NUR 212 Test 1

4 Many mothers who consume approximately the same number of calories while breastfeeding as they did when they were pregnant do lose weight while breastfeeding.

A 2-day-postpartum breastfeeding woman states, "I am sick of being fat. When can I go on a diet?" Which of the following responses is appropriate? 1. "It is fine for you to start dieting right now as long as you drink plenty of milk." 2. "Your breast milk will be low in vitamins if you start to diet while breastfeeding." 3. "You must eat at least 3,000 calories per day in order to produce enough milk for your baby." 4. "Many mothers lose weight when they breastfeed because the baby consumes about 600 calories a day."

2 An assessment of the woman's fundus is the most important assessment to perform on this client.

A breastfeeding client, G10 P6408, delivered 10 minutes ago. Which of the following assessments is most important for the nurse to perform at this time? 1. Pulse. 2. Fundus. 3. Bladder. 4. Breast.

3 The abdominal wall is the appropriate placement for the skin thermal sensor.

A neonate is in the warming crib for poor thermoregulation. Which of the following sites is appropriate for the placement of the skin thermal sensor? 1. Xiphoid process. 2. Forehead. 3. Abdominal wall. 4. Great toe.

1 The gavage tubing must be measured to approximate the length of the insertion.

A nurse is inserting a gavage tube into a preterm baby who is unable to suck and swallow. Which of the following actions must the nurse take during the procedure? 1. Measure the distance from the tip of the ear to the nose. 2. Lubricate the tube with an oil-based solution. 3. Insert the tube quickly if the baby becomes cyanotic. 4. Inject a small amount of sterile water to check placement.

A. Assess for hypovolemia and notify the health care provider. Symptoms of hypovolemia include cool, clammy, pale skin, sensations of anxiety or impending doom, restlessness, and thirst. When these symptoms are present, the nurse should further assess for hypovolemia and notify the health care provider.

A nurse performs an assessment on a client who is 4 hours PP. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. The nurse prepares immediately to: A. Assess for hypovolemia and notify the health care provider B. Begin hourly pad counts and reassure the client C. Begin fundal massage and start oxygen by mask D. Elevate the head of the bed and assess vital signs

B

A nurse provides instructions to a new mother who is about to breast-feed her newborn infant. The nurse observes the new mother as she breast-feeds fo the first time and intervenes if the new mother: A. Turns the newborn infant on his side, facing the mother B. Tilts up the nipple or squeezes the areola, pushing it into the newborn's mouth C. Draws the newborn the rest of the way onto the breast when the newborn opens his mouth D. Places a clean finger in the side of the newborn's mouth to break the suction before removing the newborn from the breast.

B ~ The child is experiencing neglect when the parents take away the opportunity to attend school. The other children may also be experiencing physical neglect, but more data should be gathered before making the actual assessment. The information presented does not indicate a high risk for sexual abuse, and no concrete evidence of physical abuse is present.

A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, "I want to go to school, but we cant afford a babysitter. It doesn't matter; I'm too dumb to learn." What preliminary assessment is evident? a. Insufficient data are present to make an assessment. b. Child and siblings are experiencing neglect. c. Children are at high risk for sexual abuse. d. Children are experiencing physical abuse.

A ~ An abuse-prone individual is an individual who has experienced family violence and was often abused as a child. This phenomenon is part of the cycle of violence. The other options may be present but are not as predictive.

A patient tells the nurse, "My husband is abusive most often when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me."" What risk factor was most predictive for the husband to become abusive? a. History of family violence b. Loss of employment c. Abuse of alcohol d. Poverty

1 This woman has just been violated.It is essential that she be in a location where she feels safe.

A woman has just entered an emergency department after a stranger rape. Which of the following interventions is highest priority at this time? 1. Create a safe environment. 2. Offer postcoital contraceptive therapy. 3. Provide sexually transmitted disease prophylaxis. 4. Take a thorough health history.

3 Diaphoresis is normal during the post- partum period.

A woman, 24 hours postpartum, is complaining of profuse diaphoresis. She has no other complaints. Which of the following actions by the nurse is appropriate? 1. Take the woman's temperature. 2. Advise the woman to decrease her fluid intake. 3. Reassure the woman that this is normal. 4. Notify the neonate's pediatrician.

D (The nurse needs to understand that decreased immune functioning increases the risk for infection. Growth and development, thermoregulation, and feeding may be affected, although only indirectly.)

Because of the premature infant's decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant? a. Delayed growth and development b. Ineffective thermoregulation c. Ineffective infant feeding pattern d. Risk for infection

A. "Are you being threatened or hurt by your partner?" The use of simple, direct question, asked in an emphatic manner, is best to validate the presence of an abusive situation. Options B, C, and D: The other questions are indirect and may not lead to the discussion of an abusive situation.

During a prenatal assessment, the clinic nurse suspects that her client was abused. Which of the following questions would be most appropriate? A. "Are you being threatened or hurt by your partner?" B. "Are you frightened of your partner?" C. "Is something bothering you?" D. "What happens when you and your partner argue?"

1 The appropriate action is to provide the client with warm blankets.

Immediately after delivery, a woman is shaking uncontrollably. Which of the following nursing actions is most appropriate? 1. Provide the woman with warm blankets. 2. Put the woman in the Trendelenburg position. 3. Notify the primary health care provider. 4. Increase the intravenous infusion.

A. Peripheral vascular disease. These medications are avoided in clients with significant cardiovascular disease, peripheral disease, hypertension, eclampsia, or preeclampsia. These conditions are worsened by the vasoconstriction effects of these medications.

Methergine or Pitocin are prescribed for a client with PP hemorrhage. Before administering the medication(s), the nurse contacts the health provider who prescribed the medication(s) in which of the following conditions is documented in the client's medical history? A. Peripheral vascular disease B. Hypothyroidism C. Hypotension D. Type 1 diabetes

4 Broccoli is very high in vitamin A and also contains iron.

The nurse is caring for a breastfeeding mother who asks advice on foods that will provide both vitamin A and iron. Which of the following should the nurse recommend? 1. 1/2 cup raw celery dipped in 1 ounce cream cheese. 2. 8 ounce yogurt mixed with 1 medium banana. 3. 12 ounce strawberry milk shake. 4. 11/2 cup raw broccoli.

2 Prolactin will elevate sharply in the client's bloodstream.

The third stage of labor has just ended for a client who has decided to bottle feed her baby. Which of the following maternal hormones will increase sharply at this time? 1. Estrogen. 2. Prolactin. 3. Human placental lactogen. 4. Human chorionic gonadotropin.

B) Notify the physicianRationale: Normally, one may find a few small clots in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the most appropriate action is to notify the physician.

When performing a PP assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate? A) Document the findings B) Notify the physician C) Reassess the client in 2 hours D) Encourage increased intake of fluids

A, B, C These are all indications that a female child has been the victim of sexual abuse. Options D, E, and F are signs of physical abuse of a child, not sexual abuse.

Which nursing assessment findings are physical signs of sexual abuse of a female child? Select all that apply. A. Enuresis B. Red and swollen labia and rectum C. Vaginal tears D. Injuries in different stages of healing E. Cigarette burns F. Lice infestation

1 Fundal assessment is the priority nursing action.

Which of the following is the priority nursing action during the immediate postpartum period? 1. Palpate fundus. 2. Check pain level. 3. Perform pericare. 4. Assess breasts.

a

Which of the following tokens of remembrance would be appropriate for the nurse to provide to parents who are grieving the death of their infant? A. Lock of hair, footprints. B. Baptism or naming. C. Visit from chaplain. D. Sympathy card from staff.

D. Lochia rubra

Which type of lochia should the nurse expect to find in a client 2 days PP? A. Foul-smelling B. Lochia serosa C. Lochia alba D. Lochia rubra

c Rotating positions at feedings is one action that can help to minimize the severity of sore nipples.

A breastfeeding mother states that she has sore nipples. In response to the complaint, the nurse assists with "latch on" and recommends that the mother do which of the following? 1. Use a nipple shield at each breastfeeding. 2. Cleanse the nipples with soap 3 times a day. 3. Rotate the baby's positions at each feed. 4. Bottle feed for 2 days then resume breastfeeding.

4 The nurse should discuss the action of oxytocin.

A multigravid, postpartum woman reports severe abdominal cramping whenever she nurses her baby. Which of the following responses by the nurse is appropriate? 1. Suggest that the woman bottle feed for a few days. 2. Instruct the patient on how to massage her fundus. 3. Instruct the patient to feed using an alternate position. 4. Discuss the action of breastfeeding hormones.

D. Eight peripads per day. The normal amount of lochia may vary with the individual but should never exceed 4 to 8 peripads per day. The average number of peripads is 6 per day.

A nurse in a PP unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed the need for: A. One peripad per day B. Two peripads per day C. Three peripads per day D. Eight peripads per day

B. An indication of a maladaptive interaction is refusal to interact with or care for the infant. Options C and D identify situations in which the mother plans to or is demonstrating interaction with the infant. Expressing discomfort with the role of motherhood is not maladaptive.

A nurse is evaluating the mother-infant bonding process during the postpartum period. An indication of a maladaptive interaction would be if the mother: A. Expressed discomfort with the role of motherhood B. Encouraged the nurse to feed the baby because she continues to be too tired C. Showed that she was willing to learn how to care for the umbilical cord D. Talked to the baby

D. "I need to stop breastfeeding until this condition resolves." In most cases, the mother can continue to breastfeed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. Option A: Antibiotic therapy assists in resolving the mastitis within 24-48 hours Options B and C: Additional supportive measures include ice packs, breast supports, and analgesics.

A nurse is providing instructions to a mother who has been diagnosed with mastitis. Which of the following statements if made by the mother indicates a need for further teaching? 1. "I need to take antibiotics, and I should begin to feel better in 24-48 hours." 2. "I can use analgesics to assist in alleviating some of the discomfort." 3. "I need to wear a supportive bra to relieve the discomfort." 4. "I need to stop breastfeeding until this condition resolves."

3 ~ The most appropriate response by the nurse is to talk with the client about options so that the client does not have to return to the abusive environment. It is essential that clients make decisions on their own without the nurse being the rescuer. Imposing judgments and giving advice is non-therapeutic.

A woman comes to an emergency department with a broken nose and multiple bruises after being beaten by her husband. She states, "The beatings have been getting worse, and I'm afraid, next time, he will kill me." Which is the appropriate nursing response? 1. Leopards don't change their spots, and neither will he. 2. There are things you can do to prevent him from losing control. 3. Lets talk about your options so that you don't have to go home. 4. Why don't we call the police so that they can confront your husband with his behavior?

A. Ask the client to empty her bladder. A full bladder may displace the uterine fundus to the left or right side of the abdomen. Catheterization is unnecessary invasive if the woman can void on her own

On completing a fundal assessment, the nurse notes the fundus is situated on the client's left abdomen. Which of the following actions is appropriate? A. Ask the client to empty her bladder B. Straight catheterize the client immediately C. Call the client's health provider for direction D. Straight catheterize the client for half of her uterine volume

A, B, C (Risk factors for NEC include asphyxia, respiratory distress syndrome, umbilical artery catheterization, exchange transfusion, early enteral feedings, patent ductus arteriosus, congenital heart disease, polycythemia, anemia, shock, and gastrointestinal infection. Bronchopulmonary dysphasia and retinopathy are not associated with NEC.)

Risk factors associated with necrotizing enterocolitis (NEC) include (Select all that apply): a. Polycythemia. b. Anemia. c. Congenital heart disease. d. Bronchopulmonary dysphasia. e. Retinopathy.

d

The maternal newborn nurse interprets that anticipatory grieving is likely to occur in a client who has experienced which of the following situations? A. Sudden Infant Death Syndrome. B. Ectopic pregnancy. C. Placental abruption during labor. D. Fetal anomaly identified during pregnancy.

c The blood volume does drop precipi- tously during the early postpartum period.

The nurse monitors his or her postpartum clients carefully because which of the following physiological changes occurs during the early postpartum period? 1. Decreased urinary output. 2. Increased blood pressure. 3. Decreased blood volume. 4. Increased estrogen level.

A. Supplemental feedings with formula. Routine formula supplementation may interfere with establishing an adequate milk volume because decreased stimulation to the mother's nipples affects hormonal levels and milk production.

Which of the following factors might result in a decreased supply of breastmilk in a PP mother? A. Supplemental feedings with formula B. Maternal diet high in vitamin C C. An alcoholic drink D. Frequent feedings

1 This response is correct. Reassuring the client is appropriate.

A 1-day postpartum woman states, "I think I have a urinary tract infection. I have to go to the bathroom all the time." Which of the following actions should the nurse take? 1. Assure the woman that frequent urination is normal after delivery. 2. Obtain an order for a urine culture. 3. Assess the urine for cloudiness. 4. Ask the woman if she is prone to urinary tract infections.

C. The mother should NOT discontinue breast-feeding

A discharge nurse is discussing mastitis with a postpartum client. Which of the following statements by the client would indicate a need for further instruction? A. "If I develop a hot, reddened, triangle-shaped area on my breast, I should contact my healthcare provider." B. " I may develop mastitis if I wear underwire bras, experience excessive fatigue, or suddenly decrease the number of feedings." C."If I develop a fever, chills, or body aches at any time after discharge I should stop breast feeding immediately." D. "Antibiotics, rest, warm compresses, and adequate fluid intake are all important for the treatment of mastitis."

1 ~ The nurse should determine that a child who shrinks at the approach of adults in addition to having bruises and burns may be a victim of abuse. Maltreatment is considered, whether or not the adult intended to harm the child.

A kindergarten student is frequently violent toward other children. A school nurse notices bruises and burns on the child's face and arms. What other symptom should indicate to the nurse that the child may have been physically abused? 1. The child shrinks at the approach of adults. 2. The child begs or steals food or money. 3. The child is frequently absent from school. 4. The child is delayed in physical and emotional development.

