Exam 1 (Ch. 1, 3-4, 8-22)
It is noted that the amniotic fluid of a 42-week-gestation baby, born 30 seconds ago, is thick and green. Which of the following actions by the nurse would be critical at this time? SATA. A. Prepare the baby for intubation B. Assess the carotid pulse C. Deep suction the baby's trachea D. Stimulate the baby to cry E. Page a neonatologist to the delivery
A. Prepare the baby for intubation D. Stimulate the baby to cry E. Page a neonatologist to the delivery The baby should be stimulated to breathe, but if the baby does not breathe spontaneously, intubation may be needed. If the baby does not breathe spontaneously, additional resuscitation measures should be instituted. The heart rate is assessed via the brachial, umbilical, or apical routes. Routine deep suctioning of babies exposed to meconium is no longer recommended. If it is required, it would be performed by the neonatologist. Routine resuscitation measures should be performed at the birth. The nurse should stimulate the baby to breath by vigorously rubbing the baby's back, head, and feet. Because the possibility of complications and the need for resuscitation exists, the nurse should make sure the neonatologist is present at the delivery.
A nurse teaching an adolescent health class about the male genital system informs the students of the glands that produce fluid to carry sperm during ejaculation. Which of the following is one of the glands that produces seminal fluid? A. Prostate B. Epididymis C. Testes D. Vas deferens
A. Prostate The prostate gland does produce seminal fluid. The seminal vesicles and the bulbourethral glands also produce seminal fluid. Sperm are stored and mature in the epididymis. Sperm are produced in the testes. The tests also produce testosterone. The vas deferens is the tube throughout which the sperm travel between the epididymis and the urethra.
A pregnant woman who has a history of cesarean sections is requesting to have a vaginal birth after cesarean (VBAC). In which of the following situations should the nurse advise the client that her request will definitely be denied? A. Transverse fetal lie B. Flexed fetal attitude C. Previous low-flap uterine incision D. Positive vaginal candidiasis
A. Transverse fetal lie A baby in the transverse lie is lying sideways in the uterus. This lie is incompatible physiologically with a vaginal delivery.
A nurse should question a physician's order for beta-agonist tocolytics when a client has been diagnosed with which of the following medical problems? A. Type I diabetes mellitus B. Cerebral palsy C. Myelomeningocele D. Positive group B streptococci culture
A. Type I diabetes mellitus Beta-agonists often elevate serum glucose levels. The nurse should question the order.
A. 36-week-gestation client is being seen in the prenatal clinic. Where would the nurse expect the fundal height to be felt? A. At the diploid process B. At a point between the umbilicus and the xiphoid C. At the umbilicus D. At a level directly above the symphysis pubis
A. At the diploid process At 36 weeks' gestation, the fundus should be felt at the xiphoid process. At 20 weeks' gestation, the fundus should be felt at the umbilicus. At 12 weeks' gestation, the fundus should be felt directly above the symphysis pubis.
An infant admitted to the newborn nursery has a blood glucose level of 55 mg/dL. Which of the following actions should the nurse perform at this time? A. Provide the baby with routine feedings B. Assess the baby's blood pressure C. Place the baby under the infant warmer D. Monitor the baby's urinary output
A. Provide the baby with routine feedings This blood glucose level is normal. The nurse should provide routine nursing care.
A nurse has counseled a client who states that she is a strong believer in vitamin supplements to maintain her health. The nurse knows that the counseling was effective when the client states that she will refrain from taking supplements of which of the following vitamin? A. Vitamin A B. Vitamin B2 (Niacin) C. Vitamin B12 (Cobalamin) D. Vitamin C
A. Vitamin A It is unsafe to consume large doses of vitamin A during pregnancy. It is a fat-soluble vitamin that has been shown to be teratogenic.
Put the pregnancy acronym in correct order. A. G TALP B. G PALT C. G TPAL D. G TPLA
C. G TPAL
The nurse is counseling a client who wants to become pregnant. She tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. When will the client's next fertile period occur? A. January 14 to 15 B. January 22 to 23 C. January 29 to 30 D. February 6 to 7
C. January 29 to 30 This client can expect her next period to begin 36 days from the first day of her last menstrual period. Her next period would begin on February 12. Ovulation occurs 14 days before the first day of the menstrual period. The client can expect ovulation to occur January 29 to 30. Options A, B, and D are incorrect.
Start and end of 3rd trimester. A. 28-42 weeks B. 27-39 weeks C. 26-40 weeks D. 28-40 weeks
D. 28-40 weeks
Definition of a woman who is pregnant for the first time. A. Lucky! B. Primipara C. Multigravida D. Primigravida
D. Primigravida
A post-cesarean section client has been ordered to receive 500 mL of 5% dextrose in water every 4 hours. The drop factor of the macrodrip tubing is 10 gtt/mL. To what drip rate should the nurse regulate the IV? __________ gtt/min
volume multiplied by drop factor / time in min = drip rate (500 mL x 10 gt/mL) / (4 hours x 60 min/hour) = 21 gtt/min
Which statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn? A. "Breastfeeding my infant consistently every 3-4 hours stops ovulation and my period." B. "Breastfeeding my baby immediately after drinking alcohol is safer than waiting for the alcohol to clear my breastmilk." C. "I can start smoking cigarettes while breastfeeding because it will not affect my breast milk." D. "When I take a warm shower after I breastfeed, it relieves the pain from being engorged between breastfeedings."
