Exam 2 Practice Questions
A postpartum client is experiencing pain from an episiotomy. Which actions will the nurse suggest to the client to decrease discomfort? Select all that apply. A) Washing the area with soap and water every day B) Tightening the buttocks before sitting C) Changing peripads daily D) Performing leg scissor kicks several times a day E) Increasing the intake of meat, cheese, fish, eggs, and nuts
B E
A client at 16 weeks' gestation is diagnosed with tuberculosis (TB). Which statement by the nurse is appropriate when instructing the client regarding the needs for both the client and fetus? A) "You have been prescribed isoniazid; therefore, you must also take pyridoxine (vitamin B6)." B) "Your contact with the baby will be limited for several months after delivery." C) "You will not be able to breastfeed your baby because of this diagnosis." D) "You are free to have contact with anyone as TB is not contagious when diagnosed during pregnancy."
A
A client delivers a newborn son and plans to breastfeed. When the nurse attempts to help the newborn latch on for breastfeeding, the client states, "I would like to bottle feed my baby for the first few days." Which reason might the nurse hear regarding why the client wants to delay breastfeeding? A) Colostrum is bad for the baby. B) The birthing process spoils breast milk. C) It will cause "evil eye." D) Newborns require feeding on demand.
A
A client who gave birth to her first child 12 hours ago has the following assessment findings: nausea for 2 hours; boggy fundus that firmed with massage; moderately heavy lochia rubra; ecchymotic and edematous perineum; and pain rating of 6 on a scale of 0-10. The client's partner is present and supportive. Breastfeeding has been successful three times. Based on this data, which is the priority nursing diagnosis? A) Acute Pain related to perineal trauma B) Risk for Deficient Fluid Volume secondary to boggy fundus and nausea C) Deficient Knowledge related to birth of first child D) Readiness for Enhanced Family Coping related to partner involvement
A
A premature newborn's neuronal immaturity may contribute to what complication? A) Apnea of prematurity B) Patent ductus arteriosus C) Respiratory distress syndrome D) Anemia of prematurity
A
Because of the immature development of the kidney, the nurse needs to assess preterm infants for what condition? A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis
A
If a woman had a prepregnancy daily requirement of 1800 calories and she decides to breastfeed her newborn, how many calories should the nurse recommend the woman take in each day? A) 2300 calories B) 2500 calories C) 2000 calories D) 1800 calories
A
The laboring client's fetal heart rate baseline is 120 beats per minute (bpm). Accelerations are present to 135 bpm. During contractions, the fetal heart rate gradually slows to 110 bpm and is at 120 bpm by the end of the contraction. Which nursing action is appropriate? A) Documenting the fetal heart rate B) Preparing for imminent delivery C) Applying oxygen via mask at 10 liters per minute D) Assisting the client into the Fowler position
A
The nurse is caring for a 14-year-old client who is pregnant. What will the nurse need to consider that may affect this client more than older adolescents? A) The client may be more concerned about modesty. B) The client may be more concerned with state marriage laws. C) The client may be more concerned about parents finding out about the pregnancy. D) The client may be more concerned about finding a support person
A
The nurse is caring for a 3-year-old client on the pediatric unit who was in an automobile accident. The client's mother was killed in the accident, and the client recently learned of her mother's death. Which nursing intervention would be most appropriate to support the developmental needs of this client? A) Work with the surviving family members to ensure that the client's routine remains as normal as possible after release from the hospital. B) Do not correct the client when she expresses the belief that her mother will "wake up and come home." C) Provide the client with the same level of reassurance and attention as any other client on the unit. D) Avoid answering the client when she asks questions about her mother's death.
A
The nurse is caring for a 36-year-old pregnant woman. She has two children, ages 15 and 13, from a previous marriage, and this is her first child from her second marriage. The client has indicated that her two older children seem very upset by her pregnancy and have been increasingly belligerent the closer she gets to delivery. What can the nurse say to support this family? A) "It may help to remind your older children that you will still make time for them and that you won't expect them be responsible for the baby unless they want to." B) "You could tell your older children that the stress and anxiety that comes with a new baby will help improve your family relationships." C) "They are probably just embarrassed because you are pregnant. They'll get over it once you have the baby." D) "Your older children probably just want to know what their new roles will be once the baby is born. You should tell them what their responsibilities will be in caring for the baby."
