OB exam 3
The plan of care for a client with osteoporosis includes active and passive exercises, calcium supplements, and daily vitamins. How does a nurse determine that the desired effect of therapy is attained? 1) mobility increases 2) fewer muscle spasms occur 3) there is a more regular heartbeat 4) there are fewer bruises than before therapy
1) mobility increases Rationale: This regimen limits bone demineralization and reduces bone pain, which promote increased activity.
Contraceptives that have estrogen-like and/or progesterone-like compounds are prepared in a variety of forms. Which contraceptives should a nurse identify as having a hormonal component? SATA 1. oral agents 2. diaphragms 3. cervical caps 4. female condoms 5. foam spermicides 6. transdermal agents
1 & 6
During the initial assessment of a newborn the nurse suspects a congenital heart defect. Which clinical manifestations support this suspicion? SATA 1. nasal flaring 2. sternal retractions 3. grunting respirations 4. short periods of apnea 5. cyanotic hands and feet 6. heart rate of 160 bpm
1, 2, 3 Rationale: Nasal flaring occurs because of the stress of breathing; the flaring nostrils allow more air to enter the respiratory passages. 2) Sternal retractions occur when accessory muscles of respiration contract during the stress of breathing. 3) Grunting respirations occur as the glottis closes and reopens at the height of inhalation; this momentary closure of the glottis increases the length of time oxygen and carbon dioxide are exchanged in the alveoli.
A nurse is assessing several postpartum clients. Which clients are at risk for developing postpartum hemorrhage? SATA 1. twin birth 2. overdistended bladder 3. hypertonic uterine dystocia 4. retained placental fragments 5. mild gestational hypertension
1, 2, 4 Rationale: Overdistention of the uterus may lead to delayed or inadequate uterine contractions. An overdistended bladder may inhibit uterine contractions. Retained placental fragments inhibit uterine contractions.
The nurse is differentiating between cephalohematoma and caput succedaneum. What finding is unique to caput succedaneum? 1. Scalp over the area is tender. 2. Edema crosses the suture line. 3. Edema increases during the first day. 4. Scalp over the area becomes ecchymosed.
2. Edema crosses the suture line. Rationale: this is the sign that differentiates between these two conditions; cephalohematoma does not extend beyond the suture line.
Which behavior should a nurse identify as the Moro reflex response? 1. extension and adduction of the arms 2. abduction and then adduction of the arms 3. adduction of the arms and fanning of the toes 4. extension of the arms and curling of the fingers
2. abduction and then adduction of the arms Rationale: The Moro reflex is a sudden extension and abduction of the arms at the shoulders and spreading of the fingers. This is followed by flexion and adduction of the arms with the index finger and thumb forming the letter "C"; the infant may cry.
A client at the women's health clinic tells the nurse she has endometriosis. What factors associated with endometriosis does the nurse anticipate the client will report? Select all that apply. A) Insomnia B) Ecchymoses C) Rectal pressure D) Abdominal pain E) Skipped periods F) Pelvic infections
C & D Rationale: Endometriosis is the presence of aberrant endometrial tissue outside the uterus. The tissue responds to ovarian stimulation and bleeds during menstruation, which causes rectal pressure and abdominal pain.
A client has obtained levonorgestrel as emergency contraception. After unprotected intercourse, the client calls the clinic to ask questions about taking contraceptives. The nurse realizes the client needs further explanation when she makes which statement? a. "I can wait up to 4 days after intercourse to start taking these to prevent pregnancy." b. "My boyfriend can buy levonorgestrel from the pharmacy if he is over 18 years old." c. "The birth control works by preventing ovulation or fertilization of the egg." d. "I may feel nauseated and have breast tenderness or a headache after using the contraceptive."
a. "I can wait up to 4 days after intercourse to start taking these to prevent pregnancy." Rationale: Levonorgestrel can reduce the chance of pregnancy if taken within 72 hours of unprotected intercourse, and then again 12 hours later. Waiting 4 days to take the medication reduces effectiveness.
During the postpartum period a client with heart disease and DM II asks a nurse, "Which contraceptives will I be able to use to prevent pregnancy in the near future?" a. "You may use oral contraceptives because they are almost completely effective in preventing a pregnancy." b. "You should use foam with a condom to prevent pregnancy because this is the safest method for women with your illnesses." c. "You will find that the intrauterine device is best for you because it prevents a fertilized ovum form implanting in the uterus." d. "You do not need to worry about becoming pregnant in the near future because women with your illnesses usually become infertile."
b. "You should use foam with a condom to prevent pregnancy because this is the safest method for women with your illnesses." Rationale: Some type of a barrier contraceptive (condom with foam or jelly or a diaphragm) is usually recommended for the client with diabetes and heart disease.