A. "Breastfeeding my infant consistently every 3-4 hours stops ovulation and my period." Continuous breastfeeding on a 3- to 4-hour schedule during the day will cause a release of prolactin, which will suppress ovulation and menses, but is not completely effective as a birth control method. Option B is incorrect because alcohol can immediately enter the breast milk. Nicotine is transferred to the infant in breast milk. Taking a warm shower will stimulate the production of milk, which will be more painful after breastfeedings.
Start and end of 2nd trimester. A. 13-27 weeks B. 13-30 weeks C. 9-27 weeks D. 14-27 weeks
A. 13-27 weeks
Length of pregnancy. A. 40 weeks B. 9 months C. 267 days D. I don't know
A. 40 weeks
An ultrasound of a fetus' heart shows that "normal fetal circulation is occurring." Which of the following statements is consistent with the finding? A. A right-to-left shunt is seen between the atria B. Blood is returning to the placenta via the umbilical vein C. Blood is returning to the right atrium from the pulmonary system D. A right-to-left shunt is seen between the umbilical arteries.
A. A right-to-left shunt is seen between the atria This is correct. The foramen ovale is a duct between the atria. In fetal circulation, there is a right-to-left shunt through the duct.
A post cesarean client has been diagnosed with paralytic ileus. Which of the following symptoms would the nurse expect to see? SATA. A. Abdominal distention B. Polyuria C. Diastasis recti D. Dependent edema E. Absent bowel sounds
A. Abdominal distention E. Absent bowel sounds The nurse would expect to see a distended abdomen in a client with a paralytic ileum. Polyuria is unrelated to a paralytic ileum. Diastasis recti is unrelated to a paralytic ileus. Dependent edema is unrelated to a paralytic ileus. Peristalsis is absent; therefore, no bowel sounds are heard.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client? A. Breastfeed the infant, ensuring that both breasts are completely emptied B. Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast C. Breastfeed on the unaffected breast only until the mastitis subsides D. Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant
A. Breastfeed the infant, ensuring that both breasts are completely emptied Mastitis, caused by plugged milk ducts, is related to breast engorgement, and breastfeeding during mastitis facilitates the complete emptying of engorged breasts, eliminating the pressure on the inflamed breast tissue. Option B is less painful but does not facilitate complete emptying of the breast tissue. Option C will not relieve the engorgement on the affected side. Option D will not decrease antibiotic effects on the infant.
Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized swelling on the right side of his head. In a newborn, what is the most likely cause of this accumulation of blood between the periosteum and skull that does not cross the suture line? A. Cephalhematoma, which is caused by forceps trauma B. Subarachnoid hematoma, which requires immediate drainage C. Molding, which is caused by pressure during labor D. Subdural hematoma, which can result in lifelong damage
A. Cephalhematoma, which is caused by forceps trauma Cephalhematoma, a slight abnormal variation of the newborn, usually arises within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and skull. Option C is a cranial distortion lasting 5 to 7 days, caused by pressure on the cranium during vaginal delivery, and is a common variation of the newborn. Options B and D both involve intracranial bleeding and could not be detected by physical assessment alone.
A client, who is 6 cm dilated in active labor with intact membranes, had an epidural inserted 15 minutes ago. Which of the following nursing assessments is highest priority? A. Check her blood pressure q 15 minutes B. Check her temperature q 1 hour C. Palpate her bladder q 15 minutes D. Auscultate her lungs q 1 hour.
A. Check her blood pressure q 15 minutes This statement is correct. Hypotension is the most common side effect of epidural insertion. If the blood pressure (BP) should drop too low, the fetal heart rate will be adversely affected. The BP should be checked q 5 minutes for the first 15 minutes, then q 15 minutes for the remainder of the hour.
Which findings are of most concern to the nurse when caring for a woman in the first trimester of pregnancy? SATA. A. Cramping with bright red spotting B. Extreme tenderness of the breast C. Lack of tenderness of the breast D. Increased amounts of discharge E. Increased right-side flank pain
A. Cramping with bright red spotting C. Lack of tenderness of the breast E. Increased right-side flank pain Options A and C are signs of a possible miscarriage. Cramping with bright red bleeding is a sign that the client's menstrual cycle is about to begin. A decrease of tenderness in the breast is a sign that hormone levels have declined and that a miscarriage is imminent. Option E could be a sign of an ectopic pregnancy, which could be fatal if not discovered in time before rupture. Options B and D are normal signs during the first trimester of a pregnancy.
