MCN Test 5 –Answers & Rationales
1. Mr. And Mrs. W. recently arrived in the United States from East Asia. Mr. W. brings his wife to the hospital in late labor; his mother and Mrs. W.’s sister are also present. As the nurse directs Mr. W. to the dressing room to change into a scrub suit, Mrs. W. anxiously states, “No, he can’t come with me. Get my sister and mother-in-law.” The nurse’s best response is,
1. “I’m sorry, but out hospital only allows the father into the delivery.”
2. “I’ll ask the doctor if that’s OK.
3. “When I talk to your husband, I’m sure he’ll want to be with you.”
4. “That’s fine. I’ll show your husband the waiting area.
#4. One consideration is the East Asian husband’s lack of involment during pregnancy and birth; this is a mutually agreeable separation of men’s and women’s roles.
1. The client’s cultural background must be integrated into any management strategy; referring to policy does not ensure culturally sensitive care.
2. The nurse is responsible for assessing cultural factors and integrating strategies into the client’s plan of care.
3. Nursing profession, as the profession most involved in providing holistic care to individuals, must be knowledgeable about and skilled in values, beliefs, and health-illness practices of different cultures; omission of cultural factors is a major obstacle to providing quality care.
2. During an initial prenatal visit, a woman states that her last menstrual period began on November 21; she also reports some vaginal bleeding about December 19. The nurse would calculate that this client expected date of birth (EDB) would be:
1. July 21
2. August 28
3. September 26
4. October 1
#2. If a woman has a menstrual period every 28 days and was not taking oral contraceptives, Nagele’s rule may be a fairly accurate determiner of her predicted birth date. To use this method, begin with the first day of the last menstrual period, subtract three months, and add seven days.
To use Nagele’s rule, begin with the first day of the last menstrual period, subtract three months and add seven days.
To use Nagele’s rule, begin with the first day of the last regular menstrual period, subtract three months and add seven days; some women do experience some vaginal bleeding around the time of what would have been their next period even though they are pregnant.
3. A 24-year-old woman comes to the clinic because she thinks she is pregnant. Which of the following is a probable sign of pregnancy that the nurse would expect this client to have?
1. Fetal heart tones
2. Nausea and vomiting
3. Amenorrhea
4. Chadwick’s sign
#4. Probable signs of pregnancy are the result of physiologic changes in the pelvic organs and hormonal influences; for example, the mucous membranes of the vulva, vagina, and cervix become bluish (Chadwick’s sign) as a result of hyperemia and proliferation of cells.
Detection of fetal heart tomes is a positive sign (clearly demonstrates the presence of a fetus) of pregnancy that can be detected, with a Doppler instrument, as early as 10 weeks.
Nausea and vomiting is a presumptive symptom of pregnancy because it can be caused by factors other than pregnancy.
Amenorrhea is a presumptive symptom of pregnancy because it can be caused by factors other than pregnancy.
4. A married 25-year-old housewife is six weeks gestation and is being seen for her first prenatal visit. In relation to normal maternal acceptance of pregnancy, the nurse would expect that the client fills
1. some ambivalence now that the pregnancy is confirmed
2. overwhelmed by the thought of future changes.
3. much happiness and enjoyment in the event.
4. detached from the event until physical changes occur.
#1. During the first trimester of pregnancy, women normally experience ambivalence about being pregnant. It is estimated that around 80% of women initially reject the idea of pregnancy; even women who planned pregnancy may respond at first with surprise and shock.
Feelings of being overwhelmed by changes related to pregnancy (physical, lifestyle, etc.) are an indicator of lack of acceptance of the pregnancy and are not considered normal.
Feeling happiness and enjoyment about being pregnant does occur in some women initially; however, it is not the predominant finding.
By the end of the first trimester, most women accept pregnancy but research has not found a direct relationship between this acceptance
And the physical changes; these changes are related more to the reality of the fetus than the pregnancy.
5. A woman is entering the 20th week of pregnancy. Which normal change would the nurse expect to find on assessment?
1. Fundus just below diaphragm
2. Pigment changes in skin
3. Complaints of frequent urinatio
4. Blood pressure returning to prepregnancy level
#2. From 20-24 weeks gestation, pigment changes in skin may occur from actions of hormones. These include the linea nigra, melasma on the face, and striae gravidarum (stretch marks).
Uterine growth in pregnancy follows a pattern; by the 20th week the fundus should reach the umbilicus, at about the 38th week it is just below the diaphragm until lightening (uterus drops into true pelvis) occurs before labor.
Frequency of urination occurs in the first trimester (weeks 0-12) and again in the last trimester (weeks 28-40) from pressure of the gravid uterus on the bladder.
Blood pressure in the first 24 weeks usually decreases 5-10 mmHg systolic and 10-15 mmHg diastolic due to relaxation of the vascular smooth muscle and the formation of new peripheral vascular beds. The blood pressure usually rises to prepregnancy levels by the time labor begins.