An antenatal primigravid client has just been informed that she is carrying twins. The plan of care includes educating the client concerning factors that put her at risk for problems during the pregnancy. The nurse realizes the client needs further instruction when she indicates carrying twins puts her at risk for which complication? a. preterm labor b. twin-to-twin transfusion c. anemia d. group B streptococcus
d. group B streptococcus Rationale: Group B streptococcus is a risk factor for all pregnant women and is not limited to those carrying twins.
Neonates have difficulty maintaining their body temperature, but their bodies have several mechanisms to help them do so. Which ones should a nurse remember when caring for a newborn? Select all that apply. 1. Flexed fetal position 2. Hepatic insulin stores 3. Brown fat metabolism 4. Peripheral vasoconstriction 5. Parasympathetic nervous system
1, 3, 4 Rationale: Full-term neonates have a flexed fetal position, which conserves heat. Brown fat is deposited at 28 weeks' gestation and continues for the rest of the pregnancy; when the newborn's body becomes cool, the sympathetic nervous system stimulates the breakdown of the brown fat, which releases heat as a by-product. Peripheral vasoconstriction helps to conserve heat by keeping the central core warm and preventing heat from dissipating.
A nurse is teaching breast care to a client who is breastfeeding. Which client statement indicates that the teaching was effective? 1. "I should air dry my nipples after each feeding." 2. "Mild soap is appropriate for washing my breast." 3. "My breast pads should be lined with plastic shields." 4. "I will remove my bra before I go to bed at night."
1. "I should air dry my nipples after each feeding." Rationale: Air-drying nipples after feeding limits irritation and disruption of skin integrity.
After birth, when inspecting her newborn, a mother notices a discharge from the nipple of both of her infant's breasts. She asks why this is happening. How should the nurse respond? 1. "It is an effect from maternal hormones." 2. "It is caused by Monilia contracted during birth." 3. "There may be a congenital hormonal imbalance." 4. "There was a uterine infection during the pregnancy."
1. "It is an effect from maternal hormones." Rationale: Some maternal oxytocin crosses the placenta and induces the secretion of fluids that have accumulated in the fetal breasts (sometimes called "witch's milk")
A nurse is caring for a postpartum client who is formula feeding. What should the nurse teach her about minimizing breast discomfort? 1. Apply covered ice packs to her breasts. 2. Gently apply cocoa butter to her nipples. 3. Place warm, wet washcloths on her nipples. 4. Manually express colostrum from her breasts.
1. Apply covered ice packs to her breasts. Rationale: Covered ice packs promote comfort by decreasing vasocongestion.
A primipara has just given birth at 37 weeks' gestation. What should the nurse do to help promote the attachment process between the mother and her newborn? 1. Encourage continuous rooming-in 2. Assign one nurse to care for both of them 3. Allow extra visiting privileges in the nursery 4. Teach the client how to breastfeed the baby
1. Encourage continuous rooming-in Rationale: Rooming-in provides time for the mother and newborn to be together; the mother can become acquainted with the infant more quickly.
What should be included in a plan of care to limit the development of hyperbilirubinemia in the breastfed neonate? 1. Encouraging more frequent breastfeeding during the first 2 days. 2. Instituting phototherapy for 30 minutes every 6 hours for 3 days. 3. Substituting breastfeeding with formula feeding on the second day. 4. Supplementing breastfeeding with glucose water during the first day.
1. Encouraging more frequent breastfeeding during the first 2 days. Rationale: More frequent breastfeeding stimulates more frequent evacuation of meconium, thus preventing resorption of bilirubin into the circulatory system.
A nurse observes that a client is voiding frequently in small amounts 8 hours after giving birth. What should the nurse conclude about this small output of urine during the early postpartum period? 1. It may indicate retention of urine with overflow. 2. It may be indicative of beginning glomerulonephritis. 3. This is common because less fluid is excreted after birth. 4. This is common because fluid intake diminishes after birth.
1. It may indicate retention of urine with overflow. Rationale: Retention of urine with overflow will be manifested in small, frequent voidings. The bladder should be palpated for distention.
What should a nurse include in the discharge teaching of a postpartum client? 1. The prenatal perineal tightening exercises should be continued. 2. The episiotomy sutures will be removed at the first post-partum visit. 3. She may not have a bowel movement for up to a week after the birth. 4. She should schedule a postpartum checkup as soon as her menses return.
1. The prenatal perineal tightening exercises should be continued. Rationale: Kegel exercises can be resumed immediately and should be done for the rest of the client's life because they help strengthen muscles needed for urinary continence an may enhance sexual intercourse.
