OB Final Exam
Meconium-stained amniotic fluid alerts the nurse to the possibility of which problem? a) fetal distress and perinatal asphyxia b) fetal distress and hyperbilirubinemia c) abruptio placenta and asphyxia d) placenta previa and perinatal sepsis
a) fetal distress and perinatal asphyxia
The nurse provides care for a client in labor. The client's labor progresses with regular contractions until the cervix is 9 cm dilated. The nurse identifies the client is in which stage of labor? a) first stage b) second stage c) third stage d) fourth stage
a) first stage
The provider orders Reglan (metoclopramide) 20 mg IV x 1 dose. How many mL(s) does the nurse administer? (Round to the 10th as applicable).
4 mL 20 mg ÷ 10 mg = 2 x 2 mL = 4 mL
The nurse teaches a class about gonorrhea. Which client statement indicates the teaching is successful? a) "I've heard that having gonorrhea can make you unable to have children" b) "They say this disease can affect your brain and make you go crazy" c) "I've heard you can't get rid of gonorrhea. You keep getting it over and over again" d) "My parent said you need to have cesarean deliveries after this infection"
a) "I've heard that having gonorrhea can make you unable to have children"
The patient is ordered Unasyn (Ampicillin sodium/ sulbactam sodium) 1.5 g. The Unasyn is mixed in 100 mL of normal saline and is to infuse over 20 minutes. At what rate (mL/hr) does the nurse set the pump? (Round to a whole number as applicable).
300 mL/hr Need to give 100 mL in 20 min: can be written as 100mL/20 min 100mL / 20 min x 60 min/1 hr = 6000 mL/20 hr = 300 mL/hr
A nurse is assisting with a pelvic exam on a client who is suspected of having trichomoniasis. Which findings would the nurse note as helping to confirm this diagnosis? SATA a) cervical bleeding when touched b) cervical petechiae c) vaginal erythema d) curd-like discharge in the vagina
a) cervical bleeding when touched b) cervical petechiae c) vaginal erythema
The nurse provides education on increasing dietary iron to a client diagnosed with anemia. The nurse recommends the client eat which food? SATA a) chicken livers b) pork chop c) hamburger d) bananas e) spinach f) tofu
a) chicken livers e) spinach f) tofu
The nurse explains to a client that which period of pregnancy is the most critical time for fetal development? a) first 2 weeks b) first 3 months c) the fourth through the sixth month d) the last month
b) first 3 months
The home health care nurse makes a visit to a pregnant client diagnosed with type 1 diabetes mellitus. The client states, "I have been nauseated for 24 hours". It is most important for the nurse to ask which question? a) "Have you vomited?" b) "What was your last blood glucose reading?" c) "Have you taken your insulin today?" d) "When did you last eat?"
c) "Have you taken your insulin today?"
The nurse instructs a group of expectant parents about the advantages of breastfeeding. The nurse intervenes if an expectant parents makes which statement? a) "My baby will grow faster and sleep more with breast milk" b) "My baby will receive protective immune factors from the breast milk" c) "My baby will not need any other foods or milk until 4 months of age" d) "At first, I may feed my baby about 10x per day"
a) "My baby will grow faster and sleep more with breast milk"
The nurse instructs a client how to prevent conception using the basal body temperature (BBT) method. The nurse explains that during ovulation, the basal body temperature will change in which direction? a) lowers significantly b) rises significantly c) is unchanged d) rises slightly
d) rises slightly Rationale: Just prior to ovulation, the basal body temperature lowers about 1 degree, however at the time of ovulation the body temp increases about 1-2 degrees. This slight rise is important for clients who rely on methods of childbirth planning that depend on knowledge of ovulatory cycle C temperature should decrease 2-4 days prior to menstruation, if temperature remains elevated pregnancy has occurred
The nurse provides care for a client in labor. The fetus is displaying occasional category 3 fetal heart rate patterns on the monitor. What is the first action for the nurse to perform? a) immediately call the HCP b) time the contractions from the beginning of one contraction to the beginning of the next contraction c) have the client roll onto the right side and take deep breath d) when the fetal heart rate is baseline perform fetal stimulation to assess for heart rate acceleration
d) when the fetal heart rate is baseline perform fetal stimulation to assess for heart rate acceleration Rationale: Category 3 is minimal variability with recurrent decelerations Fetal stimulation is another method of fetal assessment to use in conjunction of electronic fetal monitoring to provide additional information about the fetal status when category 3 fetal heart rate patterns are observed, it elicits an acceleration of FHR of 15 bpm for at least 15 sec and/or improve FHR variability. Should ONLY be performed when FHR is baseline
Which of the following is true regarding hormonal contraception? a. Increases the risk of uterine cancer b. Increases the risk of benign breast cancer c. Fetal anomalies are a concern d. Increases the risk for venous thromboembolism
d. Increases the risk for venous thromboembolism Rationale: There is an increased risk for venous thromboembolism in those taking hormonal contraception. There is a decreased risk of benign breast cancer and uterine cancer. Fetal anomalies are not a concern.
Which of the following measures helps prevent osteoporosis? a. Supplementing with iron b. Sleeping 8 hours nightly c. Eating lean meats only d. Walking daily
d. Walking daily
A pregnant client is scheduled for a nuchal translucency scan. Which statement by the client demonstrates understanding of the nurse's teaching about this procedure? a) "If this scan is positive, we will need further testing to confirm a diagnosis" b) "We can also determine the baby's biological sex from this scan" c) "The advantage of this scan is that it can be done before 8 weeks' pregnancy, so we will have results very early" d) "This scan will determine if our baby has any anomalies"
a) "If this scan is positive, we will need further testing to confirm a diagnosis"
Upon assessing the newborn's respirations, which finding would cause the nurse to notify the primary care provider? a) coughing and sneezing in the newborn b) short periods of apnea that lasts 10 seconds in a pink newborn c) a respiratory rate of 66 breaths per minute with nasal flaring d) a respiratory rate of 45 breaths per minute with acrocyanosis
c) a respiratory rate of 66 breaths per minute with nasal flaring
The home health nurse visits an adolescent client who delivered a full-term infant 2 weeks ago. Although the client appears mature, the nurse knows the client's age may interfere with positive parenting because of which factor? a) client is not in contact with baby's father b) client has yet to finish school c) client's parents want to place the baby in foster care d) client is still experiencing the dependency of childhood
d) client is still experiencing the dependency of childhood
A postmenopausal woman reports that she has started spotting again. Which action would the nurse take? a.Instruct the client to keep a menstrual diary for the next few months. b.Tell her not to worry since this a common but not serious event. c.Have her start warm-water douches to promote healing. d.Anticipate that the doctor will assess her endometrium thickness.
