to achieve the cooperation of an extremely anxious pregnant client during her first pelvic examination? 1.Distracting the client by asking her preference regarding the infant's sex 2.Assisting the practitioner so the client's examination can be completed quickly 3.Explaining the procedure and maintaining eye contact while touching the client gently 4.Encouraging the client to squeeze the nurse's hand, close her eyes, and hold her breath

3.Explaining the procedure and maintaining eye contact while touching the client gently

A nurse in the fertility clinic works with couples who have been trying to become pregnant for more than 1 year. How can the nurse help ease the feeling of isolation that infertile couples often experience? 1.Teach them about infertility and its treatment 2.Identify activities that are interesting and satisfying 3.Explore ways to promote communication with family and friends 4.Explain to them that men and women cope differently with stressful situations

3.Explore ways to promote communication with family and friends

A couple in their late 30s who wish to have a child are referred for genetic counseling. They tell the nurse that they have a family history of an inheritable problem but have reservations about genetic counseling because they believe that genetic clinics favor abortion when the studies reveal a defective fetus. How should the nurse respond regarding genetic counseling? 1.Abortion is suggested only when the fetus is found to have a severe defect that is not compatible with life. 2.Recommendations are made to consider adoption when defects are predicted. 3.Families are helped to understand the diagnosis, the probable cause of the disorder, and how the condition can be managed. 4.After the probability of a defect is determined, the couple's own practitioner helps the couple decide on the appropriate action.

3.Families are helped to understand the diagnosis, the probable cause of the disorder, and how the condition can be managed.

A primigravida at 8 weeks' gestation is visiting the prenatal clinic for the first time. What should an examination reveal at this time? 1.Lightening 2.Quickening 3.Goodell's sign 4.Braxton Hicks sign

3.Goodell's sign

A client measuring at 18 weeks' gestation visits the prenatal clinic stating that she is still very nauseated and vomits frequently. Physical examination reveals a brown vaginal discharge and a blood pressure of 148/90 mm Hg. What condition does the nurse suspect the client is experiencing? 1.Dehydration 2.Choriocarcinoma 3.Hydatidiform mole 4.Threatened abortion

3.Hydatidiform mole

After treatment for a bladder Infection; a client asks whether there is anything she can do to prevent cystitis in the future. What is the best response by the nurse? 1.Avoid regular use of tampons. 2.Decrease intake of prune juice. 3.Increase daily fluid consumption. 4.Cleanse the perineum from back to front

3.Increase daily fluid consumption

A thin older adult client is found to have osteoporosis. What should the nurse include in the discharge plan for this client? 1.Encouragement of gradual weight gain 2.Monitoring for decreased urine calcium 3.Instructions relative to diet and exercise 4.Safety factors in the use of opioids and nonsteroidal anti-inflammatory drugs

3.Instructions relative to diet and exercise

A pregnant client with severe preeclampsia is receiving an infusion of magnesium sulfate. What does the nurse identify as the main reason that this medication is administered? 1.It acts as a diuretic. 2.It has a sedative effect. 3.It acts as an anticonvulsant. 4.It has an antihypertensive effect

3.It acts as an anticonvulsant.

What nursing care is required for a client with a radium implant for cancer of the cervix? 1.Spending time with the client to alleviate her anxiety 2.Wearing a lead-lined apron for self-protection while in the room 3.Limiting the client's activity to avoid dislodging the radium insert 4.Using disposable sheets for protection from exposure to laundry personnel

3.Limiting the client's activity to avoid dislodging the radium insert

A client comes to the fertility clinic for hysterosalpingography using radiopaque contrast material to determine whether her fallopian tubes are patent. When preparing for the test, the nurse explains to the client that she: 1.Will receive a local anesthetic and the pain will lessen 2.Will have to rest in bed for 8 hours after the test is completed 3.May have some persistent shoulder pain for 14 hours after the test 4.May become nauseated during the test, but the nausea will subside

3.May have some persistent shoulder pain for 14 hours after the test

A nurse understands the stages of parental adjustment that follow the birth of an at-risk infant who is in the neonatal intensive care unit. To better plan nursing care, the nurse bases observations and assessments on the recognition that the: 1.Parents should be encouraged to visit their newborn within a day of birth 2.Mother should not see the infant until she has completed the necessary grief work 3.Mother should be reunited with her infant as soon as possible to enhance adjustment 4.Nurse should wait until the parents ask to see their newborn before suggesting a visit

3.Mother should be reunited with her infant as soon as possible to enhance adjustment

A client who has had a cesarean birth seems upset. She has been having difficulty breastfeeding for 2 days and now asks the nurse to bring her a bottle of formula. What is the nurse's initial action? 1.Obtaining the requested formula 2.Administering the prescribed pain medication 3.Observing the client's breastfeeding technique 4.Notifying the practitioner of the client's request to switch feeding methods

3.Observing the client's breastfeeding technique

A 38-year-old client attends the prenatal clinic for the first time. A nurse explains that several tests will be performed, one of which is the serum alpha-fetoprotein test. The client asks what the test will reveal. What should the nurse include in the reply? 1.Trisomy 21 2.Turner syndrome 3.Open neural tube defects 4.Chromosomal aberrations

3.Open neural tube defects

What is the focus of the nurse's anticipatory guidance during the first trimester of pregnancy? 1.Birthing process 2.Signs of complications 3.Physical changes of pregnancy 4.Role transition into parenthood

3.Physical changes of pregnancy

A client is admitted to the birthing unit in active labor. Amniotomy is performed by the health care provider. What physiological change does the nurse expect to occur after the procedure? 1.Diminished vaginal bleeding 2.Less discomfort with contractions 3.Progressive dilation and effacement 4.Increased maternal and fetal heart rates

3.Progressive dilation and effacement

A client in her 30th week of gestation is in preterm labor, and the practitioner prescribes betamethasone (Celestone). The client asks the nurse why she is being given this drug. As a basis for the response the nurse takes into consideration that it: 1.Prevents chorioamnionitis 2.Increases uteroplacental exchange 3.Promotes neonatal pulmonary maturity 4.Is used to treat fetal respiratory distress syndrome

3.Promotes neonatal pulmonary maturity

Which action involving client needs may a nurse delegate to a nursing assistant? 1.Assessing a newly admitted client's contraction pattern 2.Discussing pain management options with a laboring client 3.Providing ice chips to a primigravida in early labor per order 4.Obtaining a sterile urine specimen for a suspected urinary tract infection

3.Providing ice chips to a primigravida in early labor per order

A nurse is planning to administer Rhogam (Rh immune globulin). Which situation requires the administration of this medication? 1.Maternal blood type B-, B- newborn 2.Maternal blood type A+, Rh-negative newborn 3.Rh-negative woman who has had an amniocentesis 4.Rh-positive mother who gave birth to an Rh-positive infant

3.Rh-negative woman who has had an amniocentesis

A client appears at the clinic after getting a positive result on a home pregnancy test. She states that her last menstrual period began 10 weeks ago. The client expresses fear because she has been recently found to have syphilis. What prescriptions will the nurse expect to receive from the health care provider because of this information? (Select all that apply.) 1.A wait-and-see approach 2.Recommendation for elective abortion 3.Screening and testing of sexual partners 4.None; the syphilis will most likely not affect the fetus in utero 5.Intramuscular benzathine penicillin G, 2.4 million units, one dose

3.Screening and testing of sexual partners 5.Intramuscular benzathine penicillin G, 2.4 million units, one dose

A woman comes into the clinic and states that she is thinking about becoming pregnant. What can the woman do to improve the health of her baby before she becomes pregnant? 1.Go buy maternity clothes 2.Start running 3 miles a day 3.Start taking prenatal vitamins 4.Buy a crib for the baby to sleep in

3.Start taking prenatal vitamins

A nurse is evaluating a client's understanding regarding postoperative concerns after mastectomy. Which development near and around the incision noted by the client should be reported to her practitioner? 1.Persistent itching 2.Decreased sensation 3.Swelling with erythema 4.Irregular-appearing skin

3.Swelling with erythema

A client underwent a mastectomy 24 hours ago. Which information will the nurse include in the plan of care? 1.The drainage container will be kept level with the affected arm. 2.The affected arm will be abducted at the shoulder with the elbow extended. 3.The hand and elbow of the affected arm will be elevated above the shoulder. 4.The elbow and shoulder of the affected arm will be elevated, with the hand resting on the abdomen

3.The hand and elbow of the affected arm will be elevated above the shoulder.