Which findings are most critical for the nurse to report to the primary health care provider when caring for the client during the last trimester of her pregnancy? SATA. A. Increased heartburn that is not relieved with doses of antacids B. Increase of the fetal heart rate from 126 to 156 beats/min from the last visit C. Shoes and rings that are too tight because of peripheral edema in extremities D. Decrease in ability for the client to sleep for more than 2 hours at a time E. Chronic headache that has been lingering for a week behind the client's eyes
A. Increased heartburn that is not relieved with doses of antacids E. Chronic headache that has been lingering for a week behind the client's eyes Options A and E are possible signs of preeclampsia or eclampsia but can also be normal signs of pregnancy. These signs should be reported to the health care provider for further evaluation for the safety of the client and the fetus. Options B, C, and D are all normal signs during the last trimester of pregnancy.
The nurse is providing health teaching to a group of gravid women. One woman states that she is a smoker and asks about the impact on her pregnancy. The nurse responds that which of the following fetal complications may develop? A. Low neonatal birth weight B. Excess pregnancy weight gain C. Severe neonatal anemia D. Maternal hyperbilirubinemia
A. Low neonatal birth weight Low neonatal birth weight is the most common complication seen in pregnancies complicated by cigarette smoking. Severe neonatal anemia is not associated with pregnancies complicated by cigarette smoking.
The client comes to the hospital assuming she is in labor. Which assessment findings by the nurse would indicate that the client is in true labor? SATA. A. Pain in the lower back that radiates to abdomen B. Contractions decreased in frequency with ambulation C. Progressive cervical dilation and effacement D. Discomfort localized in the abdomen E. Regular and rhythmic painful contractions
A. Pain in the lower back that radiates to abdomen C. Progressive cervical dilation and effacement E. Regular and rhythmic painful contractions These are all signs of true labor. Options B and D are signs of false labor.
The nurse notes that a newborn, who is 5 minutes old, exhibits the following characteristics: HR 88 bpm, RR 8 rpm without a cry, facial grimace, blue body & face, flaccid. What does the nurse determine as the baby's Apgar score at this time? A. 2 B. 3 C. 4 D. 5
B. 3 The Apgar score is 3. HR-1, RR-1, Reflex irritability-1, Color-0, muscle tone-0.
Who are the nurse providers that may attend a birth? A. Women's Health NP B. Certified Nurse Midwife C. Clinical Nurse Specialist D. Nurse Researcher
B. Certified Nurse Midwife
A gravid woman and her husband inform the nurse that they have just purchased a three-story home that was built in the 1930s. It is critical that the nurse counsel the couple that before moving into the home they must do which of the following? A. Remove all old carpeting B. Check the water for heavy metals C. Replace all copper pipes D. Monitor the bathrooms for signs of mildew
B. Check the water for heavy metals The water should be checked for lead. Lead consumption by the woman during pregnancy and/or by the baby can result in permanent central nervous system and organ system damage in the child.
A nurse is working in the prenatal clinic. Which of the following findings would the nurse consider to be within normal limits for a client in the third trimester of pregnancy? A. Diplopia B. Epistaxis C. Bradycardia D. Oliguria
B. Epistaxis Epistaxis is commonly seen in pregnant clients. The bleeding is related to the increased vascularity of the mucous membranes. Unless the blood loss is significant, it is a normal finding.
A woman has decided to hire a doula to work with her during labor and delivery. Which of the following actions would be appropriate for the nurse to delegate to the doula? A. Document the fetal heart-rate pattern B. Give the woman a foot massage C. Check the woman's pulse & respirations D. Adjust the woman's intravenous flow rate
B. Give the woman a foot massage It would be appropriate for the doula to give the client a foot massage.
Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time? A. She eagerly reaches for the infant, undresses the infant, and examines the infant completely B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips C. Her arms and hands receive the infant and she then cuddles the infant to her own body D. She eagerly reaches for the infant and then holds the infant close to her own body
B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips Attachment and bonding theory indicates that most mothers will demonstrate behaviors described in option B during the first visit with the newborn, which may be at delivery or later. After the first visit, the mother may exhibit different touching behaviors such as eagerly reaching for the infant and cuddling the infant close to her.
A labor nurse is caring for a client, 38 weeks' gestation, who has been diagnosed with placenta previa. Which of the following physician orders should the nurse question? A. Type and cross-match her blood B. Insert an internal fetal monitor electrode C. Administer an oral stool softener D. Assess her complete blood count.
B. Insert an internal fetal monitor electrode This action is inappropriate. When a client has a placenta previa, nothing should be inserted into the vagina.
A client is at 8 weeks' gestation. Which of the following findings would the nurse expect to see? A. Multiple pillow orthopnea B. Maternal ambivalence C. Fundus at the umbilicus D. Pedal & ankle edema
B. Maternal ambivalence Ambivalence is a common finding of women during the first trimester. The funds should be at the umbilicus at 20 weeks' gestation.