d.Anticipate that the doctor will assess her endometrium thickness. Rationale: Any postmenopausal bleeding is suspicious for endometrial cancer. Bleeding after menopause is suspicious for endometrial cancer. Huge red flag. This event warrants immediate evaluation, which would include an endometrial biopsy. HIGHER INCIDENCE OF THIS recently bc of - OBESITY Bc estrogen feeds of off this PCOS - HIGH RISK OF THIS A is incorrect: postmenopausal women do not have menstrual periods unless they are taking hormone replacement therapy. B is incorrect: any postmenopausal bleeding is abnormal and needs evaluation to determine its cause. The exception would be for a woman taking hormone replacement therapy and still experiencing monthly cycles. C is incorrect: warm-water douches would not be advised for a woman experiencing postmenopausal bleeding, since it would not be therapeutic or warranted. Determining the etiology of the spotting or bleeding is imperative
A sexually active 19-year-old presents to the clinic with postcoital bleeding, dysuria, and a yellow discharge. Her cervix upon exam is red and friable. What might the nurse suspect? a.Cervical cancer b.A tampon injury c.Primary syphilis d.Chlamydia
d.Chlamydia Rationale: These clinical manifestations are typical of a chlamydia infection (postcoital bleeding, dysuria, frequency, vaginal discharge, cervical tenderness with easily induced bleeding). Response "A" is incorrect because it would be rare to have cervical cancer at such a young age and the symptoms presented are not suggestive of this diagnosis. Bleeding after intercourse think any cancer. What separates this from cancer is also the discharge. •Because yellow d/c = suspicion for infection, and her age •Cancer - increases with age •Cervical cancer: Blood spots or light bleeding between or following periods. Response "B" is incorrect because the presenting symptoms are not suggestive of a cervical injury. Response "C" is incorrect because primary syphilis would present with a chancre lesion at the site where the bacteria entered the body, typically the vulva.
The nurse instructs a group of expectant clients on how to recognize the onset of labor. The nurse knows further teaching is necessary if a client makes which statement? a) "My baby will move more when I go into labor" b) "I may feel a gush of water at the beginning of labor" c) "I may have blood-tinged vaginal discharge" d) "I will have regular uterine contractions that become stronger"
a) "My baby will move more when I go into labor" Rationale: Fetal movements remain unchanged up to the start of labor and in early labor. As labor progresses movement is generally felt between contractions, although the baby may continue to move during contractions
The nurse teaches a client about birth control methods. How long does the nurse advise the client to leave a diaphragm in place after intercourse? a) 6 hours b) 2 hours c) 24 hours d) 12 hours
a) 6 hours
The nurse is assessing a 28-year-old client who presented to the clinic with concerns about increased body hair and irregular menstrual cycles. What diagnostic testing does the nurse anticipate the provider will prescribe? SATA a) Hemoblobin A1C b) Hysterosalpingogram c) Pelvic ultrasound d) Complete blood count
a) Hemoblobin A1C c) Pelvic ultrasound
A mother presents to the clinic with her 15-year-old daughter who is reporting amenorrhea. The girl's menarche was at age 12. When conducting the health history and physical exam, which findings might the nurse identify as suggesting the underlying cause? SATA a) extreme weight change b) pregnancy c) hypothyroidism d) stress
a) extreme weight change b) pregnancy c) hypothyroidism d) stress
A client reports genital ulcers and a diagnosis of syphilis. Which nursing interventions should the nurse implement when caring for the client? SATA a) have the client urinate in water if urination is painful b) suggest the client apply ice packs to the genital area for comfort c) instruct the client to wear non-constricting, comfortable clothes d) instruct the client to wash their hands
a) have the client urinate in water if urination is painful c) instruct the client to wear non-constricting, comfortable clothes d) instruct the client to wash their hands
An abdominal ultrasound indicates that the placenta is partially covering the cervix. The client is admitted to the obstetrics unit and the physician writes several orders. Which interventions does the nurse question? Select three that apply a) infuse pitocin 2 milliunits per hour b) type and cross 2 units of packed red blood cells c) encourage activity as tolerated d) vaginal assessment for cervical dilation e) maintain client as NPO f) continuous external fetal monitoring
a) infuse pitocin 2 milliunits per hour c) encourage activity as tolerated d) vaginal assessment for cervical dilation
A primigravida diagnosed with type 1 diabetes mellitus reviews the insulin regimen with the nurse. The nurse explains which changes in insulin requirements will occur in pregnancy? a) insulin requirements will increase during pregnancy and decrease after delivery b) insulin requirements will decrease during pregnancy and increase after delivery c) insulin requirements will increase during pregnancy and remain increased after delivery d) insulin requirements decrease during pregnancy and remain decreased after delivery
a) insulin requirements will increase during pregnancy and decrease after delivery
A 22 year old woman comes to the clinic for an evaluation. Assessment findings are as follows: - age of first intercourse: 15 years - intrauterine contraception inserted 2 months ago - monogamous partner, use of condoms for sexual activity - cigarette smoking since age 16; ~1/2 to 1 pack per day The woman is diagnosed with pelvic inflammatory disease (PID). Which information from the woman's assessment would the nurse evaluate as increasing the woman's risk for this condition? SATA a) intrauterine contraceptive device insertion b) age of first intercourse c) monogamous partner d) cigarette smoking e) use of condoms
a) intrauterine contraceptive device insertion b) age of first intercourse d) cigarette smoking
The nurse provides care for a client in labor. The nurse is most concerned the fetus is experiencing distress if which heart rate pattern is observed? a) late decelerations b) early decelerations c) irregular heart rate d) variable decelerations
a) late decelerations
The nurse ambulated a postpartum client to the bathroom for the first time after the client gave birth 3 hours ago. The client reports feeling a sudden gush of bleeding from the vagina while ambulating. Which is the most likely cause of bleeding? a) lochia has pooled in client's vagina b) a cervical tear needs to be repaired c) the fundus is relaxed and requires massaging d) the client may have bladder distention and needs to void
a) lochia has pooled in client's vagina
A client is prescribed a colposcopy. The nurse tells the client which information about the purpose of this procedure? a) magnifies the tissue for examination b) directly examines the ovaries, fallopian tubes, uterus, and small intestines c) views structures in pelvic cavity d) visualizes bladder
a) magnifies the tissue for examination
A client receives magnesium sulfate IV for treatment of preeclampsia. The client's assessment reveals: BP 110/70 mmHg, P 98 bpm, R 11 breaths/min, hyporeflexia, and a urine output of 20 mL/hr. Which analysis by the nurse is best? a) maternal toxicity has occurred b) an additional dose of magnesium sulfate is needed c) desired systemic results have been reached d) drug therapeutic levels have been attained
a) maternal toxicity has occurred
The nurse is providing education to a patient with newly diagnosed gestational diabetes about potential complications of pregnancy. Which of the following would be including in teaching? Select 3 that apply a) neonatal hyperbilirubinemia b) fetal macrosomia c) respiratory distress of the newborn d) newborn diabetes
