Reproduction 2 Questions
13) A client of Hispanic descent delivers a newborn son and plans to breastfeed. When the nurse attempt to help the newborn latch on for breastfeeding the client states, "I would like to bottle feed my baby for the first few days." Which reason does the nurse anticipate regarding why the client wants to delay breastfeeding? A) Colostrum is bad for the baby. B) Breast milk causes skin rashes. C) It will cause "evil eye." D) Thin milk causes diarrhea.
Answer: A Explanation: A) Some Hispanic cultures believe breastfeeding should be delayed because colostrum is bad for the baby. The belief that breast milk causes skin rashes is from the Haitian culture. The Latino culture does not believe that breastfeeding causes evil eye but rather that touching the head or the face of the baby causes "evil eye." The belief that thin milk causes diarrhea is a Haitian cultural belief.
11) The nurse is proving care to a 1-hour old newborn who was born at 39 weeks' gestation. Which assessment data is cause for concern? Select all that apply. A) Respiratory rate of 72 breaths per minute B) Negative Babinski reflex C) Mean blood pressure of 52 mmHg D) Acrocyanosis E) Presence of meconium stool
Answer: A, B Explanation: A) Assessment data that would cause this nurse concern include a respiratory rate of 72 breathes per minute and a negative Babinski reflex. Respirations within 2 hours of delivery are expected to be between 60-70 breaths per minute. A positive Babinksi reflex is an expected finding. A negative Babinski could indicate neurological compromise. The nurse would expect a mean blood pressure of 52 mmHg (normal range is 50-55 mmHg), acrocyanosis, and passing meconium stool.
5) The nurse is planning care for a client who had a cesarean birth 4 hours ago. Which actions should be included in this client's plan of care? Select all that apply. A) Encourage the use of breathing, relaxation, and distraction. B) Encourage deep breathing and coughing every 2 to 4 hours. C) Encourage to ambulate to the bathroom to void. D) Discourage leg exercises. E) Withhold all analgesics.
Answer: A, B Explanation: A) Encouraging deep breathing and coughing every 2 to 4 hours and encouraging the use of breathing, relaxation, and distraction all address the client's nursing care needs, which are similar to those of other surgical clients. Encouraging the client to ambulate to the bathroom to void might be an intervention done on the first or second day postpartum, but not in the first 4 hours. Leg exercises should be encouraged. Withholding analgesics may leave the client in pain.
3) The nurse is providing postpartum care to a client from a different culture. What nursing actions are appropriate to include in the client's plan of care? Select all that apply. A) Assess for any assistance required during breastfeeding. B) Ask if there are any specific customs the client wants to follow. C) Assess for any specific foods or fluids to hasten recovery. D) Limit client visitors to the immediate family. E) Restrict interactions with the client.
Answer: A, B, C Explanation: A) When providing postpartum care to a client of a different culture, the nurse should assess for any specific customs the client wants to follow, if there are any foods or fluids in the culture that are believed to hasten recovery, and if the client requires any assistance during breastfeeding. Restricting visitors would not support the postpartum client's needs. Restricting interactions would not support the client's physiologic or psychological needs.
28) A client with syphilis is allergic to penicillin. Based on this data, which medications does the nurse anticipate as appropriate for this client? Select all that apply. A) Doxycycline B) Amoxicillin C) Tetracycline D) Gentamicin E) Erythromycin
Answer: A, C Explanation: A) Clients allergic to penicillin are given oral doses of doxycycline or tetracycline for 14 days for the treatment of syphilis. Gentamicin, amoxicillin, and erythromycin are not prescribed for the treatment of syphilis.
27) The nurse instructs a married couple on the importance of treatment for a chlamydia infection. Which statements indicate that teaching was effective? Select all that apply. A) "He could get an infection in the tube that carries the urine out." B) "She could have severe vaginal itching." C) "It could cause us to develop rashes." D) "She could develop a worse infection of the uterus and tubes." E) "She could become pregnant."
Answer: A, D Explanation: A) Chlamydia is a major cause of nongonococcal urethritis (NGU) in men. Chlamydia cervicitis can ascend and become pelvic inflammatory disease, or infection of the uterus, fallopian tubes, and sometimes ovaries. Chlamydia does not cause a woman to become pregnant. Chlamydia does not cause vaginal itching. Chlamydia does not cause a rash.