During labor, the nurse determines that the fetus is at +1 station and is in the LOP position. Which of the following symptoms would the nurse expect to see? A. Fetal heart decelerations B. Maternal back pain C. Marked fetal movement D. Bulging of the maternal perineum
B. Maternal back pain The mother would likely experience back pain. When the fetus is in the LOP (left occipital posterior) position, the fetal head presses on the mother's coccyx, causing pain.
The nurse notes each of the following findings in a 12-week-gestation client. Which of the findings would enable the nurse to tell the client that she is probably pregnant? A. Fetal heart rate via Doppler B. Positive pregnancy test C. Positive ultrasound assessment D. Absence of menstrual period
B. Positive pregnancy test A positive pregnancy test is a probable sign of pregnancy. It is not a positive sign because the hormone tested for - human chorionic gonadotropin (hCG) - may be produced by, for example, a hydatidiform mole.
A primigravid client received Cervidil (dinoprostone) for induction 12 hours ago. The Bishop score is now 3. Which of the following actions by the nurse is appropriate? A. Perform nitrazine analysis of the amniotic fluid B. Report the lack of progress to the obstetrician C. Place the woman on her left side D. Ask the doctor for an order for oxytocin
B. Report the lack of progress to the obstetrician Little progress has taken place. The Bishop score of a primigravida will need to be 9 or higher before oxytocin will be effective.
When performing Leopold's maneuvers on a client in early labor, the nurse notes that the fetus is in the right sacral anterior position. Where should the nurse place a fetoscope best to hear the fetal heart sounds? A. Left upper quadrant B. Right upper quadrant C. Left lower quadrant D. Right lower quadrant
B. Right upper quadrant The nurse would expect to hear the fetal heart rate best via the fetal back. In a baby in the right sacral anterior (RSA) position, the monitor should be placed in the right upper quadrant.
Ten minutes after the birth of a full-term baby, the nurse notes that the uterus feels spherical and that a gush of blood has drained from the vagina. The nurse's action at this time is based on which of the following factors? A. The client is exhibiting signs of postpartum hemorrhage B. The woman is about to deliver the placenta C. The client is at high risk for pulmonary embolism D. The woman is exhibiting signs of uterine rupture.
B. The woman is about to deliver the placenta The woman is about to deliver the placenta. One additional sign of placental delivery is lengthening of the umbilical cord.
A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny-looking head." Which response by the nurse is best? A. "This is not an unusually shaped head, especially for a first baby." B. "It may look odd, but newborn babies are often born with heads like that." C. "That is normal. The head will return to a round shape within 7-10 days." D. "Your pelvis was too small, so the head had to adjust to the birth canal."
C. "That is normal. The head will return to a round shape within 7-10 days." Option C reassures the mother that this is normal in the newborn and provides correct information regarding the return to a normal shape. Although option A is correct, it implies that the client should not worry. Any implied or spoken "don't worry" is usually the wrong answer. Option B is condescending and dismissing; the mother is seeking reassurance and information. Option D is a negative statement and implies that molding is the mother's fault.
After a sex education class, the school nurse overhears an adolescent woman discussing safe sex practices. Which of the following comments by the young woman indicates that additional teaching about sexually transmitted infection (STI) control issues is needed? A. "I could get an STI even if I just have oral sex." B. "Girls over 16 are less likely to get STIs than younger girls." C. "The best way to prevent an STI is to use a diaphragm." D. "Girls get HIV easier than boys do."
C. "The best way to prevent an STI is to use a diaphragm." This statement is untrue. The young woman needs further teaching. Condoms protect against STIs and pregnancy. In addition, condoms can be kept in readiness for whenever sex may occur spontaneously. Using condoms does not require the teen to plan to have sex. A diaphragm is not an effective infection-control method. Plus, it would require the teen to plan for intercourse. Young women have especially high risk for becoming infected with STIs.
The results of a pregnant woman's 2-hour prenatal glucose tolerance test are as follows: fasting—105 mg/dL; 1 hour—200 mg/dL; 2 hour—156 mg/dL. Which of the following is appropriate information for the nurse to give the client at this time? A. "You will need to inject insulin at least once a day for the rest of the pregnancy." B. "Daily oral medicines will be prescribed for you to take." C. "You will be given an appointment to see a registered dietitian by your healthcare provider." D. "The results are within normal limits, so no intervention is needed."
C. "You will be given an appointment to see a registered dietitian by your healthcare provider." This statement is correct. The majority of patients with gestational diabetes are managed with diet and exercise alone. The client should be referred to a registered dietitian for dietary counseling.
Start and end of 1st trimester. A. 0-14 weeks B. 0-9 weeks C. 0-12 weeks D. 0-27 weeks
C. 0-12 weeks
Who establishes Standards of Practice for nurses in OB and newborn care? A. ACOG, AMA, ADA B. Texas board of nursing C. ANA, AWHONN, ACNM, NANN D. ANA, ACOG, AWHONN, ACNM, AMA, ADA
C. ANA, AWHONN, ACNM, NANN
A woman who is being seen in the prenatal clinic is found to be 12 weeks pregnant. She confides to the nurse that she is afraid her baby may be permanently damaged because she takes penicillin every day to prevent rheumatic fever. In addition to advising the client's primary healthcare provider of the information, which of the following actions by the nurse would be appropriate? A. Advise the client that very few medications cross the placenta, so it is unlikely that the baby has been affected B. Refer the client to a perinatologist for a high-resolution ultrasound scan to see if the baby was affected C. Consult a medication reference text D. Recommend the client abort the fetus
C. Consult a medication reference text In addition to advising the client's primary healthcare provider, the nurse should consult a medication reference text.