a) neonatal hyperbilirubinemia b) fetal macrosomia c) respiratory distress of the newborn
A nurse is reviewing the history and physical examination of a client diagnosed with polycystic ovary syndrome (PCOS). Which factors would the nurse most likely find? SATA a) obesity b) acne and facial hair c) Type 1 diabetes d) irregular menstrual cycles
a) obesity b) acne and facial hair d) irregular menstrual cycles
The nurse completes a postpartum assessment on a patient who have birth vaginally 1 hour ago. Which assessment findings require immediate follow up? SATA a) quantitative blood loss of 800 mL b) boggy uterus c) SpO2 of 96 on room air d) T 36.5 e) history of asthma f) HR 120 bpm g) distended bladder h) patient reports feeling weak i) BP 90/50
a) quantitative blood loss of 800 mL b) boggy uterus f) HR 120 bpm g) distended bladder h) patient reports feeling weak i) BP 90/50
The nurse assesses four newborns. Which characteristics noted by the nurse are most common in a preterm infant? a) red, wrinkled skin, lanugo, and hypotonic muscles b) vernix caseosa, silky hair, and facial edema c) absent nose bridge, depressed fontanels, and absent lanugo d) mottled skin, meconium stools, and hypertonic muscles
a) red, wrinkled skin, lanugo, and hypotonic muscles Rationale: Red, wrinkled skin is d/t lack of subQ fat which accumulates during the 3rd trimester. Lanugo is downy fine hair found on shoulders, forehead, and cheeks and is more noticeable in preterm infants. Floppy, poor head control and limp extremities indicate hypotonia, also more prevalent in preterm infants B these describe a full term infant, vernix is a cheesy white substance that acts a protective covering for infant's skin C depressed fontanelles indicate fluid volume deficit, a low of absent nasal bridge can indicate a genetic disorder D meconium stool is normal, mottle skin is a symptom of cold stress, and hypertonia is not seen with preterm infants
A woman comes to the local women's health clinic for an evaluation. The woman is diagnosed with chlamydia. Which action(s) by the nurse would be important? SATA a) report the condition to public health authorities b) teach the woman how to use the intravaginal medication c) instruct client to avoid alcohol with treatment d) explain that there is no cure for the infection e) discuss the need for treatment for gonorrhea as well
a) report the condition to public health authorities e) discuss the need for treatment for gonorrhea as well
Patient is able to deliver the fetal head, and the provider states that there is a shoulder dystocia. Which of the following actions are the responsibility of the registered nurse? SATA a) support patient's legs in McRobert's position b) call for help c) take note of the time the fetal head delivered d) run to the hallway to find help e) take a maternal blood pressure f) prepare to do suprapubic pressure
a) support patient's legs in McRobert's position b) call for help c) take note of the time the fetal head delivered f) prepare to do suprapubic pressure
A FHR tracing shows an early deceleration pattern. The nurse is aware that this indicates which interpretation? a) the FHR slows early in the contraction, which is a normal finding b) the FHR slows early in the contraction, which indicates fetal hypoxia c) the FHR slows at the peak of the contraction, which is a normal finding d) the FHR slows at the peak of the contraction, which indicates maternal hypoxia
a) the FHR slows early in the contraction, which is a normal finding
Metronidazole is prescribed for a woman diagnosed with trichomoniasis. The nurse's instructions to the woman should include: a. Both partners must be treated with the medication b. Alcohol intake is allowed if taken after 4 hours after medication c. It will turn your urine orange d. All of the above
a. Both partners must be treated with the medication Rationale: A. Both partners should be treated. No alcohol intake while on antibiotic course. It does not change urine to orange. Both partners need to be tx bc otherwise will get passed back and forth No ETOH = NV, bad taste in mouth Abx that will turn urine orange = ex: Rifampin
What are the most common symptoms experienced by women with endometriosis? a.Chronic pelvic pain and infertility b.Fatigue and constipation c.Infertility and heavy bleeding d.Depression and premenstrual vaginal spotting
a. Chronic pelvic pain and infertility Rationale: The MOST COMMON symptoms experienced by women with endometriosis are chronic pelvic pain and infertility. However, they can also be asymptomatic. Other clinical manifestations include pain before and during menstrual periods, pain during or after sexual intercourse (dyspareunia), depression, fatigue, painful bowel movements, hypermenorrhea, pelvic adhesions, irregular and more frequent menses, and premenstrual spotting. "Symptoms include infertility, pain with menstruation, intercourse, urination, defecation, pelvic adhesions, chronic pelvic pain, and infertility."
A nurse practitioner is performing a clinical breast exam and notes a mass. Which findings would lead the nurse practitioner to suspect that the mass is benign? SATA a. absence of nipple retraction b. skin dimpling c. firmness on palpation d. irregularly shaped e. clearly delineated margins
a. absence of nipple retraction c. firmness on palpation e. clearly delineated margins Rationale: Benign breast masses are usually firm and rubbery with clearly delineated margins and no nipple retraction. Malignant breast masses often are hard on palpation and irregularly shaped with skin dimpling.
The most common cause of irregular menses in a reproductive-age woman is: a.ectopic pregnancy b.coagulopathy c.carcinoma anovulation
a. anovulation Abnormal uterine bleeding typically occurs when menstrual ovulation doesn't occur within the monthly cycle. Chronic anovulation causes a variety of abnormal bleeding patterns. Response A is incorrect because amenorrhea would be present secondary to the pregnancy, although misplaced. Response B is incorrect because other symptoms would be present due to a coagulation problem systemically. Response C is incorrect since most uterine cancers occur in postmenopausal women, not reproductive-aged women Irregular menses can mean: Menorrhagia - abnormally long heavy period, prolonged bleeding Oligomenorrhea - bleeding at intervals > 35 days Metrorrhagia - bleeding between periods Polymenorrhea - too frequent periods
A nurse in an infertility clinic is providing care to a couple who has been unable to conceive for 18 months. Which of the following data should be included in the assessment? (SATA) a. occupation b. menstrual history c. childhood infectious diseases d. history of falls e. recent blood transfusions
a. occupation b. menstrual history c. childhood infectious diseases Rationale: Occupational hazards may include exposure to teratogenic substances in the workplace, such as radiation, chemicals, herbicides, and pesticides. Menstrual history can identify hormone-related patterns, such as anovulation, pituitary disorders, and endometriosis. Childhood infectious diseases may identify the male partner having had the mumps.
A nurse is reviewing the various treatment options with a client diagnosed with uterine fibroids (uterine myomas). The nurse determines that the teaching was successful based on which statement? a."If I use hormone therapy, my fibroids may grow back when I stop the medication." b."A myomectomy will not allow me to keep my uterus." c."Uterine artery embolization is will not affect our future fertility plans." d."Magnetic resonance focused ultrasound cauterizes the fibroids so none will regrow."
a."If I use hormone therapy, my fibroids may grow back when I stop the medication." Rationale: Typically, with hormonal therapy, fibroids regrow when the medication is stopped. A myomectomy preserves the uterus. Uterine artery embolization may affect long-term perfusion to the uterus and affect fertility. Cauterization does not guarantee no regrowth of fibroids.