For what should the nurse assess in a newborn of a mother who is known to abuse opioids? 1. dehydration 2. hyperactivity 3. hypotonicity of muscles 4. prolonged periods of sleep
2. hyperactivity As the opioid is cleared from the newborn's body, signs of withdrawal become evident. Tremors, irritability, difficulty sleeping, twitching, and convulsions result.
A nurse is counseling a postmenopausal obese client how to prevent bone loss. Which statements indicate understanding of the strategies to prevent bone loss? SATA 1) "I must go on a strict diet." 2) "I will take 400 mg of vitamin D daily." 3) "I should take 1200 mg of calcium daily." 4) "Swimming or bike riding 5 x week is good for me." 5) "Joining an aerobics class 3x week will help my bones."
3) "I should take 1200 mg of calcium daily." 5) "Joining an aerobics class 3x week will help my bones." Rationale: This is the daily recommended intake of calcium for postmenopausal women, and weight bearing activities are best for building bone mass.
A nurse is caring for a client who just had a mastectomy. How should the nurse position the client's arm on the affected side? 1) in adduction supported by sandbags 2) in abduction surrounded by sandbags 3) on pillows with the hand higher than the arm 4) with the arm lower than the level of the heart
3) on pillows with the hand higher than the arm Rationale: Postoperatively the arm on the operated side is elevated on pillows, with the hand higher than the arm to prevent muscle strain and edema.
A nurse is assessing a client for the potential for developing osteoporosis. Which factor in the client's history increases the risk for this disorder? 1) estrogen therapy 2) hypoparathyroidism 3) prolonged immobility 4) excessive calcium intake
3) prolonged immobility Rationale: Prolonged immobility results in bone demineralization because there is decreased bone production by osteoblasts and increased resorption by osteoclasts.
Which food selected by a client with osteoporosis indicates that the nurse's dietary instruction was effective? 1) red meat 2) soft drinks 3) turnip greens 4) enriched grains
3) turnip greens Rationale: Turnip greens are high in calcium and vitamins.
The nurse notices that a client who has just given birth is short of breath, is ashen in color, and begins to cough. She becomes limp on the birthing table. At last assessment 1/2 hour ago, her temp. was 98 F, HR 78 bpm, and RR 16. Determine the nursing actions in the order they should occur. All options must be used. 1. Open airway using head tilt-chin lift. 2. Ask staff to activate emergency response system. 3. Establish unresponsiveness. 4. Give two breaths. 5. Begin compressions
3, 2, 5, 1, 4
While a mother is inspecting her newborn she expresses concern that her baby's eyes are crossed. How should the nurse respond? 1. "Take another look. They seem fine to me." 2. "It's all right. Most babies have crossed eyes." 3. "This is expected. Your baby is trying to focus." 4. "You're right. I'll contact your health care provider."
3. "This is expected. Your baby is trying to focus." Rationale: Newborn's eye movements are uncoordinated and the eyes appear crossed as they try to focus. As the eye muscles mature, the apparent strabismus disappears.
A nurse must continuously monitor a preterm infant's temperature and provide appropriate nursing care because unlike the full-term infant, the preterm infant: 1. cannot use shivering to produce heat 2. cannot break down glycogen to glucose 3. has a limited supply of brown fat available to provide heat. 4. has a limited amount of pituitary hormones to control internal heat
3. has a limited supply of brown fat available to provide heat. Because neonates are unable to shiver, they use the breakdown of brown fat to supply body heat; the preterm infant has a limited supply of brown fat available for this breakdown.
A nurse suspects that a newborn is experiencing opioid withdrawal. Which assessment support this suspicion? 1. lethargy and constipation 2. grunting and low-pitched cry 3. irritability and nasal congestion 4. watery eyes and rapid respirations
3. irritability and nasal congestion Opioid withdrawal affects the CNS and respiratory systems.
An infant's intestines are sterile at birth, thus lacking the bacteria necessary for the synthesis of: 1. bilirubin 2. bile salts 3. prothrombin 4. intrinsic factor
3. prothrombin Rationale: Bacteria, especially Escherichia coli, produce substances necessary to synthesize prothrombin.
A nurse is writing a teaching plan about osteoporosis. The nurse should include in language that most clients would understand that osteoporosis is best described as: 1) avascular necrosis 2) pathologic fractures 3) hyperplasia of osteoblasts 4) decrease in bone substance
4) decrease in bone substance Rationale: This defect in bone matrix formation weakens the bones, making them unable to withstand usual functional stresses.