6. Mrs. W., blood type A+, rubella negative, hemoglobin 12 g, hematocrit 35%, is a primigravida in the first trimester. During her second prenatal visit she complains of being very tired, experiencing frequent urination, and a white vaginal discharge; she also states that her nausea and occasional vomiting persists. Based on these findings, the nurse would select which of the following nursing diagnoses?
1. Activity intolerance related to nutritional deprivation.
2. Alteration in elimination related to a possible infection
3. High risk for injury related to hematologic incompatibility
4. Alteration in physiologic responses related to pregnancy
#4. All of the data stated are within the normal expected range for a first trimester pregnancy. These factors are related to hormonal changes and the growing uterus.
The findings of fatigue, nausea and vomiting, and the hemoglobin and hematocrit count are all within the norm for a first trimester pregnancy.
Frequency of urination, from pressure of the growing uterus on the bladder, and a white vaginal discharge, from increased activity of cervical and vaginal cells, are all normal findings for a first trimester pregnancy.
There are no data to support this nursing diagnosis; a blood type of 0, or if the woman was Rh negative, would increase the risk for this type of injury to the fetus
7. Ms. R. had her frequency confirmed and has completed her first prenatal visit. Considering that all data were found to be within normal limits, the nurse would plan that the next visit should be in
1. one week
2. two weeks
3. one month
4. two months
#3. In a low-risk pregnancy, the recommended frequency of prenatal visits is: every 4 weeks for the first 28 weeks, every 2 weeks until the 36th week, then every week until birth.
For low-risk pregnancy, this sequence of visits would be too frequent and unnecessary.
For a low-risk pregnancy in the early weeks, this sequence of visits would be too frequent and unnecessary.
Even in a low-risk pregnancy, this sequence of visits would be inadequate to detect danger signs of complications or administer needed care and assessments.
8. Which statement by a pregnant client would indicate to the nurse that diet teaching has been effective?
1. “The most important time to take my iron pills is during the early weeks when the baby is forming.”
2. “I don’t like milk, but I’ll increase my intake of cheese and yogurt.”
3. “I’ll be very careful about using salt while I’m pregnant.
4. “ Because I’m overweight to begin with, I can continue my weight loss diet.”
#2 To meet increased calcium needs, pregnant women need to increase their intake of dairy products or consider a calcium supplement that provides 600 mg of calcium per day; it is not necessary to drink milk.
The fetus stores iron during the last trimester of pregnancy; because of this, and other increased needs for iron during pregnancy, an additional daily supplement of 30-60 mg of ferrous salts is recommended beginning about 12 weeks gestation.
Because of the extra requirements for sodium storage in the body, sodium intake should not be restricted during pregnancy; rigid sodium restriction has been observed to lead to neonatal hyponatremia.
Although the ideal weight gain for obese pregnant women appears to be less than that recommended for normal-weight women, pregnancy is not the time to diet to lose weight; in weight loss, ketones are formed and these may lead to neurologic damage to the fetus.
9. Mrs. C., age 40, gravida 3 para 2 is eight weeks pregnant. She is a full-time office manager, states she “usually unwinds with a few glasses of wine” with dinner, smokes about five cigarettes a day, and was “surprised” by his pregnancy. After the assessment, which of the following would the nurse select as the priority nursing diagnosis?
1. High risk for an alteration in bonding related to an unplanned pregnancy
2. High risk for injury to the fetus related to advanced age.
3. Ineffective individual coping related to low self-esteem
4. Knowledge deficit related to effects of substance abuse.
#4. Evidence exists that smoking, consuming alcohol, or using social drugs during pregnancy may be harmful to the fetus.
Initially, even if the pregnancy is planned, there is an element of surprise that conception has occurred. This feeling of ambivalence does not, in itself, indicate that acceptance and normal bonding will not occur.
A major risk for the older expectant couple relates to the increased incidence of Down syndrome in children born to women over age 35 or 40; however, the risk for injury to the fetus is greater from substance abuse.
No data support this nursing diagnosis.
10. A young couple has just completed a preconception visit in the maternity clinic. Before leaving, the woman asks the nurse why she was instructed not to take any over-the-counter medications. The nurse should reply.
1. “Research has found that many of these drugs have been linked to problems with getting pregnant.”
2. “At conception, and in the first trimester, these drugs can be as dangerous to the fetus as prescription drugs.
3. “You should only take drugs that the physician has ordered during pregnancy.”
4. “Any drug is dangerous at this time; later on in pregnancy if won’t matter.”
#2. It is best to avoid any medication when planning a pregnancy and during the first trimester; the greatest potential for gross abnormalities in the fetus occurs during the first trimester, when fetal organs are first developing. The greatest danger extends from day 31 after the last menstrual period to day 71.
Problems with fertility have been linked to many areas, such as smoking, alcohol (in male infertility), and pelvic inflammatory disease; this connection has not been found with most common over-the-counter medications.
Even prescription drugs may have a teratogenic effect (cause serious defects) on the fetus; the rule to follow is that the advantage of using a particular medication must outweigh the risks.