A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement? A. Encourage frequent use of a pacifier so that the infant becomes accustomed to sucking B. Hold the infant's head firmly against the breast until he latches onto the nipple C. Encourage the mother to stop feeding for a few minutes and comfort the infant D. Provide formula for the infant until he becomes calm, and then offer the breast again
C. Encourage the mother to stop feeding for a few minutes and comfort the infant The infant is becoming frustrated and so is the mother; both need a time out. The mother should be encouraged to comfort the infant and to relax herself. After such a time out, breastfeeding is often more successful. Options A and D would cause nipple confusion. Option B would only cause the infant to be more resistant, resulting in the mother and infant becoming more frustrated.
A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective in preventing nipple soreness? A. Wear a cotton bra with nonbinding support B. Increase nursing time gradually over several days C. Ensure that the baby is positioned correctly for latching on D. Manually express a small amount of milk before nursing
C. Ensure that the baby is positioned correctly for latching on The most common cause of nipple soreness is incorrect positioning of the infant on the breast for latching on. The baby's body is in alignment with the ears, shoulders, and hips in a straight line, with the nose, cheeks, and chin touching the breast. Option A helps prevent chafing, and nonbinding support aids in prevention of discomfort from the stretching of the Cooper ligament. Option B is important but is not necessary for all women. Option D helps soften an engorged breast and encourages correct infant latching on but is not the best answer.
Positive signs of pregnancy. A. N & V, breast changes, quickening, urinary frequency B. Chadwick's sign, N & V, breast changes, Braxton hicks C. Fetal heart beat, visualization by U/S D. Quickening, urinary frequency, linea nigra, + pregnancy test
C. Fetal heart beat, visualization by U/S
A woman who has had no prenatal care was found to have hydramnios on admission to the labor unit and has since delivered a baby weighing 4,500 grams. The nurse concludes that which of the following complications of pregnancy likely contributed to these findings? A. Pyelonephritis B. Pregnancy-induced hypertension C. Gestational diabetes D. Abruptio placentae
C. Gestational diabetes Untreated gestational diabetics often have hydramnios and often deliver macrosomic babies.
A 25-year-old client has a positive pregnancy test. One year ago she had a spontaneous abortion at 3 months of gestation. Which is the correct description of this client that should be documented in the medical record? A. Gravida 1, para 0 B. Gravida 1, para 1 C. Gravida 2, para 0 D. Gravida 2, para 1
C. Gravida 2, para 0 This is the client's second pregnancy or second gravid event, so option C is correct. The spontaneous abortion (miscarriage) occurred at 3 months of gestation (12 weeks), so she is a para 0. Parity cannot be increased unless delivery occurs at 20 weeks of gestation or beyond. Option A does not take into account the current pregnancy, nor does option B, which also counts the miscarriage as a "para," an incorrect recording. Although option D is correct concerning gravidity, para 1 is incorrect.
Ideal places where babies can be born. A. Basket, hospital, taxi, home B. Stork delivery from France C. Home, birthing center, hospital D. Home, birthing center, taxi, hospital
C. Home, birthing center, hospital
A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating and states that because she has had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority? A. Altered nutrition, less than body requirements for lactation B. Alteration in comfort relate to nausea and abdominal distention C. Impaired bowel motility related to pain medication and immobility D. Fatigue related to cesarean delivery and physical care demands of infant
C. Impaired bowel motility related to pain medication and immobility Impaired bowel motility caused by surgical anesthesia, pain medication, and immobility is the priority nursing diagnosis and addresses the potential problem of a paralytic ileus. Options A and B are both caused by impaired bowel motility. Option D is not as important as impaired motility.
Definition of abortion. A. Medical term for any pregnancy terminated before birth B. Medical term for any pregnancy terminated before 16 weeks C. Medical term for any pregnancy terminated before 20 weeks D. Medical term for any pregnancy terminated before 8 weeks
C. Medical term for any pregnancy terminated before 20 weeks
The nurse is caring for a client, G1 P0000, who is in active labor with fetal heart rate of 146, with good variability, and with rupture of membranes for 25 hours. Which of the following nursing actions is contraindicated for this client? A. Administering a soapsuds enema B. Encourage the client to labor in the shower C. Performing frequent vaginal exams D. Providing the client with ice chips to chew on
C. Performing frequent vaginal exams Because the client has had ruptured membranes for many hours, the nurse should not perform vaginal examinations unless absolutely necessary. Every time an exam is performed, there is a possibility that infectious organisms could be introduced into the uterine cavity.
