Maternity

Courtney, a 34-year-old suspects that she is pregnant. An immunoassay test is performed to determine if she is pregnant. Which of the following statements is true about the test? A) Highly accurate within 8-10 days after conception B) Similar to the over-the-counter self administered pregnancy tests C) Used with blood specimen D) Used with a urine specimen only

ANSWER: A Explanation: - All serology pregnancy tests are designed to detect human chorionic gonadotropin (hCG), which is a glycoprotein hormone secreted by the developing placenta shortly after fertilization. In normal pregnancy, the hCG hormone can be found in detectable amounts in serum and urine of pregnant women 7-10 days following fertilization - The appearance of hCG in urine soon after conception and its subsequent rise in concentration during early gestational growth make it an excellent marker for the early detection of pregnancy - Random urine specimens are appropriate for hCG testing, but the first morning urine is optimal because it generally contains the highest concentration of hCG

The patient with mastitis asks the nurse if her infant will be infected if she continues to breastfeed. Which of the following is the appropriate response by the nurse? A) Continue breastfeeding because the bacteria is localized in the breast tissue and will not enter the breast milk B) The infant received immunity through the breast milk and will not be infected C) The infant will need to be started on antibiotic therapy D) Yes, your infant will be infected and you have to stop breastfeeding

ANSWER: A Explanation: - Breastfeeding is continued because frequent emptying will help prevent growth of bacteria. Complete emptying of breasts prevents stasis of milk and engorgement. This aids in reducing the risk of further infection and pain - The organism causing the infection usually enters through cracked or fissured nipples. The bacteria remain localized in the breast tissue and will not enter the breast milk - Do not discontinue breastfeeding unless breast infection is untreated and forms an abscess. If an abscess forms, breastfeeding is discontinued. However, the woman is encouraged to continue to pump breast milk until the abscess has resolved - The woman, not the infant, will be placed on a broad spectrum antibiotic - Breastfeeding has major physiologic advantages for the infant. Breast milk contains secretory immunoglobulin A, providing the infant with additional immunity

A newborn has just undergone PlastiBell circumcision. The nurse has spoken with the parents about post circumcision care to avoid complications. What should she do next to minimize potential problems? A) Check the infant for bleeding every 15 minutes for the first hour B) Document if the infant has voided after the procedure C) Observe the tenderness, redness or if the baby cries D) Teach the parents to keep the area clean and covered with petroleum

ANSWER: A Explanation: - Complications that can occur after circumcision include hemorrhage, infection, and urethral fistula formation. To keep the risk to a minimum, the first priority of the nurse is to check the infant for bleeding every 15 minutes for the first hour after the procedure - Secondly, it is also important to document if the infant has voided after circumcision - For the first 3 days, parents should be taught how to keep the area clean and covered until the healing is complete. Alert them to check often the area for any signs of redness, tenderness, constant crying from pain, or having foul odor - Normally, circumcision sites appear red but never have a strong odor or discharge. A film of yellowish mucus often covers the glans by the second day after surgery - Petroleum jelly should be applied after circumcision, except when a PlastiBell is used

A nurse is caring for a patient with gestational diabetes that will require glucose monitoring at home. The nurse should begin discharge planning: A) On admission to the hospital B) Upon discharge to home C) When the patient is ready D) When the patient requests information

ANSWER: A Explanation: - Discharge planning and instruction should begin the moment the patient is admitted to the hospital - In order to plan for discharge, the nurse should begin collecting information about the patient's support systems, home environment, and finances

A patient was recently discovered to have an ectopic pregnancy. The nurse should tell the patient: A) Ectopic pregnancy can be either medically or surgically treated B) If she must have a fallopian tube removed, she will be sterile afterward C) Most ectopic pregnancies go to completion, although the newborn is usually small D) She will have a continous nagging pain through the rest of her pregnancy

ANSWER: A Explanation: - Ectopic pregnancies can be managed either surgically or medically. A ruptured ectopic pregnancy requires surgery to repair or cut the affected fallopian tube. If the ectopic pregnancy is unruptured, medical intervention is done. Physician orders oral administration of Methotrexate followed by leucovorin. Methotrexate, a folic acid antagonist chemotherapeutic agent, attacks and destroys fast-growing cells - An ectopic pregnancy is one in which implantation occurs outside the uterine cavity. Immediately after the union of ovum and spermatozoon, the zygote cannot travel the length of the tube. It implants into the lining of the tube instead of the uterine wall - Ectopic pregnancies are rarely viable - As the fetus grows in the fallopian tube, there is a tendency to rupture. If a tube is removed, the woman is theoretically only 50% fertile, because every other month, when she ovulates from the ovary next to the removed tube, sperm cannot reach the ovum on that side

A premature neonate is experiencing severe respiratory distress in the delivery room. Once bag/mask ventilation and oxygen are provided, the condition of the infant deteriorates further. The abdomen appears sunken, low body temperature, cyanotic and nasal flaring. Which action should be strongly considered? A) Assist with endotracheal intubation and assist ventilation B) Give pancuronium bromide intravenously to increase pulmonary blood floow C) Initiate continuous positive airway pressure D) Place in hood oxygen and achieve an oxygen saturation greater than 90%

ANSWER: A Explanation: - For a premature infant, respiratory distress syndrome can be largely prevented by the administration of synthetic surfactant through an endotracheal tube. Ventilation are pressure-cycled to control the force of the air delivery - The infant is suctioned before surfactant administration. Afterwards, the infant's airway should not be suctioned for as long as possible to avoid suctioning out the surfactant - A possible complication of oxygen therapy in the immature or very ill infant is retinopathy of prematurity or bronchopulmonary dysplasia - Pancuronium is a muscle relaxant used during endotracheal intubation and can increase pulmonary blood flow

A patient visits the clinic for her regular prenatal check up at nine months gestation. The nurse monitors her weight. How many pounds per week is considered normal weight gain during the ninth month of pregnancy? A) 1 lb B) 2 lb C) 2.5 lb D) 5 lb

ANSWER: A Explanation: - In the average woman, weight gain is considered excessive if it is more than 3 kg (6.6 lbs) per month during the second and third trimesters. Therefore the answer is 1 lb per week - A weight gain of 25 to 35 pounds is currently recommended as an average weight gain in pregnancy. Weight gain in pregnancy occurs from both fetal growth and accumulation of maternal stores - Women who are underweight coming into pregnancy should gain slightly more weight, while an obese woman might be advised to gain less than average

To accurately assess for jaundice in a patient with dark skin, the nurse should examine which area of the body? A) Hard palate of the mouth B) Nail beds C) Sclera D) Skin on back of the hand

ANSWER: A Explanation: - Jaundice is best assessed in the sclera. However, the dark-skinned patient may normally have yellow pigmentation in the sclera. Inspection of the hard palate for a yellow color can confirm the presence of jaundice - Cyanosis is best observed in the nail beds - Skin on the palm of the hand can indicate jaundice but not skin on the back of the hand - Jaundice can be assessed on the soles of the feet in a patient with dark skin. However, it is better assessed in the hard palate

Methylergonovine has been ordered for a postpartum patient. The nurse should withhold this drug when which of the following is present? A) Blood pressure of 170/95 B) Increased uterine blood flow C) Pulse of 89 and respiratory rate of 20 D) Tender breasts and temperature of 100.1 degrees Fahrenheit

ANSWER: A Explanation: - Methylergonovine (Methergine) is ordered to prevent postpartal hemorrhage. However, Methergine can cause hypertension by vasoconstriction. It is important to obtain a baseline blood pressure before administering the drug. Methergine should not be given to women with an elevated blood pressure - Methylergonovine administration is necessary up to 8 hours after birth to promote uterine contraction to prevent postpartal hemorrhage. If the uterus suddenly relaxes there will be an abrupt gush of blood from the placental site - Increased uterine blood flow will increase the risk of severe hemorrhage, this is not a contraindication - The woman should be informed that tender breasts after birth is normal since the breasts begin to engorge to prepare for lactation - Temperature of 100.1 should be reassessed after 15 minutes. Slight increase in temperature might happen if the woman is confined in a humid environment

A nurse is assessing a newborn's reflexes. Which of the following best describes the Babinski reflex? A) Dorsiflexion of the great toe when the sole is scratched B) Extension of the leg when the patellar tendon is struck C) Flexion of the forearm when the biceps tendon is tapped D) Tremor of the foot following brisk, forcible dorsiflexion

ANSWER: A Explanation: - The Babinski reflex is characterized by dorsiflexion of the great toe and fanning of the other toes when the sole of the foot is stimulated - In adults, the normal plantar reflex causes plantar flexion of the great toe - When the Babinski reflex is present in adults and in children over the age of 24 months, it may indicate damage to the pyramidal tracts - Flexion of the forearm describes the biceps reflex - Extension of the leg describes the patellar reflex - Tremor of the foot occurs with ankle clonus

While caring for a one-day-old newborn, the nurse performs her morning assessment. When assessing the chest comparatively to the head, she would expect: A) The chest circumference to be about 2 cm less than the head circumference B) The head and chest circumference is equal C) The head circumference to be 3 cm more than the chest circumference D) The head circumference to be about 2 cm less than the chest circumference

ANSWER: A Explanation: - The chest circumference in a term newborn is usually about 2 cm less than the head circumference - Chest circumference is measured at the level of the nipples. If edema of the breasts is present, this measurement will not be accurate until the edema has subsided - In a mature newborn, the head circumference is usually 34 to 35 cm, 2 cm greater than the chest circumference. A mature newborn with a head circumference greater than 37 cm or less than 33 cm should be carefully investigated for neurologic involvement