Even thought he most dangerous time for the fetus is conception and the first trimester of pregnancy, some medications have teratogenic effects 9cause serious defects) when taken in the second and third trimesters.
11. The pregnant couple asks the nurse what is the purpose of prepared childbirth classes. The nurse’s best response would be.
1. “The main goal of most types of childbirth classes is to provide information that will help eliminate fear and anxiety.
2. “The desired goal is childbirth without the use of analgesics.”
3. “These classes help to reduce the pain of childbirth by exercise and relaxation methods.
4. “The primary aims is to keep you and your baby healthy during pregnancy and after!”
#1. All programs in prepared childbirth have some similarities; all have an educational component to help eliminate fear.
Expectant parents are taught that childbirth preparation classes do not exclude the use of analgesics but that they often reduce the amount necessary. To set childbirth without pain relief as a goal can be extremely destructive to the woman’s self-concept.
Most prepared childbirth classes do teach the mother coping strategies to deal with the pain and discomforts of birth; these may not directly reduce the pain itself and also other methods maybe used instead of exercises and relaxation, such as hypnosis.
Maintaining a healthy pregnancy with a positive outcome for mother and newborn is a goal of prenatal care by a physician, nurse midwife, or other qualified health care provider; childbirth education classes are not a substitute for this important intervention.
12. A woman in her 38th week of pregnancy is to have an amniocentesis to evaluate fetal maturity. The L/S (lecithin/sphingomyelin) ratio is 2:1. The nurse knows that this finding indicates.
1. fetal lung maturity
2. that labor can be induced.
3. the fetus is not viable
4. a non-stress test is indicated
#1. Lecithin and sphingomyelin are phosphilipids produced by the type II alveolar cells. The L/S ratio increases with gestation and a ratio of 2:1 indicates lung maturity.
An L/S ratio of 2:1 indicates lung maturity but there are several potential problems with this indicator; thus other parameters must also be measured. Meconium or blood in amniotic fluid alters the ratio and, despites a mature ratio in pregnancies complicated by diabetes, the neonate may still develop respiratory distress syndrome.
Viability refers to the fetus being capable of living outside the womb, now considered to be 25 weeks gestation due to advanced technology; L/S ratio is not used to measure viability.
A non-stress test is used to identify the fetus who may not be adapting well to the intrauterine environment; it does not indicate fetal maturity.
13. Mrs. T is having a contraction stress test (CST) in her last month of pregnancy. When assessing the fetal monitor strip, the nurse notices that with most of the contractions, the fetal heart rate uniformly slows at mid-contraction and then returns to baseline about 20 seconds after the contraction is over. The nurse would interpret the test result to be
1. negative: normal
2. reactive: negative
3. positive: abnormal
4. unsatisfactory
#3. The CST subjects the fetus to uterine that compress the arteries supplying the placenta, thus reducing placental blood flow an the flow of oxygen to the fetus; the fetus with minimal metabolic reserve will have late decelerations where the fetal heart rate does not return to the baseline until the contraction ends. Fetal compromise is therefore suggested.
In a negative normal CST there are no late decelerations occurring with contractions. This indicates fetal well-being related to uteroplacental function.
A reactive negative result refers to a normal non-stress test in which the fetal heart rate accelerates with fetal movement.
This term refers to a test that cannot be read adequately, for example, inability to stimulate at least three contractions in 10 minutes or unsatisfactory tracings related to positioning or fetal movement.
14. Mrs. P., 36 weeks gestation, is having a CST with an oxytocin IV infusion pump. After two contractions, the uterus stays contracted. The best initial action of the nurse is to
1. help the client turn on her left side.
2. turn off the infusion pump
3. wait three minutes for the uterus to relax.
4. administer prn terbutaline sulfate (Brethine)
#2. When IV oxytocin is being used to stimulate uterine contractions in a contraction stress test, the oxytocin infusion si stopped if contractions occur more often than every two minutes or last longer than 60 seconds, if uterine tetany (remains contracted) takes place, or if continued fetal heart rate decelerations are noted.
Turning a client, in late pregnancy, on her left side will relieve pressure of the gravid uterus on the inferior vena cava; it will have no effect on a contracted uterus.
A contracted uterus reduces placental blood flow and the flow of oxygen to the fetus; this condition can result in fetal hypoxia so it must be resolved immediately.
It is possible that this tocholytic drug may be given to inhibit uterine contractions, but first the cause of the contraction must be eliminated.
15. A pregnant woman, in the first trimester, is to have a transabdominal ultrasound. The nurse would include which of the following instructions
1. Nothing by mouth (NPO) from6:00 A.M. the morning of the test.
2. Drink one to two quarts of water and do not urinate before the test.
3. Come to the clinic first for injection of the contrast dye.
4. No special instructions are needed for this test.
#2. To obtain clearer images during the first trimester, women are required to drink one to two quarts of clear fluid to fill the urinary bladder and thereby push the uterus higher into the abdomen where it can be more accurately scanned.