A
The nurse is caring for a client who has experienced fetal demise at 23 weeks' gestation and will have labor induced to deliver the fetus. The client's extended family insists on being present for the delivery. Which action is most appropriate for the nurse to take in this situation? A) Ask the client about her preferences regarding the family's request. B) Call security to escort the family out of the hospital. C) Speak with the nurse manager about supporting the family's wishes. D) Show the family to the waiting room.
A
The nurse is caring for a client who lost his job and is having a difficult time finding another job. The nurse recognizes that the client is grieving. Which pattern of behavior would be the nurse's priority concern? A) Alcohol or drug use B) Excessive sleeping C) Overeating D) Failing to exercise
A
The nurse is planning care for a group of clients who are experiencing grief. Which principle from accepted grief models should the nurse use to guide care? A) No clear timetables for grief exist, nor are there clear-cut stages of grief. B) There is strong research evidence indicating that these models are not useful for many dying clients. C) These models serve as clear and definitive predictors of grief behaviors. D) The Kübler-Ross model is primarily used to describe anticipatory grief.
A
The nurse is providing counseling to the family of a terminally ill client. The family has children of varying ages. Which statement regarding the reactions of children to death is appropriate for the nurse to include in the counseling session? A) "Older school-age children begin to understand that death is irreversible." B) "Adolescents tend to cope better with death than adults." C) "Preschool children view death as a spiritual release." D) "Toddlers are able to fully comprehend the ideas related to death."
A
The nurse is teaching childbirth exercises to a pregnant client with a history of back pain. Which is most appropriate for this client? A) Perform the pelvic rock exercise only in the standing position. B) Exercise in the supine position throughout the pregnancy. C) Perform the pelvic rock exercise while in the hands and knees position. D) Soak in a hot tub for approximately 30 minutes after exercise.
A
The staff nurse is planning for a client who is grieving the loss of a spouse. Which should the nurse identify as an appropriate independent nursing intervention? A) Teach the client about the grieving process B) Select an appropriate antidepressant C) Conduct complicated grief therapy (CGT) D) Provide chaplain services
A
Which symptom would the nurse recognize as being consistent with postpartum endometritis at 4 weeks postpartum? A) Foul-smelling lochia B) Bright red lochia C) Upper abdominal pain D) Bradycardia
A
The nurse is planning care for a client who had a cesarean birth 4 hours ago. Which actions should be included in this client's plan of care? Select all that apply. A) Encourage the use of breathing, relaxation, and distraction. B) Encourage deep breathing and coughing every 2 to 4 hours. C) Encourage to ambulate to the bathroom to void. D) Discourage leg exercises. E) Withhold all analgesics.
A B
The nurse is proving care to a 1-hour-old newborn who was born at 39 weeks' gestation. Which assessment data is cause for concern? Select all that apply. A) Respiratory rate of 82 breaths per minute B) Negative Babinski reflex C) Mean blood pressure of 52 mmHg D) Acrocyanosis E) Presence of soft heart murmur
A B
The nurse is preparing to assess a client whose spouse died several weeks ago. Which of the following symptoms is the nurse most likely to observe in the client as part of the classic grief response? Select all that apply. A) Weight loss B) Frequent headaches C) Difficulty sleeping D) Excessive energy E) Increased appetite
A B C
The nurse is providing postpartum care to a client from a different culture. What nursing actions are appropriate to include in the client's plan of care? Select all that apply. A) Assess for any assistance required during breastfeeding. B) Ask if there are any specific customs the client wants to follow. C) Assess for any specific foods or fluids to hasten recovery. D) Limit client visitors to the immediate family. E) Restrict interactions with the client.