A nurse is caring for a patient that is 6 centimeters dilated. The nurse should follow the protocol for care of the patient in: A) Active phase, first stage of labor B) Latent phase, first stage of labor C) Second stage of labor D) Transition, first stage of labor

ANSWER: A Explanation: - The patient is in the active phase of the first stage of labor, when the cervix is dilated from 5 to 8 centimeters. - The first stage of labor is in the period from onset of true labor to full cervical dilation. This stage has three phases: latent, active, and transition - Incorrect: The latent phase begins at the onset of regular uterine contractions and ends with rapid cervical dilation of one-to-five centimeters. Contractions occur every 15-to-30 minutes and are 15-to-30 seconds in duration with mild intensity - Incorrect: The transition phase is the last and final phase of the first stage of labor. During this phase, contractions reach their peak and intensity, occurring every 2-to-3 minutes. Cervical dilation increases from 8 to 10 cm

A nurse administers vitamin K to newborn babies because they lack the intestinal required to make vitamin K. Why is it important for our bodies to use vitamin K at birth? A) Vitamin K is required for blood coagulation B) Vitamin K is required for bone formation C) Vitamin K is required for platelet formation D) Vitamin K is required for renin synthesis

ANSWER: A Explanation: - Vitamin is used for the synthesis of clotting factors in the liver. Newborns are at risk for bleeding disorders due to the lack of intestinal flora needed to make vitamin K - Vitamin K is not required for bone formation, renin synthesis, or platelet formation

Claire delivered a 3,400 gram baby boy and was transferred to the postpartum unit. On the second postpartum day the patient experiences tenderness and breast engorgement from breast feeding. To relieve her discomfort the nurse should encourage the patient to: A) Apply warm compresses to the breasts B) Discontinue breastfeeding C) Massage her breasts D) Remove her bra

ANSWER: A Explanation: - Warm compresses should be applied between findings to reduce discomfort. Cold compresses can be applied if the patient is not breast feeding - Breast milk forms in response to the fall of estrogen and progresterone levels that follows delivery of the placenta. When the production of milk begins, the milk ducts become distended. The breasts become fuller, larger and firmer. The distention is not limited to the milk ducts, it also occurs in the surrounding tissue - The feeling of tension in the breasts on the third or fourth day is termed primary engorgement - Do not discontinue breastfeeding. Primary engorgement fades as the infant begins effective sucking and empties the breasts of milk - Do not remove the bra because a supportive bra provides pain relief and comfort to engorged breasts

The nurse is caring for a woman in the first stage of labor. The fetal position is left occiputoanterior. When her membranes rupture, the nurse's first action should be to: A) Assess the fetal heart rate B) Measure the amount of fluid C) Notify the physician D) Perform a vaginal examination

ANSWER: A Explanation: The first stage of labor is the longest and involves three phases: - Latent Phase: onset to 4 cm dilation/contractions 15-30 min apart, 15-30 secs long - Active Phase: 4 to 7 cm dilation/contractions 3-5 min apart, 30-60 secs long - Transition: 8 cm to fully dilated/10 cm/contractions 2-3 min apart/45-90 secs long - Counting the fetal heart rate before, during, and after contractions is important to ensure the well-being of the fetus. FHR should be 110-160 beats/minute - Labor may begin with rupture of the membranes. If membranes rupture, first assess the FHR due to the risk of a collapsed umbilical cord, and then assess the color and clarity of the amniotic fluid to look for meconium-staining, which would indicate fetal distress. Report any unusual findings immediately - The physician does not need to be notified unless there are unusual findings because spontaneous rupture of the membranes is an expected occurrence. An exception is if the color of the amniotic fluid is yellow, which may indicate a blood incompatibility between the mother and the fetus, or meconium-stained (dark-colored) - Early rupture of the membranes can be advantageous if it causes the fetal head to settle snugly into the pelvis. However, intrauterine infection or prolapse of the umbilical cord are two risk factors associated with prolonged ruptured membranes during a long first stage of labor - Measuring the amount of fluid should only be done if the patient is experiencing oligohydramnios or hydramnios - Current clinical guidelines (Cochrane database) recommend keeping the number of vaginal examinations to a minimum to avoid promoting intraamniotic infection and for patient comfort. Routine VEs should only be performed on admission, every four hours in the first stage of labor, hourly in the 2nd stage of labor, prior to administration of analgesia, and to evaluate for suspected complications

The nurse is assessing a patient's blood pressure during labor. The patient asks why her blood pressure is measured so frequently. The nurse explains that: A) "Blood pressure changes can be a side effect of the medications you have been given" B) "Blood pressure changes may affect the fetus" C) "Decreased blood pressure indicates that the fetus is experiencing pain" D) "Following the blood pressure changes allows us to track your contractions"

ANSWER: A, B, D Explanation: - Correct: "Blood pressure changes may affect the fetus." Frequent blood pressure monitoring is needed because changes in blood pressure can affect fetal blood supply - Correct: "Following the blood pressure allows us to track you contractions." Monitoring of contraction intensity and duration is aided by monitoring of blood pressure to recognize when a patient is having a contraction, even when she may not feel it (if she has an epidural). - Correct: "Blood pressure changes can be a side effect of the medications you have been given." Many of the medications given in labor affect blood pressure and this should be explained to the patient - Incorrect: "Decreased blood pressure indicates that the fetus is experiencing pain." The mother's blood pressure does not indicate whether the fetus is experiencing pain, and this answer would frighten a mother.

The nurse is assisting a patient who just delivered a healthy baby boy weighing 3,400 grams. Upon cord traction of placenta, there is a sudden gush of a large amount of blood. The fundus is no longer palpable in the abdomen. Which of the following nursing interventions are most appropriate? (Select all that apply) A) Assess vital signs B) Check established IV patency C) Continue prescribed oxytocin D) Do not attempt to remove the placenta E) Notify the health care provider

ANSWER: A, B, D, E Explanation: - Uterine inversion is a medical emergency in which the inner uterine lining collapses into the vagina. Heavy vaginal bleeding will be seen, and the fundus is unable to be palpated in the abdomen. If not corrected immediately, cervical entrapment of the uterus may occur - Risk factors include straining after delivery, too-vigorous kneading of the fundus, or pulling on the cord before the placenta has separated - The health care provider and RN should be notified immediately and IV fluid replacement is expected for blood loss. The nurse anticipates this and prepares equipment - Administering oxytocic drugs only compound the inversion; uterotonic drugs should be discontinued to allow uterine relaxation for replacement

A woman in the first trimester of her pregnancy is attending childbirth classes. What topics are most likely to be covered during this trimester? (Select all that apply) A) Anatomy of pregnancy B) Complications and warning signs C) False and true labor D) Fetal development E) Fetal movements F) Nutrition

ANSWER: A, B, D, F Explanation: - During the early stages of pregnancy, childbirth classes should cover topics such as warning signs of complications, nutrition, anatomy, and fetal development - Fetal movements, false labor, and signs of labor are usually covered in later childbirth classes

A primapara patient asks the nurse the etiology of her physiological anemia. The nurse replied that in physiologic anemia of pregnancy, a lower hemoglobin and hematocrit is due to: (Select all that apply) A) Increased blood volume B) Increased cell mass C) Iron utilization for fetal needs D) Transfer of RBC from mother to fetus

ANSWER: A, C Explanation: - To provide an adequate exchange of nutrients in the placenta and to compensate for blood loss at birth, the circulatory blood volume of the woman's body increases al lease 30% during pregnancy - The increase in blood volume occurs gradually near the end of the first trimester. It peaks at about the 28th to the 32nd week and continues at this high level through the third trimester. As the plasma volume first increases, the concentration of hemoglobin and erythrocytes may decline, giving the woman a pseudoanemia - The fetus requires 350 to 450 mg iron to grow. The increases in the mother's circulatory red blood cell mass requires an additional 400 mg of iron. Iron absorption may be impaired during pregnancy as a result of decreased gastric acidity, additional iron is often prescribed during pregnancy to prevent true anemia

A patient with oligohydramnios presents to the hospital with intense contractions. Which of the following complications is associated with this disease? (Select all that apply) A) Cord compression B) Hypospadias C) Lesion of CN VI D) Renal malfomations E) Skeletal malformations

ANSWER: A, D, E Explanation: - Oligohydramnios is a condition characterized by amniotic fluid deficiency - Complications include cord compression, skeletal malformations, renal malformations, facial distortion, pulmonary hypoplasia, and intrauterine growth restriction - CN VI lesion and hypopadias are not associated with Oligohydraminios

A newborn's lab result indicate a phenylketonuria level of 30 mg/dl. What should the nurse do next? A) Document the result B) Immediately notify the physician of the critical test result C) Inform the parents of the normal PKU level D) Notify the physician during morning rounds

ANSWER: B Explanation: - A PKU level of 30 mg/dl is critically elevated and should be communicated to the physician immediately to provide early intervention. A normal PKU is less than 2 mg/dl - The nurse should document the result, but only after the physician has been notified - An elevated PKU that goes untreated will result in seizures, albinism, microcephaly, and cerebral impairment

A patient is having trouble adjusting to breastfeeding, and is disagreeing with her husband on the importance of breastfeeding compared to formula. Which member of the health care team should the nurse consult? A) Charge nurse B) Lactation consultant C) Physician D) Social worker

ANSWER: B Explanation: - A lactation consultant is trained to answer questions about breastfeeding and can best discuss these issues with the patient and her husband - The charge nurse, physician, and social worker do not have special breastfeeding training