A nurse is teaching a client how to self-administer a medicated douche. In which direction should the nurse instruct the client to direct the douche nozzle? 1.To the left 2.To the right 3.Toward the sacrum 4.Toward the umbilicus

3.Toward the sacrum

A young client tells the nurse that her mother complains about having dysmenorrhea and asks the nurse what this means. How should the nurse describe dysmenorrhea? 1.Cessation of menstrual periods 2.Spotting between menstrual periods 3.Uterine pain during the menstrual period 4.Scant bleeding at the time of an expected menstrual period

3.Uterine pain during the menstrual period

A pregnant client with iron-deficiency anemia is prescribed a daily iron supplement. What nutrient should the nurse suggest that the client include in her diet to potentiate the effect of the iron supplement? 1.Biotin 2.Lecithin 3.Vitamin C 4.Vitamin B complex

3.Vitamin C

A client is to undergo a tuberculin test as part of her prenatal workup. Before administering the test, what information about the client should the nurse obtain? 1.Whether she has had a previous tuberculin test 2.Whether the client is prone to respiratory diseases 3.Whether an earlier tuberculin test's result was positive 4.Whether the client's family has a history of tuberculosis

3.Whether an earlier tuberculin test's result was positive

A nurse at a women's health clinic confirms that client teaching regarding the use of an oral contraceptive is understood when the client states, "I: 1.Can stop the pill and try to get pregnant right away" 2.May miss two periods and not worry about being pregnant" 3.Will put a baby's picture on my bathroom mirror so I'll see it every morning" 4.Am so glad we won't have to use condoms even if I miss just one pill during the month"

3.Will put a baby's picture on my bathroom mirror so I'll see it every morning"

A client had a cesarean birth 3 days ago. Where should the nurse, while palpating her fundus, expect to locate the fundus if each line represents 1 cm? 1.a 2.b 3.c 4.d

3.c TIP: Three days after birth, the fundus should be located 3 cm below the umbilicus; 12 hours after birth it should be located about 1 cm above the umbilicus; each following day it drops 1 to 2 cm.

340 more calories during the second trimester

A client in labor is experiencing discomfort because her fetus is in the occiput posterior position. What nursing action will help relieve this discomfort? 1Positioning her on the left side 2Using effleurage on her abdomen 3Applying pressure against her sacrum 4Placing her in the semi-Fowler position

3Applying pressure against her sacrum

What is the best nursing action for a client in active labor whose cervix is dilated 4 cm and 100% effaced with the fetal head at 0 station? 1Document the fetal heart rate every 5 minutes 2Call the anesthesia department to alert the staff there of an imminent birth 3Assist the client's coach in helping her with the use of breathing techniques 4Suggest that the client accept the PRN medication for pain that has been prescribed

3Assist the client's coach in helping her with the use of breathing techniques

The fetus of a woman in labor is at +1 station. At what place in the pelvic area does the nurse conclude that the presenting part is located? 1Not yet engaged 2Entering the pelvic inlet 3Below the ischial spines 4Visible at the vaginal opening

3Below the ischial spines

3Gynecoid

A client who is at 12 weeks' gestation tells a nurse at the prenatal clinic that she is experiencing severe nausea and frequent vomiting. The nurse suspects that the client has hyperemesis gravidarum. What factor is frequently associated with this disorder? 1History of cholecystitis 2Large amount of amniotic fluid 3High level of chorionic gonadotropin 4Decreased secretion of hydrochloric acid

3High level of chorionic gonadotropin

The fetus of a client in labor is found to be at +1 station. What location does +1 station describe? 1On the perineum 2High in the pelvis 3Just below the ischial spines 4Slightly above the ischial spines

3Just below the ischial spines

A multipara is admitted to the birthing room in active labor. Her temperature is 98° F (36.7° C), pulse 70 beats/min, respirations 18 breaths/min, and blood pressure 126/76 mm Hg. A vaginal examination reveals a cervix that is 90% effaced and 7 cm dilated with the vertex presenting at 2+ station. The client is complaining of pain and asks for medication. Which medication should be avoided because it may cause respiratory depression in the newborn? 1Naloxone (Narcan) 2Lorazepam (Ativan) 3Meperidine (Demerol) 4Promethazine (Phenergan)

3Meperidine (Demerol)

When is it most important for a female client to know that a fetus may be structurally damaged by the ingestion of drugs? 1During early adolescence 2Throughout the entire pregnancy 3When she is planning to become pregnant 4At the beginning of the first trimester

3When she is planning to become pregnant

After the birth of her baby a client tells the nurse, "I'm so cold, and I can't stop shaking." How should the nurse respond? 1"I'm going to take your temperature right now." 2"Let me check your uterus to see whether it's firm." 3"Turn on your side so I can check the amount of lochia." 4"I'll get you some warm blankets to help make the chill go away."

4"I'll get you some warm blankets to help make the chill go away."

A client whose weight was average for her height before becoming pregnant is concerned because she has gained 15 lb (6.9 kg) after only 23 weeks of pregnancy. What is the nurse's most appropriate response? 1"You have not gained enough weight. Can you increase your daily intake of calories?" 2"Your weight is not a concern. I'll refer you to the dietitian, who will review your diet." 3"You've gained too much weight for 23 weeks' gestation. Are your rings getting tight?" 4"Your weight is expected for someone at 23 weeks' gestation. Continue the pregnancy diet."

4"Your weight is expected for someone at 23 weeks' gestation. Continue the pregnancy diet."

A 35-year-old client is scheduled for a vaginal hysterectomy. She asks the nurse about the changes she should expect after surgery. How should the nurse respond? 1. "You will stop ovulating." 2. "Surgical menopause will happen immediately." 3. "Sexual intercourse will be uncomfortable when you resume it." 4. "A hysterectomy doesn't affect the chronological age when menopause usually occurs."

4. "A hysterectomy doesn't affect the chronological age when menopause usually occurs."

A mother whose newborn infant son has a cleft lip and palate asks how to feed her baby because he has difficulty suckling. What information should the nurse provide concerning safe feeding technique for this infant? 1. "Because he tires easily, it's best to have him lying in bed while he is being fed." 2. "Hold him in a horizontal position and feed him slowly to help prevent aspiration." 3. "Try using a soft nipple with an enlarged opening so he can get the milk through a chewing motion." 4. "Give him brief rest periods and frequent burpings during feedings so he can get rid of swallowed air."

4. "Give him brief rest periods and frequent burpings during feedings so he can get rid of swallowed air."

A postpartum client is scheduled to have a tubal ligation. She has asked that her husband not be told about the procedure because she has told him that she is having exploratory surgery. The client's husband asks the nurse why his wife needs to have exploratory surgery. How should the nurse respond? 1. "What has the physician told you?" 2. "I don't know the answer to that question." 3. "I'm not allowed to give you that information." 4. "Have you talked to your wife about your concerns?"

4. "Have you talked to your wife about your concerns?" **The correct response protects the wife's confidentiality while fostering open communication between the couple.

After the birth of her baby a client tells the nurse, "I'm so cold, and I can't stop shaking." How should the nurse respond? 1. "I'm going to take your temperature right now." 2. "Let me check your uterus to see whether it's firm." 3. "Turn on your side so I can check the amount of lochia." 4. "I'll get you some warm blankets to help make the chill go away."

4. "I'll get you some warm blankets to help make the chill go away."

A client seeking advice about contraception asks a nurse about how an intrauterine device (IUD) prevents pregnancy. How should the nurse respond? 1. "It covers the entrance to the cervical os." 2. "The openings to the fallopian tubes are blocked." 3. "The sperm are kept from reaching the vagina." 4. "It produces a spermicidal intrauterine environment."

4. "It produces a spermicidal intrauterine environment."

The mother of a newborn son tells the nurse that she is concerned about circumcision because of the pain involved. What is the nurse's best response? 1. "A newborn's nerves are not mature enough for him to feel pain." 2. "It's such a short procedure that the pain won't last long." 3. "Your baby should have no memory of it, even if there is pain." 4. "The health care provider will tell you how your baby's pain will be controlled."

4. "The health care provider will tell you how your baby's pain will be controlled."

A pregnant client has a positive group B Streptoccus (GBS) test at 36 weeks' gestation. What is the priority instruction that the nurse will include in the client's teaching plan? 1. "Go straight to the outpatient area of the maternity unit for a nonstress test." 2. "You'll need to schedule visits twice a week with your health care provider until you deliver." 3. "Your baby will have to spend at least 3 days in the neonatal intensive care unit because of this infection." 4. "This information will be in your prenatal record, but please remind your labor and delivery nurse of this finding."

4. "This information will be in your prenatal record, but please remind your labor and delivery nurse of this finding."

A client arrives in the birthing room with the fetal caput emerging. What should the nurse say to the client during a contraction? 1. "Push hard." 2. "Hold your breath." 3. "Take slow, deep breaths." 4. "Use the panting-breathing pattern."

4. "Use the panting-breathing pattern."

A 24-year-old client who has been told that she is pregnant is at her first prenatal visit. She is 5 feet 6 inches tall and weighs 130 lb. What should the nutrition plan regarding her daily caloric intake include? 1. 100 more calories during the first trimester 2. 540 more calories during the third trimester 3. 300 more calories during the three trimesters 4. 340 more calories during the second trimester

4. 340 more calories during the second trimester **An extra 340 calories per day during the second trimester is the recommended caloric increase for adult women who are of average weight; this increase will meet the nutritional needs of both fetus and mother during the second trimester.