A B C
The nurse is concerned that a client whose spouse died 2 years ago is experiencing complicated grief. Which interventions should the nurse consider when planning care for this client? Select all that apply. A) Monitoring for suicidal behavior B) Psychotherapy C) Substance abuse assessment D) Alcohol abuse assessment E) Hypnosis
A B C D
A client is hospitalized for suicidal ideations as a response to complicated grief. Which collaborative interventions can the nurse anticipate including in this client's care? Select all that apply. A) Social service consult B) Bereavement group C) Antidepressant medication D) Sleep medication E) Psychotherapy
A B C E
The nurse is caring for a client who is diagnosed with complicated grieving after the loss of a child. Which treatment approaches does the nurse anticipate being included in the collaborative plan of care for this client? Select all that apply. A) Antidepressants B) Electroconvulsive therapy C) Talk therapies D) Cognitive therapy E) Anger management
A C D
A pregnant client presents to the emergency department reporting that she has started labor and is certain the baby is coming "any minute now." After assessing and monitoring the client, the healthcare team determines that the client is in "false" labor, and the nurse prepares her for discharge. Which observations support the conclusion of false labor? Select all that apply. A) The contractions do not have a regular pattern. B) Her cervix has dilated 2 cm over the 2 hours of observation. C) The frequency and intensity of the contractions have stayed about the same. D) Walking seems to increase the strength of the contractions. E) The contractions are mostly in her abdomen.
A C E
A nurse is caring for the 1-hour-old newborn of a mother with diabetes mellitus. Which actions will the nurse include in the newborn's plan of care? Select all that apply. A) Assess blood glucose frequently. B) Assess for SGA. C) Assess for hyperthyroidism. D) Assess the newborn's temperature hourly. E) Assess for hyperbilirubinemia.
A E
Upon delivery of the newborn, which nursing intervention promotes parental attachment? A) Placing the newborn under the radiant warmer B) Placing the newborn on the bed next to the mother C) Placing the newborn on the maternal chest D) Taking the newborn to the nursery for the initial assessment
C
The nurse is instructing the parents who delivered their first child at 34 weeks' gestation. Which statements made by the parents indicate that additional teaching is needed? Select all that apply. A) "Tube feedings will be required because his stomach is small." B) "Breathing might be harder for our baby because he is early." C) "Our baby will be in an incubator to keep him warm." D) "The growth of our baby will be slower than if he were term." E) "Because he came early, he will not produce urine for 2 days."
A E
A client experienced the loss of a spouse due to chronic illness, the loss of a grandchild due to stillbirth, and the loss of a long-time family pet, all within a 6-week period. This individual is experiencing what type of loss? A) Caregiver loss B) Cumulative loss C) Compound loss D) Complicated loss
B
A nurse is caring for a premature infant with a central line. The otherwise healthy, growing infant suddenly develops apnea, bradycardia, and metabolic acidosis. Which is the most likely condition causing this change in health status? A) Hyperbilirubinemia B) Bacterial sepsis C) Hypoglycemia D) Intracranial hemorrhage
B
A nurse is caring for an older adult client who is experiencing grief after the recent loss of a spouse. What should the nurse anticipate with regard to the older adult's response to grief? A) Grief in an older adult initially presents differently than in a younger adult. B) Older adults may seem to experience the emotional aspects of grief more acutely than younger adults. C) Manifestations of grief in older adults are usually less severe than those observed in younger clients. D) Manifestations of grief in older adults are usually trust issues, suspecting once-close friends and family members of judging their pain or not understanding their emotions.
B
A nurse is planning care for a couple who has experienced a miscarriage. Which aspect of the grief response is essential for the nurse to anticipate? A) The grief experienced by fathers after perinatal loss appears similarly to the grief experienced by mothers after perinatal loss. B) Postpartum depression may occur in women who have experienced perinatal loss. C) Grief is typically less severe when the perinatal loss occurs before 20 weeks' gestation. D) Perinatal loss refers only to emotional changes that occur after perinatal loss.