Which of the following is the strongest risk factor for breast cancer? a.Advancing age and being female b.High number of children c.Genetic mutations in BRCA1 and BRCA2 genes d.Family history of colon cancer
a.Advancing age and being female Rationale: The incidence of breast cancer increases with aging, especially over age 50. Only 1% of breast cancers occur in men. B is incorrect: bearing children interrupts the menstrual cycle and decreases a woman's risk of breast cancer. C is incorrect: only 7% of women have a genetic mutation resulting in breast cancer, whereas in the remaining 93% it is a sporadic occurrence. D is incorrect: colon cancer is not a risk factor for breast cancer.
The nurse is counseling a client who has been diagnosed with osteoporosis on lifestyle changes to promote bone health. Which of the following should be included in education? SATA a) Eat yellow and orange vegetables b) Incorporate a daily walk into routine c) Increase dairy products d) Drink a glass of red wine
b) Incorporate a daily walk into routine c) Increase dairy products
Scarlett presents to the OB-GYN clinic with the following complaints: profuse, thin grayish-white vaginal discharge, a "fishy" odor and vaginal itching. Based on these findings the nurse suspects that the woman has: a.Bacterial Vaginosis b.Candidiasis c.Trichomoniasis d.Gonorrhea
a.Bacterial Vaginosis Often asymptomatic Symptoms: Thin, white homogenous vaginal discharge, "stale fish" odor, not associated with swelling or pain --increases risk on acquiring other STIs Diagnosis: Three of four criteria must be met: Thin grayish white homogenous discharge which adheres to vaginal mucosa , VaginalpH > 4.5 , Positive "whiff test" , Presence of clue cells on wet mount Therapy: metronidazole orally or clindamycin cream
Which of the following dietary and lifestyle modifications might the nurse recommend to help prevent pelvic relaxation as women age? a.Eat a high-fiber diet to avoid constipation and straining. b.Avoid sitting for long periods; get up and walk around frequently. c.Limit the amount of exercise to prevent overdeveloping muscles. d.Space children a year apart to reduce wear and tear on the uterus.
a.Eat a high-fiber diet to avoid constipation and straining. Rationale: A. Preventing constipation and straining with defecation would lessen the strain on pelvic organs. B is incorrect: sitting for long periods will not affect pelvic organ movement. Gravity will create a downward pull on all organs regardless of the position, sitting or standing. C is incorrect: exercise will help to tone muscles within the body and strengthen the pelvic floor. D is incorrect: frequent childbirth contributes to pelvic organ prolapse rather than preventing it. Spacing children only a year apart would negatively influence the pelvic-floor musculature and would be a contributing factor for prolapse.
Select all the functions of the luteinizing hormone: a.Forming the corpus luteum b.Thickening the endometrium layer for implantation c.Breaking down the wall of the ovarian follicle to allow for release of the ovum d.Thinning cervical mucus
a.Forming the corpus luteum c.Breaking down the wall of the ovarian follicle to allow for release of the ovum Rationale: LH releases the ovum from the follicle and forms the corpus luteum. Estrogen is responsible for the thickening of the endometrial layer and the thinning of the cervical mucus.
In securing a health history of a 65-year-old woman, which clinical manifestation described by the client would the nurse suspect is related to pelvic organ prolapse? a.Chronic abdominal pain b.Heavy feeling or dragging in vagina c.Uterine cramping and backache d.Weight gain and edema of ankles
a.Heavy feeling or dragging in vagina Rationale: When pelvic organs prolapse into the vaginal area, most women will experience a feeling of dragging, a lump in the vagina, or something coming down. Their symptoms are related to the site and type of prolapse. Responses "A," "C," and "D" are incorrect since none of them are directly related to pelvic organ prolapse. Pelvic organ prolapse is when 1 or more of the organs in the pelvis slip down from their normal position and bulge into the vagina. Heavy feeling, fullness, or dragging feeling in the vagina = a characteristic of pelvic prolapse
A client has opted to use a hormonal intrauterine device (IUD) for contraception. About which effect of the device on monthly periods should the nurse inform the client? a.Periods become lighter. b.Periods become more painful. c.Periods become longer. d.Periods become more often.
a.Periods become lighter. Rationale: The nurse should inform the client that IUDs cause monthly periods to become lighter, shorter, and less painful.
What should the nurse do if a victim of intimate partner violence chooses not to disclose information about her abusive relationship during the interview? a.Confront the victim with the physical evidence and telltale signs of abuse. b.Contact family members to tell you about the abusive relationship. c.Call the local police department to inquire about domestic disturbance calls. d.Respect the client's right of self-determination and provide her with resources
a.Respect the client's right of self-determination and provide her with resources Rationale: Everything else would be a violation of privacy
Nurses play an important role in screening and assessment of any client abuse/violence. Which of the following statements is correct? a.Most clients are extremely reluctant to come forth with private matters. b.Any intimate partner violence questions should be asked in the presence of both partners. c.To invite disclosure, assure the woman that you won't document her statements. d.The best statement to make to the abused victim is: "You don't deserve this."
a.The best statement to make to the abused victim is: "You don't deserve this." Rationale: D. It informs the client that abuse is not acceptable under any circumstance and it is not provoked by her actions, but by aggression on her partner's quest for power and control over her. Response "A" is incorrect since many abused women would open up to a trusting nurse if asked in a nonthreatening manner. Response "B" is incorrect because it would place the abused victim in danger if the perpetrator knew there was knowledge of his actions against the woman. Legal action could be taken against him and it would place the victim in greater risk of additional abuse, injury, or death. Response "C" is incorrect since documentation of her statements about her abuse is needed for evidence against the abuser in a court of law. Any statements obtained in the nurse's assessment should be documented to build the intimate partner violence case.
A nurse is assessing a woman who has come to the clinic reporting heavy menses. The nurse suspects that that the client may have a uterine fibroid (leiomyoma) based on which findings? SATA a.feeling of fullness in the lower pelvis b.urine retention c.upper back pain d.pain accompanying menstruation
a.feeling of fullness in the lower pelvis d.pain accompanying menstruation Rationale: A woman's symptoms can include heavy or painful menses, feeling "full" in the lower pelvis, urinating frequently, pain during sexual relations, lower back pain, and infertility. Uterine fibroids and leiomyomas = same thing Uterine fibroids are noncancerous growths of the uterus that often appear
A nurse is assessing a client who comes to the clinic reporting urinary incontinence. The nurse suspects that the client may be experiencing urge incontinence based on which findings? SATA a.frequency b.pain on urination c.nocturia d.small volume of urine leakage e.burning when urinating
a.frequency c.nocturia Rationale: Urge incontinence is characterized by urgency, frequency, nocturia, and a large amount of urine loss. There is no pain or burning.