What should a nurse anticipate about the insulin requirements of a client with diabetes on her first postpartum day? 1. No change 2. A rapid increase 3. A slow, steady decrease 4. A sharp, sudden decrease

4. A sharp, sudden decrease **Insulin requirements may fall suddenly during the first 24 to 48 postpartum hours because the endocrine changes of pregnancy are reversed.

On a return visit to the fertility clinic a couple requests fertility drugs because, despite having a 28-day menstrual cycle and temperature readings that demonstrate an ovulatory pattern, the woman has been unable to conceive. What should the nurse explain to the couple? 1. A laparoscopy will be scheduled. 2. An endometrial biopsy will be required. 3. A fertility medication will be prescribed. 4. An examination of semen will be needed

4. An examination of semen will be needed **Because the client has an ovulatory cyclic pattern, the infertility may be a result of a seminal factor; the partner's semen should be examined before more extensive studies or treatments are begun.

A primigravida complains of morning sickness. What should the nurse plan to teach her? 1. Increasing her fluid intake 2. Eat three small meals a day 3. Increase the calcium in her diet 4. Avoid long periods without food

4. Avoid long periods without food

The day after a client has a cesarean birth, the indwelling catheter is removed. The nurse concludes that urinary function has returned when the: 1. Client has 90 mL of residual urine after voiding 2. Client's daily urinary output is at least 1500 mL 3. Client's urinalysis indicates that no bacteria are present 4. Client voids 300 mL of urine within 4 hours of catheter removal

4. Client voids 300 mL of urine within 4 hours of catheter removal **Voiding 300 mL of urine within 4 hours of catheter removal indicates that urinary sphincter tone has not been affected by the catheter and that urine retention with overflow has not occurred.

A nurse is teaching a pregnant client with sickle cell anemia about the importance of taking supplemental folic acid. Folic acid is important for this client because it: 1. Lessens sickling of RBCs 2. Prevents vaso-occlusive crises 3. Decreases cellular oxygen need 4. Compensates for a rapid turnover of red blood cells

4. Compensates for a rapid turnover of red blood cells

A nurse who is monitoring the blood glucose level of the term infant of a diabetic mother (IDM) identifies a blood glucose level of 48 mg/dL. What should the nurse do? 1. Check the cord serum glucose level. 2. Initiate oral feedings of 10% dextrose in water. 3. Secure a prescription for an IV infusion of 50% dextrose. 4. Continue to monitor the blood glucose level per policy.

4. Continue to monitor the blood glucose level per policy

A nurse is assessing a postpartum client for signs of an impending hemorrhage resulting from laceration of the cervix. Besides monitoring the client for a firm uterus, what other assessment is important? 1. Slowed pulse rate 2. Increased blood pressure 3. Persistent muscular twitching 4. Continuous trickling of blood

4. Continuous trickling of blood

A client arrives at the clinic in preterm labor, and terbutaline (Brethine) is prescribed. For what therapeutic effect should the nurse monitor the client? 1. Increased blood pressure and pulse 2. Reduction of pain in the perineal area 3. Gradual cervical dilation as labor progresses 4. Decreased frequency and duration of contractions

4. Decreased frequency and duration of contractions **Terbutaline sulfate (Brethine) is a β-mimetic that acts on the smooth muscles of the uterus to reduce contractility, which in turn inhibits dilation and the frequency and duration of contractions.

At 9 pm visiting hours are officially over, but the sister of a newly admitted postpartum client remains at the bedside. What is the most appropriate nursing intervention? 1. Reminding the client's sister that visiting hours are over 2. Getting written permission from the client for her sister to remain 3. Calling the evening nursing supervisor to tactfully handle the situation 4. Encouraging the sister to participate in care as much as the client wishes

4. Encouraging the sister to participate in care as much as the client wishes

A client's nipples become sore and tender as a result of her newborn's vigorous suckling. What should the nurse recommend that the mother do to alleviate the soreness? (Select all that apply.) 1. Apply ice packs before each feeding. 2. Formula feed the baby for a few days. 3. Take the prescribed analgesic medication. 4. Expose the nipples to air several times a day. 5. Apply hydrogel pads to the nipples after each feeding.

4. Expose the nipples to air several times a day. 5. Apply hydrogel pads to the nipples after each feeding. **Exposure of the nipples to air dries the nipples by way of evaporation; exposure also tends to harden the nipples, making them less tender. Hydrogel pads create a moist environment conducive to healing.

During a class for prepared childbirth, the nurse teacher discusses the importance of the spurt of energy that occurs before labor. Why is it important to conserve this energy? 1. Fatigue may increase the progesterone level. 2. Extra energy decreases the intensity of contractions. 3. Extra energy is needed to push during the first stage 4. Fatigue may influence pain medication requirements.

4. Fatigue may influence pain medication requirements.

A nurse is obtaining a health history from a primigravida on her first visit to the prenatal clinic. Before discussing the client's health habits with her, what does the nurse consider the most important factor in the survival of the client's newborn? 1. Reproductive history 2. Adequacy of prenatal care 3. Health habits and social class 4. Gestational age and birthweight

4. Gestational age and birthweight

A 31-year-old client is seeking contraceptive information. Before responding to the client's questions about contraceptives, the nurse obtains a health history. What factor in the client's history indicates to the nurse that oral contraceptives are contraindicated? 1. Older than 30 years 2. Current hypothyroidism 3. Two multiple pregnancies 4. History of borderline hypertension

4. History of borderline hypertension **Oral contraceptives may cause or exacerbate hypertension; borderline hypertension places the client at risk for a brain attack.

A nurse elicits the Babinski reflex on a newborn. The nurse concludes that this finding indicates: 1. Hypoxia during labor 2. Neurological injury during birth 3. Hyperreflexia of the muscular system 4. Immaturity of the central nervous system (CNS)

4. Immaturity of the central nervous system (CNS)

A client who suspects that she is 6 weeks pregnant appears mildly anxious as she is waiting for her first obstetric appointment. What symptom of mild anxiety does the nurse expect this client to experience? 1. Dizziness 2. Breathlessness 3. Abdominal cramps 4. Increased alertness

4. Increased alertness **Increased alertness is an expected common behavior that occurs in new or different situations when a person is mildly anxious.

A client at term is admitted in active labor. She has tested positive for HIV. Which intervention in the standard orders should the nurse question as a risk to the fetus? 1. Sonogram 2. Nonstress test 3. Sterile vaginal examination 4. Internal fetal scalp electrode

4. Internal fetal scalp electrode **The electrode used for internal fetal monitoring pierces the fetal scalp; fetal exposure to maternal blood increases the risk of the fetus' contracting HIV.

A nurse is observing a newborn's respiratory rate. What clinical findings indicate that the rate is within the expected range? 1. Regular, thoracic, 40 to 60/min 2. Irregular, thoracic, 30 to 60/min 3. Regular, abdominal, 40 to 50/min 4. Irregular, abdominal, 30 to 60/min

4. Irregular, abdominal, 30 to 60/min **The expected breathing pattern is abdominal and irregular in rhythm and depth (alternating between shallow and deep); the expected rate ranges from 30 to 60 breaths/min.Newborns' respirations are irregular and abdominal.

At a client's first prenatal visit, the healthcare provider performs a pelvic examination, stating that the client's cervix is bluish purple, which is known as the Chadwick sign. The client becomes concerned and asks whether something is wrong. The best response is "This is expected; it: 1. Helps confirm your pregnancy" 2. Is not unusual, even in women who are not pregnant" 3. Occurs because the blood is trapped by the pregnant uterus" 4. Is caused by increased blood flow to the uterus during pregnancy"

4. Is caused by increased blood flow to the uterus during pregnancy" **Stating that the Chadwick sign is caused by increased blood flow to the uterus during pregnancy underscores the normalcy of Chadwick's sign and provides a simple explanation of the cause; women often need reassurance that the physical changes associated with pregnancy are expected.

A 23-year-old woman comes to the clinic for a Pap smear. After the examination, the client confides that her mother died of endometrial cancer 1 year ago and says that she is afraid that she will die of the same cancer. Which risk factor stated by the client after an education session on risk factors indicates that further teaching is needed? 1. Obesity 2. High-fat diet 3. Hypertension 4. Late-onset menarche

4. Late-onset menarche

A pregnant client at 37 weeks' gestation is taught about signs and symptoms that should be reported immediately to the primary care provider. The nurse determines that the client understands the information presented when she states that she will immediately report: 1. Lower back pain 2. White vaginal discharge 3. Irregular strong contractions 4. Leakage of fluid from the vagina

4. Leakage of fluid from the vagina **Leakage may indicate rupture of the amniotic membranes; the client is at risk for an ascending infection from the vagina if birth does not occur within 24 hours or if early treatment is not instituted.