B
A pregnant woman at 41 weeks' gestation has a Bishop score of 5. What does this score indicate? A) The cervix is favorable for a normal vaginal delivery. B) The cervix is unfavorable and induction of labor may be necessary. C) The cervix is unfavorable and a cesarean section may be necessary. D) The cervix is favorable and labor has been successfully induced.
B
An older adult client whose spouse died 6 months ago tells the nurse stories about the deceased spouse. When care has been completed, the client thanks the nurse for listening and states, "My children will not listen to these stories." From which type of intervention would this client most likely benefit? A) Antidepressant medication B) Referral to a support group C) Occupational therapy D) Referral to a social worker
B
Before a first-time mother is discharged from the hospital with her newborn, the nurse notices that the mother is taking directions on newborn care from her parents and in-laws. What stage of maternal role attainment is the new mother in? A) Anticipatory stage B) Formal stage C) Informal stage D) Personal stage
B
During a home care visit, an older adult client states to the nurse, "My wife died 3 years ago." Which action is a possible indicator that the client is experiencing complicated grief? A) The client tells the nurse that his wife was an awful cook and that he has eaten better meals since she died. B) The client says he hasn't seen the doctor since his wife died because the doctor's office reminds him of his wife. C) The client has an album of photographs of his wife open on the living room table. D) The client indicates that he sends his laundry out to be done because he doesn't know how the washer works.
B
During a postpartum examination of a client who delivered an 8-pound newborn 6 hours ago, the nurse assesses the following: fundus firm and at the umbilicus, and moderate lochia rubra with a steady trickle of blood noted from the vagina. Which assessment finding requires immediate follow-up? A) Moderate lochia rubra B) Steady trickle of blood C) Fundus at the umbilical level D) Firm fundus
B
The nurse is caring for a 15-year-old pregnant adolescent during the labor and delivery process. The client has no support person with her, and she plans to give up her baby for adoption. What nursing intervention can the nurse implement to facilitate the grieving process for this client? A) Encourage the client to avoid seeing and holding the baby. B) Encourage the client to see and hold the baby. C) Encourage the client to have the adoptive parents present for the birth. D) Encourage the client to sign the adoption papers as soon as possible after the birth.
B
The nurse is caring for a client on the unit who has just died. The client's adolescent daughter is very quiet, and the nurse attempts to talk with her. The adolescent remains silent, not wishing to talk about the loss. Which action by the nurse is appropriate to assist the adolescent? A) Ask the doctor to prescribe a sedative for the adolescent. B) Ask the adolescent if any friends are available to talk. C) Provide the adolescent with paper, pens, and pencils. D) Notifying the hospital chaplain to come talk with the adolescent.
B
The nurse is caring for a client who found a loved one who committed suicide. In addition to the normal grief process, the nurse recognizes the client may be at risk for what other complication? A) Seasonal affective disorder (SAD) B) Posttraumatic stress disorder (PTSD) C) Obsessive-compulsive disorder (OCD) D) Major depressive disorder (MDD)
B
The nurse is caring for a family whose 8-year-old son recently died. The remaining family members include the mother, father, and two young children. Which of the following questions would best help the nurse assess this family's level of functioning? A) "Have you returned to your normal schedule yet?" B) "How have you expressed your feelings about the loss?" C) "When do you think your grieving process will be complete?" D) "Have any of you experienced prior loss?"
B
The nurse is caring for a newborn boy who was circumcised an hour ago. Which is the priority nursing diagnosis for the newborn? A) Risk for Injury B) Risk for Infection C) Risk for Imbalanced Nutrition D) Risk for Ineffective Breathing Pattern
B
The nurse is preparing to provide an enteral feeding to a preterm infant. Which is the priority nursing action prior to administering the feeding? A) Weigh the current diaper. B) Measure abdominal girth. C) Weigh the baby. D) Measure pulse oximetry.