A newborn less than 3 hours old has a split S2 that is heard on inspiration and a HR of 140 beats/minute. What should the nurse do next? A) Assess the newborn's neurological status B) Document the finding C) Notify the physician D) Warn the parents that something may be wrong

ANSWER: B Explanation: - A split S2 on inspiration is a normal finding for newborns during the first few hours of life. All the nurse needs to do at this point is to document the finding - Normal HR for newborns is from 120-160 beats/minute - There is no need to notify the physician or inform the parents of a normal finding - Assessing the newborn's neurological status is not needed based on the scenario

In planning postpartum nursing care for a patient with cardiac disease, the nurse would question which of the following physician orders: A) High fiber diet B) High fluid intake C) Monitor vital signs ever 2 hours D) Strict monitoring of input and ouput

ANSWER: B Explanation: - An excessive fluid intake in a patient with cardiac disease would increase the risk of heart failure - The postpartum patient with cardiac disease is already at risk for fluid overload due to the extra accumulation of fluid from pregnancy - Monitoring input and output of the patient is the top priority of the nurse to prevent risk of fluid overload. - Vital signs should be monitored every 2-4 hours to monitor the cardiac condition of the patient - High fiber diet is recommended to prevent constipation and straining

Upon the delivery of a newborn, the APGAR score of the child within the first minute was five, this means: A) Good and just needs suctioning B) Guarded and may need clearing of airway C) Serious danger and needs resuscitation D) Strong and doesn't need any clearing of airways

ANSWER: B Explanation: - An infant scoring 5 means that the condition is guarded and may need clearing of the airway and/or supplementary oxygen - An infant scoring below 4 is considered critical and may need resuscitation - A score of 7 to 10 is considered good, indicating that the baby doesn't need clearing of airways - The APGAR is assessed at 1 minute and 5 minutes after birth

A patient has meconium stained amniotic fluid. Fetal scalp sampling indicates a blood pH of 7.12 and fetal bradycardia is present. Based on these findings, the nurse should take which action? A) Administer amnioinfusion B) Prepare for cesarean secion C) Reposition the patient D) Start IV infusion as prescribed

ANSWER: B Explanation: - Based on the assessment, fetal acidosis is present. Infants with meconium stained amniotic fluid may have respiratory difficulties and bradycardia at birth. These findings pose a great threat to the newborn's wellbeing. Therefore a cesarean section is required - Amnioinfusion is an infusion of sterile isotonic solution into the uterine cavity during labor to reduce umbilical cord compression. This is also done to dilute meconium in amniotic fluid, reducing the risk that the infant will aspirate thick meconium at birth. This procedure is done only if the patient does not experience fetal hypoxia

A woman experiences a sharp, stabbing pain high in the uterine fundus. Tenderness is felt on uterine palpation and heavy bleeding accompanies premature separation of the placenta. Once blood infiltrates the uterine musculature, the uterus becomes hard. This condition is known as: A) Android uterus B) Couvelaire uterus C) Gynecoid uterus D) Platypelloid uterus

ANSWER: B Explanation: - Couvelaire uterus is a life threatening condition in which abruptio placentae causes blood to infiltrate the uterine myometrium and into the peritoneal vavity - A hard, boardlike uterus is formed with no apparent or minimal bleeding - When placenta abruption occurs, there will be external bleeding if the placenta separates first at the edges and blood escapes freely from the cervix. If the center of the placenta separates first, blood will pool under the placenta and be hidden from view - The remaining answer choices are pelvic types that determine whether a vaginal birth or C-section is indicated

The nurse is caring for a patient that has been addicted to drugs for several years. The patient has just delivered a male infant 48 hours ago. Which of the following assessment findings can the nurse expect in the infant? A) Cuddles when held B) Irritability C) Minimal crying D) Polyphagia

ANSWER: B Explanation: - Drug addicted newborns usually experience drug withdrawal symptoms beginning 24-48 hours birth (but it may take up to a week for symptom to appear). This includes low birth weight, nervousness, irritability, tremors, seizures, poor feeding, piercing cry, and respiratory distress - Illicit drugs tend to be a small molecular weight, so they cross the placenta readily. As a result, the fetus of an addicted mother has a drug concentration of about 50% that of the mother

Six family members of a healthy newborn arrive on the unit demanding to see the infant. A new nurse assigned to the patient should do which of the following? A) Allow every family member into the room to see the newborn B) Ask the charge nurse or nurse manager about the unit policy on visitation C) Ask the family to leave since they are demanding to see the infant D) Ask the family to wear gloves, gown, and mask before entering the room

ANSWER: B Explanation: - Due to the amount of family members present, the new nurse should verify the unit policy on visitation before allowing everyone into the room - Asking the family to leave is not appropriate, they have not threatened the staff - Gown and mask are not required for visiting a healthy newborn

A 24-year-old primipara is now on her active phase of first stage of labor. She tells the nurse that she wants a general anesthesia to relieve intense pain. The nurse advises the patient that general anesthesia is never preferred for childbirth because: A) It can cause cardiac arrhythmias B) It carries the dangers of hypoxia and possible inhalation of vomitus during administration C) It causes an increase in blood pressure D) It lowers the FHT and causes palpitations

ANSWER: B Explanation: - General anesthesia administration is never preferred for childbirth, because it carries the dangers of hypoxia and possible inhalation of vomitus during administration - Pregnant women are particularly prone to gastric reflux because of increased stomach pressure from the weight of the full uterus beneath it - All women who receive general anesthesia must be observed closely in the postpartum period because of the possibility of uterine atony and hemorrhage

A nurse teaches parents who moved into a home with lead pipes. What does the nurse most correctly teach the parents about formula preparation for a six moth old infant? A) Boil tap water for five minutes and cool for use in mixing the infants milk B) Run cold tap water for two minutes and store for use in mixing formula C) Use bottled spring water for all powdered infant formula mixing D) Use premixed, liquid formula preparation from the manufacturer

ANSWER: B Explanation: - Most bottled water does not contain fluoride, a fluoride supplement may be necessary. Also, some bottled waters have not been tested and may not be appropriate for consumption. This is also a costly option - Correct- the EPA and CDC recomment runninf cold tap water, not hot, for 30 seconds to 2 minutes, filling jugs for later, and using this water for drinking use - Boiling water does not reduce lead in the water. However, boiling water for exactly one minute reduces other contaminants and could be done after running cold water for storage - Liquid formulations of infant formula are considered sterile, powder is not, and its use is sometimes warranted, especially for infants under three moths of age and premature infants. For the older infant, liquid formula is quite expensive, the infant is drinking more, and is less susceptible to infection from powdered formula Mnemonic: Lead Poisoning Symptoms ABCDEFG - Anemia - Basophilic stippling - Colicky pain, constipation - Decreased concentration - Encephalopathy - Foot drop -Gum (lead line)

A patient is admitted at 22 weeks gestation for preterm labor. The nurse administers nifedipine (Procardia) as ordered. The patient is most likely to complain of which side effects? A) Confusion and blurred vision B) Headache and dizziness C) Metalic taste D) Vomiting and constipation

ANSWER: B Explanation: - Nifedipine (Procardia) is a calcium channel blocker that is commonly used to delay premature labor - Common side effects include headache, dizziness, edema, flushing, nausea, and gingival hyperplasia Mnemonic: Calcium Channel Blocker Side Effects SHED the GAPS - Stevens Johnson syndrome - Headache - Edema - Dizziness - Gingival hyperplasia - Angina - Palpitations - Sleepiness

A newly-wed is experiencing amenorrhea, nausea and vomiting. She consults as physician and finds out that she is pregnant. The patient is very excited and at the same time feels afraid of the impending situation of her pregnancy. What psychological state of pregnancy has the patient achieved? A) Accepting the baby B) Accepting the pregnancy C) Preparing for end of pregnancy D) Preparing for parenthood

ANSWER: B Explanation: - Often, women spend time recovering from the shock of learning they are pregnant and concentrate on what it feels like to be pregnant. A common reaction is ambivalence, or feeling both positive and negative toward the pregnancy - As many as 50% of pregnancies are unintended, unwanted, or mistimed. Every pregnancy is a surprise to some extent, either because the woman had not planed on becoming pregnant or had been looking forward to being pregnant but cannot believe it has happened

A patient is admitted to the hospital to deliver through labor induction. The nurse administers oxytocin (Pitocin) as ordered by the physician. Knowing the potential complications of oxytocin (Pitocin), the nurse should closely monitor: A) Cervix dilation B) Fetal heart rate C) Maternal heart rate D) Maternal neurological status

ANSWER: B Explanation: - Oxytocin (Pitocin) stimulates uterine contractions, which can cause decreased fetal heart rate and hypoxia. The nurse should closely monitor the fetal heart rate for any changes. - Although it is important to monitor cervical dilation, maternal heart rate, and maternal neurological status, fetal heart rate is the most critical assessment to monitor when giving oxytocin (Pitocin).

