Final Exam

A nurse is measuring a pregnant womans fundal height and finds to be dilated at 30 cm . The nurse interprets this to indicate that the client is at how many weeks?

30 weeks gestation

Assessment of a pregnant woman reveals that the presenting part of the fetus is at the level of the maternal ischial spine . The nurse documents this as which station?

0

A nurse is working with a group of women who are victims of intimate partner violence. The nurse focuses interventions on which area as the primary goal?

1 convincing them to leave the abuser soon 2 helping them cope with their life as it is 3 empowering them to regain control of their life 4 arresting the abuser so he or she cannot abuse again answer: 3

Which finding would the nurse expect to find in a client with endometriosis?

1 hot flashes 2 dyspareunia 3 fluid retention 4 fever answer: 2

Which measure would the nurse include in the teaching plan for a woman to reduce the risk of osteoporosis after menopause?

1 taking vitamin supplements 2 eating high-fiber, high-calorie foods 3 restricting fluid to 1,000 mL daily 4 participating in regular daily exercise answer: 4

A client is suspected of having endometrial cancer. The nurse would most likely prepare the client for which procedure to confirm the diagnosis?

1 transvaginal ultrasound 2 colposcopy 3 pap smear 4 endometrial biopsy answer: 4

In this weeks reading and in class, we discussed 8 newborn reflexes that are tested. Can you name 5 of them? (no partial credit, must get all correct)

1. Moro 2.Babinski 3. Rooting 4.Tonic Neck 5.Palmar Grasp 6.Planta Grasp 7.Stepping

Which of the following are the 5 factors affecting the labor process?

1. Passageway 2. Powers 3.Pyschological response 4. Position 5. Passanger

A new mother who is breast-feeding her newborn asks the nurse, "How will I know if my baby is drinking enough?" Which response by the nurse would be most appropriate?

1."If he seems content after feeding, that should be a sign." 2."Make sure he drinks at least 5 minutes on each breast." 3."He should wet between 6 to 12 diapers each day." 4."If his lips are moist, then he's okay." answer: (3) "He should wet between 6 to 12 diapers each day."

A nurse is conducting a class for pregnant women who are in their third trimester. The nurse is reviewing information about the emotional changes that occur in the postpartum period, including postpartum blues and postpartum depression. After reviewing information about postpartum blues, the group demonstrates understanding when they make which statement about this condition?

1."Postpartum blues is a long-term emotional disturbance." 2."Getting some outside help for housework can lessen feelings of being overwhelmed." 3."The mother loses contact with reality." 4."Extended psychotherapy is needed for treatment." answer: (2) "Getting some outside help for housework can lessen feelings of being overwhelmed."

A nurse is teaching postpartum client and her partner about caring for their newborn's umbilical cord site. Which statement by the parents indicates a need for additional teaching?

1."We can put him in the tub to bathe him once the cord falls off and is healed." 2."The cord stump should change from brown to yellow." 3."Exposing the stump to the air helps it to dry". 4."We need to call the primary care provider if we notice a funny odor." answer: the cord stump should change from brown to yellow

A primiparous client who is bottle feeding her neonate at 12 hrs after birth asks the nurse, "When will my menstrual cycle return?" Which response by the nurse would be most appropriate?

1."Your menstrual cycle will return i 3-4 weeks." 2."It will probably be 6-10 weeks before it starts again." 3."You can expect your menses to start in 12-14 weeks." 4."Your menses will return in 16-18 weeks." answer: "It will probably be 6-10 weeks before it starts again."

A pregnant woman is diagnosed with chlamydia and asks the nurse "How will this infection affect my baby and pregnancy?" Which responses by the nurse are accurate? SELECT ALL THAT APPLY

1."Your newborn can be infected during birth." 2."Your newborn may have eye infections from this infection." 3."Your membranes may rupture earlier than normal." 4."Your newborn is protected from this infection." 5."It will not have any effect on your pregnancy ans: 1,2,3

A client who is breast-feeding her newborn tells the nurse, I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now? Which response by the nurse would be most appropriate?