A client who had a mastectomy asks about the term ERP-positive. The nurse explains that tumor cells are evaluated for estrogen receptor protein to determine the: 1) need for supplemental estrogen 2) feasibility of breast reconstruction 3) degree of metastasis that has occured 4) potential response to hormone therapy
4) potential response to hormone therapy Rationale: Estrogen receptor protein (ERP)-positive tumors have a more dramatic response to hormonal therapies that reduce estrogen.
A client is diagnosed with uterine fibroids, and the health care provider advises a hysterectomy. The client expresses concern about having a hysterectomy at age 45 because she has heard from friends that she will undergo severe symptoms of menopause after surgery. What is the nurse's most appropriate response? 1) "You are correct, but there are medicines you can take that will ease the symptoms." 2) "This sometimes occurs in women of your age, but you needn't worry about it at this time." 3) "Perhaps you should talk to your surgeon because I am not allowed to discuss this with you." 4) "Some women may experience symptoms of menopause if their ovaries are removed with their uterus."
4. "Some women may experience symptoms of menopause if their ovaries are removed with their uterus." Rationale: A hysterectomy involves only removal of the uterus. The ovaries, which secrete estrogen and progesterone, are not removed. Therefore, menopause will not be precipitated but will occur naturally.
A multigravida has a spontaneous vaginal birth. Five minutes later the placenta is expelled. Where does a nurse expect to locate the uterine fundus at this time? 1. In the pelvic cavity 2. Just below the xiphoid process. 3. At the umbilicus and in the right quadrant. 4. Halfway between the symphysis pubis and the umbilicus.
4. Halfway between the symphysis pubis and the umbilicus. Rationale: Immediately after birth the fundus is palpated midway between the symphysis pubis and the umbilicus.
A newborn's Apgar score at 5 minutes is 5. With what condition that requires does a low Apgar score at 5 minutes after birth correlate that requires intensive monitoring of this neonate? 1. Cerebral palsy 2. Genetic defects 3. Mental retardation 4. Neonatal morbidity
4. Neonatal morbidity Rationale: This is related to neonatal morbidity and mortality; by 5 minutes the healthy neonate is relatively stable with an Apgar score of 8-10 and requires routine care.
A nurse in a woman's health clinic is counseling clients about the signs of gynecological problems. What early manifestation of cervical cancer should prompt a client to seek professional care? 1) abdominal heaviness 2) pressure on the bladder 3) foul-smelling discharge 4) bloody spotting after intercourse
4. bloody spotting after intercourse Rationale: Any sign of abnormal vaginal bleeding may indicate cervical cancer and must be investigated.
A newborn has an asymmetric Moro reflex. What does a nurse identify as a cause of this problem? 1. Down syndrome 2. cranial nerve damage 3. cerebral or cerebellar birth injuries 4. brachial plexus, clavicular, or humeral birth injuries
4. brachial plexus, clavicular, or humeral birth injuries Injury to the brachial plexus, clavicle, or humerus during birth prevents abduction and adduction movements of an upper extremity.
A preterm neonate admitted to the neonatal intensive care nursery (NICU) has muscle twitching, seizure, cyanosis, abnormal respirations, and a short, shrill cry. What complication does the nurse suspect? 1. tetany 2. spina bifida 3. hyperkalemia 4. intracranial hemorrhage
4. intracranial hemorrhage Intracranial bleeding may occur in the subdural, subarachnoid, or intraventricular spaces of the brain, causing pressure on vital centers; clinical signs are related to the area and degree of cerebral involvement.
A nurse is assessing a newborn's respirations. What clinical findings indicate that the respirations are within the expected range? 1. regular, thoracic, 40-60/min 2. irregular, thoracic, 30-60/min 3. regular, abdominal, 40-50/min 4. irregular, abdominal, 30-60/min
4. irregular, abdominal, 30-60/min Rationale: The expected breathing patterns are abdominal and irregular in rhythm and depth (alternates between shallow and deep); the expected rate ranges from 30-60 breath/min
During the first hour after a cesarean birth, a nurse observes that the client's locia has saturated one perineal pad. Based on the knowledge of the expected lochial flow, what should the nurse conclude that this indicates? 1. scant lochial flow 2. postpartum hemorrhage 3. retained placental fragments 4. lochial flow within expected limits
4. lochial flow within expected limits Rationale: It is expected that up to two perineal pads can be saturated in the first hour.
A nurse is caring. for preterm infants with respiratory distress in the NICU. What is the priority nursing action? 1. limit caloric intake to decrease metabolic rate 2. maintain the prone position to prevent aspiration 3. limit oxygen concentration to prevent eye damage 4. maintain a high-humidity environment to promote gas exchange
4. maintain a high-humidity environment to promote gas exchange The moisture provided by the humidity liquefies the tenacious secretions, making gas exchange possible.