An infant shows tendency to bleed 2 days after birth. The nurse understands this is most likely caused by which reason? a) hemophilia b) absence of intestinal bacteria and lack of vitamin K c) an immature liver that is unable to synthesize clotting factors d) delayed production of RBCs
b) absence of intestinal bacteria and lack of vitamin K
A client comes to the prenatal clinic for the first visit. The nursing history reveals the client's last menstrual period was 5 months ago, and the client is certain of pregnancy, and reports feeling the baby move. Which response by the nurse is best? a) "Since you have felt fetal movement, I am sure you are pregnant" b) "Lie down so that I can listen for fetal heart tones with the Doppler" c) "We'll collect a urine specimen for testing to confirm that you are pregnant" d) "Have you noticed feeling more fatigued lately?"
b) "Lie down so that I can listen for fetal heart tones with the Doppler"
The nurse makes a home care visit who delivered an 8 lb 5 oz (3770.5 g) baby 3 days ago. The client expresses alarm when hearing the baby has lost 8 oz (226.8 g). Which response by the nurse is most appropriate? a) "perhaps you don't have enough milk for the baby and need to supplement the diet with forumla" b) "That is a normal weight loss. Sometimes babies lose as much as 10% of the birth weight" c) "Babies usually lose some weight, but that's more than usual. Your baby may need an IV infusion" d) "Most babies immediately lose their intrauterine water deposits and 20% of their birth weight"
b) "That is a normal weight loss. Sometimes babies lose as much as 10% of the birth weight"
A client is admitted to the hospital and is scheduled to have a modified radical mastectomy. The client asks the nurse about the surgical procedure. Which explanation does the nurse give? a) "Only the tissue is removed, leaving all the muscles and lymph nodes" b) "The breast, axillary nodes, and superior apical nodes are removed, but the muscles are preserved" c) "The breast, axillary nodes, and the major and minor pectoral muscles are preserved" d) "The sternum will be split and the lymph nodes will be dissected from the mediastinum"
b) "The breast, axillary nodes, and superior apical nodes are removed, but the muscles are preserved"
A community health nurse is conducting a class on STIs. She states that "STIs are discriminatory". What would the nurse most likely use to support this statement? a) All individuals are susceptible if exposed to the infectious organism" b) "Women are diagnosed with 2/3s of the new cases of STIs annually" c) "After only a single exposure, women are less likely as men to acquire STIs" d) "Women are equally diagnosed over men as they will seek treatment first"
b) "Women are diagnosed with 2/3s of the new cases of STIs annually"
The nurse provides care for a client 24 hours after delivery, and the client states "I have been urinating so much!" Which response by the nurse is best? a) "You probably have a UTI" b) "Your body is getting rid of the increased fluid" c) "You must be drinking large amounts of fluid" d) "Your blood glucose is probably elevated"
b) "Your body is getting rid of the increased fluid"
Which of the following patients would be considered to have experienced a perinatal loss? SATA a) A client with a fetus born at 37 weeks with trisomy 21 b) A client with a history of Type 1 Diabetes who had a stillborn infant at 37 weeks gestation c) A client with a fetus diagnosed with trisomy 13 and had a termination at 15 weeks d) A client who had a miscarriage (SAB) at 7 weeks gestation e) A client who had a full term baby with multiple anomalies who lived for less than 48 hours post delivery
b) A client with a history of Type 1 Diabetes who had a stillborn infant at 37 weeks gestation c) A client with a fetus diagnosed with trisomy 13 and had a termination at 15 weeks d) A client who had a miscarriage (SAB) at 7 weeks gestation e) A client who had a full term baby with multiple anomalies who lived for less than 48 hours post delivery
The nurse identifies which pregnant woman as most likely to have a problem with Rh incompatibility with the fetus? a) An Rh-positive client who conceived with a Rh-negative partner and has two children who are Rh-positive b) An Rh-negative client who conceived with a Rh-positive partner and have birth 3 years ago to an Rh-positive infant c) An Rh-positive client who conceived with a Rh-positive partner, who previously aborted a fetus at 12 weeks gestation d) An Rh-negative client who conceived with a Rh-negative partner and never received Rh0(D) immune globulin
b) An Rh-negative client who conceived with a Rh-positive partner and have birth 3 years ago to an Rh-positive infant
The nurse is admitting a 10 pound (4.5 kg) well appearing newborn to the nursery. What is priority for the nurse to monitor during the transaction period for this newborn? a) apgar score b) blood sugar c) temperature d) heart rate
b) blood sugar
A college student is seen at the sexual health clinic reporting dysuria, mucopurulent vaginal discharge with bleeding between periods, conjunctivitis, and a painful rectal area. What STI would the nurse suspect? a) syphilis b) chlamydia c) herpes d) gonorrhea
b) chlamydia
A client is in active labor. As labor progresses, the client becomes irritable and reports feeling increasingly uncomfortable. The client is 8 cm dilated. Which action does the nurse take first? a) contact the HCP b) coach the client in proper breathing and relaxation technique c) administer an analgesic d) remove the fetal monitor to allow the client to move around
b) coach the client in proper breathing and relaxation technique Rationale: Assist the client to cope with the transition phase of labor. Stay with the client, provide constant reassurance, help the client to reestablish breathing patterns, and provide comfort C narcotic analgesics are contraindicated during the transition phase of labor because they can cause respiratory depression in newborn
A pregnant patient with diabetes at 9 weeks' gestation has a glycosylated hemoglobin (HbA1c) level of 13% (Ref range 4-5.6%). At this time the nurse should be most concerned about which possible fetal outcome? a) preterm birth b) congenital anomalies c) abruptio placentae d) stillbirth
b) congenital anomalies Rationale: A HbA1c level of 13% indicates poor glucose control. This, in conjunction with the woman being in the first trimester, increases the risk for congenital anomalies. Elevated glucose levels are not associated with incompetent cervix, placenta previa, or abruptio placentae.