A pregnant woman, 23 weeks gestation, is admitted due to spotting. The physician suspects that the patient is having disseminated intravascular coagulation and orders blood tests. The nurse checks her blood tests and expects: A) Hemoglobin of 12.9 g/dL B) Longer than normal PTT value C) Platelet count increased D) WBC count of 6,109 cells/ml

ANSWER: B Explanation: - Patients with DIC will have a PTT value longer than normal - DIC is a condition of an unknown cause and shows diffuse fibrin deposition within arterioles and capillaries. There is widespread, systemic coagulation an subsequent depletion of clotting factors.This prolongs PT and PTT values of patients - The second and third choices are within normal range, while the platelet count of patients with DIC is usually decreased - Hemoglobin normal range is 14-18 g/dl for men and 12-16 g/dl for women - WBC normal range is 4,000-10,000 cells/ml

A woman who has been in labor for 6 hours is now 9 cm dilated and has intense contractions every 1 to 2 minutes. She is anxious and feels the need to bear down with her contractions. What is the best action for the nurse to take? A) Allow her to push so that the delivery can be expedited B) Encourage panting through contractions to prevent pushing C) Provide back rubs during contractions to distract her D) Reposition her in a squatting position to make her more comfortable

ANSWER: B Explanation: - Since the woman has not reached full cervical dilatation, which is 10 cms, it is best for the nurse to encourage the woman to breathe, using repeated short puffs to prevent pushing - Allowing the woman to push without a fully dilated cervix will predispose her to bleeding and cervical laceration - During this time, the woman has already reached the transition phase of the first stage of labor. The contractions have reached its peak of intensity, occurring 1 to 2 minutes. A woman in this phase may experience intense discomfort, so strong that she may also experience a feeling of loss of control, anxiety, panic, and irritability - During first stage of labor, it is best to position the woman in the left side lying position. This position causes the heavy uterus to tip forward, away from the vena cava, allowing blood return from the lower extremities and adequate placental filling and circulation - During Transition phase, the woman often becomes irritable and restless. The patient may resist being touched and push away

The nurse is caring for a primigravida complaining of lightheadedness, faintness, cold clammy skin and palpitations after lying supine. The appropriate nursing intervention is: A) Ambulation B) Left side lying position C) Lie on her backside with head raised D) Reassure the patient that this is a normal phenomena during pregnancy

ANSWER: B Explanation: - Supine hypotension syndrome can be corrected easily by having the woman turn onto her side (preferably the left side) to enhance blood flow through the vena cava. To increase the collateral blood circulation during pregnancy, teach the patient to rest on her left side rather than her back - When a pregnant woman lies supine, the weight of the growing fetus presses the vena cava against the vertebrae, obstructing blood flow from the lower extremities. This causes a decrease in blood return to the heart and decreased cardiac output and hypotension - Ambulation cannot relieve supine hypotension syndrome, however, it can stimulate circulation

A nurse is providing care to a woman 38 weeks pregnant. During the most recent vaginal examination, the nurse notes that the cervix is 6 centimeters dilated, 100% effaced, with the vertex at -1 station. What is the best interpretation? A) Active labor with the head as presenting part, fully engaged B) Active labor with the head as presenting part, not yet engaged C) Latent phase with the backside as presenting part, fully engaged D) Transition phase with the backside as presenting part, fully engaged

ANSWER: B Explanation: - The best interpretation is that the woman is in active labor with the head as presenting part. This is because cervical dilatation is 6 centimeters and not yet engaged (the vertex lies at -1 station). - Transition phase and Latent phase are incorrect because the cervical dilation, which is 6cm, is in the active phase of the first stage labor. Transition phase starts to peak in contractions and dilatation of 8 to 10 cms. Furthermore, Latent phase is the onset of the first stage of labor and is when cervical dilatation begins - Active labor, fully engaged is also incorrect because the woman is still at -1 station or not yet engaged

A nurse is reviewing her assignments, which patient should she assess first? A) 12-hour old infant who is small for gestational age B) Four hour infant with a cardiac defect C) Nine hour old infant who has not voided D) Three day old infant waiting for discharge

ANSWER: B Explanation: - The infant with cardiac defect is at risk for complications and should be assessed first - The other options do not require immediate assessment by the nurse

The nurse assesses a postpartum patient as having moderate lochia rubra with clots on her second postpartum day. Which of the following interventions would be appropriate? A) Administer Methergine IM per physician's order B) Assess the fundus and bladder status C) Catheterize the patient D) Notify the physician immediately

ANSWER: B Explanation: - There is no complications or any signs of postpartal hemorrhage. To assess involution process, the nurse should palpate the fundus to see if it is firm and well contracted. During birth, the fetal head exerts pressure on the bladder and urethra as it passes on the bladder's underside. The pressure may leave the bladder with a transient loss of tone To prevent permanent damage to the bladder from over distention, assess the woman's abdomen frequently - Lochia rubra is a postpartum vaginal discharge consisting almost entirely of blood. There are oftern small particles of deciduas and mucus during the first 3 postpartum days - The other intervention choices are inappropriate because the woman is not suffering from blood loss - Methergine should not be given because thewoman is in her second postpartal day and has a normal lochia as expected

A new mother is interested in seeing what her infant's eyes look like. Which is the most effective way for the nurse to stimulate the infant to open their eyes? A) Gently separate the infant's eyelids with the fingers B) Hold the infant in an upright postion C) Shine a penlight toward the infant's face D) Stimulate the moro reflex

ANSWER: B Explanation: - When help upright, an infant will open eyes reflexively - Separating the eyelids causes the eyes to close due to the blink reflex - Moro reflex also causes the eyes to close - Infants are sensitive to light and will close their eyes in the presence of a bright light

Christine, a primipara, was observed to have thick, green colored amniotic fluid when her membranes ruptured spontaneously. Soon after the birth of her baby, the neonate had difficulty establishing respirations, appeared cyanotic, had tachypnea and retractions. The nurse understands which of the following is a priority intervention for the neonate? A) Administer oxygen under pressure before suctioning the neonate B) Infant should be intubated and meconium should be suctioned C) Introduce antibiotic therapy D) Suction with bulb syringe while at the perineum before the delivery of the shoulders

ANSWER: B Explanation: - When meconium aspirations occurs, intubation and immediate suctioning of the airway is needed - It was once recommended that the infant be suctioned by a bulb syringe as soon as the head is delivered. However, the American Academy of Pediatrics no longer recommends this - Do not administer oxygen under pressure until the infant has been intubated and suctioned. This is so the oxygen pressure does not drive small plugs of meconium further down into the lungs - After tracheal suction, infants may be treated with oxygen administration. Antibiotic therapy may be used to prevent the development of pneumonia

A nurse preforms an initial assessment on a neonate. The neonate has a heart rate of 130 beats/minutes and is gasping for air. The neonate has blue extremities and is moving vigorously. When stimulated, the infant only grimaces. What should the nurse do next? A) Assign an APGAR of 7 and begin resuscitation B) Assign an APGAR of 7, place the patient in modified Trendelenburg, and apply oxygen C) Assign an APGAR of 9 and begin resuscitation D) Assign an APGAR of 9, place the patient in modified Trendelenburg, and apply oxygen

ANSWER: B Explanation: The patient's APGAR score is 7. The patient is in respiratory distress and is having trouble oxygenating her extremities. Placing the patient in modified Trendelenburg will ensure adequate blood flow to her brain and vital organs - The patient does not need resuscitation Apgar scored from 0-10. Each category scored 0-2 - Appearance: Blue/pale all over, blue extremities/pink body, entire body pink - Pulse: Absent, <100, >100 - Grimace: No response to stimulation, grimace/feeble cry, cry or pull away - Activity: None, some flexion, flexed extremities that resist extension - Respiration: Absent, weak/irregular/gasping, strong cry

The nurse is educating a new mother about the dangers of sunburn for her 3-month-old infant. Which of the following is the best advice? (Select all that apply) A) "Apply sunscreen every 2 hours" B) "Babies under 6 months old should be kept out of the sun as much as possible" C) "Sunscreen should not be used on infants younger than 6 months" D) "Sunscreen will prevent the absorption of vitamin D, causing a deficiency" E) Use SPF 50 while the infant is in the sun"

ANSWER: B, C Explanation: - Infant's skin is very sensitive to the sun. Therefore, they should be kept out of the sun until six months of age - Sunscreen should not be used until the infant can be out in the sun

The patient in labor is being monitored for contractions. Which of the following should the nurse document related to contractions? (Select all that apply) A) Cervical dilation B) Contraction Intensity C) Contraction duration D) Contraction frequency E) Patient position

ANSWER: B, C, D Explanation: - The nurse needs to document uterine contractions. This includes frequency, intensity, and duration of contractions - Dilation of the cervix should be documented separately from uterine contractions - Patient position can affect the length of labor and this should be documented in the patient's chart

A 20-year-old primipara is admitted and diagnosed with pregnancy induced hypertension. Magnesium sulfate is ordered. Which of the following nursing responsibilities should be done before administering the drug? (Select all that apply) A) Assess bowel function to prevent an ileus B) Asses urine output C) Check blood pressure D) Check respiratory rate, if its below 12 cycles per minute, withhold the drug E) Elicit a positive deep tendon reflex F) Perform a vaginal examination

ANSWER: B, C, D, E Explanation: - Serum magnesium levels should be maintained at 4 to 8 mEq/L to prevent pre-eclamptic seizures. If the blood serum level rises above this, respiratory depression, hyporeflexia, cardiac arrhythmias, and cardiac arrest can occur - Checking the respiratory rate establishes a baseline before administration of the drug. If respirations fall below 12 per minute, the nurse would withhold the drug - Checking the blood pressure establishes a baseline before administration of the drug. - As plasma magnesium levels rise above 4mEq/L, deep tendon reflexes lessen, disappearing altogether at 10 mEq/L. Performing this test prior to administering the medication will help identify a baseline so the nurse will recognize if levels become high - Because magnesium is excreted from the body almost entirely through the urine, urine output must be monitored - The nurse does not need to asses bowel function or perform a vaginal exam at this time