Which should the nurse explain to a new mother will be delayed until her newborn is 36-48 hrs old? 1. vitamin K injections 2. test for blood glucose level 3. test for necrotizing enterocolitis 4. screening for phenylketonuria
4. screening for phenylketonuria Rationale: in 36-48 hrs the newborn will have ingested an ample amount of the amino acid phenylalanine, which if not metabolized because of a lack of a specific liver enzyme, can result in excess levels of phenylalanine in the bloodstream and brain, resulting in mental retardation; early detection is essential to prevent this.
Which newborn assessment identified immediately after birth will probably necessitate prolonged follow-up care? 1. Apgar score of 5 2. Weight of 3500 grams 3. blood glucose level of 50 mg/dL 4. umbilical cord with 2 blood vessels
4. umbilical cord with 2 blood vessels Rationale: The congenital absence of a blood vessel in the umbilical cord is often associated with life threatening congenital anomalies. There should be two arteries and one vein.
A thin older adult client is diagnosed with osteoporosis. What should the nurse include in the discharge plan for this client? A) Encouragement of gradual weight gain B) Monitoring for decreased urine calcium C) Instructions relative to diet and exercise D) Safety factors when using opioids and NSAIDS
C) Instructions relative to diet and exercise Rationale: A diet high in calcium and exercise, which helps deposit calcium into bone, are the most important factors in limiting the extent of osteoporosis.
A multigravid client will be using medroxyprogesterone acetate (Depo-Provera) as a family planning method. After the nurse instructs the client about this method, which of the following client statements indicates effective teaching? a) "This method of family planning requires monthly injections." b) "I should have my first injection during my menstrual cycle." c) "One possible side effect is absence of a menstrual period." d) "This drug will be given by subcutaneous injections."
c. "One possible side effect is absence of a menstrual period." Rationale: medroxyprogesterone acetate can cause irregular periods and amenorrhea. Other adverse effects of this medication include weight gain, breakthrough bleeding, headaches, and depression. This method requires deep IM injections every 3 months. The first injection should occur within 5 days after menses.
A client asks a nurse why she developed cervical polyps. How should the nurse respond? a) "They are often malignant and must be removed." b) "Cervical polyps usually are precursors of uterine cancer." c) "They are usually benign and a biopsy rules out a malignancy." d) "Cervical polyps do not cause bleeding unless they are malignant."
c. "They are usually benign and a biopsy rules out a malignancy." Rationale: Polyps are usually benign, but a biopsy should be done because epidermoid cancer occasionally arises from cervical polyps.
Which instruction should the nurse include in the teaching plan for a 30-year-old multiparous client who will be using an intrauterine device (IUD) for family planning? a. amenorrhea is a common adverse effect of IUDs. b. The client needs to use additional protection for conception. c. IUDs are more costly than other forms of contraception. d. Severe cramping may occur when the IUD is inserted.
d. Severe cramping may occur when the IUD is inserted. Rationale: Severe cramping and pain may occur as the device is passed through the internal cervical os. The insertion of the device is generally done when the client is having her menses because it is unlikely that she is pregnant at that time.
A nurse is teaching a group of women about the side effects of different types of contraceptives. What is the most frequent side effect associated with the use of an intrauterine device (IUD)? a. a tubal pregnancy b. a rupture of the uterus c. an expulsion of the device d. an excessive menstrual flow
d. an excessive menstrual flow Rationale: Subsequent to IUD insertion there may be an excessive menstrual flow for several cycles; because the IUD is a foreign body, there is an increase in the blood supply as a result of the inflammatory process.
The nurse is working with four clients on the obstetrical unit. Which client will be the highest priority for a c-section? a. client at 40 weeks; gestation whose fetus weighs 8lb by ultrasound estimate b. client at 37 weeks' gestation with fetus in ROP position c. client at 32 weeks' gestation with fetus in breech position d. client at 38 weeks' gestation with active herpes lesions
d. client at 38 weeks' with active herpes lesions
A nurse is testing a newborn's heel blood for the level of glucose. Which newborns does the nurse anticipate will experience hypoglycemia? SATA 1. preterm infants 2. infants with Down syndrome 3. small-for-gestational-age infants 4. Large-for-gestational-age infants 5. Appropriate-for-gestational-age infants
1, 3, 4 Rationale: 1. These infants have low glycogen stores. 3. These infants have low glycogen stores. 4. These infants are prone to hyperinsulinemia; often they have mothers who have diabetes, which exposes them to high circulating glucose level while in utero. After prolonged exposure to high glucose level, hyperplasia of the pancreas occurs, resulting n hyperinsulinemia.