10) The nurse is providing care to a client who gave birth to a newborn by cesarean section. When providing care to this client, which nursing actions are appropriate? Select all that apply. A) Encouraging coughing and deep breathing every 2 hours until the client is able to ambulate B) Monitoring the episiotomy site every shift C) Encouraging the client to lay on the right side to promote passing gas D) Assessing bowel sounds every 8 hours E) Assessing the client hourly while receiving a continuous epidural infusion
Answer: A, E Explanation: A) Appropriate nursing actions when providing care to a client who gave birth by cesarean section includes encouraging coughing and deep breathing every 2 hours until the client is able to ambulate and assessing the client hourly while receiving a continuous epidural infusion. The client will not have an episiotomy after a cesarean birth; however, the nurse would monitor the abdominal incision. The nurse would monitor bowel sounds but the frequency is every 4 hours, not every 8 hours. The nurse would encourage the client to lie on the left side, not the right side, to promote the passing of gas.
15) A nurse is caring for the 1-hour-old newborn of a diabetic mother. Which actions will the nurse include in the newborns plan of care? Select all that apply. A) Assess blood glucose hourly and then every 4 hours. B) Evaluate blood glucose levels at birth and at 6-hour intervals. C) Assess for hyperthyroidism. D) Assess the newborn's temperature hourly. E) Use formula for all feedings, avoiding 5% dextrose.
Answer: A, E Explanation: A) Newborns of diabetic mothers can require frequent feedings to maintain normal levels of blood glucose. Formula feedings contain protein and will maintain blood sugar better than glucose water alone. Alteration in temperature is not associated with newborns of diabetic mothers. The onset of hypoglycemia occurs at 1-3 hours after birth and can continue for several days. Blood glucose levels should be checked hourly during the first 4 hours and then at 4-hour intervals until stable normal levels are attained. Hyperthyroidism is not associated with newborns of diabetic mothers.
4) A client who gave birth to her first child 12 hours ago has the following assessment findings: nausea for 2 hours; boggy fundus that firmed with massage; moderately heavy lochia rubra; ecchymotic and edematous perineum; and pain rating of 6 on scale of 1-10. The client's partner is present and supportive. Breastfeeding has been successful three times. Based on this data, which is the priority nursing diagnosis? A) Acute Pain related to perineal trauma B) Risk for Deficient Fluid Volume secondary to boggy fundus and nausea C) Deficient Knowledge related to birth of first child D) Readiness for Enhanced Family Coping related to partner involvement
Answer: B Explanation: A) Fluid volume is a critical physical issue and is therefore the highest-priority nursing diagnosis. Although the nursing diagnosis of Acute Pain fits, it is a lower priority than the risk of fluid volume deficit. Although the nursing diagnosis of Readiness for Enhanced Family Coping fits, it is a lower priority than the risk of fluid volume deficit. Although the nursing diagnosis of Deficient Knowledge fits, a knowledge deficit is a psychosocial issue and therefore a much lower priority than the critical physical diagnosis of risk for deficient fluid volume.
29) The nurse is planning care to address pain in the client with genital herpes. Which intervention would be appropriate for this client? A) Increase the intake of cranberry juice. B) Clean lesions 2 or 3 times a day with warm water and soap. C) Dry lesions with a hair dryer turned to the hot setting. D) Wear tight cotton clothing.
Answer: B Explanation: A) Measures to reduce the discomfort of herpes lesions include cleansing the lesions two or three times a day with warm water and soap. Lesions should be dried using a hair dryer turned to a cool setting. It is important to wear loose cotton clothing that will not trap moisture. Fluids that increase urine acidity such as cranberry juice should be avoided.
26) The nurse is planning care for a client with a history of sexually transmitted infections. What should be included in this plan of care? A) Instruction to limit sexual contact until recovered from illness B) Plan for the client to contact sexual partners regarding the diagnosis C) Need to increase fluids and rest D) Importance of adequate nutrition
Answer: B Explanation: A) The client has a history of sexually transmitted infections. The nurse should discuss with the client a plan for sexual partners to be contacted regarding the diagnosis. The need to increase fluids, rest, and nutrition are important, but not as important as the client contacting sexual partners regarding the diagnosis. The nurse should instruct the client to avoid, not just limit, sexual contact until recovered from the illness.
25) A client diagnosed with a sexually transmitted infection reports having "no idea" how the illness was contracted. Which nursing diagnosis would be appropriate for the client at this time? A) Anxiety B) Knowledge Deficit C) Ineffective Coping D) Sexual Dysfunction
Answer: B Explanation: A) The client having no idea how the illness was contracted indicates a deficit in knowledge regarding the transmission of sexually transmitted infections. There is not enough information to determine if the client has sexual dysfunction, ineffective coping, or anxiety.