What should the nurse discuss with new parents to help them prepare for infant care? 1. Allowing crying time to help the lungs develop 2. Establishing a set feeding schedule to promote steady weight gain 3. Counting the number of stool diapers daily to confirm adequate hydration 4. Learning specific behaviors involving states of wakefulness to promote positive interactions

4. Learning specific behaviors involving states of wakefulness to promote positive interactions

A client is admitted to the high-risk prenatal unit with the diagnosis of placenta previa. What should the nurse instruct the client to do? 1. Breathe deeply to ensure that the fetus gets oxygen 2. Keep movement to a minimum to diminish bleeding 3. Remain on her back to minimize pressure on the cervix 4. Lie on her side to avoid putting pressure on the vena cava

4. Lie on her side to avoid putting pressure on the vena cava

A pregnant client's blood test reveals an increased alpha-fetoprotein (AFP) level. What condition does the nurse suspect that this result indicates? 1. Cystic fibrosis 2. Phenylketonuria 3. Down syndrome 4. Neural tube defect

4. Neural tube defect

A nurse is trying to determine whether a pregnant woman's membranes have ruptured. What findings support the conclusion that they have ruptured? (Select all that apply.) 1. The expelled fluid totals 500 mL. 2. The expelled fluid is light yellow. 3. The expelled fluid smells similar to urine. 4. Nitrazine paper turns blue on contact with the fluid. 5. Microscopic examination of the fluid reveals ferning/

4. Nitrazine paper turns blue on contact with the fluid. 5. Microscopic examination of the fluid reveals ferning/

Which client should a nurse suspect is at increased risk for postpartum hemorrhage? 1. One who breastfeeds in the birthing room 2. One who receives a pudendal block for the birth 3. One whose third stage lasts less than 10 minutes 4. One who gives birth to an infant weighing 9 lb 8 oz

4. One who gives birth to an infant weighing 9 lb 8 oz

What antidote to the side effects of terbutaline (Brethine) should a nurse have available? 1. Levodopa (l-Dopa) 2. Furosemide (Lasix) 3. Ritodrine (Yutopar) 4. Propranolol (Inderal)

4. Propranolol (Inderal) **Propranolol (Inderal) is a beta-blocking agent that reverses the uterine inhibitory responses and cardiovascular effects of terbutaline (Brethine).

A nurse is providing dietary counseling to a client at 14 weeks' gestation. The client is a recent immigrant from Asia, and the nurse explores the foods that the client usually eats. Which foods should the nurse counsel the client to avoid during pregnancy? (Select all that apply.) 1. Yogurt 2. Oily fish 3. Apricots 4. Raw shellfish 5. Herbal supplements 6. Soft-scrambled eggs

4. Raw shellfish 5. Herbal supplements 6. Soft-scrambled eggs

During the second reactive period a newborn becomes more alert and responsive and there is an increase in mucus production and gagging. What should the nurse do first? 1. Report this finding 2. Administer nasal oxygen 3. Lower the head of the bassinette 4. Remove secretions from the pharynx

4. Remove secretions from the pharynx

A client who recently gave birth is transferred to the postpartum unit by the nurse. What must the nurse do first to avoid a charge of abandonment? 1. Assess the client's condition 2. Document the client's condition and the transfer 3. Orient the client to the room and explain unit routines 4. Report the client's condition to the responsible staff member

4. Report the client's condition to the responsible staff member **Because the nurse is responsible for the client's care until another nurse assumes that responsibility, the nurse should report directly to the client's primary nurse.

A nurse is counseling a pregnant woman with type 1 diabetes. What is the most important nursing consideration in the planning of care for this client? 1. Higher risk for fetal mortality 2. Possible need for cesarean birth 3. Expectation of lowered insulin needs 4. Requirement of intensive prenatal care

4. Requirement of intensive prenatal care

A 16-year-old client has a steady boyfriend with whom she is having sexual relations. She asks the nurse how she can protect herself from contracting HIV. What should the nurse advise her to do? 1. Ask her partner to withdraw before ejaculating 2. Make certain their relationship is monogamous 3. Insist that her partner use a condom when having sex 4. Seek counseling about various contraceptive methods

4. Seek counseling about various contraceptive methods

A nurse is planning care with a client for the recovery period after a laparoscopic hysterectomy and bilateral salpingo-oophorectomy. What should be included among the changes that the client should expect after surgery? 1. Depression 2. Weight gain 3. Urine retention 4. Surgical menopause

4. Surgical menopause

A pregnant client with diabetes is referred to the dietitian in the prenatal clinic for nutritional assessment and counseling. What should the nurse emphasize when reinforcing the client's dietary program? 1. The need to increase high-quality protein and decreasing fats 2. The need to increase carbohydrates to meet energy demands and prevent ketosis 3. The need to eat a low-calorie diet that maintains the current insulin coverage and helps prevent hyperglycemia 4. The need to eat a pregnancy diet that meets increased dietary needs and to adjust the insulin dosage as necessary

4. The need to eat a pregnancy diet that meets increased dietary needs and to adjust the insulin dosage as necessary

In her 37th week of gestation, a client with type 1 diabetes has amniocentesis to determine fetal lung maturity. The lecithin/sphingomyelin ratio is 2:1, phosphatidylglycerol is present, and creatinine is 2 mg/dL. What conclusion should the nurse draw from this information? 1. A cesarean birth will be scheduled. 2. A birth must take place immediately. 3. The fetus need not be monitored any longer. 4. The newborn should be free from respiratory problems.

4. The newborn should be free from respiratory problems.

A client at 12 weeks' gestation arrives in the prenatal clinic complaining of cramping and vaginal spotting. A pelvic examination reveals that the cervix is closed. Which probable diagnosis should the nurse expect? 1. Missed abortion 2. Inevitable abortion 3. Incomplete abortion 4. Threatened abortion

4. Threatened abortion **Because the cervix is closed, it is considered a threatened abortion. The lifeless products of conception are retained in a missed abortion.

When discussing dietary needs during pregnancy, a client tells the nurse that milk causes her to be constipated at times. What should the nurse teach the client? 1. Substitute a variety of cheeses for the milk. 2. Replace fat-free or low fat milk for whole milk. 3. Increase intake of prenatal supplements and omit the milk. 4. Treat constipation when it occurs and continue drinking milk.

4. Treat constipation when it occurs and continue drinking milk.

A nurse is giving discharge instructions to a client who has undergone anterior colporrhaphy. The nurse knows the teaching has been understood if the client says: 1."I know that my sutures need to be removed in a week." 2."I'm ready to start my aerobics class again next week." 3."I'm glad I can help get my bedridden husband up to his chair now." 4." For discomfort I can try using warm compresses on my abdomen."

4." For discomfort I can try using warm compresses on my abdomen."

The mother of a pregnant teenager asks the nurse how her daughter could have been so foolish because birth control had been discussed with her many times. How should the nurse respond? 1."Apparently your daughter wasn't listening to you." 2."You should have made sure that her boyfriend understood birth control, too." 3."Teenagers often fail to use birth control because they forget to discuss it with their sexual partners." 4."Although teenagers can intellectually discuss birth control, they often don't believe that they will become pregnant."

4."Although teenagers can intellectually discuss birth control, they often don't believe that they will become pregnant."

A woman who has just delivered an infant asks to take the placenta home with her and her new baby on discharge. What is the most appropriate response? Incorrect1 "I'll wrap that right up for you." 2 "I'm sorry, but you can't do that." 3 "I'll give it to you for your husband to take home now." 4."I need to check the hospital protocol for our policy on that practice."

4."I need to check the hospital protocol for our policy on that practice."

A new mother who has begun breastfeeding asks for assistance removing the baby from her breast. What should the nurse teach her? 1."Pinch the baby's nostrils gently to help release the nipple." 2."Let the baby nurse as long as desired without interruption." 3."Pull your nipple out of the baby's mouth when the baby falls asleep." 4."Insert your finger in the corner of the baby's mouth to break the suction."

4."Insert your finger in the corner of the baby's mouth to break the suction."

A 17-year-old client tells the nurse that her sister had an ectopic pregnancy about 3 months ago and had to have her fallopian tube removed. The nurse determines that this young woman needs additional information when she states: 1."Pelvic infections can cause this to happen." 2."This kind of thing could happen to my sister again." 3."I guess I'll have to wait a while to become an aunt." 4."My sister is lucky, because she won't have a period again."

4."My sister is lucky, because she won't have a period again."

A client asks the nurse what she should do if she forgets to take the pill one day. How should the nurse respond? 1."Take your pills as instructed." 2."Call your practitioner immediately." 3."Continue as usual, and there shouldn't be a problem." 4."On the next day take one pill in the morning and one before bedtime."

4."On the next day take one pill in the morning and one before bedtime."