There are not diet restrictions necessary to prepare for an ultrasound.
Ultrasound is a technique that involved the sue of high-frequency sound waves; the sound waves bounce off tissues of differing acoustic density. No contrast dye is needed.
There are special instructions needed when a woman in the first trimester is to have a transabdominal ultrasound.
16. Mrs. F., pregnant for the first time, calls the clinic to say she is bleeding. To obtain important information, the nurse should next ask,
1. “When did you last feel the baby move.”
2. “How long have you been pregnant.”?
3. “When was your pregnancy test done?”
4. “Are you having any uterine cramping?”
#2. When a pregnant woman is bleeding vaginally, the nurse should first ask her how many weeks or months pregnant she is; management of bleeding differs in an early pregnancy contrasted with bleeding in late pregnancy. Additional information would include if tissue amniotic fluid was discharged and what other symptoms, such as cramps or pain, are present.
Feeling fetal movement is a good indicator of fetal well-being in late pregnancy. If this client were in the third trimester, this would be additional information obtained.
The actual timing of a pregnancy test does not relate to the length of pregnancy; testing can be done at any time.
Careful assessment is required to determine whether the cause of the bleeding is a threatened abortion; this would include other symptoms, such as cramps or abdominal pain, that maybe present. The nurse must first determine the length of gestation.
17. Ms. Y. is hospitalized with a possible ectopic pregnancy. In addition to the classic symptoms of abdominal pain, amenorrhea, and abnormal vaginal bleeding, the nurse knows that which of the following factors in Ms. Y. history may be associated with this condition.?
1. Multiparity
2. Age under 20
3. Pelvic inflammatory disease (PID)
4. Habitual spontaneous abortions
#3. The incidence of ectopic pregnancy in the Untied States has increased by a factor of 4.9 during recent years. This is attributed primarily to the growing number of women of childbearing age who experience PID and endometriosis, who use intrauterine devices, or who have had tubal surgery.
Multiparity (having had two or more children) has not been found to be a factor in the incidence of ectopic pregnancy; infertile women treated with assisted reproductive technology are at higher risk.
The incidence of ectopic pregnancy increases with age; youth is not an individual factor.
A history of therapeutic abortions has been found to be a factor in extopic pregnancy, not spontaneous abortions (miscarriage).
18. Ms. C is being discharged after treatment for a hydatidiform mole. The nurse should include which of the following in the discharge teaching plan?
1. Do not become pregnant for at least one year.
2. Have blood pressure checked weekly for six months.
3. RhoGAM must be received with next pregnancy and delivery
4. An amniocentesis can detect a recurrence of this disorder in the future.
#1. The follow-up protocol of critical importance after a molar pregnancy is the assessment of serum chorionic gonadotropin (hCG); hCG is considered a highly specific tumor marker for gestational trophoblastic disease (GTD). The hCG levels are assayed at intervals for one year; a rise or plateau necessitates further diagnostic assessment and usually treatment. Pregnancy would obscure the evidence of choriocarcinoma by the normal secretion of hCG.
Pregnancy-induced hypertension (PIH) may be seen earlier than the usual 20 weeks of gestation when there is a molar pregnancy; after evacuation of the mole there is no need for long-term blood pressure assessment.
The administration of RhoGAM is indicated to prevent hemolytic disease of the newborn as seen in a Rh-negative pregnancy.
In a molar pregnancy, cell differentiation is halted and trophoblastic tissue proliferates; the disorder becomes evident in the first trimester. An amniocentesis, usually performed at 16+ weeks of pregnancy, is not related to this disorder.
19. Mrs. T., 40 weeks gestation, is admitted to the labor and delivery unit with possible placenta previa. On the admission assessment, the nurse would expect to find
1. signs of a Couvelaire uterus
2. severe lower abdominal pain
3. painless vaginal bleeding
4. a board-like abdomen
#3. Placenta previa, when the placenta is implanted in the lower uterine segment, often is characterized by the sudden onset of bright red bleeding in the third trimester. Usually this bleeding is painless and may or may not be accompanied by contractions.
A Couvelaire uterus can occur in severe abruptio placentae when blood extravasates into the uterine musculature and prevents contraction of the uterus after delivery.
Severe lower abdominal pain, especially in a woman in labor, can be a sign of a ruptured uterus.
This sign can be part of the classic presentation of abruptio placenta, which also includes constant abdominal pain and uterine tenderness on palpation.
20. Mrs. S., 30 weeks gestation, is being discharged to home care with a diagnosis of placenta previa. The nurse knows that the client understanding her care at home when the client states,
1. “As I get closer to my due date I will have to remain in bed.”
2. “ I can continue with my office job because it’s mostly sitting
3. “My husband won’t be too happy with this ‘no sex’ order.”
4. “I’m disappointed that I will need a cesarean section.
#3. In placenta previa, any sexual arousal is contraindicated because it can cause the release of oxytocin, which can cause the cervix to pull away from the low-lying placenta; this results in bleeding and potential jeopardy to the fetus.