1."Your uterus is still shrinking in size; that's why you're feeling this pain." 2."Let me check your vaginal discharge just to make sure everything is fine." 3."Your body is responding to the events of labor, just like after a tough workout." 4."The baby's sucking releases a hormone that causes the uterus to contract." answer:"Your uterus is still shrinking in size; that's why you're feeling this pain."

The nurse is assessing a postpartum client's lochia and finds that there is about a 4-inch stain on the perineal pad. The nurse interprets this finding as indicating which amount of blood loss?

1.10ml 2.10 to 25 mL 3.25 to 50 mL 4.over 50 mL

Assessment of a newborn's head circumference reveals that it is 34 cm. The nurse would suspect that this newborn's chest circumference would be:

1.30 cm. 2.32 cm. 3.34cm. 4.36cm. answer: (2) 32 cm.

While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning bluish. What would the nurse do first?

1.Alert the primary care provider stat, and turn the newborn to her right side. 2.Administer oxygen via facial mask by positive pressure. 3.Administer oxygen via facial mask by positive pressure. 4.Aspirate the oral and nasal pharynx with a bulb syringe. answer: (4) Aspirate the oral and nasal pharynx with a bulb syringe.

In your reading and in class, we discussed the APGAR scoring assessment tool. The APGAR tests 5 areas to determine the newborns adaptation to life outside the uterus. What are the 5 areas? (must list all 5 for full credit)

1.Appearance 2.Pulse/ HR 3.Tone 4.Respiration 5.Grimmace

A nurse is assessing a newborn's reflexes. The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot to elicit which reflex?

1.Babinski 2.tonic neck 3.stepping 4.plantar grasp answer: (1)Babinski

After teaching a group of students about the different methods for contraception, the instructor determines that the teaching was successful when the students identify which contraceptive methods as mechanical barrier methods? SELECT ALL THAT APPLY

1.Condom 2.Cervical Cap 3.Diaphram 4.Cervical Ring 5.Cervical Sponge answer:1,2,3,5

Which method would be most effective in evaluating the parents' understanding about their newborn's care?

1.Demonstrate all infant care procedures. 2.Allow the parents to state the steps of the care. 3.Observe the parents performing the procedures. 4.Routinely assess the newborn for cleanliness. answer: (3) Observe the parents performing the procedures.

A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 66 beats per minute. Which of these actions should the nurse take?

1.Document the finding, as it is a normal finding at this time. 2.Contact the primary care provider, as it indicates early DIC. 3.Contact the primary care provider, as it is a first sign of postpartum eclampsia. 4.Obtain an order for a CBC, as it suggests postpartum anemia. answer: Document the finding, as it is a normal finding at this time.

A 19-year old with multiple sex partners is being counseled about the hepatitis B vaccination. During the counseling sessions, which of the following should the nurse advise the client to receive?

1.Hepatitis B immune globulin before receiving the vaccine 2.Vaccine booster every 10 years 3.Complete series of three intramuscular injections 4.Vaccine as soon as she becomes 21 answer:3

Assessment of a newborn reveals a heart rate of 180 beats/minute. To determine whether this finding is a common variation rather than a sign of distress, what else does the nurse need to know?

1.How many hours old is this newborn? 2.How long ago did this newborn eat? 3.What was the newborn's birthweight? 4.Is acrocyanosis present? answer: How many hours old is this newborn?

A client has been diagnosed with pubic lice. Which of the following signs/symptoms would the nurse expect to see?

1.Macular rash on the labia 2.Pruritus 3.Hyperthermia 4.Foul-smelling discharge answer: Pruritis

A neonate born addicted to cocaine is now being treated with medication for acute neonatal abstinence syndrome. Which medication will be ordered to relieve withdrawal symptoms?