The nurse provides care for a client receiving an oxytocin infusion to induce labor. The nurse stops the infusion if which occurs? a) contractions are at 3 min intervals and last for 55-60 seconds b) contractions are at 2 min intervals and last 90-120 seconds c) contractions are at 3 min intervals and last 80-90 seconds d) contractions are at 2 min intervals and last 60-90 seconds
b) contractions are at 2 min intervals and last 90-120 seconds
The nurse monitors a client at 30 weeks gestation, and the client reports periodic heartburn. It is most important for the nurse to make which recommendation? a) lie down after eating a meal b) eat frequent small meals c) take Alka-Seltzer as needed d) sip milk in between meals
b) eat frequent small meals Rationale: Client should avoid large meals and gas-producing, spicy, fatty, or fried foods. This will decrease symptoms of GERD. A it is best to remain sitting up after eating, the increased progesterone produced during pregnancy slows GI tract motility and relaxes the cardiac sphincter allowing the reflux of gastric contents into the esophagus C it's best to avoid sodium bicarbonate which might interfere with sodium balance as well as aspirin. Client may take OTC aids such as Tums, Rolaids, or Maalox for occasional GERD symptoms D while it's true that milk can temporarily buffer stomach acid, when the fat from the milk is digested it increases the acid in the stomach
A female client at the infertility clinic for the first time asks, "What could have caused my infertility?" Learning has taken place when the client can identify which common causes of infertility? SATA a) cervical factors b) endometriosis c) blocked fallopian tubes d) ovarian dysfunction
b) endometriosis c) blocked fallopian tubes d) ovarian dysfunction
The nurse provides care for a client in the 2nd stage of labor. The nurse notes the client is tiring after a few hours of pushing and is no longer making progress. Which does the nurse anticipates the HCP will ask for? a) an infusion of oxytocin b) forceps or vacuum c) an infusion of magnesium sulfate d) the OR to be prepped for a c-section
b) forceps or vacuum
The nurse is providing education to a primigravida with type 2 diabetes. Which of the following will be anticipated in the plan of care? a) decrease insulin doses as pregnancy progresses b) frequent ultrasounds to assess fetal growth c) delivery by cesarean section d) folic acid supplementation beginning after first trimester
b) frequent ultrasounds to assess fetal growth
While in active labor, a multigravid client received magnesium sulfate for treatment of gestational hypertension. Due to the effects of magnesium sulfate, which newborn symptom is expected? a) bradycardia b) hypotonia c) tachypnea d) hypertension
b) hypotonia
A nurse is conducting a review course on tocolytic therapy for perinatal nurses. After teaching the group, the nurse determines that teaching was successful when they identify which drugs as being used for tocolysis for preterm labor? Select 3 that apply a) misoprostol b) indomethacin c) magnesium sulfate d) nifedipine e) dinoprostone
b) indomethacin c) magnesium sulfate d) nifedipine
When the nurse accidentally bumps into a newborn's bassinet, the newborn jumps and pulls the extremities into the trunk. The nurse identifies the newborn is demonstrating which reflex? a) tonic neck b) moro c) babinski d) rooting
b) moro Rationale: Moro reflex is also called the startle reflex and disappears at 3-4 months
The nurse understands a preterm infant is at greatest risk for developing which disorder? a) hypoglycemia b) respiratory distress syndrome c) hydrocephalus d) scoliosis
b) respiratory distress syndrome Rationale: Respiratory distress syndrome is caused by underdeveloped lungs and lack of surfactant C Hydrocephalus is the accumulation of fluid in the subdural or subarachnoid spaces, frequently occurs in infants with myelomeningocele; bulging anterior fontanel and head circumference that increases at an abnormal rate
The nurse provides care for a neonate born 2 hours ago. Which occurrence initiates the changes that take place in the neonate's circulatory system after birth? a) the space constraints of the uterus are removed b) the newborn begins pulmonary ventilation c) newborn is exposed to excessive sensory stimuli d) ambient temperature of the newborn is reduced
b) the newborn begins pulmonary ventilation
During auscultation of the FHR during labor, the nurse assesses a rate of 59 beats/minute. Which actions does the nurse take first? a) turn the client on the right side, opens the IV line, and call the HCP b) turn the client on the left side, administer oxygen by nasal cannula, and verifies IV access c) place the client in semi-Fowler position, provide ice, and call HCP d) place the client in Trendelenburg position, administer oxygen, and forces fluids
b) turn the client on the left side, administer oxygen by nasal cannula, and verifies IV access
The nurse provides care for a client in labor about to deliver twins. For which complication does the nurse identify that this client is at higher risk? a) precipitate labor b) uterine dysfunction c) placenta previa d) eclampsia
b) uterine dysfunction
Which of the following is a common side effect of Depo Provera? a. Increase in bone mass density b. Weight gain c. Severe dysmenorrhea d. Altered levels of creatinine
b. Weight gain
A nurse is conducting a class for a local woman's group about recommendations for a Papanicolaou test. One of the participants asks, "At what age should a woman have her first test?" The nurse responds by stating that a woman should have her first Papanicolaou test at which age? a.18 b.21 c.25 d.28
b.21 Rationale: Although professional medical organizations disagree as to the recommended frequency of screening for cervical cancer, ACOG (2018b) recommends that cervical cancer screening should begin at age 21 years (regardless of sexual history), since women younger than age 21 are at very low risk for cancer. Start at 21, every 3-5 years.
Which of the following is not a component of early detection? a.Breast self-exam b.BRCA gene detection c.Clinical breast exam d.Mammography
b.BRCA gene detection
The nurse provides care for a client after an abdominal hysterectomy. The client asks when the indwelling urinary catheter will be removed. Which statement by the nurse is most appropriate? a) "You will keep the catheter until you develop a temperature" b) "You will have the catheter until discharge so that we can measure your output accurately" c) "The catheter is removed as soon as you are able to ambulate" d) "The catheter will be removed when there is no further bleeding from bladder"
c) "The catheter is removed as soon as you are able to ambulate" Rationale: Indwelling urinary catheter is usually removed when client begins ambulating, nurse will assess client can void without bleeding B it does allow staff to measure output accurately but it is more important to decompress the bladder immediately after surgery
The nurse instructs a client about dietary adjustments that may be necessary during breastfeeding. Which client statement indicates to the nurse that the client understands the instructions? a) "Dietary changes that enhance weight loss are acceptable" b) "I mist drink milk to make milk" c) "There are no specific restrictions on food or drinks" d) "Herbal teas are recommended to enhance milk supply"
c) "There are no specific restrictions on food or drinks"
The parents of a preterm infant visit the infant in the newborn nursery. When they see the infant resting comfortably in the isolette, the parents express concerns about disturbing the baby to hold it. Which response by the nurse is best? a) "preterm infants have immature immune systems and handling them increases the risk of infection" b) "preterm infants need to conserve their strength, so it is best if you do not pick the infant up" c) "preterm infants needs to develop a sense of trust and security and holding the infant promotes this" d) "preterm infants can become irritable if handled while sleeping, so first wake the infant up"
c) "preterm infants needs to develop a sense of trust and security and holding the infant promotes this"
The nurse assesses an infant born by vaginal delivery. At birth, the infant is crying and moving all extremities, and respirations and pulse rates are good. One minute after birth, the baby is noted to have slightly cyanotic extremities. At 5 min after birth, the extremities are pink. Which is the Apgar score for the baby at 1 min and 5 min? a) 8 and 9, respectively b) 7 and 10, respectively c) 9 and 10, respectively d) 7 and 9, respectively