A client who is scheduled for an amniocentesis says, "I'm glad that this test will show if my baby is well." How should the nurse respond? 1."The test will confirm your baby's health." 2."It will identify any congenital defects." 3."New technologies have made these tests even more reliable." 4."Potential defects caused by chromosomal errors can be detected."

4."Potential defects caused by chromosomal errors can be detected."

On the first day after a mastectomy, a nurse encourages the client to perform exercises such as flexion and extension of the fingers and pronation and supination of the hand. The client asks why she has to do these exercises. The best response by the nurse is: 1."They preserve muscle tone." 2."They prevent joint contractures." 3."They help us assess the extent of lymphedema." 4."They will help stimulate peripheral circulation."

4."They will help stimulate peripheral circulation."

A new mother who wishes to breastfeed her infant asks a nurse whether she needs to alter her diet. How should the nurse respond? 1."Just keep eating as you have been during your pregnancy." 2."Drink more milk; you need the calcium to make your own milk." 3."Don't worry; your body will produce the amount of milk your baby needs." 4."You'll need extra amounts of the same foods you've been eating, plus more fluids."

4."You'll need extra amounts of the same foods you've been eating, plus more fluids."

A new mother wishes to breastfeed her infant and asks the nurse whether she needs to alter her diet. How should the nurse respond? 1."Eat as you have been during your pregnancy." 2."Drink a lot of milk—the added calcium will help you make milk." 3."Your body produces the milk your baby needs as a result of the vigorous suckling." 4."You'll need greater amounts of the same foods you've been eating and more fluids."

4."You'll need greater amounts of the same foods you've been eating and more fluids."

A couple in their late 30s, expecting their first child, plans to have an amniocentesis. At what point in the pregnancy should the nurse tell the couple that the test it will be scheduled? 1.When quickening is felt 2.During the last trimester 3.At the 10th week of gestation 4.After the 14th week of pregnancy

4.After the 14th week of pregnancy

The nurse is teaching a client who is scheduling a vasectomy. What information is essential that the nurse explain to the client? 1.Recanalization of the vas deferens is impossible. 2.Unprotected coitus is safe within 1 week to 10 days . 3.Some impotency is to be expected for several weeks after the procedure. 4.At least 15 ejaculations to clear the tract of sperm must occur before the semen is checked.

4.At least 15 ejaculations to clear the tract of sperm must occur before the semen is checked.

A primigravida complains of morning sickness. What should the nurse plan to teach her? 1.Increasing her fluid intake 2.Eat three small meals a day 3.Increase the calcium in her diet 4.Avoid long periods without food

4.Avoid long periods without food

4.Clear and stretchable

The day after a client has a cesarean birth, the indwelling catheter is removed. The nurse concludes that urinary function has returned when the: 1.Client has 90 mL of residual urine after voiding 2.Client's daily urinary output is at least 1500 mL 3.Client's urinalysis indicates that no bacteria are present 4.Client voids 300 mL of urine within 4 hours of catheter removal

4.Client voids 300 mL of urine within 4 hours of catheter removal

After a modified radical mastectomy a client has two portable wound drainage systems in place. What is an important intervention as the nurse cares for these drainage systems? 1.Irrigating the tubes with normal saline to ensure patency 2.Attaching the tubes to straight drainage to monitor the output 3.Leaving the drains open to the air to ensure maximum drainage 4.Compressing the drainage receptacles after emptying them to maintain suction

4.Compressing the drainage receptacles after emptying them to maintain suction

A 24-year-old client complains to the nurse in the women's health clinic that her breasts become tender before her menstrual period. What should the nurse recommend that the client do 1 week before an expected menses? 1.Take salt tablets daily 2.Increase protein intake 3.Eliminate daily exercise 4.Decrease caffeine intake

4.Decrease caffeine intake

What is the safest and most reliable birth control method for the nurse to recommend to a client with type 1 diabetes? 1.Vaginal sponge 2.Oral contraceptive 3.Rhythm method with a condom 4.Diaphragm with a spermicidal gel

4.Diaphragm with a spermicidal gel

A client had a fourth-degree perineal laceration during the birth of her neonate. What should the nurse recommend to protect the area from additional trauma? 1.Take sitz baths at least three times each day. 2.Apply a premoistened anesthetic pad to the area. 3.Avoid straining at stool with the use of an enema. 4.Eat a high-fiber diet with increased fluid intake

4.Eat a high-fiber diet with increased fluid intake

What nursing intervention should be implemented routinely after a client has a vacuum aspiration abortion? 1.Giving the client the prescribed oxytocic medication 2.Preparing the client for discharge within 30 minutes 3.Teaching the client about the various methods of birth control 4.Encouraging the client to take the prescribed antibiotic medication

4.Encouraging the client to take the prescribed antibiotic medication

A client is taking a progesterone oral contraceptive (minipill). The nurse instructs the client to take one pill daily during the: 1.Five days of the ovulatory cycle 2.Latter part of the ovulatory cycle 3.First week of the menstrual cycle 4.Entire menstrual cycle

4.Entire menstrual cycle

What is the priority nursing intervention during the 2 hours after a cesarean birth? 1.Evaluating fluid needs to maintain optimum hydration 2.Monitoring the incision to help prevent the onset of infection 3.Encouraging bonding to promote mother-infant interaction 4.Evaluating the lochia to identify the complication of hemorrhage

4.Evaluating the lochia to identify the complication of hemorrhage

A nurse is obtaining a health history from a primigravida on her first visit to the prenatal clinic. Before discussing the client's health habits with her, what does the nurse consider the most important factor in the survival of the client's newborn? 1.Reproductive history 2.Adequacy of prenatal care 3.Health habits and social class 4.Gestational age and birthweight

4.Gestational age and birthweight

A client who wishes to postpone having children until she and her husband are financially sound tells the nurse she has been taking oral contraceptive pills for several years. What finding indicates a potential risk in regard to continued use of birth control pills? 1.Dysmenorrhea 2.Lack of ovulation 3.Midcycle bleeding 4.Increased blood pressure

4.Increased blood pressure

At a client's first prenatal visit, the healthcare provider performs a pelvic examination, stating that the client's cervix is bluish purple, which is known as the Chadwick sign. The client becomes concerned and asks whether something is wrong. The best response is "This is expected; it: 1.Helps confirm your pregnancy" 2.Is not unusual, even in women who are not pregnant" 3.Occurs because the blood is trapped by the pregnant uterus" 4.Is caused by increased blood flow to the uterus during pregnancy"

4.Is caused by increased blood flow to the uterus during pregnancy"

A 23-year-old woman comes to the clinic for a Pap smear. After the examination, the client confides that her mother died of endometrial cancer 1 year ago and says that she is afraid that she will die of the same cancer. Which risk factor stated by the client after an education session on risk factors indicates that further teaching is needed? 1.Obesity 2.High-fat diet 3.Hypertension 4.Late-onset menarche

4.Late-onset menarche

A pregnant client at 37 weeks' gestation is taught about signs and symptoms that should be reported immediately to the primary care provider. The nurse determines that the client understands the information presented when she states that she will immediately report: 1.Lower back pain 2.White vaginal discharge 3.Irregular strong contractions 4.Leakage of fluid from the vagina

4.Leakage of fluid from the vagina

During the postpartum period a nurse determines that a client's rubella titer is negative. What action should the nurse plan to take? 1.Checking for allergies to penicillin 2.Alerting the staff in the newborn nursery 3.Assuring the client that she has active immunity 4.Obtaining a prescription for immunization at discharge

4.Obtaining a prescription for immunization at discharge

A left modified radical mastectomy is performed on a client with breast cancer. What is the most important measure to be included in the care plan for the first postoperative day? 1.Having someone from Reach to Recovery visit the client 2.Emptying the portable wound drainage system after each shift 3.Keeping the left arm and shoulder immobile until drainage ceases 4.Placing the client in the semi-Fowler position with the left arm and hand elevated

4.Placing the client in the semi-Fowler position with the left arm and hand elevated

A strict vegetarian (vegan) becomes pregnant and asks the nurse whether there is anything special she should do in regard to her diet during pregnancy. What is most the important measure for the nurse to instruct the client to take? 1.Eat at least 40 g/day of protein. 2.Drink at least 1 quart/day of milk. 3.Take a vitamin supplemented with iron every day. 4.Plan to eat from specific groups of vegetable proteins each day.

4.Plan to eat from specific groups of vegetable proteins each day.