1.Meperidine 2.Adrenalin 3.Naloxone 4.Morphine sulphate answer: (4) Morphine sulphate

Which approach would be most appropriate when counseling a woman who is a suspected victim of violence?

1.Offer her a pamphlet about the local battered women's shelter. 2.Call her at home to ask her some questions about her marriage. 3.Wait until she comes in a few more times to make a better assessment. 4.Ask, "Have you ever been physically hurt by your partner?" answer: 4

A client who has just given birth to a healthy newborn required an episiotomy. Which action would the nurse implement immediately after birth to decrease the client's pain from the procedure?

1.Offer warm blankets. 2.Encourage the woman to void. 3.Apply an ice pack to the site. 4.Offer a warm sits bath. answer: (3) Apply an ice pack to the site.

A 33 weeks' gestation neonate is being assessed for necrotizing enterocolitis (NEC). Which nursing action would the nurse implement? Select all that apply.

1.Perform hemoccult tests on stools. 2.Monitor abdominal girth. 3.Measure gastric residual before feeds. 4.Assess bowel sounds before each feed. 5..Assess urine output. answer: 1, 2,3 ,4

A nurse is conducting an orientation program for a group of newly hired nurses. As part of the program, the nurse is reviewing the issue of informed consent. The nurse determines that the teaching was effective when the group identifies which situation as a violation of informed consent?

1.Performing a procedure on a 15-year-old without parental consent 2.Serving as a witness to the signature process on an operative permit 3.Asking whether the client understands what she is signing following receiving education 4.Getting verbal consent over the phone for an emergency procedure from the spouse of a uncons answer: 1

The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal?

1.Prevent cold stress. 2.Increase surfactant levels in the lungs. 3.Promote respiratory stability. 4.Decrease the serum bilirubin level. answer: Decrease the serum bilirubin level.

The nurse administers vitamin K intramuscularly to the newborn based on which rationale?

1.Stop Rh sensitization. 2.Increase erythropoiesis. 3.Enhance bilirubin breakdown. 4.Promote blood clotting. answer: (4) Promote blood clotting.

A nurse is providing teaching to a new mother about her newborn's nutritional needs. Which suggestions would the nurse most likely include in the teaching? Select all that apply.

1.Supplement with iron if the woman is breast-feeding. 2.Provide supplemental water intake with feedings. 3.Feed the newborn every 2 to 4 hours during the day. 4.Burp the newborn frequently throughout each feeding. 5.Use feeding time for promoting closeness. answer: 3,4,5

The nurse is teaching a client regarding the treatment of pubic lice. Which of the following should be included in the teaching session?

1.The antibiotics should be taken for a full 10 days 2.All clothing should be pretreated with bleach before wearing 3.Shampoo should be applied for at least 2 hours before rinsing 4.The pubic hair should be combed after shampoo is removed answer: 4

A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information would the nurse integrate into the explanation to support this description?

1.The cardiac murmur heard at birth disappears by 48 hours of age. 2.Pulmonary vascular resistance (PVR) is decreased as lungs begin to function. 3.Heart rate remains elevated after the first few moments of birth. 4.Breath sounds will have rhonchi for at least the first day of life as fluid is absorbed. answer: (2) Pulmonary vascular resistance (PVR) is decreased as lungs begin to function.

A client with genital herpes simplex infection asks the nurse, Will I ever be cured of this infection? Which response by the nurse would be most appropriate?

1.There is a new vaccine available that prevents the infection from returning. 2.All you need is a dose of penicillin and the infection will be gone. 3.There is no cure, but drug therapy helps to reduce symptoms and recurrences. 4.Once you have the infection, you develop an immunity to it answer: 3

A new mother is changing the diaper of her 12-hour-old newborn and asks why the stool is black and sticky. Which response by the nurse would be most appropriate?

1.You probably took iron during your pregnancy and that is what causes this type of stool. 2.This is meconium stool and is normal for a newborn. 3.I'll take a sample and check it for possible bleeding. 4.This is unusual, and I need to report this to your pediatrician. answer:(2) This is meconium stool and is normal for a newborn.