The nurse is caring for a woman in labor. What signs would indicate that the patient is in the transition phase of labor? (Select all that apply) A) Bulging at the perineum B) Complaints of nausea C) Increased irritability D) Notes an uncontrollable urge to push or bear down E) She has heavier bloody show

ANSWER: B, C, E Explanation: - During the transition phase of the first phase of labor, the maximum cervical dilation of 8 to 10 cm occurs, contractions reach their peak of intensity and occurring every 2 to 3 minutes and a duration of 60 to 90 seconds - During the transition phase, the woman may experience intense discomfort so strong it is accompanied by nausea and duration of contractions, she may experience a feeling of loss of control, anxiety, panic and irritability. Since dilatation continues at a rapid rate, the membranes rupture and heavy show is present - Uncontrollable urge to push or bear down and bulging at the perineum are signs of the second stage of labor

A woman who is two months pregnant complains of nausea after taking her prenatal vitamin. The nurse should instruct the patient to do which of the following to alleviate this side effect? (Select all that apply) A) Crush the vitamin and mix it with orange juice B) Take the vitamin at night C) Take the vitamin in the morning D) Take the vitamin with fod E) Try the generic brand

ANSWER: B, D Explanation: - Taking a prenatal vitamin with food can help reduce nausea. Also, taking the vitamin before bedtime can also help - Using a different brand of prenatal vitamins may not help - The acidity of orange juice can worsen nausea

Which of the following signs in a postpartum patient would make the nurse concerned for endometritis? (Select all that apply) A) Constipation B) Cramping C) Hemorrhoids D) Purulent, foul smelling lochia E) Uterine tenderness

ANSWER: B, D, E Explanation: - Endometritis is an infection/inflammation of the endometrium (lining of the uterus). It can occur during pregnancy of after childbirth or when it occurs unrelated to pregnancy it is called pelvic inflammatory disease - Endometritis may be caused by organisms that are normal inhabitants of the vagina and cervix; however, organisms such as gonorrhea and chlamydia may be frequently encountered during pregnancy. If left untreated, these infections may lead to postpartum endometritis and a potential for maternal and/or noenatal morbidity - Major signs and symptoms of endometritis are fever, chills, malaise, lethargy, anorexia, abdominal pain, and cramping, uterine tenderness and purulent, foul-smelling lochia - The nurse should expect treatment of the organisms according to CDC guidelines if indicated - Constipation and hemorrhoids are common postpartum complications but are unrelated to endometritis

Which of the following clinical manifestations is a priority for the nurse to report on a woman in the second stage of labor? (Select all that apply) A) Bulging of the perineum B) Indentation across the abdomen C) Involuntary bearing down efforts D) Maternal urge to push E) Persistent vaginal bleeding

ANSWER: B, E Explanation: - An indentation across the abdomen, abdomen pain, or vaginal bleeding during the second stage of labor should be reported to the physician. These symptoms are signs of impending rupture of the uterus and is a medical emergency - All other choices are normal events for a woman in the second stage of labor. During this time the woman will experience uncontrollable urges to push or bear down with contractions. As the fetal head touches the internal side of the perineum, the perineum begins to bulge and appear tense

A woman has been admitted to the labor and delivery unit with a macular rash and lymphadenopathy. Lab tests reveal WBC count of 11,000, platelet count of 200,000, creatinine of 0.9, and the nontreponemal antibody test is positive. What should the nurse do next? A) Ask the patient if she has been using illicit drugs B) Encourage the patient to increase fluid intake C) Notify the physician D) Place the patient in a dorsal recumbent position

ANSWER: C Explanation: - A positive nontreponemal test, along with a rash and lymphadenopathy are indicative of secondary syphilis. The physician should be notified immediately so proper treatment can be initiated - Syphilis infection during pregnancy can result in stillbirth, prematurity, and congenital syphilis - Increased fluid intake, dorsal recumbent position, and illicit drug use are unrelated to secondary syphilis and have no impact on treatment

A nurse is teaching the parents of a newborn proper post-circumcision care. Which of the following should the nurse not include? A) 2 to 5 days of site care is required after discharge B) Lubricating ointment should be applied to the penis after each diaper change C) Report any amount of blood found on the diaper D) The patient cannot be discharged until after voiding

ANSWER: C Explanation: - A small amount of bleeding is normal finding after a circumcision, parents should report only a large amount of blood (i.e area of blood larger than a quarter) - The other three answer choices should be included in the teaching plan

The nurse evaluates a newborn immediately after birth to have a heart rate of 90, blue extremities, no response to a catheter in the naris, weak respiratory effort, and no muscle tone. The nurse should document the APGAR as: A) 1 B) 2 C) 3 D) 5

ANSWER: C Explanation: - APGAR stands for Appearance, Pulse, Grimace, Activity, and Respiration. Each is rated as 0, 1, or 2, then all scores are added up - For appearance: 0 is pale or blue all over, 1 is blue at extremities, and 2 is body and extremities pink - Pulse rate: 0 is heart rate absent, 1 is heart rate below 100, 2 is heart rate above 100 - Reflex irritability (Grimace): 0 is absence of response to stimulation, 1 is a feeble cry or grimace after stimulation, 2 is cry or pulls away after stimulation - Muscle tone: 0 is not, 1 is some flexion and 2 is flexed arms and legs that can resist extension - Respiration: 0 is absent, 1 is weak and irregular, and 2 is strong cries

According to Bartholomew's rule, if the fondus is at the level of the umbilicus, the age of gestation is: A) 12 weeks B) 16 weeks C) 20 weeks D) 36 weeks

ANSWER: C Explanation: - Bartholomew's rule of fourths is a method used to determine the estimated age of gestation of pregnancy in relation to the fundal height. In this method all you need to do is to remember 3 landmarks: the symphisis pubis, the umbilicus and the xiphoid process. When the fundus is at the level of: - Symphisis pubis - 12 weeks - Midway between symphysis pubis & umbiicus - 16 weeks - Umbilicus - 20 weeks - Xiphoid process - 38 weeks Mnemonic: Bartholomews Rule of Fours: - 12 weeks: Symphisis pubis - 16 weeks: Midway between symphysis pubis and umbilicus - 20 weeks: Umbilicus - 36 weeks: Xiphoid process

A postpartum patient is experiencing urinary retention. The nurse would expect the physician to order which drug, in order to stimulate bladder contractions? A) Atropine B) Benztropine (Cogentin) C) Bethanechol (Urecholine) D) Scopolamine (Hycosine)

ANSWER: C Explanation: - Bethanechol (Urecholine) is a cholinergic agent that stimulates muscarinic receptors - Atropine, Benztropine (Cogentin), and Scoplamine (Hycosine) are all anticholinergic drugs and would worsen urinary retention Mnemonic: Muscarinic Agonist Drug Effects SLUDGE BAM - Salivation/Sweating/Secretions - Lacrimation - Urination - Defecation - Gastrointestinal upset - Emesis - Bradycarida - Abdominal cramps - Miosis

A woman is completely dilated and at +2 station. Her contractions are strong and last 50 to 70 seconds. Based on this information, the nurse should know that the patient is in which stage of labor? A) First stage of labor B) Fourth stage of labor C) Second stage of labor D) Third stage of labor

ANSWER: C Explanation: - Considering that the woman has already reached full cervical dilation and already lies at +2 station, the nurse should anticipate caring for the mother at the second stage of labor - The presenting part is now below the ischial spines. As the fetal head touches the internal side of the perineum, the perineum begins to bulge and appear tense. The circle enlarges until the fetus is pushed out of the birth canal - First stage of labor is incorrect because the first stage of labor starts from onset of regularly perceived uterine contractions and ends with full cervical dilation - Third stage of labor or the placental stage, follows after the expulsion of the infant and ends with the delivery of the placenta - The fourth stage of labor is incorrect because the fourth stage follows placental expulsion to 1-4 hours postpartum

An anemic woman, 34 weeks pregnant, is taking iron supplements. Which of the following foods should the patient take with iron? A) Carrots B) Fortified milk C) Orange juice D) Yogurt

ANSWER: C Explanation: - Consuming vitamin C rich foods, like orange juice, will increase the absorption of iron - Calcium containing foods such as milk and yogurt will decrease the absorption of iron - Carrots have no effect on iron absorption

A 30-year-old primipara is administered an epidural anesthesia. During the first hour of post-epidural anesthesia administration, which of the following signs and symptoms should be referred immediately to the anesthesiologist? A) Chills, and cold clammy skin B) Nausea and vomiting C) Respiratory distress D) Urinary frequency

ANSWER: C Explanation: - Epidural anesthesia can cause serious potentially life threatening complications, safe and effective management requires a coordinated multidisciplinary approach. It can cause respiratory depression if opioids are used. - Side effects of Epidural opioids may include nausea and vomiting, pruritus and delayed maternal depression. The possibility of late respiratory depression exists for up to 24 hours after the administration of an epidural opioid, depending on the duration of action of the drug used - Regonal pain control methods may be used for intrapartum analgesia, surgical anesthesia or both. These methods provide pain relief without loss of consciousness. Epidural provides pain control during much of labor and for birth itself

A 40-year-old, G7, P4, A2, 36 weeks pregnant was admitted because of complaints of vaginal bleeding.. She also noticed lack of fetal activity in the 3 days prior to admission. The nurse's first action is to: A) Ask for X-ray of the abdomen B) Ask for ultrasound examination C) Check for fetal heart tones D) Palpate for fetal movement