An infant born in the 36th week of gestation weights 4 lb 3 oz (2062 g) and has Apgar scores of 7/9. What nursing actions will be performed upon admission to the nursery? SATA 1. Recording vital signs 2. administering oxygen 3. offering a bottle of dextrose in water 4. evaluating the neonate's health status 5. supporting the neonate's body temperature
1, 4, 5 Rationale: 1. This is an important part of record keeping for all newborns. 4. All newborns are evaluated upon admission to the nursery. 5. All newborns should be kept warm to maintain a stable body temperature.
An infant develops purulent conjunctivitis on the fourth day of life and is brought to the emergency department. What is the priority nursing action? 1. assess for signs of pneumonia 2. secure an order for allergy testing of the infant 3. Bathe the infant's eyes with tepid boric acid solution. 4. Teach the mother to wash her hands before touching the infant
1. assess for signs of pneumonia Chlamydia trachomatis is associated with the development of pneumonia in the newborn.
A nurse teaches a group of postpartum clients that all their newborns will be screened for phenylketonuria (PKU) to: 1. assess protein metabolism 2. reveal potential retardation 3. detect chromosomal damage 4. identify thyroid insufficiency
1. assess protein metabolism Rationale: Phenylalanine is an essential amino acid necessary for growth that may be absent in infants with phenylketonuria (PKU); testing is done on all neonates born in the U.S.
An infant is born with a bilateral cleft palate. Plans are made to begin reconstruction immediately. What nursing intervention should be included to promote parent-infant attachment? 1. demonstrating a positive acceptance of the infant 2. placing the infant in an nursery away from the view of the general public 3. explaining to the parents that the infant will look normal after the surgery 4. encouraging the parents to limit contact with the infant until after the surgery
1. demonstrating a positive acceptance of the infant Rationale: By demonstrating acceptance of the infant, without regard for the defect, the nurse acts as a role model for the parents, thus enhancing their acceptance.
What is a nurse's primary critical observation when performing an assessment for determining an Apgar score? 1. heart rate 2. respiratory rate 3. presence of meconium 4. evaluation of moro reflex
1. heart rate Rationale: The heart rate is vital for life and is the most critical observation in Apgar scoring.
A nurse anticipates that newborns of mothers who have diabetes often have tremors, periods of apnea, cyanosis, and poor sucking ability. With what complication are these signs associated? 1. hypoglycemia 2. hypercalcemia 3. central nervous system edema 4. congenital depression of the islets of Langerhans
1. hypoglycemia Rationale: The pancreas of a fetus of a diabetic mother responds to the mother's hyperglycemia by secreting large amounts of insulin; this leads to hypoglycemia after birth.
A nurse must meet the hydration needs of a preterm infant. What should the nurse consider about the preterm infant's kidney function? 1. large amounts of urine are excreted 2. It is the same as in full-term newborn. 3. Urine is concentrated with an elevated specific gravity. 4. Acid-base and electrolyte balance are adequately mainained.
1. large amounts of urine are excreted The preterm infant has a reduced glomerular filtration rate and reduced ability to concentrate urine or conserve water.
A newborn has small, whitish, pinpoint spots over the nose that are caused by retained sebaceous secretions. When documenting this observation, a nurse identifies them as: 1. milia 2. lanugo 3. whiteheads 4. mongolian spots
1. milia Rationale: Milia are common, are not indicative of illness, and eventually disappear.
Sitz baths are ordered for a client with an episiotomy during the postpartum period. A nurse encourages her to take the sitz baths because they aid the healing process by: 1. promoting vasodilation 2. cleansing perineal tissue 3. softening the incision site 4. tightening the rectal sphincter
1. promoting vasodilation Rationale: Heat causes vasodilation and an increased blood supply to the area.
A client tells a nurse that she does not want an episiotomy and would rather tear naturally. What information should be offered regarding each birthing method? 1. lacerations are more painful than an episiotomy. 2. Lacerations are easier to repair than an episiotomy. 3. An episiotomy causes less posterior trauma than lacerations. 4. An episiotomy is preferred over lacerations according to evidence-based practice.
2. Lacerations are easier to repair than an episiotomy. Rationale: Lacerations require less suture time and cause less perineal trauma, which can have lifelong implications such as rectal-vaginal fistulas.
A client is bleeding excessively after the birth of a neonate. The health care provider orders fundal massage and prescribes an IV infusion containing 10 units of oxytocin at 100mL/hr. A nurse's evaluation of the client's responses to these interventions is BP: 135/90 uterus: boggy at 3 cm above the umbilicus and displaced to the right; perineal pad: saturated with bright red lochia. What is the nurse's next action? 1. increase the infusion rate 2. assess for a distended bladder 3. continue to perform fundal massage 4. continue to assess the blood pressure
2. assess for a distended bladder Rationale: A displaced and boggy uterus usually is caused by a full bladder; if the bladder is distended, the nurse should have the client void and then reassess the fundus, and if still boggy, massage until firm.