When developing a teaching plan for a couple who are considering contraception options, the nurse would include which statement?

1.You should select one that is considered to be 100% effective. 2.The best one is the one that is the least expensive and most convenient. 3.A good contraceptive doesn't require a primary care provider's prescription. 4.The best contraceptive is one that you will use correctly and consistently answer: The best contraceptive is one that you will use correctly and consistently.

A nurse is preparing a presentation for a group of community nurses about benign and malignant breast masses. The nurses demonstrate understanding when they identify which indication of a benign breast mass. SELECT ALL THAT APPLY

1.absence of pain 2.unilateral location 3.firm consistency 4.absence of dimpling 5.fixed to the chest wall firm consistinency , absence of dimpling

A client with trichomoniasis is to receive metronidazole. What should the nurse instruct the client to avoid while taking this drug?

1.alcohol 2.nicotine 3.chocolate 4.caffeine answer: alcohol

When developing the plan of care for a woman who has had an abdominal hysterectomy, the nurse would identify which action as contraindicated?

1.ambulating the client 2.massaging the client's legs 3.applying elasticized stockings 4.encouraging range-of-motion exercises answer: 2

When a nurse suspects that a client may have been abused, the first action should be to:

1.ask the client about the injuries and if they are related to abuse. 2.encourage the client to leave the batterer immediately. 3.set up an appointment with a domestic violence counselor. 4.ask the suspected abuser about the victim's injuries answer: 1.ask the client about the injuries and if they are related to abuse.

When a nurse suspects that a client may have been abused, the first action should be to:

1.ask the client about the injuries and if they are related to abuse. 2.set up an appointment with a domestic violence counselor. 3.ask the suspected abuser about the victim's injuries. 4.ask the victim to call the police answer: 1

The nurse is providing an in-service education program to a group of home health care nurses who provide care to postpartum women. After teaching the group about the process of involution, the nurse determines that additional teaching is needed when the group identifies which process as being involved?

1.catabolism 2.muscle fiber contraction 3.epithelial regeneration 4.vasodilation answer: (4) vasodilation

When discussing contraceptive options, the nurse would recommend which option as being the most reliable?

1.coitus interruptus 2.lactationlactational amenorrheal method (LAM) 3.natural family planning 4.intrauterine system answer: 4

When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation?

1.deep red, fleshy-smelling 2.voiding of 350 cc 3.blood pressure 90/50 mm Hg 4.profuse sweating answer: (3) blood pressure 90/50 mm Hg

A client is diagnosed with uterine fibroids. When reviewing the client's health history, the nurse would identify which finding as associated with the client's condition?

1.diarrhea 2.chronic pelvic pain 3.amenorrhea 4.upper back pain answer: 2

A nurse is preparing a teaching plan for victims who are recovering from abusive situations. The nurse would focus the teaching on ways to:

1.enhance their personal appearance and hairstyle. 2.develop their creativity and work ethic. 3.improve their communication skills and assertiveness. 4.plan more nutritious meals to improve their own health. answer: 3..improve their communication skills and assertiveness.

The nurse dries the neonate thoroughly and promptly changes wet linens. The nurse does so to minimize heat loss via which mechanism?

1.evaporation 2.conduction 3.convection 4.radiation answer: (1) evaporation

A postpartum client has a fourth-degree perineal laceration. The nurse would expect which medication to be ordered?

1.ferrous sulfate 2.methylergonovine 3.docusate 4.bromocriptine answer: (3) docusate

A woman comes to the clinic. Assessment reveals a firm, rubbery, movable mass in the upper outer quadrant of the left breast. The edges of the mass are clearly delineated. The nurse interprets these findings as suggestive of which disorder?