ANSWER: C Explanation: - Finding the fetal heart tones is the easiest way to check status of the pregnancy in this situation - If no fetal heart tones are noted, A sonogram is ordered to confirm fetal status - There will be no fetal activity if the fetus dies in utero - An x-ray of the abdomen will not assess whether the fetus is alive or not

The nurse is assessing a patient after delivery and finds the uterine fundus boggy and one centimeter above the umbilicus. Which of the following is the priority nursing intervention? A) Assess the perneal area B) Assess the vital signs C) Massage the uterus D) Notify the physician

ANSWER: C Explanation: - If there is uterine atony, the first priority intervention of the nurse is to control hemorrhage by attempting uterine massage to encourage contraction. Contraction will compress the vessels and reduce blood flow - Second priority is to notify the physician if the uterus remains uncontracted. The physician will order oxytocics to help the uterus maintain tone. - When the uterus is firm, observe the perineum for passage of clots and blood - Assess vital signs after ensuring that the uterus is well-contracted

A pregnant college student is waiting patiently to be discharged after being treated for premature uterine contractions. The nurse assesses the patient before discharge and notices a pool of blood under the patient's pelvis. The patient reports no pain, discomfort, or nausea. The nurse should do which of the following before discharging the patient? A) Ask the patient to "teach back" the discharge instructions to help confirm the patient's knowledge B) Explain to the patient that a small amount of blood is normal C) Stop the discharge and notify the physician D) Tell the patient to report any amount of bleeding while at home

ANSWER: C Explanation: - Painless, vaginal bleeding is indicative of placenta previa, a life-threatening condition that requires continued hospitalization and close monitoring. - Placenta previa is caused by implantation of the placenta over the internal os of the cervix. Severe bleeding is the main symptom of placenta previa, which most commonly occurs during the third trimester of pregnancy - The other three options are incorrect because painless bleeding is not normal. Although the teach back method is useful, the patient's immediate complication is the priority and discharge should be put on hold.

A patient was transported to the post-anesthesia care unite (PACU) after a cesarean section. The PACU nurse was informed that the patient received epidural anesthesia for the procedure. What is the safest position for this patient? A) Flat in bed B) Knee-chest position C) Semi-Fowler's position D) Sims position

ANSWER: C Explanation: - Post-operative patients who have received epidural anesthesia must be positioned in semi-Fowler's position to prevent upward migration of the opioid in the spinal cord, thus decreasing the risk for respiratory depression - The other options are inappropriate positions for patients who have received epidural anesthesia

A pregnant woman is attending a check up at the physician's office. The mother discovers that her child has chromosomal abnormalities and will be mentally and physically handicapped. The mother begins to cry. How should the nurse respond? A) Contact the social worker to provide the patient with resources B) Recommend a second opinion C) Sit with the patient and allow her to cry and express her feelings D) Suggest an elective termination of the pregnancy

ANSWER: C Explanation: - The mother is overwhelmed with the unexpected news. The nurse should provide comfort and support. - The nurse should wait to contact the social worker - Recommending a second opinion at this time may be premature. Let the patient adjust to the news - The nurse should not tell the patient what to do

A patient is on her third postpartum day when she tells the nurse that she sometimes has difficulty getting the infant to such. She describes the infant opening the mouth when the breast touches her face but turning the head in the opposite direction. The nurse correctly explains that this behavior is related to: A) The extrusion reflex, which is normal for newborns B) The infant's immaturity and unfamiliarity with the technique when positioning C) The rooting reflex, which suggests improper technique when positioning the infant D) Tonic neck reflex, which suggests breast fed infants are most sensitive to tactile stimulation

ANSWER: C Explanation: - The mother may have pressed the baby's face, not the cheek, against her breast. This will cause the child to turn away from the mother - Brushing the infant's cheek with a nipple stimulates the newborn's rooting reflex. The baby will then turn toward the breast - Tonic neck reflex is elicited through turning the newborn's head to the side. The arm on that side will extend while the opposite arm will contract. This prepares the infant for voluntary reaching and may be precursor to hand/eye coordination. - Extrusion reflex is not associated with feeding. A newborn will extrude any substance that is placed on the anterior portion of the tongue. This protective reflex prevents the swallowing of inedible substances

A newborn is admitted to the ICU with multiple heart defects. How can the nurse support the patient and her parent's needs? (Select all that apply) A) Ask the parents not to touch their child to keep a stress-free environment B) Assume the parents know about their child's disease C) Provide support during the grieving process by encouraging involvement D) Tell the parents they need to know how to do everything on their own

ANSWER: C Explanation: - The nurse should provide emotional support to the parents while encouraging them to support their child and be involved with their child's care - Parents need to be able to touch their child to provide comfort to them and the child - Never assume somebody knows about a certain illness or disease - Telling the parents they need to know everything may frighten them and place too much pressure on them

A patient has been prescribed to oral contraceptives. Which statement by the patient indicates the need for further education? A) "I need to take my pill everyday" B) "I will take my pill at the same time everyday" C) "Once I start this medication, I don't need to use condoms" D) "This pill will not protect me from sexually transmitted infections"

ANSWER: C Explanation: - The patient should be instructed to use a back up method of birth control for the first 7 days of taking oral contraceptives - The other option are all correct statements

A pregnant patient in her first trimester comes to the clinic concerned because she has urinary frequency and white vaginal discharge. The nurse's appropriate response to the woman is: A) "Are you practicing a polygamous relationship?" B) "This is an abnormal finding and could be associated with cervical cancer" C) "You don't have to worry, both are normal discomforts or pregnancy" D) "You might have a urinary tract infection and must see a doctor for antibiotic treatment"

ANSWER: C Explanation: - The pregnant woman may notice an increase in urinary frequency during the first 3 months of pregnancy until the uterus rises out of the pelvis. Frequency of urination may return at the end of pregnancy as lightening occurs and the fetal head exerts renewed pressure on the bladder - Leukorrhea, or white vaginal discharge is cause by an increase in estrogen. This results in elevated blood flow to the vagina and is considered normal during pregnancy - Due to the increased level of progesterone, the ureters increase in diameter and the bladder capacity increases to about 1,500 ml. The uterus tends to rise on the right side of the abdomen because it is pushed slightly in that direction b the greater bulk of the sigmoid colon - Pressure on the right ureter may lead to urinary stasis and pylonephritis if not relieved. Pressure on the urethra may lead to poor bladder emptying and bladder infection. Such infections are potentially dangerous to the pregnant woman because they can ascend to become kidney infections

A 9 week premature infant is prescribed I.V. theophylline. The mother asks how the medication works. The nurse responds knowing that theophylline: A) Increases alveoli perfusion B) Relaxes bronchial smooth muscle C) Stimulates alpha receptors in the arteries D) Stimulates baroreceptors

ANSWER: C Explanation: - Theophylline is a xanthine derivative similar to caffeine. It relaxes bronchial smooth muscles and stimulates the CNS and skeletal muscles - Theophylline and caffeine are commonly used on premature neonates with apnea

A new mother with pregnancy induced hypertension calls the hospital complaining of a severe headache and blurred vision. How should the nurse respond? A) Ask the patient how often she experiences these symptoms B) Tell the patient to drive to the hospital for an evaluation C) Tell the patient to hang up and call 911 immediately D) Tell the patient to take ibuprofen

ANSWER: C Explanation: - This patient is having symptoms of severe hypertension, which puts her at risk for seizures - The patient needs to be treated immediately in order to reduce her blood pressure and prevent complications - Pregnancy induced hypertension can last for several weeks after delivery

A newly married patient comes to the clinic suspecting that she is pregnant. The physician confirmed her pregnancy with an ultrasound. The nurse advises her to take calcium for her bones and for her unborn baby. What vitamin should also be taken to increase calcium absorption? A) Vitamin A B) Vitamin C C) Vitamin D D) Vitamin E

ANSWER: C Explanation: - Vitamin D increases calcium absorption in the GI tract - The recommended amount of calcium during pregnancy is 1,200 to 1,500 mg. Women under age 24 should aim for the higher end The skeleton and teeth constitute a major portion of the fetus. Initial calcification of the teeth occurs around 14 weeks.. Bones begin to calcify at 12 weeks. To supply adequate calcium and phosphorous for bone formation, pregnant women need to eat food high in calcium and vitamin D.

A nurse is caring for a patient in need of birth control. The patient questions the nurse about the proper method of using a diaphragm. Which of the following is correct? A) Spermicide is not needed B) The diaphragm is in place at all times C) The diaphragm should be left in place for 6 hours after intercourse D) The diaphragm should be removed immediately after intercourse

ANSWER: C Explanation: - Acting as a reservoir for spermicide, the diaphragm must be left in place for 6 hours after intercourse to be effective - Having the diaphragm in place at all times is not recommended - Not using spermicide or removing the diaphragm immediately after intercourse will decrease the effectiveness.