A mother expresses fear about changing the infant's diaper after circumcision. What information should the nurse include in the teaching plan? A. Cleanse the penis with prepackaged diaper wipes every 3-4 hours B. Wash off the yellow exudate on the glans once every day to prevent infection C. Place petroleum ointment around the glans with each diaper change and cleansing D. Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding occurs
C. Place petroleum ointment around the glans with each diaper change and cleansing With each diaper change, the glans penis should be washed with warm water to remove any urine or feces, and petroleum ointment should be applied to prevent the diaper from sticking to the healing surface. Prepackaged wipes often contain other products that may irritate the site. The yellow exudate, which covers the glans penis as the area heals and epithelializes, is not an infective process and should not be removed. If bleeding occurs at home, the client should be instructed to apply gentle pressure to the site of the bleeding with sterile gauze squares and call the health care provider.
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60 mm Hg. Which action should the nurse take immediately? A. Notify the health care provider or anesthesiologist B. Continue to assess the BP every 5 minutes C. Place the client in a lateral position D. Turn off the continuous epidural
C. Place the client in a lateral position The nurse should immediately turn the client to a lateral position or place a pillow or wedge under one hip to deflect the uterus. Other immediate interventions include increasing the rate of the main line IV infusion and administering oxygen by facemask. If the blood pressure remains low after these interventions or decreases further, the anesthesiologist or health care provider should be notified immediately. To continue to monitor blood pressure without taking further action could constitute malpractice. Option D may also be warranted, but such action is based on hospital protocol.
Six hours after an oxytocin (Pitocin) induction was begun and 2 hours after spontaneous rupture of the membranes, the nurse notes several sudden decreases in the fetal heart rate with quick return to baseline, with and without contractions. Based on this fetal heart rate pattern, which intervention is best for the nurse to implement? A. Turn the client to her side B. Begin oxygen by nasal cannula at 2 L/min C. Place the client in a slight Trendelenburg position D. Assess for cervical dilation
C. Place the client in a slight Trendelenburg position The goal is to relieve pressure on the umbilical cord, and placing the client in a slight Trendelenburg position is most likely to relieve that pressure. The FHR pattern is indicative of a variable fetal heart rate deceleration, which is typically caused by cord compression and can occur with or without contractions. Option A may be helpful but is not as likely to relieve the pressure as the Trendelenburg position. Option B is not helpful with cord compression. Option D is not the priority intervention at this time. After repositioning the client, a vaginal examination is indicated to rule out cord prolapse and assess for cervical change.
A woman, 28 weeks' gestation, is 1 cm dilated and contracting q 5 minutes. She is receiving magnesium sulfate IV piggyback. Which of the following maternal vital signs is most important for the nurse to assess each hour? A. Temperature B. Pulse C. Respiratory rate D. Blood pressure
C. Respiratory rate For the patient receiving magnesium sulfate - The respiratory rate is the most important vital sign. Respiratory depression is a sign of magnesium toxicity. The temperature should be monitored, but it is not the most important vital sign.
The nurse has taken a health history on four multigravid clients at their first prenatal visits. It is high priority that the client whose first child was diagnosed with which of the following diseases receives nutrition counseling? A. Development dysplasia of the hip B. Achondroplastic dwarfism C. Spina bifida D. Muscular dystrophy
C. Spina bifida The incidence of spina bifida is much higher in women with poor folic acid intake. It is a priority that this client receives nutrition counseling.
A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in preterm labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her labor contractions. What are the primary side effects of terbutaline sulfate? A. Drowsiness and paroxysmal bradycardia B. Depressed reflexes and increased respirations C. Tachycardia and a feeling of nervousness D. A flushed warm feeling and dry mouth
C. Tachycardia and a feeling of nervousness Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the drug may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of nervousness. Option A is not a side effect. Options B and D are side effects of magnesium sulfate.
Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first? A. The baby with respirations 52, oxygen saturation 98% B. The baby with Apgar 9/9, weight 2,960 grams C. The baby with temperature 96.3ºF, length 17 inches D. The baby with glucose 60 mg/dL, heart rate 132
C. The baby with temperature 96.3ºF, length 17 inches This baby should be assessed first. The baby's temperature is low. The baby therefore could develop cold stress syndrome. In addition, the baby is short and therefore could be preterm.
While performing Leopold's maneuvers on a laboring woman, the nurse palpates a flat area in the fundal region, a hard round mass on the left side, a soft round mass on the right side, and small parts just above the symphysis. The nurse concludes which of the following? A. The fetal position is right occiput posterior B. The fetal attitude is flexed C. The fetal presentation is scapular D. The fetal lie is vertical
C. The fetal presentation is scapular. Scapular is a shoulder presentation. It is not possible to determine whether the attitude is flexed or not when doing Leopold's maneuvers. The lie is transverse or horizontal.