2 The nurse should stabilize the base of the uterus with his or her dependent hand.

A nurse is assessing the fundus of a client during the immediate postpartum period. Which of the following actions indicates that the nurse is performing the skill correctly? 1. The nurse measures the fundal height using a paper centimeter tape. 2. The nurse stabilizes the base of the uterus with his or her dependent hand. 3. The nurse palpates the fundus with the tips of his or her fingers. 4. The nurse precedes the assessment with a sterile vaginal exam.

3 The client is exhibiting normal post- partum behavior.

A primipara, 2 hours postpartum, requests that the nurse diaper her baby after a feeding because "I am so tired right now. I just want to have something to eat and take a nap." Based on this information, the nurse concludes that the woman is exhibiting signs of which of the following? 1. Social deprivation. 2. Child neglect. 3. Normal postpartum behavior. 4. Postpartum depression.

2 This is an appropriate statement.

A woman is being seen in the gynecology clinic. The nurse notes that the woman has a swollen eye and a bruise on her cheek. Which of the following is an appropriate statement for the nurse to make? 1. "I am required by law to notify the police department of your injuries." 2. "Women who are abused often have injuries like yours." 3. "You must leave your partner before you are injured again." 4. "It is important that you refrain from doing things that anger your partner."

A. Soft, non-tender; colostrum is present. Breasts are essentially unchanged for the first two to three days after birth. Colostrum is present and may leak from the nipples

As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is one day postpartum. An expected finding would be: A. Soft, non-tender; colostrum is present B. Leakage of milk at let down C. Swollen, warm, and tender upon palpation D. A few blisters and a bruise on each areola

b

The client being seen for a postpartal exam after delivering a stillborn girl six weeks ago asks the nurse, "When will I feel normal?" The nurse's reply reflects the understanding that grief work takes approximately how long? A. Two to three months. B. About one year. C. Four to six months. D. Not more than eight months.

3 Preterm babies are born with an insufficient supply of brown adipose tissue that is needed for thermogenesis, or heat generation.

A 1-day-old neonate, 32 weeks' gestation, is in an overhead warmer. The nurse assesses the morning axillary temperature as 96.9°F. Which of the following could explain this assessment finding? 1. This is a normal temperature for a preterm neonate. 2. Axillary temperatures are not valid for preterm babies. 3. The supply of brown adipose tissue is incomplete. 4. Conduction heat loss is pronounced in the baby.

1 Clients should be strongly encouraged exclusively to breastfeed their babies to prevent engorgement.

A 3-day-postpartum breastfeeding woman is being assessed. Her breasts are firm and warm to the touch. When asked when she last fed the baby her reply is, "I fed the baby last evening. I let the nurses feed him in the nursery last night. I needed to rest." Which of the following actions should the nurse take at this time? 1. Encourage the woman exclusively to breastfeed her baby. 2. Have the woman massage her breasts hourly. 3. Obtain an order to culture her expressed breast milk. 4. Take the temperature and pulse rate of the woman.

1, 2, 3, and 5 are correct. 1. Bronchopulmonary dysplasia often is a consequence of the respiratory therapy that preemies receive in the NICU. 2. Cerebral palsy results from a hypoxic insult that likely occurred as a result of the baby's prematurity. 3. Retinopathy of the premature is a disease resulting from the immaturity of the vascular system of the eye. 5. Seizure disorders can result either from a hypoxic insult to the brain or from a ventricular bleed. Both of these conditions likely occurred as a result of the prematurity.

A 6-month-old child is being seen in the pediatrician's office. The child was born preterm and remained in the neonatal intensive care unit for the first 5 months of life. The child is being monitored for 5 chronic problems. Which of the following problems are directly related to the prematurity? Select all that apply. 1. Bronchopulmonary dysplasia. 2. Cerebral palsy. 3. Retinopathy. 4. Hypothyroidism. 5. Seizure disorders.

4 Because of the heavy lochia, the nurse should notify the woman's health care provider.

A G2 P2002, who is postpartum 6 hours from a spontaneous vaginal delivery, is assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia rubra, and perineal sutures are intact. Which of the following actions should the nurse take at this time? 1. Do nothing. This is a normal finding. 2. Massage the woman's fundus. 3. Take the woman to the bathroom to void. 4. Notify the woman's primary health care provider

B. Enlarged, hardened veins. Thrombosis of the superficial veins is usually accompanied by signs and symptoms of inflammation. These include swelling of the involved extremity and redness, tenderness, and warmth.

A PP nurse is assessing a mother who delivered a healthy newborn infant by C-section. The nurse is assessing for signs and symptoms of superficial venous thrombosis. Which of the following signs or symptoms would the nurse note if superficial venous thrombosis were present? A. Paleness of the calf area B. Enlarged, hardened veins C. Coolness of the calf area D. Palpable dorsalis pedis pulses

B. 3 days PP. After birth, the nurse should auscultate the woman's abdomen in all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days PP. Surgery, anesthesia, and the use of narcotics and pain control agents also contribute to the longer period of altered bowel function.

A PP nurse is providing instructions to a woman after delivery of a healthy newborn infant. The nurse instructs the mother that she should expect normal bowel elimination to return: A. One the day of the delivery B. 3 days PP C. 7 days PP D. within 2 weeks PP

4 This response is appropriate. The client should be examined to assess her involution.

A bottle-feeding woman, 11/2 weeks postpartum from a vaginal delivery, calls the obstetric office to state that she has saturated 2 pads in the past 1 hour. Which of the following responses by the nurse is appropriate? 1. "You must be doing too much. Lie down for a few hours and call back if the bleeding has not subsided." 2. "You are probably getting your period back. You will bleed like that for a day or two and then it will lighten up." 3. "It is not unusual to bleed heavily every once in a while after a baby is born. It should subside shortly." 4. "It is important for you to be examined by the doctor today. Let me check to see when you can come in."

3 This response is correct. The woman should be encouraged to use a lubricat- ing jelly or oil.

A breastfeeding client, 7 weeks postpartum, complains to an obstetrician's triage nurse that when she and her husband had intercourse for the first time after the delivery, "I couldn't stand it. It was so painful. The doctor must have done something terrible to my vagina." Which of the following responses by the nurse is appropriate? 1. "After a delivery the vagina is always very tender. It should feel better the next time you have intercourse." 2. "Does your baby have thrush? If so, you should be assessed for a yeast infection in your vagina." 3. "Women who breastfeed often have vaginal dryness. A vaginal lubricant may remedy your discomfort." 4. "Sometimes the stitches of episiotomies heal too tight. Why don't you come in to be checked?"

2 This statement is true. The best way to prevent engorgement is to feed the baby every 2 to 3 hours.

A breastfeeding woman has been counseled on how to prevent engorgement. Which of the following actions by the mother shows that the teaching was effective? 1. She pumps her breasts after each feeding. 2. She feeds her baby every 2 to 3 hours. 3. She feeds her baby 10 minutes on each side. 4. She supplements each feeding with formula

2 This is true. Oxytocin stimulates sexual orgasms and is also the hormone that stimulates the milk ejection reflex.

A breastfeeding woman, 11/2 months postdelivery, calls the nurse in the obstetrician's office and states, "I am very embarrassed but I need help. Last night I had an orgasm when my husband and I were making love. You should have seen the milk. We were both soaking wet. What is wrong with me?" The nurse should base the response to the client on which of the following? 1. The woman is exhibiting signs of pathological galactorrhea. 2. The same hormone stimulates orgasms and the milk ejection reflex. 3. The woman should have a serum galactosemia assessment done. 4. The baby is stimulating the woman to produce too much milk.

3 ~ The nurse should explain that a rapist uses weapons to terrorize and subdue the victim. Rape is the expression of power and dominance by means of sexual violence. Rape can occur over a broad spectrum of experience, from violent attack to insistence on sexual intercourse by an acquaintance or spouse.

A client asks, "Why does a rapist use a weapon during the act of rape?" Which is the most appropriate nursing response? 1. To decrease the victimizer's insecurity. 2. To inflict physical harm with the weapon. 3. To terrorize and subdue the victim. 4. To mirror learned family behavior patterns related to weapons.

3 This is the most important goal during the immediate postdelivery period.

A client has just been transferred to the postpartum unit from labor and delivery. Which of the following nursing care goals is of highest priority? 1. The client will breastfeed her baby every 2 hours. 2. The client will consume a normal diet. 3. The client will have a moderate lochial flow. 4. The client will ambulate to the bathroom every 2 hours.

3 This action can be delegated to a nursing assistant. Once the vital signs are checked, the nursing assistant can report the results to the nurse for his or her interpretation.

A client has just been transferred to the postpartum unit from labor and delivery. Which of the following tasks should the registered nurse delegate to the nursing care assistant? 1. Assess client's fundal height. 2. Teach client how to massage her fundus. 3. Take the client's vital signs. 4. Document quantity of lochia in the chart

4 and 5 are correct. The mother should be advised to wear a supportive bra 24 hours a day for a week or so. The mother should be advised to stand with her back toward the warm shower water.

A client informs the nurse that she intends to bottle feed her baby. Which of the following actions should the nurse encourage the client to perform? Select all that apply. 1. Increase her fluid intake for a few days. 2. Massage her breasts every 4 hours. 3. Apply heat packs to her axillae. 4. Wear a supportive bra 24 hours a day. 5. Stand with her back toward the shower water.

1, 2, and 4 are correct. A buccal swab may be taken. The woman's DNA must be ruled out when compared to any specimens obtained. Pubic hair samples may be obtained. These are compared with any specimens taken. Head hair samples are obtained. These are compared with any specimens taken.

A client is being seen following a sexual assault. A rape examination is being con- ducted. Which of the following specimens may be collected from the victim during the examination? Select all that apply. 1. Buccal swab for genetic analysis. 2. Samples of pubic hair. 3. Toenail scrapings. 4. Samples of head hair. 5. Sputum for microbiological analysis

2 ~ The most appropriate nursing action is to remain nonjudgmental and actively listen to the clients description of the event. It is important to also communicate to the victim that he/she is safe and that it is not his/her fault. Nonjudgmental listening provides an avenue for catharsis, which contributes to the healing process.

A client is brought to an emergency department after being violently raped. Which nursing action is appropriate? 1. Discourage the client from discussing the rape, because this may lead to further emotional trauma. 2. Remain nonjudgmental while actively listening to the client's description of the violent rape event. 3. Meet the client's self-care needs by assisting with showering and perineal care. 4. Probe for further, detailed description of the rape event.

C. Multiple gestation. Multiple gestation, breastfeeding, multiparity, and conditions that cause overdistention of the uterus will increase the intensity of after-pains. Options A and B: Bottle-feeding and diabetes aren't directly associated with increasing severity of afterpains unless the client has delivered a macrosomic infant.

A client is complaining of painful contractions, or after pains, on postpartum day 2. Which of the following conditions could increase the severity of afterpains? A. Bottle-feeding B. Diabetes C. Multiple gestation D. Primiparity

2 This is the best response. A right mediolateral episiotomy is angled away from the perineum and rectum.

A client who delivered a 3,900-gram baby vaginally over a right mediolateral episiotomy states, "How am I supposed to have a bowel movement? The stitches are right there!" Which of the following is the best response by the nurse? 1. "I will call the doctor to order a stool softener for you." 2. "Your stitches are actually far away from your rectal area." 3. "If you eat high-fiber foods and drink fluids you should have no problems." 4. "If you use your topical anesthetic on your stitches you will feel much less pain."

1 This response is correct. The couple is encouraged to wait until after involu- tion is complete.

A client who is 3 days postpartum asks the nurse, "When may my husband and I begin having sexual relations again?" The nurse should encourage the couple to wait until after which of the following has occurred? 1. The client has had her six-week postpartum checkup. 2. The episiotomy has healed and the lochia has stopped. 3. The lochia has turned to pink and the vagina is no longer tender. 4. The client has had her first postpartum menstrual period.

4 ~ The nursing supervisor is accurate when stating that clients who are in abuse relationships are paralyzed into inaction by a combination of physical threats and a sense of powerlessness. Women often choose to stay with an abusive partner: for the children, for financial reasons, for fear of retaliation, for lack of a support network, for religious reasons, or because of hopefulness.

A client who is in a severely abusive relationship is admitted to a psychiatric inpatient unit. The client fears for her life. A staff nurse asks, "Why doesn't she just leave him?" Which is the nursing supervisors most appropriate response? 1. These clients don't know life any other way, and change is not an option until they have improved insight. 2. These clients have limited cognitive skills and few vocational abilities to be able to make it on their own. 3. These clients often have a lack of financial independence to support themselves and their children, and most have religious beliefs prohibiting divorce and separation. 4. These clients are paralyzed into inaction by a combination of physical threats and a sense of powerlessness.

4 This statement is correct. The client should begin with Kegel exercises shortly after delivery, move to abdominal tightening exercises in the next couple of days, and then slowly progress to stomach crunches, and so on.

A client, 2 days postpartum from a spontaneous vaginal delivery, asks the nurse about postpartum exercises. Which of the following responses by the nurse is appropriate? 1. "You must wait to begin to perform exercises until after your six-week postpartum checkup." 2. "You may begin Kegel exercises today, but do not do any other exercises until the doctor tells you that it is safe." 3. "By next week you will be able to return to the exercise schedule you had during your prepregnancy." 4. "You can do some Kegel exercises today and then slowly increase your toning exercises over the next few weeks."

2 This action is the first that the nurse should take.

A client, G1 P0101, postpartum 1 day, is assessed. The nurse notes that the client's lochia rubra is moderate and her fundus is boggy 2 cm above the umbilicus and deviated to the right. Which of the following actions should the nurse take first? 1. Notify the woman's primary health care provider. 2. Massage the woman's fundus. 3. Escort the woman to the bathroom to urinate. 4. Check the quantity of lochia on the peripad.