For women with placenta previa whose condition is stable, but the fetus is premature, a regimen of restricted activity and bedrest is indicated.
For women with placenta previa whose condition is stable, but the fetus is premature, a regimen of restricted activity and bedrest is indicated.
In placenta previa, if the woman’s condition is stable, and the previa is less than 30% (a partial or marginal previa), a vaginal delivery may be possible with careful monitoring.
21. A teenage patient, 38 weeks gestation, is admitted with a diagnosis of pregnancy-induced hypertension (PIH). Data include: blood pressure 160/100, generalized edema, weigh gain of 10 pounds in last 2 weeks, and proteinuria of +3; the patient is also complaining of a headache and nausea. In planning care for this client, the nurse would set the following priority goal. The client will
1. demonstrate a decreased blood pressure within 48 hours
2. not experience a seizure prior to delivery.
3. maintain a strict diet prior to delivery
4. comply with medical and nutritional regimen.
#2. Preeclampsia may progress to eclampsia, the convulsive phase of PIH. Symptoms that herald the progression include headache, visual disturbances, epigastric pain, nausea or vomiting, hyperreflexia, and oliguria; classical signs of PIH also intensify.
In this disorder, placental perfusion is already compromised, decreasing maternal blood pressure can further reduce perfusion and stress the fetus; if the diastolic pressure exceeds 110 mmHg, an antihypertensive drug maybe administered.
Weight gain in advancing PIH is an indication of progressive water retention and not a sign of an inappropriate diet; a weight gain exceeding 1.5 kg per week during the third trimester is a sign of PIH.
The signs described here are indicators of progressive PIH; the data do not support noncompliance.
22. Mrs. S., 32 weeks gestation, has developed mild PIH. The nurse evaluates that the client understands her treatment regimen when the client states,
1. “it is most important not to miss any of my blood pressure medication.”
2. I will watch my diet restrictions very carefully.”
3. “I will spend most of my time in bed, on my left side.
4. “I’m happy that this only happens during a first pregnancy.
#3. Modified bedrest in the left lateral position may be advised for the client with mild PIH. This position improves venous return and placental and renal perfusion; urine output increases, and blood pressure may stabilize or decrease.
If diastolic pressure exceed 110 mmHg, an antihypertensive drug may be administered IV in more severe PIH; in PIH, placental perfusion is already compromised and lowering maternal blood pressure can further reduce perfusion and stress the fetus.
Dietary restrictions are no longer advised, and the client may follow a regular, well-balanced diet as tolerated.
Previous PIH predisposes to recurrence of PIH.
23. A pregnant client with class 3 cardiac disease is seen during an initial prenatal visit. The nurse selects which of the following priority nursing diagnoses”
1. Knowledge deficit related to self-care during pregnancy.
2. Fear, client and family, related to pregnancy outcome
3. Alteration in nutrition related to sodium-restricted diet.
4. Activity intolerance related to compromised cardiac status
#4. Once pregnancy is established, the focus of management is on minimizing any extra cardiac demands on the pregnant woman. In class 3 cardiac disease, the client experiences fatigue, palpitation, dyspnea, or angina when she undertakes less than ordinary activity. Physical activity is markedly restricted; this includes bedrest throughout the pregnancy.
Pregnant women with cardiac disease do need to learn self-care to minimize the risk of complications; this, however, does not take priority over physiologic safety.
Pregnancies with serious complications instill fear in the client and family; however, physiological needs take priority.
Pregnant women with cardiac disease are likely to be placed on a sodium-restricted diet; however, this does not take priority over the risk of cardiac decompensation.
24. The nurse includes the importance of self-monitoring of glucose in the care plan for a diabetic client planning a pregnancy. The goal of this monitoring is to prevent
1. congenital malformations in the fetus
2. maternal vasculopathy
3. accelerated growth of the fetus.
4. delayed maturation of fetal lungs.
#1. There is increasing evidence that the degree of control for an insulin-dependent diabetic woman prior to conception greatly affects the fetal outcome. Studies find that poor maternal glucose control underlies the incidence of congenital malformations in the infants of diabetic mothers.
In diabetic woman with vascular disease, White’s class D, or one who has had diabetes for at least 20 years, even careful control of glucose at this point will not prevent these cardiovascular changes.
Macrosomia, excessive fetal growth, can occur in infants of diabetic mothers from hyperinsulinism; however, this is a concern in alter pregnancy, not at conception.
Infants of diabetic mothers have a higher incidence of respiratory distress syndrome because hypersulinism has a delaying effect on fetal lung maturation; however, this is a concern in later pregnancy.
25. After a prenatal class on healthy behaviors during pregnancy, the nurse can evaluate that learning has occurred when a client states,
1. “Alcohol in the first trimester of pregnancy is very dangerous, later it’s OK.”
2. “Drinking alcohol during pregnancy is the most preventable cause of mental retardation”
3. “Alcohol is bad during pregnancy, but a little with breast feeding helps with let-down
4. “problems for the baby usually only occur with heavy drinking of alcohol.