c) 9 and 10, respectively
The nurse counsels a couple in their early 30s who have had difficulty conceiving a child. The couple states that they are worried they are infertile. The nurse teaches the couple that infertility testing is usually done when? a) after 3 months of unprotected intercourse and the inability to conceive b) after at least 6 months of unprotectted intercourse and the inability to conceive c) after 1 year of unprotected intercourse and the inability to conceive d) after 2 years of unprotected intercourse and the inability to conceive
c) after 1 year of unprotected intercourse and the inability to conceive
Which action should the nurse take immediately after the newborn is circumcised? a) leaves the area open to air b) diapers the baby with a cloth diaper c) applies petroleum gauze and observes carefully for bleeding d) administers prophylactic antibiotics
c) applies petroleum gauze and observes carefully for bleeding
The nurse provides care for a client 6 hours later after a vaginal delivery and assists the client to perform perineal care. Fifteen minutes later, the nurse notes the perineal pad is soaked and there is blood underneath the client's buttocks. Which action does the nurse take first? a) obtains the client's blood pressure b) notifies the HCP c) assesses the fundus d) administers oxygen at 8-10 L/min
c) assesses the fundus
When the nurse is assessing a postpartum client approximately 6 hours after birth, which finding would warrant further investigation? a) deep red, fleshy-smelling lochia b) profuse sweating c) blood pressure 90/50 mmHg d) voiding of 350 cc
c) blood pressure 90/50 mmHg
The nurse understands which medication is most likely to be prescribed for a client with a diagnosis of gonorrhea? a) penicillin vaginal suppositories b) penicillin G benzathine IM in divided doses once a week c) ceftriaxone IM plus doxycycline for seven days by mouth d) ampicillin by mouth
c) ceftriaxone IM plus doxycycline for seven days by mouth Rationale: CDC recommends a one time dose of ceftriaxone IM and a 7 day course of doxycycline PO as primary treatment for gonorrhea A is not used to treat gonorrhea B is the treatment for syphilis D is not a treatment for gonorrhea
A client visiting a community clinic describes some soft and movable masses felt in the breasts that become enlarged during menstruation. The nurse is aware the client is most likely describing which condition? a) cancer of the breast b) fibroids of the breast c) fibrocystic breast disease d) hyperplasia of the breast
c) fibrocystic breast disease Rationale: Fibrocystic disease of the breast involves benign cysts of the breast, presents as soft, tender freely moving cysts that become enlarged during menstruation A breast cancer presents as a single, small, painless lump which is firm and nonmobile B fibroids are benign tumors occurring in the uterus or on the endometrial lining D hyperplasia of the breast refers to enlarged breast tissues, does not change with menstruation
A client comes to the clinic with abdominal pain. Based on her history the nurse suspects endometriosis. The nurse expects to prepare the client for which evaluatory method to confirm this suspicion? SATA a) pelvic examination b) transvaginal ultrasound c) laparoscopy d) hysterosalpingogram
c) laparoscopy Rationale: The only certain method of diagnosing endometriosis is by seeing it. Therefore, the nurse would expect to prepare the client for a laparoscopy to confirm the diagnosis. A pelvic examination and transvaginal ultrasound are done to assess for endometriosis but do not confirm its presence. Hysterosalpingography aids in identifying tubal problems resulting in infertility.
The nurse assesses an apical pulse on a 8 lb 4 oz (3742.14 g) newborn infant. The nurse takes which action? a) places the diaphragm of the stethoscope between the left nipple and sternal notch b) places the diaphragm of stethoscope between second and third intercostal spaces at the left midaxillary line c) places the bell of the stethoscope at the fourth intercostal space at the left midclavicular line d) places the bell of the stethoscope between the second and third intercoastal spaces at the left sternal border
c) places the bell of the stethoscope at the fourth intercostal space at the left midclavicular line
The nurse prepares a client for an emergency c-section. The client asks how the anesthesia is going to affect the baby. Which answer by the nurse is best? a) the overall dosage of anesthesia is lower for a client undergoing a c-section b) the dosages of sedatives and hypnotics are lower for a client undergoing a c-section c) the anesthesia is not administered until immediately prior to the cesarean incision d) all preoperative medications are routinely withheld prior to cesarean delivery
c) the anesthesia is not administered until immediately prior to the cesarean incision
The nurse in the prenatal clinic assesses a client at 31 weeks gestation. The client's blood pressure is 150/96, serum albumin levels is 3 g/dL, 3+ protein is found in the urine, and the client's face and hands are edematous. Which instruction by the nurse is most important? a) the client should decrease caloric intake b) the client should eliminated all salt from the diet c) the client should ensure adequate protein d) the client should increase the intake of iron
c) the client should ensure adequate protein Rationale: The client has preeclampsia and will be placed on bedrest lying on the left side and will be instructed to maintain adequate intake of fluids and protein. Proteins restore osmotic pressure
A nurse is reviewing the history and physical examination findings of a 60-year-old woman just diagnosed with ovarian cancer. Which findings would the nurse correlate with an increased risk for developing this disease? SATA a. Multiparity b. Menarche at age 14 years c. Menopause at age 58 years d. Use of perineal talcum powder e. Hormone replacement use for 2 years
c. Menopause at age 58 years d. Use of perineal talcum powder Rationale: Risk factors associated with ovarian cancer include nulliparity, early menarche (before age 12), late menopause (after age 55), use of perineal talcum powder or hygiene sprays, and use of hormone replacement therapy for more than 10 years. Ovarian cancer: it's a numbers game = the more times you ovulate, the higher the chance you can get ovarian cancer ---it's like a printer - the more you use it, the more it's likely to jam So, if you start your periods at an early age, the more ovulations you've had in a life time. The later you have menopause, the more ovulations you've had in a life time. If you never get pregnant, that's 9 more months (plus/minus a few months of breastfeeding) of ovulation in a life time. It's a number's game.
The nurse is preparing to teach a class to a group of middle-aged women regarding the most common vasomotor symptoms experienced during menopause and possible modalities of treatment available. Which of the following would be a vasomotor symptom experienced by menopausal women? a.Weight gain b.Bone density loss c.Hot flashes d.Heart disease
c.Hot flashes Rationale: Examples of vasomotor symptoms are night sweats and hot flashes. Symptoms such as fatigue, confusion, forgetfulness, irritability, loss of libido, and appetite can be symptoms of menopause, but are not classified as vasomotor ones.
Women with polycystic ovarian syndrome (PCOS) are at increased risk for developing which of the following long-term health problems? a.Osteoporosis b.Lupus c.Type 2 diabetes d.Migraine headaches
c.Type 2 diabetes Rationale: Insulin resistance is characterized by failure of insulin to enter cells appropriately, resulting in hyperinsulinemia, a characteristic of PCOS. Factors that contribute to this include obesity, physical inactivity, and poor dietary habits. This person is at risk for developing type 2 diabetes secondary to insulin resistance. A is incorrect: osteoporosis develops in aging women because of declining estrogen and calcium levels, not due to PCOS. B is incorrect: lupus is an autoimmune condition and is not related to PCOS. D is incorrect: migraine headaches are not associated with PCOS but rather with changes in cranium vessels.