4 This response shows that the nurse has an understanding of the client's feelings.

A client, G1 P1, who had an epidural, has just delivered a daughter, Apgar 9/9, over a mediolateral episiotomy. The physician used low forceps. While recovering, the client states, "I'm a failure. I couldn't stand the pain and couldn't even push my baby out by myself!" Which of the following is the best response for the nurse to make? 1. "You'll feel better later after you have had a chance to rest and to eat." 2. "Don't say that. There are many women who would be ecstatic to have that baby." 3. "I am sure that you will have another baby. I bet that it will be a natural delivery." 4. "To have things work out differently than you had planned is disappointing."

4 This is the appropriate action by the nurse.

A client, G1 P1001, 1 hour postpartum from a spontaneous vaginal delivery with local anesthesia, states that she needs to urinate. Which of the following actions by the nurse is appropriate at this time? 1. Provide the woman with a bedpan. 2. Advise the woman that the feeling is likely related to the trauma of delivery. 3. Remind the woman that she still has a catheter in place from the delivery. 4. Assist the woman to the bathroom.

3 This action is very important. If the legs are removed from the stirrups one at a time then the woman is at high risk for back and abdominal injuries.

A client, G2 P1102, is 30 minutes postpartum from a low forceps vaginal delivery over a right mediolateral episiotomy. Her physician has just finished repairing the incision. The client's legs are in the stirrups and she is breastfeeding her baby. Which of the following actions should the nurse perform? 1. Assess her feet and ankles for pitting edema. 2. Advise the client to stop feeding her baby while her blood pressure is assessed. 3. Lower both of her legs at the same time. 4. Measure the length of the episiotomy and document the findings in the chart.

1 ~ The client who realizes that sexual assault was not her fault is handling the situation in a healthy manner. The nurse should provide nonjudgmental listening and communicate statements that instill trust and validate self-worth.

A college student was sexually assaulted when out on a date. After several weeks of crisis intervention therapy, which client statement should indicate to a nurse that the student is handling this situation in a healthy manner? 1. I know that it was not my fault. 2. My boyfriend has trouble controlling his sexual urges. 3. If I don't put myself in a dating situation, I won't be at risk. 4. Next time I will think twice about wearing a sexy dress.

C. Impaired parenting, related to role reversal of mother and child. The role of a 12-year-old child in a family should not be that of a parent. In this situation, the child and mother have reversed roles. Options A, B, and D: There is no evidence that the child has delayed growth or development, the mother in this situation is not demonstrating signs of anxiety, and there is no evidence in this situation that the family is socially isolated.

A community nurse conducts a primary prevention, home-visit assessment for a newborn and mother. Mrs. Smith has three other children, the oldest of whom is age 12. She tells the nurse that her 12-year-old daughter is expected to prepare family meals, to look after the young children, and to clean the house once a week. Which of the following is the most appropriate nursing diagnosis for this family situation? A. Delayed growth and development, related to performance expectations of the child. B. Anxiety (moderate), related to difficulty managing the home situation. C. Impaired parenting, related to the role reversal of mother and child. D. Social isolation, related to lack of extended family assistance.

A. Family violence affects every socioeconomic level. Family violence occurs in all socioeconomic levels, races, religions, and cultural groups. Option B: Although violence is associated with substance abuse, it is not the singular cause. Option C: The statement that the family violence predominantly occurs in lower socioeconomic levels is false. Option D: Abuse often occurs during pregnancy; about 23% of all pregnant women seeking prenatal care are victims of abuse.

A group of nursing students at Nurseslabs University is currently learning about family violence. Which of the following is true about the topic mentioned? A. Family violence affects every socioeconomic level. B. Family violence is caused by drugs and alcohol abuse. C. Family violence predominantly occurs in lower socioeconomic levels. D. Family violence rarely occurs during pregnancy.

1, 2, 3, and 4 are correct. 1. Babies with NEC have blood in their stools. 2. The abdominal girth measurements of babies with NEC increase. 3. When babies have NEC, they have increasingly larger undigested gastric contents after feeds. 4. The neonates' bowel sounds are diminished with NEC.

A neonate is being assessed for necrotizing enterocolitis (NEC). Which of the following actions by the nurse is appropriate? Select all that apply. 1. Perform hemoccult test on stools. 2. Monitor for an increase in abdominal girth. 3. Measure gastric contents before each feed. 4. Assess bowel sounds before each feed. 5. Assess for anal fissures daily.

C. Prepare the client for surgery. The use of an epidural, prolonged second stage labor and forceps delivery are predisposing factors for hematoma formation, and a collection of up to 500 ml of blood can occur in the vaginal area. Although the other options may be implemented, the immediate action would be to prepare the client for surgery to stop the bleeding.

A new mother received epidural anesthesia during labor and had a forceps delivery after pushing 2 hours. At 6 hours PP, her systolic blood pressure has dropped 20 points, her diastolic BP has dropped 10 points, and her pulse is 120 beats per minute. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider, the nurse immediately plans to: A. Monitor fundal height B. Apply perineal pressure C. Prepare the client for surgery. D. Reassure the client

B(The nurse is instrumental in the initial interactions with the infant. The nurse can help the parents "see" the infant, rather than focus on the equipment. The importance and purpose of the apparatus that surrounds their infant also should be explained to them. Parents often need encouragement and recognition from the nurse to acknowledge the reality of the infant's condition. Parents need to see and touch their infant as soon as possible to acknowledge the reality of the birth and the infant's appearance and condition. Encouragement from the nurse is instrumental in this process. Telling the parents only about the newborn's physical condition and cautioning them to avoid touching their baby is an inappropriate action.)

A newborn was admitted to the neonatal intensive care unit after being delivered at 29 weeks of gestation to a 28-year-old multiparous, married, Caucasian woman whose pregnancy was uncomplicated until premature rupture of membranes and preterm birth. The newborn's parents arrive for their first visit after the birth. The parents walk toward the bedside but remain approximately 5 feet away from the bed. The nurse's most appropriate action would be to: a. Wait quietly at the newborn's bedside until the parents come closer. b. Go to the parents, introduce himself or herself, and gently encourage the parents to come meet their infant; explain the equipment first, and then focus on the newborn. c. Leave the parents at the bedside while they are visiting so they can have some privacy. d. Tell the parents only about the newborn's physical condition, and caution them to avoid touching their baby.

C. Holding the infant close so that body warmth can be felt initiates a positive experience for the parent. It is also self-quieting and consoles the infant. The use of a high-pitched voice and participating in infant care promote parental-infant attachment. Infants should not be allowed to sleep between the parents, not only because of the danger of suffocation but also because the parent's will require meaningful rest and time to be alone as a couple.

A nurse assigned to care for a postpartum client plans to promote parental-infant bonding by encouraging the parents to: A. Use a low-pitched voice to speak to the infant B. Allow the nursing staff to assume the infant care during hospitalization so they may rest C. Hold and cuddle the infant closely D. Allow the infant to sleep in the parental bed between the parents

B Salty water is a slang/street name for GHB (g-hydroxy-butyric acid), a Schedule III central nervous system depressant associated with rape. Use of alcohol would produce an increased risk for respiratory depression. GHB has a duration of 1-12 hours, but the duration is less important that the potential for respiratory depression. Seeking evidence is less important than the victim's physiologic stability.

A nurse in the emergency department assesses an unresponsive victim of rape. The victim's friend reports, "That guy gave her salty water before he raped her." Which question is most important for the nurse to ask of the victim's friend? a. "Does the victim have any kidney disease?" b. "Has the victim consumed any alcohol?" c. "What time was she given salty water?" d. "Did you witness the rape?"

B. Tachypnea and retractions The infant with respiratory distress syndrome may present with signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts.

A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome? A. Hypotension and Bradycardia B. Tachypnea and retractions C. Acrocyanosis and grunting D. The presence of a barrel chest with grunting

D The patient's statements reflect use of denial, an ego defense mechanism. This mechanism may be used unconsciously to protect the person from the emotionally overwhelming reality of the rape. The patient's statements do not reflect somatization, compensation, or projection.

A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The patient says, "I can't talk about it. Nothing happened. I have to forget." What is the patient's present coping strategy? a. Compensation c. Projection b. Somatization d. Denial

C. Changes in vital signs. Changes in vitals indicate hypovolemia in the anesthetized PP woman with vulvar hematoma. Options A and B: Because the woman has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Option D: Heavy bruising may be visualized, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues.

A nurse is caring for a PP woman who has received epidural anesthesia and is monitoring the woman for the presence of a vulva hematoma. Which of the following assessment findings would best indicate the presence of a hematoma? A. Complaints of a tearing sensation B. Complaints of intense pain C. Changes in vital signs D. Signs of heavy bruising

D. Prepare an ice pack for application to the area. Application of ice will reduce swelling caused by hematoma formation in the vulvar area. Options A, B, and C: The other options are not interventions that are specific to the plan of care for a client with a small vulvar hematoma.

A nurse is developing a plan of care for a PP woman with a small vulvar hematoma. The nurse includes which specific intervention in the plan during the first 12 hours following the delivery of this client? A. Assess vital signs every 4 hours B. Inform health care provider of assessment findings C. Measure fundal height every 4 hours D. Prepare an ice pack for application to the area.

B. An increase in the pulse from 88 to 102 BPM. During the 4th stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. Option A: A slight rise in temperature is normal. The respiratory rate is increased slightly. Option D: The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage.

A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the following signs, if noted in the mother, would be an early sign of excessive blood loss? A. A temperature of 100.4*F B. An increase in the pulse from 88 to 102 BPM C. An increase in the respiratory rate from 18 to 22 breaths per minute D. A blood pressure change from 130/88 to 124/80 mm Hg

C. Scant= <1 inch on pad in 1 hour Light = <4 inches on pad in 1 hour Moderate= <6 inches on pad in 1 hour Heavy= Saturated pad in 1 hour Excessive= Saturated pad in 15 minutes

A nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 1 hour. The nurse reports the amount of lochial flow as: A. Scant B. Light C. Heavy D. Excessive

C. Hematoma is suspected when the client reports pain or pressure in the vulvar area. Massive hemorrhage into the tissues can occur, resulting in hypovolemia and shock; therefore the clients complaints must be assessed so that interventions can begin immediately.

A nurse is performing an assessment on a 2-day postpartum mother. The mother complains of severe pain and an intense feeling of swelling and pressure in the vulvar area. After hearing these complaints the nurse specifically checks the client's... A. Episiotomy for drainage B. Rectum for hemorrhoids C. Vulva for a hematoma D. Vagina for lacerations

B, D, and E. Mastitis are an infection of the lactating breast. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3 L a day, and taking analgesics to relieve discomfort. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. Option A: Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. Option C: Continued decompression of the breast by breastfeeding or pumping is important to empty the breast and prevent formation of an abscess.

A nurse is preparing a list of self-care instructions for a PP client who was diagnosed with mastitis. Select all instructions that would be included on the list. A. Take the prescribed antibiotics until the soreness subsides. B. Wear supportive bra C. Avoid decompression of the breasts by breastfeeding or breast pump D. Rest during the acute phase E. Continue to breastfeed if the breasts are not too sore.

A. Massage the fundus until it is firm. If the uterus is not contracted firmly, the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Options B and D: Elevating the client's legs and encouraging the client to void will not assist in managing uterine atony. If the uterus does not remain contracted as a result of the uterine massage, the problem may be distended bladder and the nurse should assist the mother to urinate, but this would not be the initial action. Option C: Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage.

A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. When the nurse locates the fundus, she notes that the uterus feels soft and boggy. Which of the following nursing interventions would be most appropriate initially? A. Massage the fundus until it is firm B. Elevate the mother's legs C. Push on the uterus to assist in expressing clots D. Encourage the mother to void

C) Ask the mother to urinate and empty her bladder Rationale: Before starting the fundal assessment, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. When the nurse is performing fundal assessment, the nurse asks the woman to lie flat on her back with the knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy and soft, and then it should be massaged gently until firm.

A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following? A) Ask the client to turn on her side B) Ask the client to lie flat on her back with the knees and legs flat and straight C) Ask the mother to urinate and empty her bladder D) Massage the fundus gently before determining the level of the fundus.

C. Ask the mother to urinate and empty her bladder. Before starting the fundal assessment, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. Options A and B: When the nurse is performing a fundal assessment, the nurse asks the woman to lie flat on her back with the knees flexed. Option D: Massaging the fundus is not appropriate unless the fundus is boggy and soft, and then it should be massaged gently until firm.

A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following? A. Ask the client to turn on her side B. Ask the client to lie flat on her back with the knees and legs flat and straight. C. Ask the mother to urinate and empty her bladder D. Massage the fundus gently before determining the level of the fundus.

A.Vital signs are to return to normal within the first hour postpartum if no complication arise. If the temperature is greater than 2F above normal this may indicate infection, and the physician should be notified. Options B, C, and D are inaccurate nursing interventions for the client's temperature of 102F 2 hours following delivery.

A nurse obtains the vital signs on a mother who delivered a healthy newborn infant 2 hours ago and notes that the mother's temperature is 102 F. The appropriate nursing action would be to: A. Notify the physician B. Remove the blanket from the client's bed C. Document the finding and recheck the temperature in 4 hours. D. Administer Acetaminophen (Tylenol) and recheck the temperature in 4 hours.

1 ~ The nursing instructor should include the concept that power and control are central to the dynamic of domestic violence. Battering is defined as a pattern of coercive control founded on physical and/or sexual violence or threat of violence. The typical abuser is very possessive and perceives the victim as a possession.

A nursing instructor is developing a lesson plan to teach about domestic violence. Which information should be included? 1. Power and control are central to the dynamic of domestic violence. 2. Poor communication and social isolation are central to the dynamic of domestic violence. 3. Erratic relationships and vulnerability are central to the dynamic of domestic violence. 4. Emotional injury and learned helplessness are central to the dynamic of domestic violence.