1.fibrocystic breast disorder 2.duct ectasia 3.intraductal papilloma 4.fibroadenoma answer: 4

A newborn is scheduled to undergo a screening test for phenylketonuria (PKU). The nurse prepares to obtain the blood sample from the newborn's:

1.finger. 2.heel 3.scalp vein 4.umbilical vein. answer: (2) heel

A nurse is observing a postpartum woman and her partner interact with their newborn. The nurse determines that the parents are developing parental attachment with their newborn when they demonstrate which behavior? Select all that apply.

1.frequently ask for the newborn to be taken from the room 2.identify common features between themselves and the newborn refer to the newborn as having a monkey-face 3.make direct eye contact with the newborn 4.refrain from checking out the newborn's features answer: 2,3

The nurse observes the stool of a newborn who has begun to breast-feed. Which finding would the nurse expect?

1.greenish black, tarry stool 2.yellowish-brown, seedy stool 3.yellow-gold, stringy stool 4.yellowish-green, pasty stool answer: (2) yellowish-brown, seedy stool

The nurse institutes measure to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they:

1.have a smaller body surface compared to body mass. 2.lose more body heat when they sweat than adults. 3.have an abundant amount of subcutaneous fat all over. 4.are unable to shiver effectively to increase heat production. answer: (4) are unable to shiver effectively to increase heat production.

When teaching new parents about the sensory capabilities of their newborn, which sense would the nurse identify as being the least mature?

1.hearing 2.touch 3.taste 4.vision answer: vision

A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for a postpartum infection based on which information? Select all that apply.

1.history of diabetes labor of 12 hours 2.rupture of membranes for 16 hours 3.hemoglobin level 10 mg/dL 4.placenta requiring manual extraction answer: 1,3,4

A nurse teaches a postpartum woman about her risk for thromboembolism. The nurse determines that additional teaching is required when the woman identifies which as a factor that increases her risk?

1.increase in clotting factors 2.vessel damage 3.immobility 4.increase in red blood cell production answer: (4) increase in red blood cell production

Which finding would alert the nurse to suspect that a newborn has developed NEC?

1.irritability 2.sunken abdomen 3.clay-colored stools 4.bilious vomiting answer: (4) bilious vomiting

The nurse prepares to administer a gavage feeding for a newborn with transient tachypnea based on the understanding that this type of feeding is necessary because:

1.lactase enzymatic activity is not adequate. 2.oxygen demands need to be reduced. 3.renal solute lead must be considered. 4.hyperbilirubinemia is likely to develop. answer: (2) oxygen demands need to be reduced.

A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem?

1.lochia rubra with a fleshy odor 2.respiratory rate of 16 breaths per minute 3.temperature of 101° F (38.3° C) 4.pain rating of 2 on a scale from 0 to 10 answer: temperature of 101° F (38.3° C)

During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as:

1.milia. 2.Mongolian spots. 3.stork bites. 4.birth trauma. answer: (2) mongolian spots

While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as:

1.molding. 2.microcephaly. 3.caput succedaneum. 4.cephalhematoma. answer: caput succedaneum.

Which factor in a client's history would alert the nurse to an increased risk for postpartum hemorrhage?

1.multiparity, age of mother, operative delivery 2.size of placenta, small baby, operative delivery 3.uterine atony, placenta previa, operative procedures 4.prematurity, infection, length of labor answer: 3 uterine atony, placenta previa, operative procedures

After teaching a group of young women how to reduce their risk for ovarian cancer, the nurse determines that additional teaching is needed when the group identifies which element?

1.oral contraceptives 2.pregnancy 3.breast-feeding 4.feminine hygiene spray answer: feminine hygiene spray

A nurse has completed the assessment of a client. The nurse suspects that the client may have a malignant breast mass based on which finding?

1.painful lump 2.absence of dimpling 3.regularly shaped mass 4.nipple retraction answer: nipple retraction

A new mother reports that her newborn often spits up after feeding. Assessment reveals regurgitation. The nurse responds integrating understanding that this most likely is due to which factor?