14) The nurse is caring for a newborn male who was circumcised an hour ago. Which is the priority nursing diagnosis for the newborn? A) Risk for Injury B) Risk for Infection C) Risk for Imbalanced Nutrition D) Risk for Ineffective Breathing Pattern
Answer: B Explanation: A) The client is at increased risk for infection because of the circumcision. Risk for Injury would be appropriate if the client were having difficulty metabolizing bilirubin. Risk for Ineffective Breathing Pattern would be appropriate if the client were demonstrating signs of ineffective breathing. Risk for Imbalanced Nutrition would be appropriate if the client were demonstrating signs of ineffective feeding behaviors.
2) During a postpartum examination of a client who delivered an 8-pound newborn 6 hours ago, the nurse assesses the following: fundus firm and at the umbilicus, and moderate lochia rubra with a steady trickle of blood noted from the vagina. Which assessment finding requires immediate follow-up? A) Moderate lochia rubra B) Steady trickle of blood C) Fundus at the umbilical level D) Firm fundus
Answer: B Explanation: A) The steady trickle of blood could indicate a laceration in the birth canal and should be reported to the healthcare provider for follow up. A firm fundus is a desired finding and is considered normal. Six hours after birth, the fundus at the umbilicus would not be a concern. Moderate lochia rubra is considered a normal finding.
16) The nurse is instructing a new mother on how to care for the newborn's circumcision site. Which statements indicate that the nurse's education session was effective? Select all that apply. A) "I should not use petroleum jelly on the penis." B) "Every time I change the diaper I am to wash the area with warm water." C) "I should report any pus drainage or change in diaper wetness to the physician." D) "Swelling is expected." E) "I am to use soap and water to remove yellow tissue on the penis."
Answer: B, C Explanation: A) The nurse should instruct the mother to wash the area with warm water after every diaper change, to use petroleum jelly to protect the penis and prevent bleeding, and to report any pus drainage or change in urine output to the physician. Yellow tissue on the penis is granulation tissue, which is evidence of healing and should not be washed off with soap and water. Swelling is not expected after a circumcision and should be reported to the physician.
22) During an assessment, the nurse suspects a client is experiencing genital herpes. Which clinical manifestations cause the nurse to come to this conclusion? Select all that apply. A) Low blood pressure B) Headache C) Fever D) Back pain E) Vaginal discharge
Answer: B, C, D, E Explanation: A) Manifestations of genital herpes include headache, fever, vaginal discharge, and back pain. Low blood pressure is not a manifestation of genital herpes.
17) When administering an intramuscular dose of vitamin K (AquaMEPHYTON) to a newborn, which actions by the nurse are appropriate? Select all that apply. A) Using a 23-gauge 1/2-inch needle B) Cleaning the skin with an alcohol swab C) Preparing 5 mg of the medication for injection D) Using the middle third of the vastus lateralis muscle E) Washing the skin with soap and water
Answer: B, D Explanation: A) A single dose of vitamin K (AquaMEPHYTON) is administered to newborns within 1 hour of birth. The nurse should use the middle third of the vastus lateralis muscle, clean the skin with an alcohol swab, and use a 27-gauge 1/2-inch needle. The skin is not to be washed with soap and water before the injection. The medication dosage is between 0.5 and 1.0 mg.
7) A postpartum client is experiencing pain from an episiotomy. Which actions will the nurse suggest to the client to decrease discomfort? Select all that apply. A) Washing the area with soap and water every day B) Tightening the buttocks before sitting C) Changing peripads daily D) Performing leg scissor kicks several times a day E) Increasing the intake of meat, cheese, fish, eggs, and nuts
Answer: B, E Explanation: A) Lysine has been identified as an essential amino acid that decreases the pain of an episiotomy. This amino acid is present in meat, cheese, fish, eggs, and nuts. The nurse should instruct the client to tighten the buttocks before sitting to reduce the pain. The client should wash the area daily and the peripad should be changed four times a day to decrease the risk of infection, not pain. Performing leg scissor kick exercises would put strain on the incision site and should not be done.
18) The nurse is providing discharge instructions for a first time mother and her baby. Which statement is appropriate for the nurse to include in the teaching session? A) "Your baby's stools will change to a dark green color when your milk comes in." B) "Call your pediatrician if the baby's temperature is 98°F." C) "Your infant should have 6 wet diapers each day." D) "You can wipe away any green eye drainage that might form."