1, 2, 4 ~ Intimate partner violence is a pattern of abusive behavior that is used by an intimate partner. It is used to gain power and control over the other intimate partner. Women ages 25 to 34 experience the highest per capita rates of intimate violence. Eighty-five percent of victims of intimate violence are women. Battered women represent all age, racial, religious, cultural, educational, and socioeconomic groups. They may be married or single, housewives or business executives.

A nursing instructor is teaching about intimate partner violence. Which of the following student statements indicate that learning has occurred? (SATA) 1. Intimate partner violence is a pattern of abusive behavior that is used by an intimate partner. 2. Intimate partner violence is used to gain power and control over the other intimate partner. 3. Fifty-one percent of victims of intimate violence are women. 4. Women ages 25 to 34 experience the highest per capita rates of intimate violence. 5. Victims are typically young married women who are dependent housewives.

A ~ The diagnosis of a concussion suggests violence as a cause. The patient is exhibiting indicators of abuse including fearfulness, depressed affect, poor eye contact, and a possessive spouse. The patient may be also experiencing depression, anxiety, and migraine headaches, but the nurses advocacy role necessitates an assessment for intimate partner violence.

A patient at the emergency department is diagnosed with a concussion. The patient is accompanied by a spouse who insists on staying in the room and answering all questions. The patient avoids eye contact and has a sad affect and slumped shoulders. Assessment of which additional problem has priority? a. Risk of intimate partner violence b. Phobia of crowded places c. Migraine headaches d. Major depression

4 It is likely that this client is dehydrated. She should be advised to drink fluids.

A patient, G2 P1102, who delivered her baby 8 hours ago, now has a temperature of 100.2°F. Which of the following is the appropriate nursing intervention at this time? 1. Notify the doctor to get an order for acetaminophen. 2. Request an infectious disease consult from the doctor. 3. Provide the woman with cool compresses. 4. Encourage intake of water and other fluids

2. Every 15 minutes during the first hour and then every 30 minutes for the next two hours.

A postpartum nurse is preparing to care for a woman who has just delivered a healthy newborn infant. In the immediate postpartum period the nurse plans to take the woman's vital signs: A. Every 30 minutes during the first hour and then every hour for the next two hours. B. Every 15 minutes during the first hour and then every 30 minutes for the next two hours. C. Every hour for the first 2 hours and then every 4 hours D. Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours.

D. Increase hydration by encouraging oral fluids. The mother's temperature may be taken every 4 hours while she is awake. Temperatures up to 100.4 F (38 C) in the first 24 hours after birth are often related to the dehydrating effects of labor. The most appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Option C: Although the nurse would document the findings, the most appropriate action would be to increase the hydration.

A postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours ago. The nurse notes that the mother's temperature is 100.2*F. Which of the following actions would be most appropriate? A. Retake the temperature in 15 minutes B. Notify the physician C. Document the findings D. Increase hydration by encouraging oral fluids

A(Surfactant can be administered as an adjunct to oxygen and ventilation therapy. With administration of artificial surfactant, respiratory compliance is improved until the infant can generate enough surfactant on his or her own. Surfactant has no bearing on the sedation needs of the infant. Surfactant is used to improve respiratory compliance, including the exchange of oxygen and carbon dioxide. The goal of surfactant therapy in an infant with respiratory distress syndrome (RDS) is to stimulate production of surfactant in the type 2 cells of the alveoli. The clinical presentation of RDS and neonatal pneumonia may be similar. The infant may be started on broad-spectrum antibiotics to treat infection.)

A premature infant with respiratory distress syndrome receives artificial surfactant. How would the nurse explain surfactant therapy to the parents? a. "Surfactant improves the ability of your baby's lungs to exchange oxygen and carbon dioxide." b. "The drug keeps your baby from requiring too much sedation." c. "Surfactant is used to reduce episodes of periodic apnea." d. "Your baby needs this medication to fight a possible respiratory tract infection."

B. Provide time for the mother to reflect on the events of and her behavior during childbirth. The focus of the taking-in stage is nurturing the new mother by meeting her dependency needs for rest, comfort, hygiene, and nutrition. Once they are met, she is more able to take an active role, not only in her own care but also the care of her newborn. Women express a need to review their childbirth experience and evaluate their performance. Short teaching sessions, using written materials to reinforce the content presented, are a more effective approach.

A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment following birth. The nurse, recognizing the needs of women during this stage, should: A. Foster an active role in the baby's care B. Provide time for the mother to reflect on the events of and her behavior during childbirth C. Recognize the woman's limited attention span by giving her written materials to read when she gets home rather than doing a teaching session now D. Promote maternal independence by encouraging her to meet her own hygiene and comfort needs

A Although the victim may have made choices that made her vulnerable, she is not to blame for the rape. Correcting this distortion in thinking allows the victim to begin to restore a sense of control. This is a positive response to victimization. The distracters do not permit the victim to begin to restore a sense of control or offer use of non-therapeutic communication techniques. In this interaction, the victim needs to talk about feelings rather than prevention.

A rape victim says to the nurse, "I always try to be so careful. I know I should not have walked to my car alone. Was this attack my fault?" Which communication by the nurse is most therapeutic? a. Support the victim to separate issues of vulnerability from blame. b. Emphasize the importance of using a buddy system in public places. c. Reassure the victim that the outcome of the situation will be positive. d. Pose questions about the rape and help the patient explore why it happened.

D A reflective communication technique is most helpful. Looking at one's role in the event serves to explain events that the victim would otherwise find incomprehensible. The distracters discount the victim's perceived role and interfere with further discussion.

A rape victim tells the nurse, "I should not have been out on the street alone." Select the nurse's most therapeutic response. a. "Rape can happen anywhere." b. "Blaming yourself increases your anxiety and discomfort." c. "You are right. You should not have been alone on the street at night." d. "You feel as though this would not have happened if you had not been alone."

3 ~ This client is most likely demonstrating a controlled response pattern. In the controlled response pattern, the client's feelings are masked or hidden, and a calm, composed, or subdued affect is seen. In the expressed response pattern, feelings of fear, anger, and anxiety are expressed through crying sobbing, smiling, restlessness, and tension.

A raped client answers a nurses questions in a monotone voice with single words, appears calm, and exhibits a blunt affect. How should the nurse interpret this clients responses? 1. The client may be lying about the incident. 2. The client may be experiencing a silent rape reaction. 3. The client may be demonstrating a controlled response pattern. 4. The client may be having a compounded rape reaction.

A.Culture and sensitivity results should be obtained before any antibiotic therapy is begun to avoid masking the microorganisms identified in the culture. Options B and D are standard parts of therapy for this type of infection but are not completed first. Although the client's temperature is monitored, checking the temperature is not the first action.The data in the question indicate that the temperature has already been checked.

A second-day postpartum client with diabetes mellitus has scant lochia with a foul odor and a temperature of 101.6 degrees F. The physician suspects infection and writes orders to treat the client. Which of the following orders written by the physician would the nurse complete first? A. Obtain culture and sensitivity of lochia and urine B. Administer Ceftriaxone (Rocephin) C. Check the client's temperature D. Increase the intake of oral fluids.

3 ~ The nurse should recognize that this client is exhibiting an expressed response pattern. In the expressed response pattern, feelings of fear, anger, and anxiety are expressed through crying, sobbing, smiling, restlessness, and tension. In the controlled response pattern, the client's feelings are masked or hidden, and a calm, composed, or subdued affect is seen.

A survivor of rape presents in an emergency department crying, pacing, and cursing her attacker. A nurse should recognize these client actions as which behavioral defense? 1. Controlled response pattern 2. Compounded rape reaction 3. Expressed response pattern 4. Silent rape reaction

B ~ The only outcome indicator clearly attainable within this time is for a staff member to provide the victim with information about community resources that can be contacted. The development of insight into the abusive relationship requires time. Securing a restraining order can be quickly accomplished but not while the patient is in the emergency department. Facilitating the abuser's counseling may require weeks or months.

A victim of physical abuse by an intimate partner is treated for a broken wrist. The patient has considered leaving but says, "You stay together, no matter what happens." Which outcome should be met before the patient leaves the emergency department? The patient will: a. limit contact with the abuser by obtaining a restraining order. b. name two community resources that can be contacted. c. demonstrate insight into the abusive relationship. d. facilitate counseling for the abuser.

4 ~ The nurse should suspect that this client may be a victim of incest. Many women who are battered have low self-esteem and have feelings of guilt, anger, fear, and shame. Women in abusive relationships often grew up in an abusive home.

A woman presents with a history of physical and emotional abuse in her intimate relationships. What should this information lead a nurse to suspect? 1. The woman may be exhibiting a controlled response pattern. 2. The woman may have a history of childhood neglect. 3. The woman may be exhibiting codependent characteristics. 4. The woman may be a victim of incest.

D Acute anxiety results from the personal threat to the victim's safety and security. In this case, the patient's symptoms of rapid, dissociated speech, inability to concentrate, and indecisiveness indicate severe anxiety. Weak is not a level of anxiety. Mild and moderate levels of anxiety would allow the patient to function at a higher level.

A woman was found confused and disoriented after being abducted and raped at gunpoint by an unknown assailant. The emergency department nurse makes these observations about the woman: talking rapidly in disjointed phrases, unable to concentrate, indecisive when asked to make simple decisions. What is the woman's level of anxiety? a. Weak c. Moderate b. Mild d. Severe

2, 3, 4, and 5 are correct. It is very important to assist the victim to develop a safety plan. The victim will likely be in danger once the abuser learns that she has decided to leave. It is very important to remind the victim that the abuse was not her fault. Many victims believe that they deserve the violence. It is very important to assure the victim that she will receive support for her decision. It is very scary to decide to break off a relationship, especiallyif the abuser is the victim's source of financial support. It is very important to help the victim to contact a domestic violence center. This is a very difficult step for victims to take.

A woman who has been abused for a number of years is finally seeking assistance in leaving her relationship. Identify the actions that the nurse should take at this time. Select all that apply. 1. Comment that the victim could have left long ago. 2. Assist the victim to develop a safety plan. 3. Remind the victim that the abuse was not her fault. 4. Assure the victim that she will receive support for her decision. 5. Help the victim to contact a domestic violence center.

2 This is essential. The client must be interviewed in private.

A woman with multiple bruises on her arms and face is seen in the emergency de- partment, accompanied by her partner. When asked about the injuries, the partner states, "She ran into a door." Which of the following actions by the nurse is of high- est priority? 1. Take the woman's vital signs. 2. Interview the woman in private. 3. Assess for additional bruising. 4. Document the location of the bruises.

4 It is likely that this woman has been a victim of a sexual assault after ingesting a date rape drug

A young woman in a disheveled state is admitted to the emergency department. She states that she awoke this morning without her underwear on but with no memory of what happened the evening before. She thinks she may have been raped. Which of the following assessments by the nurse is most likely accurate? 1. The woman is spoiled and is exhibiting attention-seeking behavior. 2. The woman is experiencing a psychotic break. 3. The woman regrets having had consensual sex. 4. The woman unknowingly ingested a date rape drug.

4 This statement is true. Although EC works up to 5 days after unprotected intercourse, it is most effective when taken within 72 hours of the exposure.

A young woman was a victim of a sexual assault. After the rape examination was con- cluded, the client requests to be given emergency contraception (EC). Which of the following information should the nurse teach the client regarding the therapy? 1. EC is illegal in all 50 states. 2. The most common side effect of EC is excessive vaginal bleeding. 3. The same medicine that is used for EC is used to induce abortions. 4. EC is best when used within 72 hours of contact.

B Reactions of the acute phase of the rape-trauma syndrome are shock, emotional numbness, confusion, disbelief, restlessness, and agitated motor activity. Flashbacks, dreams, fears, and phobias are seen in the long-term reorganization phase of the rape-trauma syndrome. Decreased motor activity by itself is not indicative of any particular phase.

After an abduction and rape at gunpoint by an unknown assailant, which assessment finding best indicates that a patient is in the acute phase of the rape-trauma syndrome? a. Decreased motor activity c. Flashbacks and dreams b. Confusion and disbelief d. Fears and phobias

C. Placement in a warm environment

All of the following are important in the immediate care of the premature neonate. Which nursing activity should have the greatest priority? A. Instillation of antibiotic in the eyes B. Identification by bracelet and footprints C. Placement in a warm environment D. Neurological assessment to determine gestational age

C ~ Examples of emotional abuse include having an adult demean a child's worth or frequently criticize or belittle a child. No data support physical battering or endangerment, sexual abuse, or economic abuse.

An 11-year-old child is absent from school to care for siblings while the parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly says, "My parents don't like me. They call me stupid and say I never do anything right." Which type of abuse is likely? a. Sexual b. Physical c. Emotional d. Economic

A ~ The child has indicated a belief in being too dumb to learn. The child receives frequent negative and demeaning feedback from the parents. Deficient knowledge is a nursing diagnosis that refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and nonself. Grieving may apply, but a specific loss is not evident in this scenario. Low self-esteem is more relevant to the child's statements.

An 11-year-old child says, "My parents don't like me. They call me stupid and say I never do anything right, but it doesn't matter. I'm too dumb to learn." Which nursing diagnosis applies to this child? a. Chronic low self-esteem, related to negative feedback from parents b. Deficient knowledge, related to interpersonal skills with parents c. Disturbed personal identity, related to negative self-evaluation d. Complicated grieving, related to poor academic performance

C ~ The honeymoon stage is characterized by kindly, loving behaviors toward the abused spouse when the perpetrator feels remorseful. The victim believes the promises and drops plans to leave or seek legal help. The tension-building stage is characterized by minor violence in the form of abusive verbalization or pushing. The acute battering stage involves the abuser beating the victim. The violence cycle does not include a recovery stage.