B
The nurse is providing care to a pregnant client who is experiencing ptyalism. Which will the nurse include in the plan of care for this client? A) Use a cool-mist vaporizer B) Suck on hard candy C) Avoid use of nasal sprays and decongestants D) Use low-sodium antacids
B
The nurse is providing discharge instructions for a healthy 37-year-old first-time mother and her newborn. What should the nurse include in her instructions for this mother and her spouse? A) Information related to contraception and sexually transmitted infections (STIs). B) A reminder that addition of a newborn will alter established routines. C) A referral to a group class that provides information on newborn care. D) A referral for follow-up care with healthcare providers other than the obstetrician.
B
The nurse will commonly need to work with all except which member of the healthcare team to provide care to the newborn? A) Audiology specialist B) Cardiac surgeon C) Lactation consultant D) Pediatrician
B
A client who recently learned of being pregnant tells the nurse that she stopped eating meat years ago and started eating fish daily because it is healthier. Which teaching points are appropriate for this client based on her current diet? Select all that apply. A) Avoid shrimp, salmon, and catfish because these have higher mercury levels. B) Eat up to 12 ounces a week of a variety of fish and shellfish. C) Do not eat more than 6 ounces per week of albacore tuna. D) Eat plenty of fish such as king mackerel while pregnant. E) Follow a complete vegetarian diet while pregnant as an alternative to eating fish.
B C
The nurse is instructing a new mother on how to care for the newborn's circumcision site. Which statements indicate that the nurse's education session was effective? Select all that apply. A) "I should not use petroleum jelly on the penis." B) "Every time I change the diaper I am to wash the area with warm water." C) "I should report any pus drainage or change in diaper wetness to the physician." D) "Swelling is expected." E) "I am to use soap and water to remove yellow tissue on the penis."
B C
The nurse is providing care to a client with a history of rheumatoid arthritis (RA) who is 5 months pregnant. Which nursing actions are appropriate when providing care to this client? Select all that apply. A) Telling the client there is an increased risk for preterm delivery because of salicylate therapy B) Monitoring the client for anemia due to salicylate therapy C) Suggesting the client begin supplemental pyridoxine D) Educating the client that medication therapy may be discontinued due to remission E) Teaching the client that RA may be contracted by the fetus during pregnancy
B D
When administering an intramuscular dose of vitamin K (phytonadione) to a newborn, which actions by the nurse are appropriate? Select all that apply. A) Using a 23-gauge 1/2-inch needle B) Cleaning the skin with an alcohol swab C) Preparing 5 mg of the medication for injection D) Using the middle third of the vastus lateralis muscle E) Washing the skin with soap and water
B D
A 16-year-old has just given birth, and she plans to keep and care for the baby. However, the nurse determines that the young mother has low self-esteem, and she does not appear to have adequate social support. The nurse should encourage adequate follow-up care for this young mother for what reason? A) She is at risk for postpartum hemorrhage. B) She is at risk for postpartum endometritis. C) She is at risk for postpartum depression. D) She is at risk for postpartum weight gain.
C
A client who is at 12 weeks' gestation is experiencing nausea, breast tenderness, and fatigue. She tells the nurse her husband is upset with her constant complaints. Which is the priority nursing diagnosis based on this data? A) Ineffective Breastfeeding B) Dysfunctional Family Processes C) Nausea D) Fatigue
C
During an assessment, the nurse notes the client in the fourth stage of labor is experiencing intense shaking and chills. Based on this data, which conclusion by the nurse is appropriate? A) This is evidence of incomplete expulsion of the placenta. B) The client has a full bladder. C) This is a normal reaction to the ending of the physical exertion of labor. D) The client has a fever from a postpartum infection.
C
The community nurse is developing a seminar to help children who have experienced a loss. Which information should the nurse include to help these children adapt? A) Explain that magical thinking helps with the pain. B) Remind the child that big children don't cry. C) Help create new memories. D) Pretend that the individual has not really gone.
C
The home health nurse is visiting an older client with a terminal illness for a routine medication check. The nurse determines that the client has declined since the last home visit. The nurse suggests that the client should be transported to the hospital; however, the family members state that they want the client to stay in the home. Which action by the nurse is most appropriate? A) Follow the decision of the family. B) Call for an ambulance to transport the client to a hospital. C) Ask the client's preference regarding transport to the hospital. D) Encourage the family to take the client to the hospital.