What antidote to the side effects of terbutaline (Brethine) should a nurse have available? 1.Levodopa (l-Dopa) 2.Furosemide (Lasix) 3.Ritodrine (Yutopar) 4.Propranolol (Inderal)

4.Propranolol (Inderal)

A nurse is providing dietary counseling to a client at 14 weeks' gestation. The client is a recent immigrant from Asia, and the nurse explores the foods that the client usually eats. Which foods should the nurse counsel the client to avoid during pregnancy? (Select all that apply.) 1.Yogurt 2.Oily fish 3.Apricots 4.Raw shellfish 5.Herbal supplements 6.Soft-scrambled eggs

4.Raw shellfish 5.Herbal supplements 6.Soft-scrambled eggs

Before the administration of Rho(D) immune globulin (RhoGAM) the nurse reviews the laboratory data of a pregnant client. Which blood type and Coombs test result must a pregnant woman have to receive RhoGAM after giving birth? 1.Rh-positive and Coombs positive 2.Rh-negative and Coombs positive 3.Rh-positive and Coombs negative 4.Rh-negative and Coombs negative

4.Rh-negative and Coombs negative

A client who has had a mastectomy asks what the term ERP-positive means. How should the nurse explain this finding? 1.The client has a need for supplemental estrogen therapy. 2.The client's estrogen level has been depleted to zero during surgery. 3.The type of cancer the client has responds poorly to hormone therapy that reduces estrogen. 4.The tumor cells generally exhibit a positive response to hormone therapy that reduces estrogen

4.The tumor cells generally exhibit a positive response to hormone therapy that reduces estrogen

A nurse is caring for a client who is being given intravenous magnesium sulfate to treat preeclampsia. Which adverse side effect alerts the nurse to notify the health care provider? 1.Respiratory rate of 18 breaths/min 2.2+ patellar reflex response 3.Magnesium blood level of 5 mEq/L 4.Urine output of less than 100 mL in 4 hours

4.Urine output of less than 100 mL in 4 hours

A client who expected to use the Lamaze technique throughout labor has an emergency cesarean birth. Three days later the client is found crying and tells the nurse that she is extremely disappointed because a cesarean birth was necessary. She asks the nurse why this happened to her. On what factor should the nurse base a response? 1The client's feelings will pass once she has bonded with her newborn. 2The client is probably suffering from postpartum depression and needs special care. 3An emergency cesarean birth affects a woman's self-concept, and the client's statement reflects this. 4An emergency cesarean birth is traumatic psychologically because of the loss of the expected birth experience

4An emergency cesarean birth is traumatic psychologically because of the loss of the expected birth experience

A nurse is obtaining the health history of a woman who is visiting the prenatal clinic for the first time. She states that she is 5 months pregnant. For what positive sign of pregnancy should the nurse look in this patient? 1Quickening 2Enlarged abdomen 3Cervical color change 4Audible fetal heartbeat

4Audible fetal heartbeat

A woman in labor with her third child is dilated 7 cm, and the fetal head is at station +1. The client's membranes rupture. What should the nurse do first? 1Notify the practitioner 2Observe the vaginal opening for a prolapsed cord 3Reposition the client on a sterile towel on her left side 4Check the fetal heart rate while observing the color of the amniotic fluid

4Check the fetal heart rate while observing the color of the amniotic fluid

A client in active labor is admitted to the birthing room. A vaginal examination reveals that the cervix is dilated 6 to 7 cm. In light of this finding, the nurse expects that the: 1Client may experience nausea and vomiting 2Client's bloody show will become more profuse 3Client will experience uncontrollable shaking of her legs 4Client's contractions will become longer and more frequent

4Client's contractions will become longer and more frequent

A primigravida asks when she will be able to hear the fetal heartbeat for the first time. The nurse should explain that the heartbeat can be heard with: 1A stethoscope at 4 weeks 2A fetoscope at 10 to 12 weeks 3Doppler ultrasound after 20 weeks 4Doppler ultrasound at 10 to 12 weeks

4Doppler ultrasound at 10 to 12 weeks

A nurse is caring for a client in labor who is receiving epidural anesthesia. For which common side effect of this route of anesthesia should the client be monitored? 1Sinus tachycardia 2Urinary frequency 3Respiratory distress 4Hypotensive episodes

4Hypotensive episodes

A nurse is trying to determine whether a pregnant woman's membranes have ruptured. What findings support the conclusion that they have ruptured? (Select all that apply.) 1The expelled fluid totals 500 mL. 2The expelled fluid is light yellow. 3The expelled fluid smells similar to urine. 4Nitrazine paper turns blue on contact with the fluid. 5Microscopic examination of the fluid reveals ferning/

4Nitrazine paper turns blue on contact with the fluid. 5Microscopic examination of the fluid reveals ferning/

A couple who recently immigrated from Israel tell a nurse in the prenatal clinic that they are concerned about a genetic disease that is prevalent among Jewish people. Which genetic screening should the nurse expect the health care provider to recommend to determine the possibility of the couple's child's inheriting the disease? 1Cystic fibrosis 2Phenylketonuria 3Turner syndrome 4Tay-Sachs disease

4Tay-Sachs disease

A 14-year-old emancipated minor at 22 weeks' gestation comes in for her second prenatal examination. As she enters the examination room with her mother, she tells the nurse that she does not want her mother present for the examination. What should the nurse say? 1"Your mother needs to be present for the examination." 2"What's the problem with your mother being present?" 3"I'm sure that your mother wants to be with you for support." 4Telling the mother, "I'm sorry, but I need to ask you to stay in the waiting area."

4Telling the mother, "I'm sorry, but I need to ask you to stay in the waiting area."

A client is admitted to the birthing room in active labor. The nurse determines that the fetus is in the left occiput posterior (LOP) position. At what point can the fetal heart be heard? 1a 2b 3c 4d

4d Fetal heart sounds are heard through the fetus's back. When the position of the fetus is in the left occiput posterior (LOP) or left occiput anterior (LOA), fetal heart sounds are heard in the left lower quadrant of the mother (d).

In childbirth classes the nurse is teaching paced breathing techniques for use during labor. In which order should the breathing techniques be used as labor progresses? 1. Slow, deep breaths 2. Pant-blow breathing 3. Modified-paced breathing 4. Slow, exhalation pushing 5. Cleansing breaths

5. Cleansing breaths 1. Slow, deep breaths 3. Modified-paced breathing 2. Pant-blow breathing 4. Slow, exhalation pushing

Severe preeclampsia With severe preeclampsia, arteriolar spasms cause hypertension and decreased arterial perfusion of the kidneys, which in turn cause an alteration in the glomeruli, resulting in oliguria and proteinuria, as well as retention of sodium and water, resulting in edema. Eclampsia is characterized by seizures; there are no data to indicate that the client is having or has had seizures. Chronic hypertension is hypertension diagnosed before pregnancy or before 20 weeks' gestation. If hypertension diagnosed during pregnancy for the first time persists beyond the postpartum period, it is also considered chronic hypertension. Gestational hypertension is hypertension that occurs during midpregnancy for the first time and without proteinuria; it is definitively diagnosed when the hypertension resolves 12 weeks after delivery.

122/86 mm Hg

A 16-year-old primigravida at 36 weeks' gestation visits the prenatal clinic for a routine examination. Her blood pressure is significantly increased, and there is 1+ proteinuria. The client's blood pressure had been averaging 92/70 mm Hg during her previous prenatal visits. What is the lowest blood pressure that should cause the nurse to become concerned?

Encouraging the client to verbalize her feelings about the loss

A 28-year-old woman is recovering from her third consecutive spontaneous abortion in 2 years. What is the most therapeutic nursing intervention for this client at her follow-up appointment?

Loss of childbearing potential

A 28-year-old woman is scheduled to undergo a laparoscopic bilateral salpingo-oophorectomy. What does a nurse expect to be the client's priority concern?

Neural tube defects

Notifying the primary health care provider about the epigastric pain, headache, and blurred vision

A 36-year-old primagravida is receiving treatment for preeclampsia at 29 weeks' gestation. In light of the latest information on the client's record, what does the nurse identify as the priority of care?

Promote clotting of the blood

A 7-lb newborn is admitted to the nursery with a prescription for intramuscular phytonadione (vitamin K, Aquamephyton) 1 mg. The nurse explains to the parents that this vitamin is administered to:

Decreased frequency and duration of contractions

A client arrives at the clinic in preterm labor, and terbutaline (Brethine) is prescribed. For what therapeutic effect should the nurse monitor the client?

Explaining why this is expected in early pregnancy

A client at 10 weeks' gestation tells the nurse in the maternity clinic that she is worried because she is voiding frequently. How should the nurse respond?

Threatened abortion

Syncope on exertion

A client at 28 weeks' gestation with previously diagnosed mitral valve stenosis is being evaluated in the clinic. Which sign or symptom indicates that the client is experiencing cardiac difficulties?

Maintaining adequate hydration

Misoprostol (Cytotec) Oxytocin (Pitocin) Dinoprostone (Prepidil)

A client at 39 weeks' gestation is admitted for induction of labor. Knowing that several medications are used to induce labor, a nurse identifies those that may be prescribed. (Select all that apply.)

Cracked and peeling skin Long scalp hair and fingernails Creases covering the neonate's full soles and palms

A client at 43 weeks' gestation has just given birth to an infant with typical postmaturity characteristics. Which postmature signs does the nurse identify? (Select all that apply.)