An adult tells the nurse, "My partner abuses me most often when drinking. The drinking has increased lately, but I always get an apology afterward and a box of candy. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents the patient from leaving? a. Tension building b. Acute battering c. Honeymoon d. Recovery

B Patients have the right to refuse legal and medical examination. Consent forms are required to proceed with these steps.

An emergency department nurse prepares to assist with evidence collection for a sexual assault victim. Prior to photographs and pelvic examination, what documentation is important? a. The patient's vital signs b. Consent signed by the patient c. Supervision and credentials of the examiner d. Storage location of the patient's personal effects

A(Listening to breath sounds and ensuring the patency of the endotracheal tube, increasing oxygen, and notifying a physician are appropriate nursing interventions to assist in optimal oxygen saturation of the infant. Oxygenation of the infant is crucial. O2 saturation should be maintained above 92%. Oxygenation status of the infant is crucial. The nurse should delay other tasks to stabilize the infant. Notifying the parents that the infant is not doing well is not an appropriate action. Further assessment and intervention are warranted before determination of fetal status.)

An infant at 26 weeks of gestation arrives intubated from the delivery room. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. The nurse's most appropriate action would be to: a. Listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician. b. Continue to observe and make no changes until the saturations are 75%. c. Continue with the admission process to ensure that a thorough assessment is completed. d. Notify the parents that their infant is not doing well.

C(The age of a preterm newborn is corrected by adding the gestational age and the postnatal age. The infant's responses are evaluated accordingly against the norm expected for the corrected age of the infant. Although it is impossible to predict with complete accuracy the growth and development potential of each preterm infant, certain measurable factors predict normal growth and development. The preterm infant experiences catch-up body growth during the first 2 to 3 years of life. The growth and developmental milestones are corrected for gestational age until the child is approximately 2.5 years old. Stating that the baby does not appear to have any problems at the present time is inaccurate. Development will need to be evaluated over time.)

An infant is being discharged from the neonatal intensive care unit after 70 days of hospitalization. The infant was born at 30 weeks of gestation with several conditions associated with prematurity, including respiratory distress syndrome, mild bronchopulmonary dysplasia, and retinopathy of prematurity requiring surgical treatment. During discharge teaching the infant's mother asks the nurse whether her baby will meet developmental milestones on time, as did her son who was born at term. The nurse's most appropriate response is: a. "Your baby will develop exactly like your first child did." b. "Your baby does not appear to have any problems at the present time." c. "Your baby will need to be corrected for prematurity. Your baby is currently 40 weeks of postconceptional age and can be expected to be doing what a 40-week-old infant would be doing." d. "Your baby will need to be followed very closely."

A ~ Older adults, particularly those with cognitive impairments, are at high risk for abuse. The other characteristics are not identified as placing an individual at high risk for abuse.

An older adult diagnosed with Alzheimer disease lives with family. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse? a. Dementia b. Living in a rural area c. Being part of a busy family d. Being home only in the evening

C ~ The assessment of physical abuse is supported by the nurse's observation of bruises. Physical abuse includes evidence of improper care, as well as physical endangerment behaviors such as reckless behavior toward a vulnerable person that could lead to serious injury. No data substantiate the other options.

An older adult diagnosed with dementia lives with family and attends a day care center. A nurse at the day care center notices the adult has a disheveled appearance, a strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? a. Psychological b. Financial c. Physical d. Sexual

ANS: B The patient's child and family were coping with care until the patient began to stay awake at night. The family needs assistance with evening and night care to resume their precrisis state of functioning. Secondary prevention calls for the nurse to mobilize community resources to relieve overwhelming stress. The other interventions may then be accomplished.

An older adult diagnosed with dementia lives with family and attends daycare. After observing poor hygiene, the nurse at the center talks with the patient's adult child. This caregiver becomes defensive and says, "It takes all my time and energy to care for my mother. She's awake all night. I never get any sleep." Which nursing intervention has priority? a. Teach the caregiver more about the effects of dementia. b. Secure additional resources for the mother's evening and night care. c. Support the caregiver to grieve the loss of the mother's ability to function. d. Teach the family how to give physical care more effectively and efficiently.

C (The infant has minimal to no fat stores. During times of cold stress the skin will become mottled, and acrocyanosis will develop, progressing to cyanosis. Even if the infant is being cared for on a radiant warmer or in an isolette, the nurse's role is to observe the infant frequently to prevent heat loss and respond quickly if signs and symptoms occur. The respiratory rate increases followed by periods of apnea. The infant initially tries to conserve heat and burns more calories, after which the metabolic system goes into overdrive. In the preterm infant experiencing heat loss, the heart rate initially increases, followed by periods of bradycardia. In the term infant, the natural response to heat loss is increased physical activity. However, in a term infant experiencing respiratory distress or in a preterm infant, physical activity is decreased.)

As a result of large body surface in relation to weight, the preterm infant is at high risk for heat loss and cold stress. By understanding the four mechanisms of heat transfer (convection, conduction, radiation, and evaporation), the nurse can create an environment for the infant that prevents temperature instability. While evaluating the plan that has been implemented, the nurse knows that the infant is experiencing cold stress when he or she exhibits: a. Decreased respiratory rate. b. Bradycardia followed by an increased heart rate. c. Mottled skin with acrocyanosis. d. Increased physical activity.

C. The nurse commends the mother's efforts and also contacts protective services. The nurse would validate and reinforce the mother's efforts to seek help; however, the nurse must also report the abuse to the appropriate protective services. The priority is to maintain the child's safety. Options A and B are inappropriate; the nurse is failing to provide for the child's safety and is not following legal guidelines. Option D: the nurse, is alienating the mother, as well as failing to follow legal guidelines and ensure the child's safety.

During a home visit to a family of three: a mother, father, and their child, The mother tells the community nurse that the father (who is not present) had hit the child on several occasions when he was drinking. The mother further explains that she has talked her husband into going to Alcoholics Anonymous and asks the nurse not to interfere, so her husband won't get angry and refuse treatment. Which of the following is the best response of the nurse? A. The nurse agrees not to interfere if the husband attends an Alcoholics Anonymous meeting that evening. B. The nurse commends the mother's efforts and agrees to let her handle things. C. The nurse commends the mother's efforts and also contacts protective services. D. The nurse confronts the mother's failure to protect the child.

2 The nurse would expect that the client would have lochia alba.

During a home visit, the nurse assesses a client 2 weeks after delivery. Which of the following signs/symptoms should the nurse expect to see? 1. Diaphoresis. 2. Lochia alba. 3. Cracked nipples. 4. Hypertension.

1, 2, and 5 are correct. 1. The nurse would assess for pain. 2. The nurse would assess for warmth. 5. The nurse would assess for redness.

During a postpartum assessment, the nurse assesses the calves of a client's legs. The nurse is checking for which of the following signs/symptoms? Select all that apply. 1. Pain. 2. Warmth. 3. Discharge. 4. Ecchymosis. 5. Redness.

A. Conflictual relationships of parents. There is no evidence in this situation that the parents are in conflict; in fact, the mother is describing that the child "needed to be disciplined." Often, in dysfunctional families, one child is singled out to be the victim and is the recipient of blame for problems. Option B: The inconsistent communication pattern is that the child received conflicting messages regarding the preparation of food. Option C: The rigid authoritarian roles demonstrated by the mothers indicate that the child needs discipline from the father. This is an example of a rigid role expectation of the father as a disciplinarian. Option D: Also, the father used violence to retain the position of control.

During a well-child checkup, a mother tells the Nurse Rio about a recent situation in which her child needed to be disciplined by her husband. The child was slapped in the face for not getting her husband breakfast on Saturday, despite being told on Thursday never to prepare food for him. Nurse Rio analyzes the family system and concludes it is dysfunctional. All of the following factors contribute to this dysfunction except: A. Conflictual relationships of parents. B. Inconsistent communication patterns. C. Rigid, authoritarian roles. D. Use of violence to establish control.

A. The client appears interested in learning about neonatal care. The third to tenth days of PP care are the "taking-hold" phase, in which the new mother strives for independence and is eager for her neonate. The other options describe the phase in which the mother relives her birth experience.

During the 3rd PP day, which of the following observations about the client would the nurse be most likely to make? A. The client appears interested in learning about neonatal care B. The client talks a lot about her birth experience C. The client sleeps whenever the neonate isn't present D. The client requests help in choosing a name for the neonate.

C. The expected weight loss immediately after birth averages about 11 to 13 pounds. Prepregnant weight is usually achieved by 2 to 3 months after birth, not within the 6-week postpartum period. Weight loss from diuresis, diaphoresis, and bleeding is about 9 pounds. Weight loss continues during breastfeeding since fat stores developed during pregnancy and extra calories consumed are used as part of the lactation process.

Following the birth of her baby, a woman expresses concern about the weight she gained during pregnancy and how quickly she can lose it now that the baby is born. The nurse, in describing the expected pattern of weight loss, should begin by telling this woman that: A. Return to pre-pregnant weight is usually achieved by the end of the postpartum period B. Fluid loss from diuresis, diaphoresis, and bleeding accounts for about a 3-pound weight loss C. The expected weight loss immediately after birth averages about 11 to 13 pounds D. Lactation will inhibit weight loss since caloric intake must increase to support milk production

C (Preterm and post-term are strictly measures of time—before 37 weeks and beyond 42 weeks, respectively—regardless of size for gestational age.)

For clinical purposes, preterm and post-term infants are defined as: a. Preterm before 34 weeks if appropriate for gestational age (AGA) and before 37 weeks if small for gestational age (SGA). b. Post-term after 40 weeks if large for gestational age (LGA) and beyond 42 weeks if AGA. c. Preterm before 37 weeks, and post-term beyond 42 weeks, no matter the size for gestational age at birth. d. Preterm, SGA before 38 to 40 weeks, and post-term, LGA beyond 40 to 42 weeks.

D. Recognize this as a behavior of the taking-hold stage. The behavior described is typical of this stage and not a reflection of ineffective attachment unless the behavior persists. Mothers need to reestablish their own well-being in order to effectively care for their baby. Option A does not take into consideration the need for the new mother to be nurtured and have her needs met during the taking-in stage.

Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should: A. Tell the woman she can rest after she feeds her baby B. Recognize this as a behavior of the taking-hold stage C. Record the behavior as ineffective maternal-newborn attachment D. Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time

B (ROP is thought to occur as a result of high levels of oxygen in the blood. NEC is caused by the interference of blood supply to the intestinal mucosa. Necrotic lesions occur at that site. BPD is caused by the use of positive pressure ventilation against the immature lung tissue. IVH results from rupture of the fragile blood vessels in the ventricles of the brain. It is most often associated with hypoxic injury, increased blood pressure, and fluctuating cerebral blood flow.)

In caring for the preterm infant, what complication is thought to be a result of high arterial blood oxygen level? a. Necrotizing enterocolitis (NEC) b. Retinopathy of prematurity (ROP) c. Bronchopulmonary dysplasia (BPD) d. Intraventricular hemorrhage (IVH)

1, 2, 4 ~ When planning care for a woman who is a survivor of domestic abuse, the nurse should be aware that it often takes several attempts before a woman leaves an abusive situation, that substance abuse is a common factor in abusive relationships, and that women in abusive relationships usually feel isolated and unsupported. Children can be affected by domestic violence from infancy, and economic factors often play a role in the victim's decision to stay.

In planning care for a woman who presents as a survivor of domestic abuse, a nurse should be aware of which of the following data? (SATA) 1. It often takes several attempts before a woman leaves an abusive situation. 2. Substance abuse is a common factor in abusive relationships. 3. Until children reach school age, they are usually not affected by abuse between their parents. 4. Women in abusive relationships usually feel isolated and unsupported. 5. Economic factors rarely play a role in the decision to stay.

A(The nurse should suspect hypovolemia and/or shock. Other symptoms could include hypotension, prolonged capillary refill, and tachycardia followed by bradycardia. Intervention is necessary.)

In the assessment of a preterm infant, the nurse notices continued respiratory distress even though oxygen and ventilation have been provided. The nurse should suspect: a. Hypovolemia and/or shock. b. A nonneutral thermal environment. c. Central nervous system injury. d. Pending renal failure.

A, C, D (Thermoregulation problems, hyperbilirubinemia, and sepsis are all conditions related to immaturity and warrant close observation. After discharge the infant is at risk for rehospitalization related to these problems. AWHONN launched the Near-Term Infant Initiative to study the problem and ways to ensure that these infants receive adequate care. The nurse should ensure that this infant is feeding adequately before discharge and that parents are taught the signs and symptoms of these complications. Late-preterm infants are also at increased risk for respiratory distress and hypoglycemia.)

Infants born between 34 0/7 and 36 6/7 weeks of gestation are called late-preterm infants because they have many needs similar to those of preterm infants. Because they are more stable than early-preterm infants, they may receive care that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these babies are at increased risk for (Select all that apply): a. Problems with thermoregulation b. Cardiac distress c. Hyperbilirubinemia d. Sepsis e. Hyperglycemia

D. Report suspicion of abuse to the proper authorities. The nurse is obligated to report suspicion of child abuse to the appropriate protective services. Failure to do so can risk further endangerment of the child, and failure to report is a misdemeanor violation on the part of the nurse. Option A: The parents will be contacted and an investigation will proceed under the legal authority of the child protective service agency. Option B: Although the nurse would expect to establish rapport with the child, encouraging the child to be truthful would send the message that the nurse believes the child is lying; therefore, this intervention would be inappropriate. Option C: Questioning the teacher may or may not provide validation of the nurse's suspicions; regardless, this intervention does not ensure the child's safety, which is the priority.