A nurse is performing a postpartum assessment 30 minutes after a vaginal delivery. Which of the following actions indicates that the nurse is performing the assessment correctly? A. The nurse measures the fundal height in relation to the symphysis pubis B. The nurse monitors the client's central venous pressure C. The nurse assesses the client's perineum for edema & ecchymoses D. The nurse performs a sterile vaginal speculum exam
C. The nurse assesses the client's perineum for edema & ecchymoses The nurse should assess the perineum for signs of edema and ecchymoses. The fundal height should be measured in relation to the umbilicus. If a speculum exam were needed, a physician or midwife would perform the procedure. Speculum exams are rarely needed postpartum.
The nurse working in an outpatient obstetrical office assesses four primigravid clients. Which of the client findings would the nurse highlight for the physician? A. 15 weeks, denies feeling fetal movement B. 20 weeks, fundal height at the umbilicus C. 25 weeks, complains of excess salivation D. 30 weeks, states that her vision is blurry
D. 30 weeks, states that her vision is blurry Blurred vision is a sign of hypertensive illness of pregnancy, also called pregnancy-induced hypertension (PIH). This finding should be reported to the woman's healthcare practitioner.
A client delivered a 2,800-gram neonate 4 hours ago by cesarean section with epidural anesthesia. Which of the following interventions should the nurse perform on the mother at this time? A. Maintain the client flat in bed B. Assess the client's patellar reflexes C. Monitor hourly urinary outputs D. Assess the client's respiratory rate
D. Assess the client's respiratory rate The client has undergone major abdominal surgery. Her respiratory function should be assessed regularly.
When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? A. At 16 weeks of gestation B. At 20 weeks of gestation C. At 24 weeks of gestation D. At 30 weeks of gestation
D. At 30 weeks of gestation Learning is facilitated by an interested pupil. The couple is most interested in childbirth toward the end of the pregnancy, when they are beginning to anticipate the onset of labor and the birth of their child. Option D is closest to the time when parents would be ready for such classes. Options A, B, and C are not the best times during a pregnancy for the couple to attend childbirth education classes. At these times they will have other teaching needs. Early pregnancy classes often include topics such as nutrition, physiologic changes, coping with normal discomforts of pregnancy, fetal development, maternal and fetal risk factors, and evolving roles of the mother and her significant others.
The nurse is teaching an uncircumcised male to use a condom. Which of the following should be included in the teaching plan? A. Always use a sexual lubricant during intercourse for comfort B. Fully cover the glans with the foreskin before applying the condom C. Snugly apply the condom to the foreskin of the penis D. Carefully remove the condom immediately after ejaculating
D. Carefully remove the condom immediately after ejaculating The condom should be removed carefully as soon as the man has ejaculated. Before applying the condom, the foreskin should be pulled back in order to expose the glans. A small space should be left at the end of the penis for the ejaculate.
A woman in the labor suite is on a subcutaneous beta-agonist for preterm labor. Which of the following common medication effects would the nurse expect to see in the mother? A. Increase in serum potassium level B. Diarrhea C. Urticaria D. Complaints of nervousness
D. Complaints of nervousness Complaints of nervousness are commonly made by women receiving subcutaneous beta-agonists.
A client, G1 P0000, is in the labor and delivery suite for induction of labor. The following assessments were made on admission: Bishop score of 3, fetal heart rate 156 with good variability and no decelerations, TPR 98.6ºF, 88, 20, BP 120/80, negative obstetrical history. A prostaglandin suppository was inserted at that time. Which of the following findings, 6 hours after insertion, would warrant the removal of the Cervidil (dinoprostone)? A. Bishop score of 5 B. Fetal heart of 152 bpm C. Respiratory rate of 24 rpm D. Contraction frequency of 3 minutes
D. Contraction frequency of 3 minutes Cervidil should be removed once labor has begun. A Bishop score of 9 or higher would indicate that the primigravid woman's cervix is ripe. A fetal heart rate of 152 is within normal limits for this fetus. A respiratory rate of 24 is within normal limits.
A 39-year-old, 16-week-gravid woman has had an amniocentesis. Before discharge, the nurse instructs the woman to call her doctor if she experiences which of the following side effects? A. Pain at the puncture site B. Macular rash on the abdomen C. Decrease in urinary output D. Cramping of the uterus
D. Cramping of the uterus The woman should report any uterine cramping. Although rare, amniocentesis could stimulate preterm labor.
The nurse has cared for a client throughout her labor experience from the latent phase of the first stage to 1 hour after delivery. During which period of the labor should the nurse monitor the client most carefully for cardiovascular compromise? A. Active phase B. Transition C. Second stage D. First hour postpartum
D. First hour postpartum The woman is most at risk for cardiovascular compromise during the first hour postpartum.
When assessing the psychological adjustment of a 22-week gravida, the nurse would expect to observe which of the following signs? A. Ambivalence B. Depression C. Anxiety D. Happiness
D. Happiness The nurse would expect the client to exhibit signs of happiness at this time. Ambivalence is often seen during the first trimester. The nurse would not expect to see depression at any time during the pregnancy. The client may express some anxiety near the time of delivery.