Morning sickness may lead to decreased food intake.

A client at 6 weeks' gestation who has type 1 diabetes is attending the prenatal clinic for the first time. The nurse explains that during the first trimester insulin requirements may decrease because:

At 10 weeks but no later than 12 weeks

Shock

A client being prepared for surgery because of a ruptured tubal pregnancy complains of feeling lightheaded. Her pulse is rapid, and her color is pale. What condition does the nurse anticipate as a common complication of a ruptured tubal pregnancy?

Vaginal hematoma

A client gives birth vaginally, with a midline episiotomy, to an infant who weighs 8 lb 13 oz (4000 g). An ice pack is applied to the perineum to ease the swelling and pain. The client complains, "This pain in my vaginal and rectum is excruciating, and my vagina feels so full and heavy." What does the nurse suspect as the cause of the pain?

Encouraging frequent ambulation

A client has a cesarean birth. What is the most important nursing intervention to prevent thromboembolism on the client's first postpartum day?

Unilateral abdominal pain History of a sexually transmitted infection

A client has a diagnosis of an unruptured tubal pregnancy. Which findings correlate with this diagnosis? (Select all that apply.)

Active genital herpes

A client in labor at 39 weeks' gestation is told by the health care provider that she will need a cesarean birth. The nurse reviews the client's prenatal history. What preexisting condition is the most likely reason for the cesarean birth?

Prolapsed cord

A client in labor is admitted with a suspected breech presentation. For what occurrence should the nurse be prepared?

Fundal height

Lie on her side to avoid putting pressure on the vena cava

A client is admitted to the high-risk prenatal unit with the diagnosis of placenta previa. What should the nurse instruct the client to do?

2:1 The lecithin concentration increases abruptly at 35 weeks, reaching a level that is twice the amount of sphingomyelin, which decreases concurrently. At 30 to 32 weeks' gestation, the amounts of lecithin and sphingomyelin are equal, indicating lung immaturity. A ratio of 1:4 does not reflect fetal lung maturity; nor does a ratio of 3:4.

"With an uncomplicated pregnancy, there are no limitations on sexual activity."

A client visiting the prenatal clinic for the first time tells the nurse that she has heard conflicting stories about sex during pregnancy and asks about continuing sexual activity. How should the nurse respond?

An emergency cesarean birth is traumatic psychologically because of the loss of the expected birth experience.

Ectopic pregnancy

A client who has missed two menstrual periods arrives at the prenatal clinic with vaginal bleeding and one-sided lower quadrant pain. What condition does the nurse suspect?

Monitoring the client for signs of electrolyte imbalances

A client who is in the first trimester is being discharged after a week of hospitalization for hyperemesis gravidarum. She is to be maintained at home with rehydration infusion therapy. What is the priority nursing activity for the home health nurse?

Administer RhoGAM within 72 hours of the miscarriage.

A client who is pregnant for the first time expels the products of conception at 12 weeks' gestation. The client's blood type is Rh negative. What should the nurse anticipate concerning the administration of Rho(D) immune globulin (RhoGAM)?

The client takes care of a cat.

Denial

A client who recently was told by her practitioner that she has extensive terminal metastatic carcinoma of the breast tells the nurse that she believes an error has been made. She states that she does not have breast cancer, and she is not going to die. The nurse determines that the client is experiencing the stage of death and dying known as:

Birth of the fetus within a day

A client whose membranes have ruptured is admitted to the birthing unit. Her cervix is dilated 3 cm and 50% effaced. The amniotic fluid is clear and the fetal heart rate is stable. What does the nurse anticipate?

"Please go on to see your daughter. I'll bring the baby to her room."

A couple arrives at the newborn nursery asking to take their newborn grandson to his mother's room. What is the best response by the nurse?

Assign an Apgar score to this infant: heart rate 110, crying vigorously, moves all extremities, cries when suctioned, blue extremities with pink body. Record your answer using a whole number. ______

A heart rate above 100 beats/min scores 2 points , vigorous crying scores 2 points, moving all extremities scores 2 points, reflex irritability scores 2 points, and blue extremities with a pink body scores 1 point, for a total Apgar score of 9.

"You may be correct. The effect of contraceptive pills depends on their being taken on a regular schedule."

"The swelling and discharge are expected. They're a response to your hormones."

A mother is inspecting her newborn girl for the first time. The infant's breasts are edematous, and she has a pink vaginal discharge. How should the nurse respond when the mother asks what is wrong?

The response is a common one in a new mother who is finding it difficult to accept that her newborn is less than perfect.

A mother is seeing her newborn, who has visible birth defects, for the first time. When she sees her baby, she becomes disturbed, pushes away, and tells a nurse, "Oh, take the baby away; I never want to see it again." What does the nurse conclude from this behavior?

Encourage the family to bring in special foods preferred in their culture

Meperidine (Demerol)

Prolapse of the umbilical cord

A multipara whose membranes have ruptured is admitted in early labor. Assessment reveals a breech presentation, cervical dilation of 3 cm, and fetal station at -2. For what complication should the nurse assess when caring for this client?

Have the mother breastfeed the newborn

A neighbor who is a nurse is called on to assist with an emergency home birth. What should the nurse do to help expel the placenta?

Cognitive Impairment

A neonate is tested for phenylketonuria (PKU) after formula feedings are initiated. The nurse explains to the parents that this is done to prevent:

30 to 60 breaths/min

A neonate weighing 5 lb 6 oz (2438 g) is born in a cesarean birth and admitted to the newborn nursery. What range of resting respiratory rate should the nurse anticipate?

"This often happens as the baby's head moves down the birth canal—the bones move for easier passage."

A new mother exclaims to the nurse, "My baby looks like a Conehead!" How should the nurse respond?

By asking her to describe her concerns more fully

A new mother with class II heart disease tells a nurse that she is afraid that her heart condition will prevent her from caring for her baby and her home when she is discharged. How should the nurse respond?

Thin upper lip Small upturned nose Smooth vertical ridge in the upper lip

A new mother's laboratory results indicate the presence of cocaine and alcohol. Which craniofacial characteristic indicates to the nurse that the newborn has fetal alcohol syndrome (FAS)? (Select all that apply.)

Rubella

A newborn has congenital cataracts, microcephaly, deafness, and cardiac anomalies. Which infection does the nurse suspect that the newborn's mother contracted during her pregnancy?

Milia

A newborn has small, whitish, pinpoint spots over the nose that are caused by retained sebaceous secretions. When documenting this observation, a nurse identifies them as:

Decrease the rate slowly

A newborn whose mother has type 1 diabetes is receiving a continuous infusion of fluids with glucose. What should the nurse do when preparing to discontinue the IV?

Notify the practitioner, because circumoral pallor may indicate cardiac problems

A newborn's hands and feet are cyanotic and there is circumoral pallor when the infant cries or feeds. What should the nurse do?

Fetal well-being

A nonstress test is scheduled for a client with preeclampsia. During the nonstress test the nurse concludes that if nonperiodic accelerations of the fetal heart rate occur with fetal movement, this probably indicates:

Color

A nurse assesses a healthy 8-lb 8-oz (3860-gm) newborn who was given Apgar scores of 9 at 1 minute and 10 at 5 minutes. Which category of the Apgar score received a 1 rating at one minute?

A nurse assesses a newborn 1 minute after birth. The body is pink with blue extremities; the heart rate is 122 beats/min; the legs are withdrawn when the soles are flicked, respiration is easy, with no evidence of distress; and the arms and legs are flexed and moving vigorously. What Apgar score should the nurse document in the newborn's medical record?

Cyanosis Tachypnea Retractions

A nurse determines that a newborn is in respiratory distress. Which signs confirm respiratory distress in the newborn? (Select all that apply.)

Slow-chest Slow-chest breathing pattern is used during the early phase of labor, when mild contractions dilate the cervix to 3 cm. The pant-blow breathing pattern is used during the transition phase of labor. The shallow-chest breathing pattern is used in combination with other breathing patterns; it is a part of the accelerated-decelerated pattern. The accelerated-decelerated breathing pattern is used during the active phase of the first stage of labor.

A nurse determines that the husband of a client in the early phase of labor understands the teaching from childbirth classes when he helps his wife use the breathing pattern of:

Immaturity of the central nervous system (CNS)

A nurse elicits the Babinski reflex on a newborn. The nurse concludes that this finding indicates:

Has type 1 diabetes

A nurse expects signs of respiratory distress syndrome (RDS) in a neonate whose mother:

How to monitor their child for signs of jaundice

A nurse identifies a right cephalhematoma on an otherwise healthy 1-day-old newborn. What should the nurse teach the parents at the time of discharge?

It can be acquired during a vaginal birth.

Increased blood volume

A nurse in the prenatal clinic reviews second-trimester physiological changes in the hematological system before explaining them to a client. What change should the nurse identify?