1.placing the newborn prone after feeding 2.limited ability of digestive enzymes 3.underdeveloped pyloric sphincter 4.relaxed cardiac sphincter answer: 4

A nurse is teaching a new mother about breast-feeding. The nurse determines that the teaching was successful when the woman identifies which hormone as responsible for milk let-down?

1.prolactin 2.estrogen 3.oxytocin 4.progesterone answer: (3) oxytocin

A nurse is preparing a class for a group of women at a family planning clinic about contraceptives. When describing the health benefits of oral contraceptives, which benefits would the nurse most likely include? SELECT ALL THAT APPLY

1.protection against pelvic inflammatory disease 2.reduced risk for endometrial cancer 3.decreased risk for depression 4.reduced risk for migraine headaches 5.improvement in acne answer: 1,2,5

A client is diagnosed with an enterocele. The nurse interprets this condition as:

1.protrusion of the posterior bladder wall downward through the anterior vaginal wall. 2.sagging of the rectum with pressure exerted against the posterior vaginal wall. 3.bulging of the small intestine through the posterior vaginal wall. 4.descent of the uterus through the pelvic floor into the vagina answer: 3.bulging of the small intestine through the posterior vaginal wall.

A newborn is experiencing cold stress. Which findings would the nurse expect to assess? Select all that apply.

1.respiratory distress 2.decreased oxygen needs 3.hypoglycemia 4.metabolic alkalosis 5.jaundice answer: 1,35

A nurse is developing a teaching plan for a postpartum woman who is breast-feeding about sexuality and contraception. Which information would the nurse most likely include? Select all that apply.

1.resumption of sexual intercourse about two weeks after delivery 2.possible experience of fluctuations in sexual interest 3.use of a water-based lubricant to ease vaginal discomfort use of combined hormonal contraceptives for the first three weeks 4.possibility of increased breast sensitivity during sexual activity answer: 2,3,4

A postpartum client comes to the clinic for her 6-week postpartum check-up. When assessing the client's cervix, the nurse would expect the external cervical os to appear:

1.shapeless. 2.circular 3.triangular 4.slit-like answer: (4) slit-like

Assessment of a newborn reveals uneven gluteal (buttocks) skin creases and a clunk when Ortolani maneuver is performed. What would the nurse suspect?

1.slipping of the periosteal joint 2.developmental hip dysplasia 3.normal newborn variation 4.overriding of the pelvic bone answer : (2) developmental hip dysplasia

A nurse is assessing a newborn. Which finding would alert the nurse to the possibility of respiratory distress in a newborn?

1.symmetrical chest movements 2.periodic breathing 3.respirations of 40 breaths/minute 4.sternal retractions answer: (4) sternal retractions

When assessing a newborn's reflexes, the nurse strokes the newborn's cheek, and the newborn turns toward the side that was stroked and begins sucking. The nurse documents which reflex as being positive?

1.tonic neck reflex 2.palmar grasp reflex 3.rooting reflex 4.Moro reflex answer: (3) rooting reflex

Assessment of a female client reveals a thick, white vaginal discharge. She also reports intense itching and dyspareunia. Based on these findings, the nurse would suspect that the client has:

1.trichomoniasis. 2.bacterial vaginosis. 3.candidiasis. 4.genital herpes simplex answer: 3

A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpates the client's fundus. Which finding would the nurse identify as expected?

1.two fingerbreadths above the umbilicus 2.at the level of the umbilicus 3.two fingerbreadths below the umbilicus 4.four fingerbreadths below the umbilicus answer:(2) at the level of the umbilicus

A client asks the nurse at a prenatal class about acquired disorders. The nurse correctly responds that an acquired disorder:

1.typically occurs at or soon after birth. 2.may result from problems experienced by the woman after her pregnancy. 3.can be defined as structural or functional or metabolic abnormalities at birth. 4.is very complex, involving many genes and gene products. answer: (1) typically occurs at or soon after birth.