#2. Prenatal alcohol exposure is a preventable cause of birth defects and neurodevelopmental deficits; it is the leading most preventable cause of mental retardation.
Research confirms that infants suffer more severe abnormalities the earlier alcohol consumption occurs during gestation; but alcohol consumption in late pregnancy is also associated with intrauterine growth retardation and preterm delivery.
Women should not drink any alcohol when breast feeding. It can cause drowsiness, weakness, decrease in linear growth, and abnormal weight gain in the infant; it may also decrease milk ejection.
No safe level has been determined for alcohol consumption during pregnancy.
26. Mrs. D. is 36 weeks gestation and the nurse is talking with her during a prenatal visit. Which statement indicates that Mrs. D. understands the onset of labor?
1. “I need to go to the hospital as soon as the contractions become painful.”
2. “If I experience bright red vaginal bleeding I know that I am about to deliver.”
3. “I need to go to the hospital when I am having regular contractions and bloody show.”
4. “My labor will not start until after my membranes rupture and I gush fluid.”
#3. Regular contractions coupled with bloody show suggest that cervical changes are occurring as a result of contractions.
Perception of pain with contractions is not a reliable indicator of true labor.
Bright red vaginal leading is a sign of a complication, not the onset of labor.
Rupture of membranes does not necessarily occur prior to the onset of labor.
27. Using Leopold’s maneuvers to determine fetal position, the nurse finds that Mrs. L’s fetus is in a vertex position with the back on the left side. Where is the best place for the nurse to listen for fetal heart tones?
1. In the right upper quadrant of the mother’s abdomen.
2. In the left upper quadrant of the mother’s abdomen.
3. In the right lower quadrant of the mother’s abdomen.
4. In the left lower quadrant of the mother’s abdomen.
#4. The left lower quadrant is the correct location since the back is on the left and the vertex is in the pelvis.
The right upper quadrant would be the place to auscultate if the back were on the right and the breech were in the pelvis.
The left upper quadrant would be the place to auscultate if the back were on the left and the breech were in the pelvis.
The right lower quadrant would be the place to auscultate if the back were on the right side.
28. Which of the following is the best way for the nurse to assess contractions in a client presenting to the labor and delivery area?
1. Place the client on the electronic fetal monitor with the labor toco at the fudus.
2. As the client to describe the frequency, duration, and strength of her contractions.
3. Use Leopold’s maneuvers to determine the quality of the uterine contractions.
4. Place the fingertips of one hand on the fundus to determine frequency, duration, and strength of contractions.
#4. The fingertips of one hand allow the nurse to feel when the contraction begins and ends and to determine the strength of by the firmness of the uterus.
Although the electronic fetal monitor can yield useful information as the patient continues to labor, it is not the best way for initial assessment to occur.
Self-report by the patient may be used to supplement the nurse’s assessment, but should not replace it.
Leopold’s maneuverses are used to determine fetal position prior to auscultation of heart rate. They do not provide information about contractions.
29. As the nurse assigned to Mrs. Q. you are listening to fetal heart tones. Which of the following findings would you consider abnormal for a patient in active labor?
1. A rate of 160 with no significant changes through a contraction
2. A rate of 130 with accelerations to 150 with fetal movement
3. A rate that varies between 120 and 130
4. A rate of 170 with a drop to 140 during a contraction
#4. A rate of 170 is suggestive of fetal tachycardia. A drop to 140 during a contraction represents some periodic change, which is not a normal finding.
A rate of 160 is normal. The absence of changes during contractions is a reassuring finding.
A rate of 130 is normal. Accelerations with fetal movement are a reassuring finding.
Baseline variability between 120 and 130is a normal finding.
30. Ms. K. arrives at the birthing center in active labor. On examination, the cervix is 5 cm dilated membranes intact and bulging, and the presenting part at – 1 station. Ms. K asks if she can go for a walk. What is the best response for the nurse to give?
1. “I think it would be best for you to remain in bed at this time because of the risk of cord prolapse.”
2. “It’s fine for you to walk, but please stay nearby. If you feel a gush of fluid, I will need to check you and your baby.”
3. “It will be fine for you to walk because that will assist the natural body forces to bring the baby down the birth canal.
4. “I would be glad to get you a bean bag chair or rocker instead.”
#2. Although there is always some risk of complications when membranes rupture, it is safe for Ms. K. to ambulate as long as she is rechecked if rupture of membranes occur.
Although cord prolapse can occur when the presenting part is not fully engaged, the incidence is highest with malpresentation, grand multiparity, multiple gestation, and low birthweight.
Although ambulation does support natural labor progress, this response is not the best one without anticipatory guidance.
Although the nurse may not feel comfortable allowing Ms. K. to walk, this response does not provide the client with any rationale for the nurse’s response and is therefore inappropriate.
31. Mrs. M., a primigravida, presents to the labor room with rupture of membranes at 40 weeks gestation. Her cervix is 2 cm dilated and 100% effaced. Contractions are every 10 minutes. What should the nurse include in the plan of care?