A patient has requested an oral contraceptive to reduce the risk of pregnancy. The physician prescribes ethinyl estradiol 30-drospirenone 3 to be cycled to 21 days and followed by a 7 day break. Which classification of contraceptive is ethinyl estradiol 30-drospienone 3? A) Extended cycle B) Implant C) Monophasic D) Multiphasic

ANSWER: C Explanation: - Ethinyl estradiol 30-drospirenone 3, trade name Yasmin, is a monophasic oral contraceptive - Monophasic contraceptives contain the same dose of estrogen and progesterone for the entire dosing schedule. The patient receives 21 days of the active drug, which is then followed by a 7 day period of a placebo to allow withdrawal bleeding. - Multiphasic contraceptives contain both estrogen and progesterone at different dosages throughout the cyle

During the first prenatal visit, a patient reports that the first day of her last menstrual cycle was October 16. Based on Naegele's rule, the nurse determines the expected day of delivery for the patient is: A) August 16 of the next year B) July 10 of the next year C) July 16 of the next year D) July 23 of the next year

ANSWER: D Explanation: - According to Naegele's rule you have to subtract 3 months and add 1 year and 7 days from the first day of the last menstrual period - The remaining choices do not follow Naegele's rule

The nurse is caring for a primagravida 1 para 0 client without complications who is near the end of the first stage of labor. Which nursing diagnosis is most appropriate at this time? A) Alteration in placental perfusion related to maternal positioning B) Anxiety related to negative experience with previous childbirth C) Anxiety related to frequent vaginal examinations D) Potential fluid volume deficit related to decreased intake of fluids

ANSWER: D Explanation: - Adequate intake of fluids and nourishment is needed to maintain hydration and energy during the early stage of labor. Traditionally fluids were restricted during labor to only ice chips due to the risk for aspiration should a maternal client require anesthesia; however, that practice has been challenged due the predominance of regional anesthesia for cesarean section - Regardless of unit policy, the nurse should recognize the clients have inadequate intake of fluids during the first stage of labor due to delayed gastric emptying and decrease PO intake. The nurse should allow the intake of clear fluids as tolerated or according to facility policy - For an uncomplicated labor, placental perfusion would not be hindered by the client who may reposition ad lib - Primagravida indicates this is the client's first pregnancy, so anxiety related to a previous delivery is not appropriate - Anxiety related to frequent vaginal examinations would not be appropriate for a client near the end of pregnancy

Which of the following should the nurse include in the plan of care for a pregnant patient with diabetes mellitus who is taking insulin? A) Administer the same dose of insulin B) Decrease the dose of insulin C) Discontinue the insulin D) Increase the dose of insulin after first trimester

ANSWER: D Explanation: - During pregnancy, a woman will need more insulin because her metabolic rate and needs increase after the first trimester - As pregnancy progresses, increasing fetal demands for glucose increases the risk of symptomatic hypoglycemia. Tight glucose monitoring is required - Approximately 3-10% of pregnancies are affected by abnormal glucose regulation - Gestational diabetes usually occurs midpoint of pregnancy when insulin resistance becomes noticeable

A 27-year-old primigravida asks the nurse how much iron she needs during her pregnancy. The correct response of the nurse is: A) 1 gram per day B) 150 mg per day C) 18 mg pere day D) 30 mg per day

ANSWER: D Explanation: - During pregnancy, approximately 30 mg of iron is needed per day - Non-pregnant women require about 18 mg of iron per dday - Iron is important in the information of hemoglobin to carry oxygen throughout the body. Iron will be transferred to the fetus even if maternal iron intake is inadequate, but this causes depletion of the mother's iron stores

A patient at 34 weeks gestation calls the hospital with concerns of leaking vaginal fluid. The nurse should: A) Advise her to have a prenatal check-up tomorrow B) Tell her not to panic, it is normal and advise her to report to the hospital once her uterine contractions are 5 minutes apart C) Tell her that she needs to be placed on home bed rest D) Tell her to report to the hospital immediately

ANSWER: D Explanation: - If the woman in early pregnancy experiences premature rupture of membranes, the fetus is in serious danger. After rupture, the seal to the fetus is lost and uterine and fetal infection may occur. It is necessary to report to the hospital immediately for prophylactic administration of broad spectrum antibiotics - Prophylactic administration of broad spectrum antibiotics may reduce risk of infection in the newborn - After being assessed by the doctor, the woman should be placed on home bed rest if labor does not begin and the fetus is too young to survive outside of the uterus - Advising her to have a prenatal check-up or telling her to report to the hospital once her uterine contractions are 5 minutes apart will pose major threat to the fetus. Delaying immediate care may put the fetus at risk for infection

A newborn has been admitted to the nursery shortly after birth. Nursing assessment reveals all of the following findings. Which finding should the nurse consider abnormal? A) Cyanosis of the hands and feet B) Mongolian spots on the buttocks C) Respiratory rate of 43 breaths per minute D) Visibile jaundice

ANSWER: D Explanation: - Jaundice during the first 24 hours after birth is always considered pathologic. Jaundice occurring after 24 hours lasting to day 8 is normal for term infants - Jaundice occurs due to an increase in serum bilirubin. This occurs in newborns because of several factors, including low enzyme activity used for the conversion and excretion of bilirubin, shorter life span of red blood cells, and low levels of intestinal flora resulting in high absorption rates of bilirubin - The other options are considered normal in the newborn

A pregnant woman is rushed to the hospital with vaginal bleeding, rapid thready pulse, rapid respirations, and falling blood pressure. After inserting a needle through the postvaginal fornix, the doctor confirmed a ruptured ectopic pregnancy. The nurse immediate action prior to surgery is to: A) Administer oxygen B) Give methotrexate per doctors order C) Obtain surgical consent D) Position the patient in trendelenburg while administering intravenous fluid using a large gauge catheter

ANSWER: D Explanation: - Once an ectopic pregnancy ruptures, it is an emergency situation and the woman's condition must be elevated quickly. Keep in mind that the amount of blood evident is a poor estimate of the actual blood loss - To keep blood to vital organs, immediately position the patient in the trendelenburg position with the feet higher than the head - After positioning the patient, intravenous fluids are administered using a large gauge catheter to restore intravascular volume. Blood can be administered through this same line as necessary - Although the therapy for a ruptured ectopic pregnancy is laparoscopy to ligate the bleeding vessels and to remove or repair the damaged fallopian tube, obtaining surgical consent is not top priority of the nurse. The physician should inform the patient and significant others of the diagnosis and its treatment options - If an ectopic pregnancy can be diagnosed b a routine sonogram before the tube has ruptured, it can be treated medically by oral methotrexate, followed by leucovorin. Methotrexate attacks and destroys fast growing cells

A 28-year-old primigravida goes to the clinic for her prenatal visit. Which of the following prenatal assessment procedures is not routinely included? A) Complete blood count B) HIV testing C) Nutritional needs D) Pelvimetry

ANSWER: D Explanation: - Pelvimetry is not routinely included in the prenatal assessment, unless the patient is at high risk - Pelvimetry assesses the female pelvis to help in determining the need for a C-section - HIV testing is not considered routine - History and a CBC are important data used to help pan the pregnancy and birth

A neonate in status epilepticus is administered phenobarbital. The nurse should be most concerned about which side effect? A) Dizziness B) Hypertensive crisis C) Rash D) Respiratory depression

ANSWER: D Explanation: - Phenobarbital, like all barbiturates, can cause severe respiratory and cardiac depression. The nurse should be prepared to administer oxygen or vasopressors - Dizziness and rash are both a potential side effects of phenobarbital, but they are not a concern in this scenario - Hypertensive crisis is not a known side effect of phenobarbital

A nurse is caring for a 3 day old infant with hyperbilrubinemia who is receiving phototherapy. A nursing action that would put the patient at risk would be to: A) Allow the parent to hold the infant to promote bonding B) Feed the infant every 2 hours C) Keep the eyes and genitalia covered throughout therapy D) Swaddle the infant to maintain body temperature

ANSWER: D Explanation: - Swaddling the infant is inappropriate. The infant receiving phototherapy must be exposed to the light. Eyes and genitalia should be covered - An infant's liver struggles to process bilirubin because the mother's circulation does this for the fetus. Upon birth, exposure to light triggers the liver to assume this function. Additional light speeds up the conversion potential of the liver - An infant receiving phototherapy should be removed from under the lights for feeding so that she/he continues to have interaction with the mother - Remove the eye patches during the time the infant is with the mother to give the infant a period of visual stimulation

A 34-year-old pregnant woman is in the clinic for her first trimester check-up. While assessing the patient's health history, the nurse should be most concerned about which of the following? A) Her father had Guillaine-Barre syndrome B) Her husband has type 1 diabetes C) She takes folic acid daily D) She takes over-the-counter medication

ANSWER: D Explanation: - Taking over-the-counter medications can be dangerous during pregnancy. The fetus is at high risk of developing deformities during the first trimester - Folic acid supplementation is encouraged during pregnancy to prevent fetal defects - Although Guillain-Barre and type 1 diabetes have a genetic link, they are not a concern during the prenatal period

A 31-year-old primipara reports to the nurse that she feels a soft spot on the head of her newly born baby. Which of the following responses would be appropriate? A) "It is uncommon but not a problem. It should heal within 12 months" B) "The baby may have experienced trauma on the head due to pressure of the cervix" C) "The bones of the skull must have not developed well. I will notify the physician immediately" D) "The soft spot you felt is an anterior fontanel, which normally closes at 12 to 18 months of age"

ANSWER: D Explanation: - The anterior fontanel will be felt as a soft spot. It should not appear indented or bulging. The anterior fontanel normally closes 12 to 18 months of age - The fontanels are the spaces or openings where the skull bones join. The anterior fontanel is located at the junction of the two parietal bones and the two fused frontal bones. It is diamond shaped - The posterior fontanel is located at the junction of the parietal bones and the occipital bones. The posterior fontanel is so small in some newborns that it cannot be palpated readily. The posterior fontanel closes by the end of the second month - The choice referencing head trauma refers to a cephalhematoma. This occurs due to the rupture of blood vessels crossing the periosteum (outer membrane of the bone). This is often caused by prolonged second stage of labor. The swelling is generally severe and is well outlined as an egg shape. It may be black and blue because of the presence of coagulated blood. - The part of the infant's head that engages the cervix molds to fit the cervix contours.