A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and returns to baseline after the contraction. Which action should the nurse implement? A. Place a wedge under the client's left side B. Determine cervical dilation and effacement C. Administer 10 L of oxygen via facemask D. Increase the rate of the oxytocin (Pitocin) infusion
D. Increase the rate of the oxytocin (Pitocin) infusion The goal of labor augmentation is to produce firm contractions that occur every 2 to 3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress. FHR accelerations are a normal response to contractions, so the oxytocin (Pitocin) infusion should be increased per protocol to stimulate the frequency and intensity of contractions. Options A and C are indicated for fetal stress. A sterile vaginal examination places the client at risk for infection and should be performed when the client exhibits signs of progressing labor, which is not indicated at this time.
Childbirth preparation methods. A. Piaget, Freud, Erickson B. Piaget, Lamaze, Bradley, & Freud C. Bradley, Erickson, Read, Leboyer D. Lamaze, Read, Leboyer, & Bradley
D. Lamaze, Read, Leboyer, & Bradley
A client with 4+ protein and 4+ reflexes is admitted to the hospital with a diagnosis of severe preeclampsia. The nurse must closely monitor the woman for which of the following? A. High leukocyte count B. Explosive diarrhea C. Fractured pelvis D. Low platelet count
D. Low platelet count Low platelet count is one of the signs associated with HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. High leukocyte count is not associated with severe pregnancy-induced hypertension (PIH) or HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome.
The nurse observes that an antepartum client who is on bed rest for preterm labor is eating ice rather than the food on her breakfast tray. The client states that she has a craving for ice and then feels too full to eat anything else. Which is the best response by the nurse? A. Remove all ice from the client's room B. Ask the client what foods she might consider eating C. Remind the client that what she eats affects her baby D. Notify the health care provider
D. Notify the health care provider The health care provider should be notified when a client practices pica (craving for and consumption of nonfood substances). The practice of pica may displace more nutritious foods from the diet, and the client should be evaluated for anemia. Option A is overreacting and may be perceived as punishment by the client. Option B allows the dietary department to customize the client's tray but fails to address physiologic problems associated with not consuming nutritious foods in pregnancy. Option C is judgmental and blocks further communication.
One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96° F, his lower lip is shaking, and when the nurse assesses for a Moro reflex, the boy's hands shake. Which intervention should the nurse implement first? A. Stimulate the infant to cry B. Wrap the infant in warm blankets C. Feed the infant formula D. Obtain a serum glucose level
D. Obtain a serum glucose level This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body temperature. The nurse should first determine the serum glucose level. Option A is an intervention for a lethargic infant. Option B should be done based on the temperature, but first the glucose level should be obtained. Option C helps raise the blood sugar, but first the nurse should determine the glucose level.
A nurse is teaching a woman about her menstrual cycle. The nurse states that which of the following is the most important change that happens during the secretory phase of the menstrual cycle? A. Maturation of the Graafian follicle B. Multiplication of the fimbriae C. Secretion of human chorionic gonadotropin D. Proliferation of the endometrium
D. Proliferation of the endometrium The proliferation of the endometrium occurs during the secretory phase of the menstrual cycle. The maturation of the Graafian follicle occurs during the follicular phase. Human chorionic gonadotropin is secreted by the fertilized ovum during the early weeks of a pregnancy.
Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention should the nurse implement first? A. Assess the husband's feelings about his wife's decision to breastfeed their baby B. Ask the woman to describe why she was unsuccessful with breastfeeding her last child C. Encourage the woman to develop a positive attitude about breastfeeding to help ensure success D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery
D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery Infants respond to breastfeeding best when feeding is initiated in the active phase soon after delivery. Options A and B might provide interesting data, but gathering this information is not as important as providing support and instructions to the new mother. Although option C is also true, this response by the nurse might seem judgmental to a new mother.
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? A. Use thread to tie off the umbilical cord B. Provide privacy for the woman C. Reassure the husband and keep him calm D. Put the newborn to the breast immediately
D. Put the newborn to the breast immediately Putting the newborn to the breast will help contract the uterus and prevent a postpartum hemorrhage. This intervention has the highest priority. Option A is not necessary; the infant can be transported attached to the placenta. Option B is an important psychosocial need but does not have the priority of option D. Although the husband is an important part of family-centered care, he is not the most important concern at this time.
A woman, seen in the emergency department, is diagnosed with pelvic inflammatory disease (PID). The nurse would expect the client to exhibit which of the following symptoms? A. Erythema B. Pruritus C. Pain D. Leukopenia
Pain, thick vaginal discharge, unusual bleeding, fever, & dyspareunia are all associated with PID.
During childbirth education classes, a nurse is discussing the cardinal moves of labor with pregnant couples. Which of the following moves should the nurse tell couples are the first two moves that babies make during a vaginal birth? Please place the following moves in the correct order. Expulsion Flexion External rotation Internal rotation Extension
The order of the cardinal moves of labor is as follows: flexion and descent, internal rotation, extension, external rotation, expulsion.