C
The nurse is assessing a premature newborn who is being cared for in the newborn intensive care unit (NICU). Which assessment finding indicates the newborn is experiencing respiratory distress? A) Acrocyanosis B) Respiratory rate of 58 breaths per minute C) Substernal and intercostal retractions D) Abdominal breathing
C
The nurse is caring for a client who has just died due to an intentional drug overdose. The client's partner is still in the room but is dry-eyed and exhibiting somber behavior. The nurse should recognize that the partner's behavior is most likely related to which of the following factors? A) The partner is waiting to grieve until the client's family can join him. B) The partner is seeking support from staff members on the unit. C) The partner anticipates that others will find the client's actions socially unacceptable. D) The partner is concerned that others may view him as weak if he shows too much emotion.
C
The nurse is caring for a grieving family who is from another culture and has different religious beliefs. The nurse is not familiar with the family's culture or religion. What should the nurse do to provide emotional support for this family? A) Encourage the family to go eat a meal and come back to the hospital later. B) Ask the physician to assess the family for ineffective coping. C) Ask the family how the nurse can meet the family's cultural needs. D) Refer the family to a group counseling session.
C
The nurse is caring for a pregnant client who has asthma. The client has a cold and has an exacerbation of asthma symptoms, including mild wheezing. To help avoid hypoxia-related complications in the fetus, which medication prescription does the nurse anticipate? A) IV corticosteroid (e.g., prednisone) B) Oral pseudoephedrine (e.g., Sudafed) C) Inhaled beta2-agonist (e.g., albuterol) D) Oral acetylsalicylic acid (e.g., aspirin)
C
The nurse is instructing a pregnant client on how the baby's condition is evaluated during labor. Which client statement indicates appropriate understanding of the information presented? A) "During labor, the nurse will verify that my contractions are strong but not too close together." B) "During labor, the nurse will look at the color and amount of bloody show that I have." C) "During labor, the nurse will assess the baby's heart rate with a Doppler ultrasound." D) "During labor, the nurse will regularly check my cervix by doing a pelvic exam."
C
The nurse is interviewing an older adult client whose spouse died 4 years ago. The client states, "I keep our home exactly the way it was the day my husband died. I still buy and prepare all his favorite foods, and I launder his dress shirts each week." The client begins to cry, explaining that caring for her husband was her sole purpose in life, so she sees no need to go on living if she can't carry out these activities. The client's comments are suggestive of which of the following conditions? A) Anticipatory grieving B) Self-care deficit in the area of feeding C) Complicated grieving D) Death anxiety
C
The nurse is planning for several women who are pregnant for the first time who are in the labor and delivery process. Which woman has the highest risk of labor and delivery complications? A) A healthy 38-year-old woman B) A 24-year-old woman with asthma C) A 36-year-old woman with diabetes D) A 31-year-old woman with hypertension
C
The nurse is providing care to a client in labor who experiences spontaneous rupture of membranes. The fetus is in the vertex position. The nurse notes that the amniotic fluid is meconium stained. Based on this data, which is the priority action by the nurse? A) Notifying the healthcare provider that birth is imminent B) Changing the client's position in bed C) Beginning continuous fetal heart rate monitoring D) Administering oxygen at 2 liters per minute
C
The nurse is providing care to the client during the second stage of labor. Which nursing action is appropriate? A) Assessing maternal temperature every 1-2 hours after amniotic membranes have ruptured B) Encouraging the client to void every 1-2 hours C) Assessing fetal heart rate every 5 minutes D) Administering antibiotics for a positive group beta strep
C
The nurse is providing discharge instructions for a first-time mother and her baby. Which statement is appropriate for the nurse to include in the teaching session? A) "Your baby's stools will change to a dark green color when your milk comes in." B) "Your baby may spit up frequently for the first few weeks." C) "Compress the bulb syringe before placing it in your baby's nose or mouth." D) "You can wipe away any green drainage that might form around the umbilical cord."