A pregnant woman is expecting to deliver in 2 months. She expresses concern about the immunization schedule for her upcoming baby, particularly the hepatitis B vaccine. Among the information below, which should be explained to the patient? A) Hepatitis B vaccine is a single-dose immunization that must be administered when the infant is 6 months old B) Hepatitis B should be given if the infant is diagnosed with a hepatitis B infection C) The first dose of hepatitis B vaccine for infants must be administered to the mother 1 month before delivery D) The first dose of hepatitis B vaccine for infants should be administered at birth

ANSWER: D Explanation: - The first dose of the hepatitis B vaccine is usually administered at birth, but it can also be given within the first 2 months of life. The second dose should be given 1 month after the first dose. The third dose must be given when the child is 6 to 18 months-old - Hepatitis B vaccine is not effective after the infant is already infected with hepatitis B. The vaccine is intended to prevent the hepatitis B infection, but it is not used as a curative agent in the presence of infection - If an infant is born to an infected mother, hepatitis B can be prevented if the infant receives hepatitis B immune globulin and the first dose of the hepatitis B vaccine within 12 hours of birth - The vaccine must be directly administered to the infant, not the mother

A woman planning on becoming pregnant is receiving education from the nurse. Which statement by the patient suggests that she understands fetal alcohol syndrome? A) "Beer is ok, since it is low in alcohol" B) "I can have a glass of wine with meals, since food absorbs the alcohol" C) "I have to drink a lot of alcohol to cause significant harm to my child" D) "If I consume alcohol, the baby can be harmed before I even know I'm pregnant"

ANSWER: D Explanation: - The first few weeks of fetal development is the period of highest risk for alcohol's teratogenic effects - Women planning to become pregnant should avoid alcohol - All alcohol consumption should be discouraged, even with meals Mnemonic: Tetratogenic Substances TAP CAP - Thalidomide - Alcohol - Progestins - Corticosteroids - Aspirin - Phenytoin

A nurse is preparing to bathe a full-term newborn for the first time since birth. The nurse should: A) Scrub the infant's skin to remove debris B) Use medicated soap C) Wait until the newborn's first void D) Wait until the newborn's vital signs are stabilized E) Wear gloves when handling the infant until after the first bath

ANSWER: D Explanation: - The infant's vital signs should be stable to prevent complications - The baby's body temperature should be at least 36.5 C (97.7 F) and the sponge bath should be given under a radiant heat source to prevent excessive heat loss - Gloves should be worn when assessing or caring for a newborn before the first bath to prevent exposure to bloodborne pathogens. Standard Precautions require handwashing before any infant care, but gloves are to be worn if there is risk of contact with body fluids (such as with diaper changes or circumcision care) - Medicated soap and scrubbing can irritate the infant's skin and cause abrasions - The nurse does not need to wait until the infant's first void

A woman receives a rebella vaccination while in the hospital. The nurse would give her which of the following instructions? A) Avoid breastfeeding the baby for at least 24 hours B) Limit contact with visitors for at least one week C) Refrain eating eggs and egg products for 48 hours D) Wait at least 28 days before becoming pregnant

ANSWER: D Explanation: - The rubella vaccine should not be administered to women who are pregnant or plan on becoming pregnant within 28 days. There is a theoretical possibility that the infant will contract congenital rubella syndrome. The patient should be instructed to use effective birth control for at least 28 days. - The patient does not have to refrain from eating eggs unless there is a history of anaphylaxis with eggs. Hypersensitivity to eggs is no longer a contraindication to the rubella vaccine - It is not necessary for the woman to avoid contact with others - The rubella vaccine may be given to women who are breastfeeding

Which of the following of Leopold's maneuvers should the nurse use to determine if the presenting part of the fetus is engaged? A) First maneuver B) Fourth maneuver C) Second maneuver D) Third maneuver

ANSWER: D Explanation: - The third maneuver determines the part of the fetus at the inlet and its mobility. If the presenting part moves upward so an examiner's hands can be pressed together, the presenting part is not engaged - The first maneuver determines fetal part lying in the fundus and the fetal presentation - The second maneuver determines which direction the fetus's back is facing - The fourth maneuver determines the fetal attitude and degree of flexion of the fetal head

After performing Leopold's maneuvers on a patient in labor, the nurse should prepare the patient for a vaginal delivery after determining if the fetus is in which of the following positions? A) Face presentations B) Oblique lie C) Transverse lie D) Vertex presentation

ANSWER: D Explanation: - The vertex presentation is the most favorable presentations for normal vaginal birth. The fetus's head is the first part to contact the cervix and the fetus' long axis is parallel with the long axis of the mother - Transverse lie poses a difficult presentation for vaginal birth. This would put both the mother and child in jeopardy. It is advisable to have a cesarean section since the fetus is lying horizontally in the pelvis - Oblique lie is a situation in which the long axis of the fetal body crosses that of the maternal body. If the fetal lie is not in line with the mother's spine, a Cesarean section may be required - In face presentation, the fetus has extended their head to make the face the presenting part. The presenting diameter is so wide that vaginal birth may be impossible

The nurse is caring for a newborn with a respiratory rate of 75 breaths/minute, heart rate of 182 beats/minute, and oxygen saturation of 88% on 2L via nasal cannula. The infant's blood glucose is 58. The physician requests that the infant be transferred to a level III NICU to provide adequate care. Which of the following is the best transportation option? A) Ambulance with a level 3 transport team B) Ambulance from the current hospital C) Ambulance with medical technicians D) Helicopter to the level III NICU

ANSWER: D Explanation: - This infant is in critical condition, a helicopter is the fastest way to transport the patient. Also, the helicopter is staffed with a specialized team and can provide necessary care immediately. - The remaining options do not provide a safe and quick means of transportation

What should the nurse document when a physician places a direct fetal scalp electrode? A) Fetal movements, time of placement & physician name B) Time of placement & fetal movements C) Time of placement, FHR, & fetal movements D) Time of placement, physician name, and FHR

ANSWER: D Explanation: - This is the most reliable way to measure FHR - When a fetal scalp electrode is placed by a physician, the nurse should document the time of placement, physician applying the electrode, & FHR - Fetal movements are irrelevant in this situation

A 25-year-old in her third trimester of pregnancy is rushed to the hospital for abrupt, painless bright red vaginal bleeding. The physician diagnoses placenta previa after an ultrasound. The nurse's immediate care measures are: A) Assess the duration of pregnancy and time bleeding began B) Do interval examination to check if the cervix is dilated C) Inspect the perineum for bleeding and estimate the present rate of blood loss D) Place the woman on bed rest in a side-lying position

ANSWER: D Explanation: - To ensure an adequate blood supply to the woman and the fetus, place the woman immediately on bed rest in a side lying position to relieve pressure of the vena cava Things to check in the subsequent assessment: - Duration of pregnancy - Determine if there was accompanying pain - Get estimate blood loss and blood color - Ask if other bleeding episodes occurred and preventative measures the patient took - Ask if the patient had prior cervical surgery - After assessment, inspect the perineum and weigh perineal pads before and after use - Pelvic or rectal examination should not be done with painless bleeding late in pregnancy because any agitation of the cervix may initiate massive hemorrhage that is fatal to the mother and infant

A patient comes to the clinic stating that she may be pregnant. The nurse knows that a pregnancy can be confirmed by: A) A positive urine test B) Amenorrhea C) Quickening D) hCG blood test

ANSWER: D Explanation: - hCG serum tests are the most commonly used assays for confirmation of pregnancy. It can detect pregnancy 8-10 days after conception - Presumptive signs of pregnancy are those that are least indicative of pregnancy. Taken as single entities, they often indicate other conditions. They are largely subjective in that they are experienced by the woman. Presumptive signs include amenorrhea and quickening - Probable signs of pregnancy can be documented by the examiner. Although they are more than the presumptive signs, they still are not positive or true diagnostic findings. Example is home pregnancy test

A pregnant patient has delayed her first prenatal visit. She visits the clinic only after she starts to experience edema in her hands and feet. You note in the obstetrical history that this is the patient's third pregnancy, the first two ending with the death of the fetus or embryo. The first time was 8 weeks pregnant and the second was 28 weeks. The correct record of her pregnancy is: A) Gravida 2, Para 0, Abortion 1 B) Gravida 2, Para 1, Abortion 1 C) Gravida 3, Para 0, Abortion 2 D) Gravida 3, Para 1, Abortion 1

ANSWER: D Explanation: - Gravida is number of times a woman has been pregnant regardless of the outcome of the pregnancy - Para is the number of births carried past 20 weeks, including viable and nonviable stillbirths - An abortion is defined as any interruption of a pregnancy before the fetus is viable (20 weeks gestation)

The nurse should perform which of the following nursing actions when a patient with preeclampsia has a seizure during the postpartum period? A) Give phenytoin, IV push, stat B) Insert a tongue blade in the patient's mouth C) Restrain the patient D) Stay with the patient, administer oxygen, position to prevent aspiration and maintain a safe environment

ANSWER:D Explanation: - The best choice is to stay with the patient, raise the handrails, and ensure safety of the patient from fall and injury - Administration of oxygen by face mask will help maintain adequate oxygenation and prevent bradycardia. To prevent aspiration, turn the woman on her side to allow secretions to drain from her mouth - Administering an anticonvulsant is not an independent nursing action and requires a physician's order - The priority care for the woman with a seizure is to maintain a patent airway. Inserting a tongue blade into the patient's mouth may predispose the patient to aspiration - Restraining may injure the patient and requires a physician's order