Answer: C Explanation: A) A minimum of six wet diapers per day indicates adequate fluid intake for the infant. A temperature of 98°F is considered normal. Stool color is often seedy and yellow or golden brown in color when breastfeeding. Green eye drainage is abnormal and should be reported to the baby's provider.
8) The nurse is providing care to a postpartum client who gave birth 4 hours ago. The client has a mediolateral episiotomy, large hemorrhoids, and states pain is a 7 on a scale of 1-10. She has a history of anaphylactic reaction to Tylenol. Based on this data, which nursing action is appropriate? A) Encourage use of benzocaine topical anesthetic spray (Dermoplast). B) Provide 2 oxycodone with acetaminophen (Percocet) by mouth. C) Offer the client 800 mg ibuprofen (Advil) orally with food. D) Run very warm water into the tub and assist her into the bath.
Answer: C Explanation: A) Offering ibuprofen (Advil) is the best option because the client is experiencing moderately severe pain with inflammation. Ibuprofen is a nonsteroidal anti-inflammatory drug that both reduces inflammation and provides pain relief. Oxycodone with acetaminophen (Percocet) is contraindicated because of the client's allergic reaction to acetaminophen (Tylenol). Topical anesthetic sprays such as Dermoplast can be a helpful adjunct in pain relief but are not sufficient when a client has moderately severe pain. Ice packs instead of a warm bath would be better at this stage, because they will cause vasoconstriction to reduce edema and pain relief.
9) When palpating the fundus of a woman on her first day postpartum, the nurse finds that the woman's uterus is higher than expected and is deviated to the right. She is not having excessive uterine bleeding. Which is the priority nursing action for this client? A) Notify the client's midwife of this condition. B) Ask another nurse to assess the client to verify the findings. C) Ask the client to void and then reassess fundal height. D) Perform a straight catheterization on the client and then reassess fundal height.
Answer: C Explanation: A) The cause of a distended fundus in a recently delivered woman is likely due to a distended bladder causing a temporary upward displacement of the uterus. Having the woman empty her bladder and then reassessing fundal height is the priority action for the nurse to take at this time. If the client is unable to void, a straight catheterization to empty the bladder is indicated, after which fundal height would then be reassessed. The nurse would not notify the client about the data unless the assessment remains unchanged after the client voids. Asking another nurse to verify the assessment findings is not an appropriate action.
21) The nurse is providing care to a newborn born after 37 weeks gestation. The newborns weight is 1,750 g (3 pounds, 10 ounces). The head circumference and length are at the 25th percentile. What statement would the nurse use to describe these assessment findings? A) Preterm appropriate for gestational age, asymmetrical intrauterine growth restriction B) Preterm appropriate for gestational age, symmetrical intrauterine growth restriction C) Preterm small for gestational age, asymmetrical intrauterine growth restriction D) Term small for gestational age, symmetrical intrauterine growth restriction
Answer: C Explanation: A) The infant is preterm at 37 weeks. Because the weight is below the 10th percentile, the infant is not appropriate for gestational age but is considered small for gestational age. Head circumference and length between the 10th and 90th percentiles indicate asymmetrical intrauterine growth restriction. Symmetrical intrauterine growth restriction would have head circumference below the 10th percentile.
30) A public health nurse is educating a group of adults regarding sexually transmitted infections. Which is an appropriate statement by the nurse? A) "Males have higher rates of gonorrhea and Chlamydia, whereas women have higher rates of syphilis." B) "Men are disproportionately affected by STIs compared to women and infants." C) "Women often experience few early manifestations of the infection, delaying diagnosis and treatment." D) "The incidence of STIs is highest among young Caucasian females."
Answer: C Explanation: A) Women often experience few early manifestations of sexually transmitted infection, delaying diagnosis and treatment. Women have higher rates of gonorrhea and Chlamydia, whereas men, especially men who have sex with men, have higher rates of syphilis. Women and infants are disproportionately affected by STIs. The incidence of STIs is highest among people of color.
1) During an assessment, the nurse notes the postpartum client is experiencing intense shaking and chills. Based on this data which conclusion by the nurse is appropriate? Select all that apply. A) This is evidence of incomplete expulsion of the placenta. B) The client has a full bladder. C) This may be a reaction to maternal adrenal production during labor and birth. D) This may be a reaction to epidural anesthesia. E) The client has a fever from a postpartum infection.