A nurse is caring for a woman who has just been diagnosed with cervical carcinoma in situ. The nurse should prepare the women for which treatment? a.uterine artery embolization (UAE) b.hysterectomy c.cervical conization with follow-up Papanicolaou test and colposcopy d.internal and external radiation therapy
c.cervical conization with follow-up Papanicolaou test and colposcopy Rationale: CIS is atypical and noninvasive; therefore, a conization with Papanicolaou test and follow up is the treatment of choice. UAE is the treatment for removal of uterine fibroids (uterine myomas). The other two treatment options are radical procedure, and the client's cancer is noninvasive. Colposcopy is a procedure to closely examine your cervix, vagina and vulva for signs of disease. Cervical conization refers to an excision of a cone-shaped sample of tissue from the mucous membrane of the cervix. Conization may be used for either diagnostic purposes as part of a biopsy or therapeutic purposes to remove pre-cancerous cells. --used to diagnose and treat cervical dysplasia or very early cervical cancer.
Breast self-examinations involve both palpation of breast tissue and... a.palpation of cervical lymph nodes. b.firm squeezing of both nipples. c.visualizing both breasts for any change. d.a mammogram to evaluate breast tissue.
c.visualizing both breasts for any change. Rationale: Visible changes to the skin of the breast take place (dimpling, contour changes, nipple discharge) and can be seen if inspected in front of a mirror. A is incorrect: breast cancer first spreads to the axillary lymph nodes, not the cervical nodes. Palpation of the axillary lymph nodes is warranted, not the cervical ones. B is incorrect: spontaneous nipple discharge is more indicative of breast cancer than discharge produced by squeezing the nipple. D is incorrect: a mammogram is not part of a breast self-examination, which the woman does in the privacy of her home.
A new mother who is breastfeeding her newborn asks the nurse, "How will I know if my baby is drinking enough?" Which response by the nurse would be most appropriate? a) "If he seems content after feeding, that should be a sign" b) "If his lips are moist, then he's okay" c) "Make sure he drinks at least 5 minutes on each breast" d) "He should wet between 6 to 12 diapers each day"
d) "He should wet between 6 to 12 diapers each day" Rationale: Soaking 6 to 12 diapers a day indicates adequate hydration. Contentedness after feeding is not an indicator for adequate hydration. Typically a newborn wakes up 8 to 12 times per day for feeding. As the infant gets older, the time on the breast increases. Moist mucous membranes help to suggest adequate hydration but not the best.
A client is in active labor with external monitoring in use. The nurse notes abrupt and rapid fluctuations in the FHR from baseline to 90 bpm and back to baseline on the monitoring device. The fluctuations in FHR occur with no relationship to the contraction patter. The client watches the monitor and asks, "Is something wrong with the baby?" Which response by the nurse is best? a) "This FHR pattern is still within normal range" b) "An emergency c-section is indicated" c) "There is interference with the fetal monitor" d) "This is a potential problem that requires a position change"
d) "This is a potential problem that requires a position change" Rationale: Rapid changes in the FHR with a rapid return to a normal baseline represent variable deceleration
A primipara client who is bottle feeding her baby begins to experience breast engorgement on her third postpartum day. Which instruction by the nurse would be most appropriate in aid in relieving her discomfort? a) "Take several warm showers daily to stimulate the milk let-down reflex" b) "express some milk from your breasts every so often to relieve the distention" c) "remove your bra to relieve the pressure on your sensitive nipples and breasts" d) "apply ice packs to your breasts to reduce the amount of milk being produced"
d) "apply ice packs to your breasts to reduce the amount of milk being produced" Rationale: For the woman with breast engorgement who is bottle feeding her newborn, encourage the use of ice packs to decrease pain and swelling. Expressing milk from breasts and taking warm showers would be appropriate for the woman who was breastfeeding. Wearing a supportive bra 24 hours a day also is helpful for the woman with engorgement who is bottle feeding.
The nurse assesses the fundus of a client 12 hours after delivery of a 7 lb 2 oz newborn. Which action should the nurse take if the fundus is noted to be approximately 1 cm above the umbilicus? a) encourage the client to void b) assess for the amount and character of the lochia c) bring the infant to the client for breastfeeding d) document the results in the client's record
d) document the results in the client's record Rationale: The fundus is about at the umbilicus or 1 cm above it within 12 hours of delivery. After this time, it should descend 1-2 cm each day. This is a normal finding
A client in active labor suddenly shouts, "I have to push! I have to push!" The nurse determines the client is 8 cm dilated. Which action does the nurse take first? a) instruct the client to take a deep breath and bear down b) applies pressure to the client's fundus c) coach the client in relaxation techniques d) encourage the client to pant with pursed lips
d) encourage the client to pant with pursed lips Rationale: Nurse should encourage client to pant to prevent pushing, the nurse should instruct client to avoid holding breath by breathing in and out constantly or by raising the chin and blowing or panting A client is not completely dilated and should not push until fully 10 cm dilated, pushing before full dilation can result in swelling of cervix and increased difficulty with delivery
The nurse palpates the fundus of a client after the 3rd stage of labor. The nurse expects the fundus to have which characteristics? a) soft and discoid b) firm and discoid c) soft and globular d) firm and globular
d) firm and globular
The nurse prepares a client for gynecological examination. The nurse explains that a pelvic examination will be performed and a Pap smear obtained. The nurse gives the client which information about the Pap smear? a) it is taken from exudates of the vagina and cervix b) it is a sample of tissue used to locate a lesion c) it is an x-ray film taken from various angles d) it is a scraping of the cervix used to identify abnormal cells
d) it is a scraping of the cervix used to identify abnormal cells
A client calls the clinic and reports a fever, fatigue and has a hard, reddened area in one breast. The client is breastfeeding. Which condition does the nurse understand that this client is most likely experiencing? a) adjustment reaction b) primary engorgement c) a blocked duct d) mastitis
d) mastitis Rationale: Infectious mastitis is a serious infection with fever, headache, flulike symptoms, and a warm, reddened, painful area in one breast and can occur anytime during lactation C a plugged duct is manifested as an area of tenderness or "lumpiness" in one breast in a woman who is breastfeeding and is otherwise feels well
A client comes to the hospital floor in labor. The membranes rupture at 0410. Which action does the nurse take first? a) identifies the amniotic fluid by performing a nitrazine tape test b) contact the HCP and prepare for immediate delivery c) document admission and notes the time or ROM d) observes the amniotic fluid for an signs of infection or meconium
d) observes the amniotic fluid for an signs of infection or meconium
The nurse provides care for a client in active labor and who is 6 cm dilated. The client is now ready for epidural anesthesia. Which position will the nurse assist the client? a) modified knee-chest with upper leg flexed and lower leg extended b) a sitting position with back straight and feet supported on a stool c) prone position, head on arms, and pillow at pelvic area d) on the left side, shoulders parallel, legs flexed, and back arched
d) on the left side, shoulders parallel, legs flexed, and back arched
The nurse instructs a client who recently had a modified radical mastectomy. The nurse explains it is very important for the client to exercise the affected arm. Which statement by the nurse is the most important reason for the client to exercise the arm? a) increase the muscle strength and diameter b) maintains body balance c) limits full range of motion d) prevents lymphedema
d) prevents lymphedema Rationale: Exercising the arm muscles pumps lymph fluid back into the circulation. The client should position the arm on a pillow with each joint higher than the proximal joint elevation