Joseph, a 12-year-old child, complains to the school nurse about nausea and dizziness. While assessing the child, the nurse notices a black eye that looks like an injury. This is the third time in 1 month that the child has visited the nurse. Each time, the child provides vague explanations for various injuries. Which of the following is the school nurse's priority intervention? A. Contact the child's parents and ask about the child's injury. B. Encourage the child to be truthful with her. C. Question the teacher about the parent's behavior. D. Report suspicion of abuse to the proper authorities.

C. Implement measures to ensure the victim's safety. The priority intervention when a child or elderly person is involved in a situation of abuse is establishing the safety of the victim. Legislation in most states mandates the reporting of such abuse to ensure prompt intervention and safety. Options A and B: The question is asking about implementing a specific nursing action, not assessing the problem or analyzing the family dynamics. Option D: Teaching coping skill is important; however, the priority action involves ensuring safety.

Mariefer is studying about abuse for the upcoming exam. For her to fully instill the topic, she should know that the priority nursing intervention for a child or elder victim of abuse is: A. Assess the scope of the abuse problem. B. Analyze family dynamics. C. Implement measures to ensure the victim's safety. D. Teach appropriate coping skills.

B. Blood pressure. Methergine and pitocin are agents that are used to prevent or control postpartum hemorrhage by contracting the uterus. They cause continuous uterine contractions and may elevate blood pressure. A priority nursing intervention is to check blood pressure. The physician should be notified if hypertension is present.

Methergine or Pitocin is prescribed for a woman to treat PP hemorrhage. Before administration of these medications, the priority nursing assessment is to check the: A. Amount of lochia B. Blood pressure C. Deep tendon reflexes D. Uterine tone

D. Mrs. Smith's explanation is a typical response of a victim accepting blame for the abuser. Self-blame is a common psychological response to a woman who is a victim of abuse. In this situation, the message that violence occurred because the woman provoked the abuser is accepted and owned by the victim; however, the victim is not responsible for the violence.

Mrs. Smith was admitted to the emergency department of Nurseslabs Medical Center with a fractured arm. She explains to the nurse that her injury resulted when she provoked her drunken husband, Mr. Smith, who then pushed her. Which of the following best describes the nurse's understanding of the wife's explanation? A. Mrs. Smith's explanation is appropriate acceptance of her responsibility. B. Mrs. Smith's explanation is an atypical reaction of an abused woman. C. Mrs. Smith's explanation is evidence that the woman may be an abuser as well as a victim. D. Mrs. Smith's explanation is a typical response of a victim accepting blame for the abuser.

B (A decrease in the incidence of NEC is directly correlated with exclusive breastfeeding. Breast milk enhances maturation of the gastrointestinal tract and contains immune factors that contribute to a lower incidence or severity of NEC, Crohn's disease, and celiac illness. The neonatal intensive care unit nurse can be very supportive of the mother in terms of providing her with equipment to pump breast milk, ensuring privacy, and encouraging skin-to-skin contact with the infant. Early enteral feedings of formula or hyperosmolar feedings are a risk factor known to contribute to the development of NEC. The mother should be encouraged to pump or feed breast milk exclusively. Exchange transfusion may be necessary; however, it is a known risk factor for the development of NEC. Although still early, a study in 2005 found that the introduction of prophylactic probiotics appeared to enhance the normal flora of the bowel and therefore decrease the severity of NEC when it did occur. This treatment modality is not as widespread as encouraging breastfeeding; however, it is another strategy that the care providers of these extremely fragile infants may have at their disposal.)

Necrotizing enterocolitis (NEC) is an acute inflammatory disease of the gastrointestinal mucosa that can progress to perforation of the bowel. Approximately 2% to 5% of premature infants succumb to this fatal disease. Care is supportive; however, known interventions may decrease the risk of NEC. To develop an optimal plan of care for this infant, the nurse must understand which intervention has the greatest effect on lowering the risk of NEC: a. Early enteral feedings b. Breastfeeding c. Exchange transfusion d. Prophylactic probiotics

B) abdominal distention, temperature instability, and grossly bloody stools. Rationale: Some generalized signs of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall.

Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs include: A) hypertonia, tachycardia, and metabolic alkalosis. B) abdominal distention, temperature instability, and grossly bloody stools. C) hypertension, absence of apnea, and ruddy skin color. D) scaphoid abdomen, no residual with feedings, and increased urinary output.

B (Some generalized signs of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall. The infant may display hypotonia, bradycardia, and metabolic acidosis.)

Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs include: a. Hypertonia, tachycardia, and metabolic alkalosis. b. Abdominal distention, temperature instability, and grossly bloody stools. c. Hypertension, absence of apnea, and ruddy skin color. d. Scaphoid abdomen, no residual with feedings, and increased urinary output.

B. Ensure privacy for interviewing the victim away from the abuser. Privacy, away from the abuser, is important. This allows the victim to discuss the problem freely, without fear of reprisal from the abuser (especially if she decides to return to the abusive situation). Option A: In this situation, it is not the nurse's responsibility to make the decision to report the abuse. However, whenever the injury is inflicted with a gun, knife, or other weapons, the nurse is obligated to report the abuse. Option C: Although the nurse would want to establish rapport with the victim, her initial concern would not be to establish rapport with the abuser. Option D: The situation does not describe the abuser as currently violent or under the influence of substances; therefore requesting a security presence is inappropriate at this time.

Nurse Angela is working in the emergency department of Nurseslabs Medical Center. She is conducting an interview with a victim of spousal abuse. Which step should the nurse take first? A. Contact the appropriate legal services. B. Ensure privacy for interviewing the victim away from the abuser. C. Establish a rapport with the victim and the abuser. D. Request the presence of a security guard.

D. The child has an interest in things of a sexual nature. An 8-year-old child is in the latency phase of development; in this stage, the child's interest in peers, activities, and school is the priority. Interest in sex and things of a sexual nature would occur appropriately during the age of puberty, not at this time. A child who is the victim of sexual abuse, however, may show an unusual interest in sex. The assessments in the other answer choices may indicate abuse, but not necessarily sexual abuse.

Nurse Meredith is observing 8-year-old Anna during a community visit. Which of the following findings would lead the nurse to suspect that Anna is a victim of sexual abuse? A. The child is fearful of the caregiver and other adults. B. The child has a lack of peer relationships. C. The child has self-injurious behavior. D. The child has an interest in things of a sexual nature.

B. History of the parent having been abused as a child One of the most important risk factors is a history of childhood abuse in the parent who abuses. Family violence follows a multigenerational pattern. Option A: Parents who are flexible in their roles are characteristic of healthy functioning, not abuse. Options C and D: Single-parent households and a history of mental illness are not established risk factors for child abuse by a parent.

Nurse Sharie is assessing a parent who abused her child. Which of the following risk factors would the nurse expect to find in this case? A. Flexible role functioning between parents B. History of the parent having been abused as a child C. Single-parent home situation D. Presence of parental mental illness

3 The nurse would expect these values— a slight decrease in both hemoglobin and hematocrit values.

On admission to the labor and delivery unit, a client's hemoglobin (Hgb) was assessed at 11.0 g/dL, and her hematocrit (Hct) at 33%. Which of the following values would the nurse expect to see 2 days after a normal spontaneous vaginal delivery? 1. Hgb 12.5 g/dL; Hct 37%. 2. Hgb 11.0 g/dL; Hct 33%. 3. Hgb 10.5 g/dL; Hct 31%. 4. Hgb 9.0 g/dL; Hct 27%.

D. Taking-in phase. The taking-in phase occurs in the first 24 hours after birth. The mother is concerned with her own needs and requires support from staff and relatives. Option B: The letting-go phase begins several weeks later when the mother incorporates the new infant into the family unit. Option C: The taking-hold phase occurs when the mother is ready to take responsibility for her care as well as the infant's care.

On the first PP night, a client requests that her baby be sent back to the nursery so she can get some sleep. The client is most likely in which of the following phases? A. Depression phase B. Letting-go phase C. Taking-hold phase D. Taking-in phase

B. Days 3 to 10 PP. On the third and fourth PP days, the lochia becomes a pale pink or brown and contains old blood, serum, leukocytes, and tissue debris. This type of lochia usually lasts until PP day 10. Lochia rubra usually last for the first 3 to 4 days PP. Lochia alba, which contain leukocytes, decidua, epithelial cells, mucus, and bacteria, may continue for 2 to 6 weeks PP.

On which of the postpartum days can the client expect lochia serosa? A. Days 3 and 4 PP B. Days 3 to 10 PP C. Days 10-14 PP D. Days 14 to 42 PP

D. Uses the peribottle to rinse upward into her vagina. The peribottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina since debris would be forced upward into the uterus through the still-open cervix.

Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: A. Uses soap and warm water to wash the vulva and perineum B. Washes from symphysis pubis back to episiotomy C. Changes her perineal pad every 2 - 3 hours D. Uses the peri bottle to rinse upward into her vagina

D (This pattern is called periodic breathing and is common to premature infants. It may still require nursing intervention of oxygen and/or ventilation. Apnea is a cessation of respirations for 20 seconds or longer. It should not be confused with periodic breathing.)

Premature infants who exhibit 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration are: a. Suffering from sleep or wakeful apnea. b. Experiencing severe swings in blood pressure. c. Trying to maintain a neutral thermal environment. d. Breathing in a respiratory pattern common to premature infants.

A and C. In the PP period, cervical healing occurs rapidly and cervical involution occurs. After 1 week the muscle begins to regenerate and the cervix feels firm and the external os, is the width of a pencil. The fundus begins to descent into the pelvic cavity after 24 hours, a process known as involution. Option B: Although the vaginal mucosa heals and vaginal distention decreases, it takes the entire PP period for complete involution to occur and muscle tone is never restored to the pregravid state. Option D: Despite blood loss that occurs during delivery of the baby, a transient increase in cardiac output occurs. The increase in cardiac output, which persists about 48 hours after childbirth, is probably caused by an increase in stroke volume because Bradycardia is often noted during the PP period. Option E: Soon after childbirth, digestion begins to begin to be active, and the new mother is usually hungry because of the energy expended during labor.

Select all of the physiological maternal changes that occur during the PP period. A. Cervical involution occurs B. Vaginal distention decreases slowly C. Fundus begins to descend into the pelvis after 24 hours D. Cardiac output decreases with resultant tachycardia in the first 24 hours E. Digestive processes slow immediately.

A) Cervical involution occurs C) Fundus begins to descend into the pelvis after 24 hours Rationale: After 1 week the muscle begins to regenerate and the cervix feels firm and the external os is the width of a pencil. Although the vaginal mucosa heals and vaginal distention decreases, it takes the entire PP period for complete involution to occur and muscle tone is never restored to the pregravid state. The fundus begins to descent into the pelvic cavity after 24 hours, a process known as involution. Despite blood loss that occurs during delivery of the baby, a transient increase in cardiac output occurs. The increase in cardiac output, which persists about 48 hours after childbirth, is probably caused by an increase in stroke volume because Bradycardia is often noted during the PP period. Soon after childbirth, digestion begins to begin to be active and the new mother is usually hungry because of the energy expended during labor.

Select all of the physiological maternal changes that occur during the PP period. (Select all that apply) A) Cervical involution occurs B) Vaginal distention decreases slowly C) Fundus begins to descend into the pelvis after 24 hours D) Cardiac output decreases with resultant tachycardia in the first 24 hours E) Digestive processes slow immediately

C ~ Injuries such as immersion or cigarette burns, facial fractures, whiplash, bite marks, traumatic injuries, bruises, and fractures in various stages of healing suggest the possibility of abuse. In older children, vague complaints such as back pain may also be suspicious. Ear infections, colic, and croup are not problems induced by violence.

Several children are seen in the emergency department for treatment of illnesses and injuries. Which finding would create a high index of suspicion for child abuse? The child who has: a. repeated middle ear infections. b. severe colic. c. bite marks. d. croup.

A, C, D, F These are all appropriate nursing interventions for the victim of domestic violence. The client is not responsible for seeking help for the abuser, and encouraging her to do so may reinforce the client's feeling responsible for the abuse. Advising the client must decide for herself whether to leave, and the nurse must respect any decision the client makes. Making the decision for the client will erode her self-esteem and reinforce her sense of powerlessness.

Sheila tells the community nurse that her boyfriend has been abusive and she is afraid of him, but she doesn't want to leave. The client asks the nurse for assistance. Which nursing interventions are appropriate in this situation? Select all that apply. A. Help Sheila to develop a plan to ensure safety, including phone numbers for emergency help. B. Help Sheila to get her boyfriend into an appropriate treatment program. C. Communicate acceptance, avoiding any implication that Sheila is at fault for not leaving. D. Help Sheila to explore available options, including shelters and legal protection. E. Tell Sheila that she should leave because things will not improve. F. Reinforce concern for Sheila's safety and her right to be free of abuse.

D

The client who experienced a perinatal demise states, "Sometimes I feel like I left my baby somewhere, and can't remember where she is. Then I remember that she isn't alive." The nurse interprets that this client is experiencing which of the following? A. Anticipatory grieving B. Disorientation C. Reorganization D. Searching and yearning

3 This response is correct. Polyuria is normal.

The day after delivery, a woman, whose fundus is firm at 1 cm below the umbilicus and who has moderate lochia, tells the nurse that something must be wrong: "All I do is go to the bathroom." Which of the following is an appropriate nursing response? 1. Catheterize the client per doctor's orders. 2. Measure the client's next voiding. 3. Inform the client that polyuria is normal. 4. Check the specific gravity of the next voiding.

A, B, D Identifying areas of control empowers the client. Supporting the client in the decisions he/she makes empowers the client and enhances the client's current problem-solving ability. Establishing trust and rapport provides the client with an ally.

The interventions common to treatment plans for survivors include which of the following? Select all that apply. A. Establish trust and rapport. B. Identify areas of control. C. Remove the client from home. D. Support the client in the decisions he/she makes. E. Encourage the client to pursue legal action.