When assessing a 9lb neonate 2 hrs after birth, a nurse identifies jitteriness, apneic episodes, tachycardia, and temperature instability. What complication do these finding indicate to the nurse? 1. hyponatremia 2. hypoglycemia 3. cardiac defect 4. immature CNS
2. hypoglycemia Rationale: Hypoglycemia causes CNS and sympathetic nervous symptom responses.
A nurse is assessing the apical and radial pulses of a postpartum client 3 hours after the birth of her second child. Which clinical finding does the nurse expect? 1. thready pulse 2. slow heartbeat 3. bounding pulse 4. irregular heartbeat
2. slow heartbeat Rationale: The heartbeat can drop as low as 50 bpm for up to 10 days after the birth. It occurs because of the decreased blood volume, and increased stroke volume after the pregnancy has terminated.
At the beginning of the first formula feeding a newborn begins to cough and choke, and the lips become cyanotic. What is the immediate nursing action? 1. stimulate crying 2. suction and then oxygenate 3. substitute the formula with sterile water 4. stop the feeding momentarily and then restart
2. suction and then oxygenate Rationale: Cyanosis, choking, and coughing are signs of aspiration and hypoxia. Suctioning and oxygenation are needed.
What is the most common complication for which the nurse must monitor preterm infants? 1. hemorrhage 2. brain damage 3. respiratory distress 4. aspiration of mucus
3. respiratory distress Immaturity of the respiratory tract in preterm infants is evidenced by a lack of functional alveoli, smaller lumina with increased possibility of collapse of the respiratory passages, weakness of respiratory musculature, and insufficient calcification of the bony thorax, leading to respiratory distress.
A nurse observes a healthy newborn lying in the supine position with the head turned to the side and legs and arms extended on the same side and flexed on the opposite side. Which reflex does the nurse identify? 1. moro 2. babinski 3. tonic neck 4. palmar grasp
3. tonic neck Rationale: The tonic neck reflex (fencing position) is a spontaneous postural reflex of the newborn; it persists until the third month.
A client who has type O Rh-positive blood gives birth to a neonate with type B Rh-negative blood. When the nurse assesses the neonate 11 hrs after birth, the infant's skin appears yellow. What is the most likely cause? 1. neonatal sepsis 2. Rh incompatibility 3. Physiologic jaundice 4. ABO incompatibility
4. ABO incompatibility Rationale: There is an apparent ABO incompatibility because the mother is O and the infant is B; incompatibility can cause jaundice within the first 24 hrs.
A newborn has a diagnosis of Erb palsy. What does a nurse identify as the cause of this complication? 1. A disease acquired in utero. 2. An X-linked inheritance pattern 3. A tumor arising from muscle tissue 4. An injury to the brachial plexus during birth
4. An injury to the brachial plexus during birth The brachial plexus is injured by excessive pressure during a difficult birth or during a vaginal breech birth.
An infant is born in the breech position and assessment of the newborn indicates the presence of Erb palsy (Erb-Duchenne paralysis). What clinical manifestation supports this conclusion? 1. Absent grasp reflex on the affected side 2. Negative Moro reflex on the unaffected side 3. Inability to turn the head to the unaffected side 4. Flaccid arm with the elbow extended on the affected side
4. Flaccid arm with the elbow extended on the affected side With Erb-Duchenne paralysis there is damage to spinal nerves C5 and C6, which causes paralysis of the arm.
A neonate 1 minute after birth is observed to have a weak cry, grimacing, a heart rate of 90 beats/min, some flexion of the extremities, and a pink body with blue extremities. What is the Apgar score for this neonate? Record your answer using a whole number. ____________
5
A nurse who is assessing a newborn 1 minute after birth determines that the cry is lusty, the heart rate is 150 bpm, and the extremities are flexed, but the bottoms of the feet have a marked bluish tinge. What Apgar score does the nurse assign to the neonate? Record your answer using a whole number _____
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The nurse is receiving shift report on 4 clients on the antenatal unit. The 4 clients are (1) a 35-week-gestation mother with severe preeclampsia started on a maintenance dose of magnesium sulfate 1 hr ago, (2) a 30-week-gestation client with preterm labor on an oral tocolytic and having no contractions in 6 hrs, (3) a hyperemesis client with emesis 4x in the past 12 hrs and, (4) a 33-week-gestation client with placenta previa who began to feel pelvic pressure during change of shift report. Which action should the nurse take first? a. Evaluate the client with the preeclampsia for maternal and fetal tolerance of magnesium sulfate and the labor pattern. b. assess the client with preterm labor for tolerance of tocolytics and the labor pattern. c. assess the client with hyperemesis for nausea, further emesis, or dehydration. d. evaluate the client with placenta previa without an exam.
d. evaluate the client with placenta previa without an exam Rationale: evaluate the client with placenta previa experiencing pelvic pressure which may be caused by a fetal head creating pressure in the pelvis indicating a potential birth. Vaginal exams are contraindicated in clients with placenta previa.