1. Allow Mrs. M. to ambulate as desired as long as the presenting part is engaged.
2. Assessed fetal heart tones and maternal status every five minutes.
3. Place Mrs. M. on an electronic fetal monitor for continuous assessment of labor.
4. Send Mrs. M. home with instructions to return when contractions are every five minutes.
#1. Ambulation will help Mrs. M.’s contractions more effectively dilate the cervix. As long as the presenting part is engaged, there is not increased risk of cord prolapse.
Assessments every five minutes are made during the second stage of labor. They are not required during the latent phase of first stage labor.
Although periodic assessments of mother and fetus are required, continuous monitoring is not indicated.
Although many patients in latent phase are sent home with instructions to return when contractions become more frequent, Mrs. M.’s ruptured membranes are a contraindication to that action.
32. Mrs. B. is in active labor at 4 cm dilated, 100% effaced, and 0 station. As she is ambulating she experiences a gush of fluid. What is the most appropriate initial action for the nurse to take?
1. Send a specimen of the amniotic fluid to the laboratory for analysis.,
2. Have Mrs. B. return to her room and place her in Trendelenburg position to prevent cord prolapse.
3. Have Mrs. B. return to her room so that you can assess fetal status, including auscultation of fetal heart tones for one full minute.
4. Call Mrs. B.’s physician because a cesarean delivery will be required.
#3. The most important nursing action after rupture of the membranes is careful fetal assessment, including fetal heart tones counted for one minute.
There is no known reason based on the available information to request amniotic fluid analysis. Therefore, not only is this not an appropriate initial action, it is not required at all.
The presenting part is at 0 station. At this station, it is unlikely that a cord prolapse would occur. Trendelenburg would be sued only if an assessment confirmed this complication.
There is no information suggesting that Mrs. B. will require operative delivery. It is more important to assess the client than anything else at this time.
33. The nurse is providing care to Ms. C. During the most recent vaginal examination the nurse feels the cervix 6 cm dilated, 100% effaced, with the vertex at – 1 station. What is the best interpretation of this information? The woman is in
1. transition with the head as presenting part not yet engaged.
2. transition with the backside as presenting part fully engaged.
3. latent phase labor with the backside as presenting part fully engaged.
4. active labor with the head as presenting part fully engaged.
#1. At 6 cm dilation and complete effacement, active labor is occurring. A station of –1 indicates that the vertex is above the ischial spines and not fully engaged.
Transition does not begin until 8 cm of cervical dilation. The vertex is the head, not backside and – 1 station is above the ischial spines and not fully engaged.
Latent phase ends by the time the cervix is 4 cm dilated. The vertex is the head, not backside and 1 – station is above the ischial spines and not fully engaged.
Although Ms. C. is in active labor with the head as presenting part, a – 1 station is not fully engaged since the head is above the ischial spines.
34. Mrs. M. is completely dilated and at +2 station. Her contractions are strong and last 50-70 seconds. Based on this information, the nurse should know that Mrs. M. is in which stage of labor?
1. First stage
2. Second stage
3. Third stage
4. Fourth stage
#2. The second stage of labor extends from complete cervical dilation to delivery of the infant.
The first stage of labor extent until the cervix is fully dilated.
The third stage of labor extends from delivery of the fetus to delivery of the placenta.
The fourth stage of labor extends from delivery placenta through the early postpartum period.
35. A 28-year primigravida is admitted to the labor room. She is 2 cm dilated, 90% effaced, and the head is at 0 station. Contractions are every 10 minutes lasting 20-30 seconds. Membranes are intact. Admitting vital signs are: blood pressure 110/70, pulse 78, respirations 16, temperature 98.80F, and fetal heart rate 144. The nurse plans to monitor
1. blood pressure and contractions hourly and fetal heart rate every 15 minutes
2. temperature, blood pressure, and contractions every 4 hours and fetal heart rte hourly.
3. contractions, effacement, and dilation of cervix, and fetal heart rte every hour.
4. contractions, blood pressure, and fetal heart rate every 15 minutes.
#1. During early labor, blood pressure and contractions should be monitored hourly and fetal heart rate every 15 minutes.
During early labor, temperature is monitored every 4 hours, blood pressure every hour and contractions every half hour to hour. Fetal hear rate is monitored every 15 minutes.
During early labor, contractions are monitored every half hour or hour, cervical effacement and dilation are assessed when there is a change in condition. Fetal heart rate is monitored every 15 minutes.
During early labor, contractions are monitored every half hour to hour and blood pressure is monitored hourly. Fetal heart rate is monitored every 15 minutes.
36. Mrs. H.’s cervix is completely dilated with the head at –2 station. The head has not descended in the past hour. What is the most appropriate initial assessment for the nurse to make?
1. Assess to determine if Mrs. H’s bladder is distended.
2. Send Mrs. H. for x-rays to determine fetal size.
3. Notify the surgical team so that an operative delivery can be planned
4. Assessed fetal status, including fetal heart tones, and scalp pH.
#1. A full bladder may prevent the head from moving down into the pelvic inlet. Often clients do not have the sensation of a full bladder late in labor, despite significant distention.