2 This statement acknowledges the fact that the client needed to regain some control over her situation.

The nurse at Victims Assistance Services is speaking with a young woman who states that she was sexually assaulted at a party the evening before. The victim states, "I ran home and took a shower as soon as it happened. I felt so dirty." Which of the follow- ing responses should the nurse make first? 1. "The evidence kit may still reveal important information." 2. "It was important for you to do that for yourself." 3. "Have you washed your clothes? If not, we might be able to obtain evidence from them." 4. "Do you remember what happened? If not, someone may have put a drug in your drink."

D Females know their offenders in almost 70% of all violent crimes committed against them, including rape. The nurse should share this information along with encouraging discussion of safety measures. The distracters fail to provide adequate information or encourage discussion.

The nurse at a university health center leads a dialogue with female freshmen about rape and sexual assault. One student says, "If I avoid strangers or situations where I am alone outside at night, I'll be safe from sexual attacks." Choose the nurse's best response. a. "Your plan is not adequate. You could still be raped or sexually assaulted." b. "I am glad you have this excellent safety plan. Would others like to comment?" c. "It's better to walk with someone or call security when you enter or leave a building." d. "Sexual assaults are more often perpetrated by acquaintances. Let's discuss ways to prevent that."

A

The nurse determines that teaching about sudden infant death syndrome has been effective when the client makes which statement? A. "No definite cause of death is found at autopsy." B. "Infants who sleep on their backs are more at risk for sudden infant death syndrome." C. "Bottle-feeding causes sudden infant death syndrome". D. "Genetic disorders are the cause of SIDS."

B. Massage her fundus. A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action would be to massage the fundus until firm, followed by options C and D, especially if the fundus does not become or remain firm with massage. Option A: There is no indication of a distended bladder since the fundus is midline and below the umbilicus.

The nurse examines a woman one hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to: A. Place her on a bedpan to empty her bladder B. Massage her fundus C. Call the physician D. Administer Methergine 0.2 mg IM which has been ordered prn

2 and 4 are correct. 2 This statement is correct. The woman should wash her hands before and after performing pericare care 4 This statement is accurate.

The nurse has taught a new admission to the postpartum unit about pericare. Which of the following indicates that the client understands the procedure? Select all that apply. 1. The woman performs the procedure twice a day. 2. The woman washes her hands before and after the procedure. 3. The woman sits in warm tap water for ten minutes three times a day. 4. The woman sprays her perineum from front to back. 5. The woman mixes warm tap water with hydrogen peroxide.

1 The client should apply ice packs to her axillae and breasts.

The nurse in the obstetric clinic received a telephone call from a bottle-feeding mother of a 3-day-old. The client states that her breasts are firm, red, and warm to the touch. Which of the following is the best action for the nurse to advise the client to perform? 1. Intermittently apply ice packs to her axillae and breasts. 2. Apply lanolin to her breasts and nipples every 3 hours. 3. Express milk from the breasts every 3 hours. 4. Ask the primary health care provider to order a milk suppressant.

2 This statement is correct. Ibuprofen has an antiprostaglandin effect.

The nurse informs a postpartum woman that which of the following is the reason ibuprofen (Advil) is especially effective for afterbirth pains? 1. Ibuprofen is taken every two hours. 2. Ibuprofen has an antiprostaglandin effect. 3. Ibuprofen is given via the parenteral route. 4. Ibuprofen can be administered in high doses.

b, e

The nurse interprets which of the following as somatic complaints of a postpartal woman who is grieving for her deceased infant? Select all that apply. A. Tingling on the back of the neck and hearing a baby's cry. B. Heaviness in the chest and fatigue. C. Increased taste sensitivity and deep sleep. D. Stiffness in the legs and arms. E. Weight loss and decreased appetite.

C. Lower than before she became pregnant. PP insulin requirements are usually significantly lower than pre pregnancy requirements. Occasionally, clients may require little to no insulin during the first 24 to 48 hours postpartum.

The nurse is about the give a Type 2 diabetic her insulin before breakfast on her first day postpartum. Which of the following answers best describes insulin requirements immediately postpartum? A. Lower than during her pregnancy B. Higher than during her pregnancy C. Lower than before she became pregnant D. Higher than before she became pregnant

B) Instruct the mother to request help when getting out of bed Rationale: Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that should caution the nurse to be aware of the client's safety. The nurse should advise the mother to get help the first few times the mother gets out of bed. Obtaining an H/H requires a physicians order.

The nurse is assessing a client who is 6 hours PP after delivering a full-term healthy infant. The client complains to the nurse of feelings of faintness and dizziness. Which of the following nursing actions would be most appropriate? A) Obtain hemoglobin and hematocrit levels B) Instruct the mother to request help when getting out of bed C) Elevate the mother's legs D) Inform the nursery room nurse to avoid bringing the newborn infant to the mother until the feelings of lightheadedness and dizziness have subsided

B. Instruct the mother to request help when getting out of bed. Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that should caution the nurse to be aware of the client's safety. The nurse should advise the mother to get help the first few times the mother gets out of bed. Option A: Obtaining an H/H requires a physician's order.

The nurse is assessing a client who is 6 hours PP after delivering a full-term healthy infant. The client complains to the nurse of feelings of faintness and dizziness. Which of the following nursing actions would be most appropriate? A. Obtain hemoglobin and hematocrit levels B. Instruct the mother to request help when getting out of bed C. Elevate the mother's legs D. Inform the nursery room nurse to avoid bringing the newborn infant to the mother until the feelings of lightheadedness and dizziness have subsided.

3 The client's hematocrit is well below normal. This value should be reported to the client's health care provider.

The nurse is assessing the laboratory report on a 2-day postpartum G1 P1001. The woman had a normal postpartum assessment this morning. Which of the following results should the nurse report to the primary health care provider? 1. White blood cells, 12,500 cells/mm3. 2. Red blood cells, 4,500,000 cells/mm3. 3. Hematocrit, 26%. 4. Hemoglobin, 11 g/dL

B) Indicates the presence of infectionRationale: Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor. Foul smelling or purulent lochia usually indicates infection, and these findings are not normal. Encouraging the woman to drink fluids or increase ambulation is not an accurate nursing intervention

The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the lochia is red and has a foul-smelling odor. The nurse determines that this assessment finding is: A) Normal B) Indicates the presence of infection C) Indicates the need for increasing oral fluids D) Indicates the need for increasing ambulation

B. Indicates the presence of infection. Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Foul smelling or purulent lochia usually indicates infection, and these findings are not normal. Option A: Normal lochia has a fleshy odor. Options C and D: Encouraging the woman to drink fluids or increase ambulation is not an accurate nursing intervention.

The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the lochia is red and has a foul-smelling odor. The nurse determines that this assessment finding is: A. Normal B. Indicates the presence of infection C. Indicates the need for increasing oral fluids D. Indicates the need for increasing ambulation

2 The nurse would expect to see well-approximated edges.

The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see? 1. Moderate serosanguinous drainage. 2. Well-approximated edges. 3. Ecchymotic area distal to the episiotomy. 4. An area of redness adjacent to the incision.

1 It is appropriate to apply an ice pack to the area

The nurse is caring for a postpartum client who experienced a second-degree perineal laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time? 1. Apply an ice pack to the perineum. 2. Advise the woman to use a sitz bath after every voiding. 3. Advise the woman to sit on a pillow. 4. Teach the woman to insert nothing into her rectum.

C) Measure the length of the NG tube from the tip of the nose to the lobe of the ear to midpoint between the xyphoid process and the umbilicus. B) Place infant in supine position. A) Lubricate the tip of the tube with sterile water. E) Gently insert the NG tube through the mouth or nose. D) Check placement of the NG tube by aspirating gastric contents.

The nurse is caring for a preterm infant who needs to have gavage feedings started and requires the insertion of a nasogastric (NG) tube. Place in correct order the steps for insertion of a nasogastric tube in a preterm infant. A) Lubricate the tip of the tube with sterile water. B) Place infant in supine position. C) Measure the length of the NG tube from the tip of the nose to the lobe of the ear to midpoint between the xyphoid process and the umbilicus. D) Check placement of the NG tube by aspirating gastric contents. E) Gently insert the NG tube through the mouth or nose.

1, 4, and 5 are correct.1. It is essential that young women remember to drink liquids only from containers that they have opened themselves and that have never been out of their possession. Young women should be encouraged to meet new dates in a public place. It is unlikely that an assault will occur in a place where others are present. When a mixed group goes out together, it is unlikely that an assault will take place.

The nurse is conducting a seminar with young adolescent women regarding date rape. Which of the following guidelines are essential to include in the discussion? Select all that apply. 1. The girls should consume drinks from enclosed containers. 2. The girls should keep extra money in their shoes or bras. 3. The girls should keep condoms in their pocketbooks. 4. The girls should meet a new date in a public place. 5. The girls should go on group dates whenever possible.

3 This statement is correct. When clients contract their buttocks before sitting, they usually feel less pain than when they sit directly on the suture line.

The nurse is developing a standard care plan for postpartum clients who have had midline episiotomies. Which of the following interventions should be included in the plan? 1. Assist with stitch removal on third postpartum day. 2. Administer analgesics every four hours per doctor's orders. 3. Teach client to contract her buttocks before sitting. 4. Irrigate incision twice daily with antibiotic solution.

2 This is a correct statement.

The nurse is discussing the importance of doing Kegel exercises during the postpar- tum period. Which of the following should be included in the teaching plan? 1. She should repeatedly contract and relax her rectal and thigh muscles. 2. She should practice by stopping the urine flow midstream every time she voids. 3. She should get on her hands and knees whenever performing the exercises. 4. She should be taught that toned pubococcygeal muscles decrease blood loss.

4 The fundus is usually 3 cm below the umbilicus on day 3 and the lochia usually has turned to serosa by day 3.

The nurse is evaluating the involution of a woman who is 3 days postpartum. Which of the following findings would the nurse evaluate as normal? 1. Fundus 1 cm above the umbilicus, lochia rosa. 2. Fundus 2 cm above the umbilicus, lochia alba. 3. Fundus 2 cm below the umbilicus, lochia rubra. 4. Fundus 3 cm below the umbilicus, lochia serosa.

3 This response is correct. The involution is normal and the lochia is rubra.

The nurse is examining a 2-day-postpartum client whose fundus is 2 cm below the umbilicus and whose bright red lochia saturates about 4 inches of a pad in 1 hour. What should the nurse document in the nursing record? 1. Abnormal involution, lochia rubra heavy. 2. Abnormal involution, lochia serosa scant. 3. Normal involution, lochia rubra moderate. 4. Normal involution, lochia serosa heavy.

2 This statement is accurate. Mothers often do not feel bladder pressure after delivery.

The nurse palpates a distended bladder on a woman who delivered vaginally 2 hours earlier. The woman refuses to go to the bathroom, "I really don't need to go." Which of the following responses by the nurse is appropriate? 1. "Okay. I must be palpating your uterus." 2. "I understand but I still would like you to try to urinate." 3. "You still must be numb from the local anesthesia." 4. "That is a problem. I will have to catheterize you."

1 This is an example of a comment made during the "honeymoon phase."

The nurse suspects that a client has been physically abused. The woman refuses to report the abuse to the police. Which statement by the client suggests to the nurse that the relationship may be in the "honeymoon phase"? 1. "My partner said that he will never hurt me again." 2. "My partner drinks alcohol only on the weekends." 3. "My partner yells less than he used to." 4. "My partner has frequent bouts of insomnia."

c

The nurse who is reviewing all subjective and objective prenatal assessment data interprets that which data is an indicator of intrauterine fetal death? A. Diminished fetal activity over a three-day period. B. A bluish discoloration in the vaginal and cervical mucosa. C. Absence of fetal heart tones and fetal movement. D. Mother saying "the baby is just not moving today".

D Agreeing to keep a follow-up appointment is a realistic short-term outcome. The victim is in the acute phase; the distracters are unlikely to be achieved during the limited time the victim is in an emergency department.

The nursing diagnosis Rape-trauma syndrome applies to a rape victim in the emergency department. Select the most appropriate outcome to achieve before discharging the patient. a. The memory of the rape will be less vivid and less frightening. b. The patient is able to describe feelings of safety and relaxation. c. Symptoms of pain, discomfort, and anxiety are no longer present. d. The patient agrees to a follow-up appointment with a rape victim advocate.

c, e

The plan of care for a pregnant client who experienced an unexplained intrauterine fetal demise during her last pregnancy should include which of the following? Select all that apply. A. Education about the causes of intrauterine fetal demise for both parents. B. Encouragement to think positively and not dwell on the previous fetal loss. C. Support for increased fears as this fetus reaches the gestational age of the previous fetal loss. D. Facilitation of grieving of the lost fetus through carrying a photo and a lock of hair at all times. E. Asking open-ended questions to determine how the parents are coping and identify any concerns.

2 The baby's airway should be established by inflating the lungs with an ambu bag.

Thirty seconds after birth a baby, who appears preterm, has exhibited no effort to breathe even after being stimulated. The heart rate is assessed at 50 bpm. Which of the following actions should the nurse perform first? 1. Perform a gestational age assessment. 2. Inflate the lungs with positive pressure. 3. Provide external chest compressions. 4. Assess the oxygen saturation level.

2 Clients should be advised to change their pads at each voiding.

To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks? 1. Apply antibiotic ointment to the perineum daily. 2. Change the peripad at each voiding. 3. Void at least every two hours. 4. Spray the perineum with povidone-iodine after toileting.

B ~ Intense protective feelings, sympathy for the victim, and anger and outrage toward the abuser are common emotions of a nurse working with an abusive family.