Which client findings require the nurse's attention first? a. a gravida 2 para 1 at 39 weeks' gestation with spontaneous rupture of membranes 1 hr ago but no contractions b. a gravida 3 para 1 at 30 weeks' gestation with nausea, vomiting, and epigastric pain c. a gravida 5 para 1 at 37 weeks' gestation with pink vaginal discharge and abdominal cramping d. a gravida 1 para 0 at 39 weeks' gestation with bruises on the arms and abdomen at various stages of healing
b. a gravida 3 para 1 at 30 weeks' gestation with nausea, vomiting, and epigastric pain Rationale: These are signs of preeclampsia and requires the nurse's attention first. Option a is not a priority. Option c cold be in early labor and is not a priority at this time. Option d could indicate she is in an abusive relationship but this is not a priority at this time.
Before advising a 24-year-old client desiring oral contraceptives for family planning, the nurse would assess the client for which signs and symptoms? a. anemia b. hypertension c. dysmenorrhea d. acne vulgaris
b. hypertension rationale: Clients who have hypertension, thrombophlebitis, obesity, or a family history of cerebral or cardiovascular accident are poor candidates for oral contraceptives.
A client at 4 weeks postpartum tells the nurse that she cannot cope any longer and is overwhelmed by her newborn. The baby has old formula on her clothes and under her neck. The mother does not remember when she last bathed the baby and states she does not want to care for the infant. The nurse should encourage the client and her husband to call their health care provider (HCP) because the mother should be evaluated further for which complication? a. postpartum blues b. postpartum depression c. poor bonding d. infant abuse
b. postpartum depression Rationale: The client is experiencing and verbalizing signs of postpartum depression, which usually appears at about 4 weeks postpartum but can occur any time within the first year after birth. It is more severe and last longer than postpartum blues.
A client asks a nurse about the most common problem associated with the use of an intrauterine device (IUD). What should the nurse respond? a. perforation of the uterus b. spontaneous device expulsion c. discomfort associated with coitus d. development of vaginal infections
b. spontaneous device expulsion Rationale: The IUD may cause irritability of the myometrium, inducing contraction of the uterus and expulsion of the device.
Several pregnant clients are waiting to be seen in the triage area of the obstetrical unit. What client should the nurse see first? a. A client at 13 weeks' gestation who is experiencing nausea and vomiting 3x a day with ketones +1 in her urine b. a 37 week gestation client who is an insulin dependent diabetic and experiencing 3-4 fetal movements per day c. a 32 week gestation client who has preeclampsia and +3 proteinuria and who is returning for evaluation of epigastric pain d. a 17 week gestation client who is not feeling fetal movement at this point in her pregnancy
c. a 32 week gestation client who has preeclampsia and +3 proteinuria and who is returning for evaluation of epigastric pain
When developing a teaching plan for an 18-year-old client who asks about treatments for sexually transmitted infections, the nurse should explain that: a. acyclovir can be used to cure herpes genitalis b. Chlamydia trachomatis infections are usually treated with penicillin c. ceftriaxone may be used to treat Neisseria gonorrhoeae infections d. metronidazole is used to treat condylomata acuminata
c. ceftriaxone may be used to treat Neisseria gonorrhoeae infections. Rationale: Ceftriaxone is commonly combined with doxycycline to treat gonorrhea
After being examined and fitted for a diaphragm, a 24-year-old client receives instructions about its use. Which of the following client statements indicates a need for further teaching? A) "I can continue to use the diaphragm for about 2 to 3 years if I keep it protected in the case." B) "If I get pregnant, I will have to be refitted for another diaphragm after the delivery." C) "Before inserting the diaphragm I should coat the rim with contraceptive jelly." D) "If I gain or lose 20 pounds, I can still use the same diaphragm."
d. "If I gain or lose 20 lbs, I can still use the same diaphragm." Rationale: Gaining or losing more than 15 lb can change the pelvic and vaginal contours to such a degree that the diaphragm will no longer protect the client against pregnancy.