A 58-year-old client comes to the clinic for evaluation. After obtaining the client's history, the nurse suspects endometrial cancer. Which information would lead the nurse to suspicion?

1.use of oral contraceptives between ages 18 and 25 2.onset of painless, red postmenopausal bleeding 3.menopause occurring at age 46 4.use of intrauterine device for 3 years answer: 2

Assessment of a newborn reveals transient tachypnea. The nurse reviews the newborn's medical record. Which factor would the nurse most likely identify as a risk for this condition?

1.vaginal birth 2.shortened labor 3.central nervous system depressant during labor 4.maternal hypertension answer: (3) central nervous system depressant during labor

Which finding would the nurse expect in a client with bacterial vaginosis?

1.vaginal pH of 3 2.fish-like odor of discharge 3.yellowish-green discharge 4.cervical bleeding on contact answer: 2

Based on maternal history of alcohol addiction, a neonate in the newborn nursery is being assessed for signs of fetal alcohol syndrome. What findings would confirm the diagnosis? Select all that apply.

1.webbed neck 2.microcephaly 3.small for gestational age 4.tremors answers: 2,3,4

A woman who has undergone a right-sided modified-radical mastectomy returns from surgery. Which nursing intervention would be most appropriate for the nurse to include in the client's plan of care at this time?

1Ask the client how she feels about having her breast removed. 2Attach a sign above her bed to have BP, IV lines, and lab work in her right arm. 3 Encourage her to turn, cough, and deep breathe at frequent intervals. 4 Position her right arm below heart leve answer: 3

Which information would the nurse include when teaching a new mother about the difference between pathologic and physiologic jaundice?

1Physiologic jaundice results in kernicterus. 2.Pathologic jaundice appears within 24 hours after birth. 3.Both are treated with exchange transfusions of maternal O- blood. 4.Physiologic jaundice requires transfer to the NICU. answer: Pathologic jaundice appears within 24 hours after birth.

A woman comes to the clinic and asks the nurse about when she should have her first mammogram. The woman is at low risk and has no family history of breast cancer. Using the recommendations of the American Cancer Society, the nurse would suggest the woman have her first mammogram at which age?

30 years 35 years 40 years 45 years answer:40 years

A primiparous client is being seen in the clinic for her first prenatal visit. It is determined that she is 11 weeks pregnant. The nurse develops a teaching plan to educate the client about what she will most likely experience during this period. Which of the following would the nurse include?

A) Ankle edema B) Urinary frequency C) Backache D) Hemorrhoids answer : Urinary Frequency

The nurse encourages a female client with human papillomavirus (HPV) to receive continued follow-up care because she is at risk for:

infertility. dyspareunia. cervical cancer. dysmenorrhea. Answer; Cervical Cancer

As the nurse is explaining the difference between true and false labor to her childbirth class, she states that the major difference is

Progressive cervical changes in true labor

A nurse is assessing a postpartum client who appears very pale and states that she is bleeding heavily. What would the nurse do first?

Assess the fundus and ask her about her voiding status

Which of the following is NOT a discomfort experienced by a pregnant client in the first trimester?

Backache

Which compound would the nurse have readily avaiable from a client who is receiveing magnesium sulfate to treat severe preecelampsia?

Calcium gluconate

In class and in your reading, you learned about cervical motion tenderness which is a sign of PID. What is the other term or "catch word" for cervical motion tenderness?

Chandelier's Sign

Which assessment finding would lead a nurse to suspect that he pateint had abruptio placenta?

Dark red vaginal bleeding

A gravid patient,G3P2 was examined 5 minutes ago. Her cervx was 8 cm dilated and 90% effaced. She now states that she needs to move her bowels. Which of the following actions should the nurse perform first?

Evaluate the progress of labor

At the end of the second stage of labor, the nurse would expect which of the following to have occured?