What feelings are most commonly experienced by nurses working with abusive families? a. Outrage toward the victim and sympathy for the abuser b. Sympathy for the victim and anger toward the abuser c. Unconcern for the victim and dislike for the abuser d. Vulnerability for self and empathy with the abuser

B ~ Each state has specific regulations for reporting child abuse that must be observed. The nurse is usually a mandated reporter. The reporter does not need to be sure that abuse or neglect has occurred but only that it is suspected. Speculation should not be documented; only the facts are recorded.

What is a nurse's legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the child's teacher, principal, and school psychologist. b. Report the suspected abuse or neglect according to state regulations. c. Document the observations and speculations in the medical record. d. Continue the assessment.

D. Transitional milk. Transitional milk comes after colostrum and usually lasts until 2 weeks PP.

What type of milk is present in the breasts 7 to 10 days PP? A. Colostrum B. Hind milk C. Mature milk D. Transitional milk

D(Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat and well-developed muscles are indications of a more mature infant.)

When assessing the preterm infant the nurse understands that compared with the term infant, the preterm infant has: a. Few blood vessels visible through the skin. b. More subcutaneous fat. c. Well-developed flexor muscles. d. Greater surface area in proportion to weight.

C. Express a strong need to review events and her behavior during the process of labor and birth. One week after birth the woman should exhibit behaviors characteristic of the taking-hold stage as described in response C. This stage lasts for as long as 4 to 5 weeks after birth. Options A and B are characteristic of the taking-in stage, which lasts for the first few days after birth. Option D reflects the letting-go stage, which indicates that psychosocial recovery is complete.

When making a visit to the home of a postpartum woman one week after birth, the nurse should recognize that the woman would characteristically: A. Express a strong need to review events and her behavior during the process of labor and birth B. Exhibit a reduced attention span, limiting readiness to learn C. Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn D. Have reestablished her role as a spouse/partner

B. Notify the physician. Normally, one may find a few small clots in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the most appropriate action is to notify the physician.

When performing a PP assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate? A. Document the findings B. Notify the physician C. Reassess the client in 2 hours D. Encourage increased intake of fluids.

A. Assist the woman into a lateral position with upper leg flexed forward to facilitate the examination of her perineum. While the supine position is best for examining the abdomen, the woman should keep her arms at her sides and slightly flex her knees in order to relax abdominal muscles and facilitate palpation of the fundus. Option C: The bladder should be emptied before the check. A full bladder alters the position of the fundus and makes the findings inaccurate. Option D: Although hands are washed before starting the check, clean (not sterile) gloves are put on just before the perineum and pad are assessed to protect from contact with blood and secretions.

When performing a postpartum check, the nurse should: A. Assist the woman into a lateral position with upper leg flexed forward to facilitate the examination of her perineum B. Assist the woman into a supine position with her arms above her head and her legs extended for the examination of her abdomen C. Instruct the woman to avoid urinating just before the examination since a full bladder will facilitate fundal palpation D. Wash hands and put on sterile gloves before beginning the check

D(Documentation of a gavage feeding should include the size of the feeding tube, the amount and quality of the residual from the previous feeding, the type and quantity of the fluid instilled, and the infant's response to the procedure. Abdominal circumference is not measured after a gavage feeding. Vital signs may be obtained before feeding. However, the infant's response to the feeding is more important. Some older infants may be learning to suck, but the important factor to document would be the infant's response to the feeding (including attempts to suck).)

When providing an infant with a gavage feeding, which of the following should be documented each time? a. The infant's abdominal circumference after the feeding b. The infant's heart rate and respirations c. The infant's suck and swallow coordination d. The infant's response to the feeding

3 ~ The client is in the honeymoon phase of the cycle of battering. In this phase, the batterer becomes extremely loving, kind, and contrite. Promises are often made that the abuse will not happen again.

When questioned about bruises, a woman states, "It was an accident. My husband just had a bad day at work. Hes being so gentle now and even brought me flowers. Hes going to get a new job, so it won't happen again." This client is in which phase of the cycle of battering? 1. Phase I: The tension-building phase 2. Phase II: The acute battering incident phase 3. Phase III: The honeymoon phase 4. Phase IV: The resolution and reorganization phase

1 ~ The nurse should recognize that a child who is often absent from school and seems apathetic and tired may be a victim of neglect. Other indicators of neglect are stealing food or money, lacking medical or dental care, being consistently dirty, lacking sufficient clothing, or stating that there is no one home to provide care.

Which assessment data should a school nurse recognize as a sign of physical neglect? 1. The child is often absent from school and seems apathetic and tired. 2. The child is very insecure and has poor self-esteem. 3. The child has multiple bruises on various body parts. 4. The child has sophisticated knowledge of sexual behaviors.

4 ~ The nurse should provide information about the accessibility of safe houses for battered women when working with a client who has symptoms of domestic physical abuse. Many women feel powerless within the abusive relationship and may be staying in the abusive relationship out of fear.

Which information should the nurse in an employee assistance program provide to an employee who exhibits symptoms of domestic physical abuse? 1. Have ready access to a gun and learn how to use it. 2. Research lawyers that can aid in divorce proceedings. 3. File charges of assault and battery. 4. Have ready access to the number of a safe house for battered women.

A. Passive and dependant. During the taking in phase, which usually lasts 1-3 days, the mother is passive and dependent and expresses her own needs rather than the neonate's needs. Options B, C, and D: The taking hold phase usually lasts from days 3-10 PP. During this stage, the mother strives for independence and autonomy; she also becomes curious and interested in the care of the baby and is most ready to learn.

Which of the following behaviors characterizes the PP mother in the taking in phase? A. Passive and dependant B. Striving for independence and autonomy C. Curious and interested in care of the baby D. Exhibiting maximum readiness for new learning

1, 2, 4, and 5 are correct. Women who skip appointments, delay reporting injuries, or simply do not report injuries should be suspected of being abused. The history should be assessed very carefully. Often the injuries are not supported by the story.Abusers frequently dominate conversations with their victims. When asked questions by the nurse, abusers frequently respond rather than allowing their partners to respond. Women who frequently skip prenatal or other follow-up appointments must be queried regarding the reason for the absences. There are many possible explanations—for example, they may have no transportation to the site or they may be forced to remain at home because of visible injuries. A visiting nurse should be sent to the home to determine the reason for the absences.

Which of the following behaviors would indicate to a nurse that a gravid woman may be being abused? Select all that apply. 1. Denies that any injuries occurred, even when bruising is visible. 2. Gives an implausible explanation for any injuries. 3. Gives the nurse eye contact while answering questions. 4. Allows her partner to answer the nurse's questions. 5. Frequently calls to change appointment times.

B. Decrease. The placenta produces the hormone human placental lactogen, an insulin antagonist. After birth, the placenta, the major source of insulin resistance, is gone. Insulin needs decrease and women with type 1 diabetes may only need one-half to two-thirds of the prenatal insulin during the first few PP days.

Which of the following changes best described the insulin needs of a client with type 1 diabetes who has just delivered an infant vaginally without complications? A. Increase B. Decrease C. Remain the same as before pregnancy D. Remain the same as during pregnancy

C. Cervical laceration. Continuous seepage of blood may be due to cervical or vaginal lacerations if the uterus is firm and contracting. Options A and D: Retained placental fragments and uterine atony may cause subinvolution of the uterus, making it soft, boggy, and larger than expected. Option B: UTI won't cause vaginal bleeding, although hematuria may be present.

Which of the following complications may be indicated by continuous seepage of blood from the vagina of a PP client, when palpation of the uterus reveals a firm uterus 1 cm below the umbilicus? A. Retained placental fragments B. Urinary tract infection C. Cervical laceration D. Uterine atony

D. Pain in left calf with dorsiflexion of left foot. Pain in left calf with dorsiflexion of left foot indicate a positive Homan sign and are suggestive of thrombophlebitis and should be investigated further. Options A and C are expected related to circulatory changes after birth. Option B: A temperature of 100.4°F in the first 24 hours is most likely indicative of dehydration which is easily corrected by increasing oral fluid intake.

Which of the following findings would be a source of concern if noted during the assessment of a woman who is 12 hours postpartum? A. Postural hypotension B. Temperature of 100.4°F C. Bradycardia — pulse rate of 55 BPM D. Pain in left calf with dorsiflexion of left foot

A. Fundus 1 cm above the umbilicus 1 hour postpartum. Within the first 12 hours postpartum, the fundus usually is approximately 1 cm above the umbilicus. The fundus should be below the umbilicus by PP day 3. The fundus shouldn't be palpated in the abdomen after day 10.

Which of the following findings would be expected when assessing the postpartum client? A. Fundus 1 cm above the umbilicus 1 hour postpartum B. Fundus 1 cm above the umbilicus on a postpartum day 3 C. Fundus palpable in the abdomen at 2 weeks postpartum D. Fundus slightly to the right; 2 cm above umbilicus on postpartum day 2

C. Teaching how to express her breasts in a warm shower. Teaching the client how to express her breasts in a warm shower aids with let-down and will give temporary relief. Ice can promote comfort by vasoconstriction, numbing, and discouraging further letdown of milk.

Which of the following interventions would be helpful to a breastfeeding mother who is experiencing engorged breasts? A. Applying ice B. Applying a breast binder C. Teaching how to express her breasts in a warm shower D. Administering bromocriptine (Parlodel)

2 The nurse would expect to see an elevated white cell count.

Which of the following laboratory values would the nurse expect to see in a normal postpartum woman? 1. Hematocrit, 39%. 2. White blood cell count, 16,000 cells/mm3. 3. Red blood cell count, 5 million cells/mm3. 4. Hemoglobin, 15 grams/dL.

4) incorrect

Which of the following nursing interventions is inappropriate for in infant with necrotizing enterocolitis? 1) The nurse inserts an NG tube and withholds all oral feedings. 2) The nurse starts an IV and administers 0.9% NS at 75 mL/hr. 3) The nurse administers high-calorie TPN feedings as ordered. 4) The nurse diapers the baby tightly to help with abdominal distention.

B. Rapid diuresis. In the early PP period, there's an increase in the glomerular filtration rate and a drop in the progesterone levels, which result in rapid diuresis. Options A: There should be no urinary urgency, though a woman may feel anxious about voiding. Options C and D: There's a minimal change in blood pressure following childbirth, and a residual decrease in GI motility.

Which of the following physiological responses is considered normal in the early postpartum period? A. Urinary urgency and dysuria B. Rapid diuresis C. Decrease in blood pressure D. Increase motility of the GI system

1, 2, 3, and 4 are correct. 1. This is a question that should be asked at each health care contact. 2. This is a question that should be asked at each health care contact. 3. This is a question that should be asked at each health care contact. 4. This is a question that should be asked at each health care contact.

Which of the following questions should be asked of women during all routine medical examinations? Select all that apply. 1. "Has anyone ever forced you to have sex?" 2. "Are you sexually active?" 3. "Are you ever afraid to go home?" 4. "Does anyone you know ever hit you?" 5. "Have you ever breastfed a child?"

D. Mothers with diabetes may breastfeed; insulin requirements may decrease from breastfeeding. Breastfeeding has an antidiabetogenic effect. Insulin needs are decreased because carbohydrates are used in milk production. Breastfeeding mothers are at a higher risk of hypoglycemia in the first PP days after birth because the glucose levels are lower. Mothers with diabetes should be encouraged to breastfeed.

Which of the following responses is most appropriate for a mother with diabetes who wants to breastfeed her infant but is concerned about the effects of breastfeeding on her health? A. Mothers with diabetes who breastfeed have a hard time controlling their insulin needs B. Mothers with diabetes shouldn't breastfeed because of potential complications C. Mothers with diabetes shouldn't breastfeed; insulin requirements are doubled. D. Mothers with diabetes may breastfeed; insulin requirements may decrease from breastfeeding.

3) Surfactant missing- respiratory difficulty

Which of the following would be the nurse's priority in a preterm newborn? 1) Heat loss 2) Immature kidneys 3) Surfactant missing 4) GI immaturity

B ~ Strong negative feelings cloud the nurse's judgment and interfere with assessment and intervention, no matter how well the nurse tries to cover or deny personal feelings. Strong positive feelings lead to over-involvement with the victim.

Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. Self-awareness protects one's own mental health. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to underinvolvement with the victim. d. Positive feelings promote the development of sympathy for patients.

A. Antonia quits her job to move in and care for a parent with severe dementia. In this situation, the adult child has given up her usual role as well as moved her place of residence to care for her parent. Caring for someone with severe dementia is very stressful, requiring almost 24-hour vigilance to ensure safety and meet needs. This situation places the caregiver at high risk for stress and abuse. The caregivers in option B are the staff working in the personal care home; the adult child does not have primary responsibility and, therefore, would not be a high risk for severe stress and abuse. In options C and D, the caregivers are receiving support and no one person has primary responsibility. This will decrease the risk for severe caregiver stress.

Which situation would Nurse Sally identify as placing a client at high risk for caregiver abuse? A. Antonia, an adult child, quits her job to move in and care for a parent with severe dementia. B. Mr. Wright, an elderly man with severe heart disease, resides in a personal care home and is frequently visited by his adult child. C. Mrs. Hale, an elderly parent with limited mobility, lives alone and receives help from several adult children. D. Antoinette cares for her husband who is in early stages of Alzheimer's disease and has a network of available support persons.

B (IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester; SGA infants have reduced brain capacity. The asymmetric form occurs in the later stages of pregnancy. Weight is less than the 10th percentile; head circumference is greater than the 10th percentile. Infants with asymmetric IUGR have the potential for normal growth and development.)

With regard to small for gestational age (SGA) infants and intrauterine growth restrictions (IUGR), nurses should be aware that: a. In the first trimester diseases or abnormalities result in asymmetric IUGR. b. Infants with asymmetric IUGR have the potential for normal growth and development. c. In asymmetric IUGR weight is slightly more than SGA, whereas length and head circumference are somewhat less than SGA. d. Symmetric IUGR occurs in the later stages of pregnancy.