C
When palpating the fundus of a woman on her first day postpartum, the nurse finds that the woman's uterus is higher than expected and is deviated to the right. She is not having excessive uterine bleeding. Which is the priority nursing action for this client? A) Notify the client's midwife of this condition. B) Ask another nurse to assess the client to verify the findings. C) Ask the client to void and then reassess fundal height. D) Perform a straight catheterization on the client and then reassess fundal height.
C
Which intervention should the nurse perform to help the family grieve following the loss of an unborn child at 36 weeks' gestation? A) Remove all baby supplies from the mother's room. B) Refrain from talking about the baby. C) Facilitate and support the family viewing and holding the infant. D) Ask to have the mother moved off the postpartum floor.
C
Which clients should the nurse identify as being at risk for prenatal loss? Select all that apply. A) The woman who drinks one cup of coffee every morning B) The woman recovering from a gastrointestinal virus C) The unmarried 14-year-old girl living in the city D) The woman who lacks access to health and prenatal care E) The woman who had a healthy baby 6 months ago resulting from a healthy pregnancy
C D E
A client in the fourth stage of labor is experiencing perineal trauma. Which nursing diagnosis is the priority at this time? A) Health-Seeking Behaviors B) Fear C) Anxiety D) Acute Pain
D
A client tells the nurse that her boyfriend died 3 weeks ago. The client states that she has been unable to grieve openly because her boyfriend was married and no one knew of their relationship. The nurse recognizes that the client is experiencing which type of grief? A) External grief B) Chronic grief C) Abbreviated grieving D) Disenfranchised grieving
D
A nurse working in labor and delivery is planning care for a client who is arriving to the unit with a suspected perinatal loss. Which nursing intervention is most appropriate in this situation? A) Place the client in a room closest to the nurse's station to closely observe the client. B) Call the hospital chaplain to ensure the chaplain can be in the client's room when the client arrives. C) Call the local funeral home and notify them of the client's situation. D) Place the client in the room farthest from the other clients.
D
After giving birth to a preterm infant who is being cared for in the neonatal intensive care unit (NICU), a client says, "My baby doesn't seem real because she's in the hospital and I'm at home." What can the nurse do to promote parent-infant attachment? A) Limit visits to the intensive care unit so as not to disrupt care the baby needs. B) Explain that once the baby is discharged to home, she will have evidence that the baby is real. C) Have the mother visit when the baby is asleep or resting. D) Provide a picture of the infant including a footprint and current weight and length.
D
During the fourth stage of labor, a client's blood pressure is 110/60 mmHg, pulse 90, and the fundus is firm, midline, and halfway between the symphysis pubis and the umbilicus. Based on this data, which is the primary action by the nurse? A) Massage the fundus. B) Turn the client onto the left side. C) Place the bed in the Trendelenburg position. D) Continue to monitor.
D
The mother of a preterm infant tells the nurse that she was not looking forward to having a baby and now that the baby is sick, she feels worse. Which nursing diagnosis is appropriate based on this data? A) Parental Role Conflict B) Impaired Parenting C) Dysfunctional Family Processes D) Compromised Family Coping
D
The nulliparous client states, "I have been in labor for 4 hours and I am still only 2 cm dilated. Why is this happening? I feel like I should be ready to push by now." Which is the best response by the nurse? A) "When your perineal body thins out, your cervix will begin to dilate much faster than it is now." B) "The hormones that cause labor to begin are just getting to the levels that will change your cervix." C) "What did you expect? You've only had contractions for a few hours. Labor takes time." D) "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress."