Fetus is born and on mothers chest

A group of nurses are preparing a program about rape and sexual assault for a community health center. Which information would the nurses include as being most accurate? SELECT ALL THAT APPLY

Few women falsely cry "rape." A rape victim feels vulnerable and betrayed afterwards. Medication and counseling can help a rape victim cope

Which of the following are probably signs and symptoms of pregnancy? SATA

Godells sign Braxton hicks contractions Hegars sign postivie pregancy test

The nurse is assessing a client who states, " I think im in labor" which of the following findings would positively confirm the clients belief?

Her cervix has dilated from 2cm to 4cm

A woman is noted to have multiple soft warts on her perineum and rectal areas. The nurse suspects that this client is infected with which of the following sexually transmitted infections?

Human papillomavirus (HPV) Human immunodeficiency virus (HIV) Syphilis Trichomomniasis answer: HPV

The nurse notices a prolapsed cord. Which of the following positions would relieve a prolapsed cord?

Knee-chest

A woman had a baby by normal spontanous delivery 10 minutes ago. The nurse notes that a gush of blood was just expelled from the vagina and the umbillical chord lengthened. What should the nurse conclude?

The women is about the deliver the placenta

The nurse is assessing the fetal pattern of a client in active labor and notes a late deceleration on the monitor strip. Which nursing actions are most appropriate? SELECT ALL THAT APPLY

Turn the client on her side Administer oxygen via face mask Place the mother in a supine position Document the findings and continue to monitor the fetal pattern Increase the rate of the IV oxytocin infusion answer: 1,2

The nurse is assesing a woman who is receiving misoprostol to ripen her cervix and induce labor. Which of the following is an advance effect of misoprostol ?

Uterine Hyperstimulation

In lecture, you learned the mneumonic VEAL CHOP. What does each letter stand for?

V=Variable E-Early Decels A-Accelerations Are Ok L-Late Decels C-Cord Compression H - Head Compression O - OK P - Placental Insufficiency

Which action is a priority when caring for a woman during the fourth stage of labor?

assesing the uterine fundus

During a vaginal exam, the nurse notes that the cervix is bluish/ purple in color. The nurse documents this finding as

chadwick signs

A woman gives birth to a healthy newborn. As part of the newborn's care, the nurse instills erythromycin ophthalmic ointment as a preventive measure related to which STI?

genital herpes hepatitis B syphilis gonorrhea answer: gonnorhea

A postmenopausal woman with uterine prolapse is being fitted with a pessary. Which of the following is NOT a side effect of a pessary?

increased vaginal discharge urinary tract infections vaginitis constipation answer: constipation

During a clinical breast examination, the nurse palpates a well-defined, firm, mobile lump in a 60-year-old woman's left breast. The nurse notifies the primary care provider. What would the nurse anticipate the care provider to order next?

mammogram hormone receptor status fine-needle aspiration genetic testing for BRC Mammogram

After discussing various methods of contraception with a client and her partner, the nurse determines that the teaching was successful when they identify which contraceptive method as providing protection against sexually transmitted infections (STIs)?

oral contraceptives tubal ligation condoms intrauterine system answer: condoms

A client comes to the clinic with abdominal pain. Based on her history the nurse suspects endometriosis. The nurse expects to prepare the client for which evaluatory method to confirm this suspicion?

pelvic examination transvaginal ultrasound laparoscopy hysterosalpingogram answer: Laparoscopy

A womens amniotic fluid is noted to be cloudy. The nurse notes this finding as

possible infection

Which information on a clients hx would the nurse note as contributing to the clients risk for ectopic pregnancy ?

reccruent pelvic infections

A client comes to the clinic for an evaluation. After assessing the client, the nurse suspects that the client may be experiencing uterine prolapse. Which finding would the nurse most likely report when notifying the primary care provider about the suspicion? SELECT ALL THAT APPLY

urge to defecate nocturnal urinary frequency abdominal pressure dyspareunia

Which of the following is NOT a sign of impending labor?

weight gain