Take a walk around the unit with her

Modeling appropriate behaviors that encourage infant bonding

A nurse is assigned an adolescent who gave birth 12 hours ago. She continually talks on the phone to her friends and does not respond when her new baby cries. What is the best immediate intervention?

Sickle cell screening α-Fetoprotein (AFP) testing for neural tube defects Serum glucose for gestational diabetes Fetal movement test Group B Streptococcus culture

Variable decelerations

A nurse is caring for a client in the first stage of labor and an external fetal heart monitor is in place. What do the tracings indicate?

Hemorrhage

A nurse is caring for a client who has had a spontaneous abortion. For what complication should the nurse monitor this client?

Hypotonia

A nurse is caring for a client who is receiving IV magnesium sulfate for preeclampsia. At 37 weeks' gestation she gives birth to an infant weighing 4 lb. What clinical finding in the newborn may indicate magnesium sulfate toxicity?

Suddenly decrease

A nurse is caring for a client with type 1 diabetes on her first postpartum day. When planning care for this client, what changes in the client's insulin requirements does the nurse expect?

Gravida I who has had an intrauterine fetal death

A nurse is caring for a group of postpartum clients. Which client is at the highest risk for disseminated intravascular coagulation (DIC)?

Pneumonia Preterm birth Conjunctivitis

A nurse is caring for a new mother who has a chlamydial infection. Which complications are associated with chlamydial infections in neonates? (Select all that apply.)

Supporting the parents

A nurse is caring for a newborn with a cephalohematoma. What is the priority nursing action?

Heparin (Hep-Lock) Enoxaparin (Lovenox)

A nurse is caring for a pregnant client with thrombophlebitis. Which anticoagulant medication may be prescribed? (Select all that apply.)

Breaks down the bilirubin into a conjugated form

A nurse is caring for a preterm neonate with physiological jaundice who requires phototherapy. What is the action of this therapy?

Having sex with many partners

A nurse is caring for the newborn of a drug-addicted mother with suspected cytomegalovirus disease. What does the nurse suspect was the cause of the disease?

Requirement of intensive prenatal care

A nurse is counseling a pregnant woman with type 1 diabetes. What is the most important nursing consideration in the planning of care for this client?

Breast size Genital development

A nurse is estimating a newborn's gestational age. What parameters should the nurse evaluate? (Select all that apply.)

Flaring nares

A nurse is observing a newborn of 33 weeks' gestation. Which sign alerts the nurse to notify the health care provider?

Irregular, abdominal, 30 to 60/min

A nurse is observing a newborn's respiratory rate. What clinical findings indicate that the rate is within the expected range?

Sneezing Hyperactivity High-pitched cry

A nurse is observing the newborn of a known opioid user for signs of withdrawal. What clinical manifestations does the nurse expect to identify? (Select all that apply.)

Audible fetal heartbeat

Encouraging her to void before the test

A nurse is preparing a pregnant client for an amniocentesis. What should nursing care include?

Each pregnancy is a unique experience that is stressful despite multiparity.

½ cup of red kidney beans

A nurse is providing nutritional counseling to a low-income pregnant client who has iron-deficiency anemia. What food should the nurse encourage the client to include in her diet each day to best address this problem?

Compensates for a rapid turnover of red blood cells

A nurse is teaching a pregnant client with sickle cell anemia about the importance of taking supplemental folic acid. Folic acid is important for this client because it:

"We'll have to have the baby fitted with prosthetic devices before he'll be able to walk."

A nurse reviews the prescribed treatment with the parents of an infant born with bilateral clubfeet. Which parental statement indicates to the nurse that further education is required?

Deafness Cardiac anomalies

A nurse suspects that a newborn's mother had rubella during the first trimester of pregnancy. Which newborn problems support this assumption? (Select all that apply.)

Adherence to a corrective diet instituted early

A nurse takes into consideration that the effect PKU has on the infant's development will depend on:

Lack the subcutaneous fat that usually provides insulation

A parent of a preterm infant in the neonatal intensive care unit, asks a nurse why the baby is in a bed with a radiant warmer. The nurse explains that preterm infants are at increased risk for hypothermia because they:

A perfect score is 10; 1 point is deducted for lessened muscle tone (the baby's arms do not flex) and 1 point for acrocyanosis, which is manifested by bluish hands and feet.

8.2

G5 T2 P1 A1 L4

Continued exposure to secondhand smoke is related to fetal growth restriction.

A pregnant client tells the nurse that her husband is a chain smoker. What information should the nurse's teaching include?

"Try to walk around every few hours during the workday."

A pregnant client uses a computer almost continuously during her working hours. This has implications for her plan of care during pregnancy. What should the nurse recommend?

Lie on the side with the head raised on a small pillow. Bedrest keeps the pressure of the fetal head off the cervix. The side-lying position keeps the gravid uterus from impeding blood flow through major vessels, thus maintaining uterine perfusion. The Trendelenburg position is used when the cord is prolapsed or the client is in shock. Sitting up in bed increases pressure on the cervix and could lead to further dilation. Assuming the knee-chest position at regular intervals throughout the day may help relieve pressure of the fetus on the cervix, but it will not enhance uterine perfusion.

A pregnant client with a history of preterm labor is at home on bedrest. What instructions should a teaching plan for this client include?

Evidence of pyelonephritis

A pregnant client with sickle cell anemia visits the clinic each month for a routine examination. What additional observation should be made during every visit?

Neural tube defect

A pregnant client's blood test reveals an increased alpha-fetoprotein (AFP) level. What condition does the nurse suspect that this result indicates?

Dehydration

Doppler ultrasound at 10 to 12 weeks

A primigravida asks when she will be able to hear the fetal heartbeat for the first time. The nurse should explain that the heartbeat can be heard with:

6th

A primigravida is admitted to the emergency department with a sharp, shooting pain in the lower abdomen and vaginal spotting. A ruptured tubal pregnancy is diagnosed. During what week of gestation does this condition most commonly occur?

Explaining that the client may still be capable of becoming pregnant

A primigravida is admitted with a ruptured fallopian tube resulting from a tubal pregnancy and surgery is performed to remove the fallopian tube. What should postoperative nursing care include?

Discontinuing the test because the pattern is reassuring

Painless vaginal bleeding

A sonogram performed on a client in the third trimester demonstrates a low-lying placenta. The nurse should teach the client that she is at risk for:

A client is scheduled for a vacuum aspiration abortion to terminate an unwanted pregnancy. What information should the nurse's teaching plan include?

A temperature of 100.4° F (38° C) or higher should be reported immediately.

Accept that she is pregnant

The Pap smear can detect cancer of the cervix.

A young sexually active client at the family planning clinic is advised to have a Papanicolaou (Pap) smear. She has never had a Pap smear before. What should the nurse include in the explanation of this procedure?

Which parts of a newborn's body are usually affected by the rash erythema toxicum neonatorum? Select all that apply. A. Face B. Palms C . Soles D. Trunk E. Buttocks

A. Face D. Trunk E. Buttocks

Add 7 days to the 1st day of the LMP and subtract 3 months.

What does an Apgar score recorded 5 minutes after birth help the nurse evaluate?

Adequacy of the transition to extrauterine life

Metabolic acidosis

After a newborn has skin-to-skin contact with the mother, a nurse places the newborn under a radiant warmer. What complication is the nurse attempting to prevent?

"It's when the fetus is expelled but other parts of the pregnancy remain in the uterus."

After an incomplete abortion, a client tells a nurse that although her health care provider explained what an incomplete abortion was, she did not understand. What is the best response by the nurse?

Protecting the sac with moist sterile gauze

After an uneventful pregnancy a client gives birth to an infant with a meningocele. The neonate has 1-minute and 5-minute Apgar scores of 9 and 10, respectively. What is the priority nursing care for this newborn?

Taking-in By discussing the experience, the client is bringing it into reality; this is characteristic of the taking-in phase . The client is not ready to assume the tasks of the letting-go phase until completing the tasks of the taking-in and taking-hold phases. The taking-hold phase is marked by an increased desire to resume independence; this statement reveals that the client is not ready for this phase. The working-through phase is not a separate phase of adjustment to parenthood; it is not relevant.

After an unexpected emergency cesarean birth the client tells the nurse, "I failed natural childbirth." Which postpartum phase of adjustment does this statement most closely typify

Gently guiding the head downward

"Newborns are deficient in vitamin K. This treatment will protect your baby from bleeding."

A nurse is caring for a newborn with a myelomeningocele. What should immediate nursing care for this infant include?

Applying sterile, moist nonadherent dressings to the sac

What is the best nursing action for a client in active labor whose cervix is dilated 4 cm and 100% effaced with the fetal head at 0 station?

Assist the client's coach in helping her with the use of breathing techniques

Wrinkled skin Long nails

At 42 weeks' gestation a client gives birth to an 8-lb 5-oz newborn. On examining the infant, what does the nurse expect to observe? (Select all that apply.)

Combined Class- Maternity Evolve- Part 2

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