D
The nurse conducting a 5-minute Apgar assessment on a newborn assigns the following ratings: Heart rate <100 beats per minute (1 point); slow, irregular respirations (1 point); some flexion of the extremities (1 point); a vigorous cry with flicking of the baby's foot (2 points); and a pink body with blue extremities (1 point). Based on this data, which nursing action is appropriate? A) Having the aide reassess the newborn's heart rate and respiratory rate when admitted to the nursery B) Swaddling the newborn to decrease the risk of increased energy expenditure C) Placing the newborn in the mother's arms and asking her to monitor her baby's breathing D) Repeating the assessment every 5 minutes for up to 20 minutes
D
The nurse is caring for an adolescent client who has just learned she is pregnant. Which assessment questions is most appropriate to determine the client's risk for perinatal loss? A) "At what age did you begin menstruating?" B) "When was your last menstrual period?" C) "Is this your first pregnancy?" D) "Do you use any substances such as drugs, alcohol, or tobacco products?"
D
The nurse is monitoring the intake and output for a preterm infant. Which action by the nurse indicates correct assessment technique when monitoring urine output? A) Document "unable to obtain" on the graphic sheet. B) Apply an external condom catheter. C) Insert an indwelling urinary catheter. D) Weigh diapers using the estimate that 1 mL = 1 gram of weight.
D
The nurse is providing care to a newborn born at 37 2/7 weeks' gestation. The newborn's weight is 1750 g (3 pounds, 10 ounces). What statement would the nurse use to describe these assessment findings? A) Preterm appropriate for gestational age B) Term appropriate for gestational age C) Preterm small for gestational age D) Term small for gestational age
D
The nurse is providing care to a newborn during the first 24 hours of life. Which is an abnormal finding? A) Respiratory rate of 58 breaths per minute B) Heart rate of 140 beats per minute C) Presence of meconium stool D) Yellowing of the skin
D
The nurse is providing care to a pregnant client and her spouse. The client requires an amniocentesis. Which client statement indicates appropriate understanding of the information presented? A) "The test has to be done before the 14th week of pregnancy." B) "If the test determines our baby has Down syndrome, we will not need to take childbirth classes." C) "It is not unusual for amniocentesis to misdiagnose a problem with the baby." D) "The results of the amniocentesis will take up to 2 weeks."
D
The nurse is reviewing exercises with a pregnant woman to help the client maintain physical fitness and appropriate weight gain throughout the pregnancy. After the teaching session, the client tells the nurse that she was taught never to reach over the head because this will harm the baby. Based on this data, which action by the nurse is appropriate? A) Provide dietary instruction instead to ensure the client does not gain excessive weight. B) Tell the client to just perform the exercises that don't require her to reach over her head. C) Provide alternative activities to do instead of exercise. D) Assure the client that reaching over the head will not harm the baby.
D
The nurse receives shift change report on infants born within the last 4 hours. Which newborn should the nurse assess first? A) Newborn born at 37 weeks' gestation. Respiratory rate of 45 breaths per minute. B) Term newborn, 2 hours old, who has not passed a meconium stool. C) Term newborn born 3 hours ago. Heart rate is 150 beats per minute. D) Term newborn born 1 hour ago who is exhibiting grunting respirations.
D
The nurse recognizes that the spouse of a terminally ill client has completed the grieving process, but the ill client is still alive. Because of this, the nurse may need to provide what interventions for the ill client? A) Interventions to prevent physical and spiritual distress of the spouse B) Interventions to prevent despair in other family members C) Interventions to prevent guilt in the client D) Interventions to prevent isolation and loneliness for the client
D
When planning the care for a preterm infant with ineffective thermoregulation, the nurse should include which intervention? A) Keep the baby's head uncovered. B) Rinse hands with cold water before providing care to the infant. C) Place incubator near a window or source of fresh air. D) Allow skin-to-skin contact with the mother to maintain warmth.
D
Which factor contributes to increased respiratory complications in the preterm infant? A) Increased constriction of blood vessels B) Decreased prostaglandin E levels C) Absence of muscular coat on pulmonary blood vessels D) Inadequate surfactant
D
Which pregnant client would have the greatest need for a nutritional assessment and individualized meal plan? A) A client who is lactose intolerant B) A client who is vegetarian C) A client who requires a Kosher diet D) A client with anorexia nervosa
D