Answer: C, D Explanation: A) Intense tremors similar to shaking chills can occur in the mother after birth and have been explained as being caused by a reaction to epidural anesthesia or a reaction to maternal adrenal production during labor and birth. The nurse would need to assess the client's temperature to determine the presence of a fever. Indications of a full bladder would most likely be a displaced uterus. Shaking chills after delivery is not evidence of incomplete expulsion of the placenta.
24) A client is experiencing dysuria, urinary frequency, and vaginal discharge. For which sexually transmitted infection(s) should the nurse prepare the client for testing? Select all that apply. A) Syphilis B) Vaginitis C) Chlamydia D) Trichomoniasis E) Gonorrhea
Answer: C, E Explanation: A) Chlamydia invades the same target organs as gonorrhea, which include the cervix and male urethra, and creates the manifestations of dysuria, urinary frequency, and discharge. The other sexually transmitted infections target other organs.
6) The nurse is instructing a postpartum client on when she can resume her normal exercise regimen of running for exercise most days of the week. Which statement indicates that teaching was effective? A) "I can start my exercise regimen in 2 weeks." B) "I will not be able to exercise because it is not recommended for breastfeeding women." C) "I can exercise if I get 8 hours of sleep per day." D) "I should check my energy level at home and increase exercise slowly."
Answer: D Explanation: A) Checking the energy level and increasing activity slowly is the correct response because when energy returns, activity can be increased. Increasing activity slowly is safer and less likely to cause injury than starting off running long distances. Running might be feasible at 2 weeks, but it will depend upon the client's energy level. Breastfeeding should take place just prior to running to minimize chest discomfort. The inability to run because of breastfeeding is not a true statement; it is more comfortable to nurse prior to running, but running is not contraindicated. The need to have 8 hours of sleep before running is not a true statement; not all clients who get a total of 8 hours of sleep feel rested, because sleep can be interrupted.
12) The nurse receives shift change report on infants born within the last 4 hours. Which newborn should the nurse assess first? A) Newborn born at 37 weeks gestation. Respiratory rate of 45 breaths per minute. B) Term newborn, 2 hours old, who has not passed a meconium stool. C) Term newborn born yesterday. Heart rate is 150 beats per minute. D) Term newborn born 1 hour ago who is exhibiting grunting respirations.
Answer: D Explanation: A) Grunting respirations are an indication of respiratory distress. This infant needs further assessment and possibly immediate intervention. A normal respiratory rate is 30-60 breaths per minute. A normal pulse is 110-16 beats per minute. If a meconium stool is not passed within the first 24 hours, this would be cause for concern.
23) A client reports an open area on the penis. Which question will help the nurse with data collection? A) "Do you think you have a disease?" B) "Have you had sexual intercourse recently?" C) "Are you promiscuous?" D) "When did you initially notice this open area?"
Answer: D Explanation: A) It will be important to record the onset of the open area. The remaining questions are closed, and will not elicit much information. Asking the client about promiscuity is judgmental. Determining the date of the last episode of sexual intercourse might be indicated later if a disease is diagnosed.
20) The nurse conducting a 5-minute Apgar assessment on a newborn assigns the following ratings: Heart rate < 100 beats per minute (1 point); slow, irregular respirations (1 point); some flexion of the extremities (1 point); a vigorous cry with flicking of the baby's foot (2 points); and a pink body with blue extremities (1 point). Based on this data, which nursing action is appropriate? A) Having the aide reassess the newborn's heart rate and respiratory rate when admitted to the nursery B) Swaddling the newborn to decrease the risk of increased energy expenditure C) Placing the newborn in the mother's arms and asking her to monitor her baby's breathing D) Repeating the assessment every 5 minutes for up to 20 minutes
Answer: D Explanation: A) With a 5-minute Apgar of 6, this newborn is at increased risk for complications compared to those with Apgar scores in the range of 7 to 10. The nurse will reassess the client every 5 minutes for up to 20 minutes. The nurse should have resuscitative equipment ready for use. The other actions are not appropriate based on the data provided.
19) The nurse is providing care to a newborn during the first 24 hours of life. Which is an abnormal finding? A) Respiratory rate of 58 breaths per minute B) Heart rate of 140 beats per minute C) Presence of meconium stool D) Yellowing of the skin
Answer: D Explanation: A) Yellowing of the skin within the first 24 hours of life is caused by pathological jaundice and often requires treatment with phototherapy. All of the other assessment findings are considered normal during the first 24 hours of life.