Although fetal size may contribute to failure of the head to descend, this is not the initial assessment required.
Notification of a surgical team is not an assessment. There is also no evidence that an operative delivery is required at this time.
Although continuous assessment of felt well-being is important, there is no indication for scalp pH. Therefore, these assessments are not the most appropriate ones to be made.
37. Ms. N. has been in labor for six hours. She is now 9 cm dilated and has intense contractions every one to two minutes. Ms. N. is anxious and feels the need to bear down with her contractions. What is the best action for the nurse to take?
1. Allow Ms. N. to push so that delivery can be expedited.
2. Encourage panting breathing through contractions to prevent pushing
3. Reposition Ms. N. in a squatting position to make her more comfortable.
4. Provide back rubs during contractions to distract Ms. N.
#2. Since Ms. N. is still in transition and not ready to deliver, encouraging her to pant will diminish the urge to push.
Pushing prior to complete dilation of the cervix may increase edema and make delivery more difficult.
Although a squatting position maybe useful as delivery approaches, it will not help diminish the urge to push prior to complete cervical dilation.
During transition, many women do not like to be touched, even if this action was perceived as helpful earlier in labor.
38. A newborn, at one minute after vaginal delivery, is pink with blue hands and feet, has a lusty cry, heart rate 140, prompt response to stimulation with crying, and maintains minimal flexion, with sluggish movement. The nurse should know that this newborn’s Apgar score is:
1. ten
2. nine
3. eight
4. seven
#3. This infant has two point for heart rate, respiratory effort and reflex irritability. One point is awarded for color and muscle tone for a total of eight.
A score of 10 would result if all five criteria received a maximum of two points. This infant does not have two points for color or for muscle tone.
A score of nine would result if four criteria received a maximum of two points and one received one point. This infant does not have two points for color or for muscle tone.
A score of seven would result if there was a total of three points off from the five criteria. This infant has a total of two points off.
39. Mrs. G. delivered a 7 lb boy by spontaneous vaginal delivery 30 minutes ago. Her fundus is firm at the umbilicus and she has moderate lochia rubra. Which nursing diagnosis is highest priority as the nurse plans care?
1. Risk for infection related to episiotomy
2. Constipation related to fear of pain
3. Potential for altered urinary elimination related to perineal edema
4. Knowledgeable regarding newborn care.
5.
#3. Perineal edema may affect urinary elimination. If allowed to continue, it may also lead to excessive postpartum bleeding because the uterus cannot firmly contracted when the bladder is excessively full.
Although this diagnosis may be appropriate during the postpartum period, it is not the highest priority.
Concerns about constipation are more often seen after the first 24 hours.
There is no information to suggest that this client has a knowledge deficit regarding newborn care. Even if she does, physiologic needs are of higher priority during the first hour after birth.
40. Mrs. G. is in the fourth stage of labor. She and her new daughter are together in the room. What assessments are essential for the nurse to make during this time?
1. Assess the pattern and frequency of contractions and the infant’s vital signs.
2. Assess Mrs. G’s vital signs, fundus, bladder, perineal condition, and lochia.
3. Assess Mrs. G.’s vital signs, fundus, bladder, perineal condition, and lochia. Return the infant to the nursery.
4. Assess the infant for obvious abnormalities. Assess Mrs.G for blood loss and firm uterine contraction.
#2. Assessment of the mother during fourth stage includes elements related to her recovery from childbirth. Infant assessment focuses on stability and transition to extrauterine life.
This information is not appropriate to fourth stage for the mother. She should not experience a pattern of contraction after delivery, although afterpains are a part of the involutional process. Infant assessment information is correct.
Although the information related to maternal assessment is correct, there is no reason to return the infant to the nursery.
These assessments would be appropriate during the third stage of labor.
41. Mrs. P. G3 P2, was admitted at 32 weeks gestation contracting every 7-10 minutes. Her cervix is 2 cm dilated and 70% effaced. What should the nurse include in the plan of care for this client?
1. Discuss with Mrs. P. the need to stop working after her discharge from the hospital.
2. Monitor Mrs. P. and her fetus for response to impending delivery.
3. Assess Mrs. P’s past pregnancy history to determine if she has experienced preterm labor in the past.
4. Start oral terbutaline to stop the contractions.
#3. As a G3P2, Mrs. P.’s past pregnancy history may provide some important information that may shape the care rendered at this time.
Although Mrs. P. may need to reduce her activity level if she continues with preterm labor, this is not the most appropriate plan at this time.
Although the nurse should monitor Mrs. P. and her fetus, this is not with the expectation of impending delivery.
Although tocolytic agents may be required, a physician’s order is necessary. The IV therapy is usually initiated first, with a switch to oral agents after contraction cease.
42. Mrs. P. was admitted in premature labor contracting every five minutes. Her cervix is 3 cm dilated and 100% effaced, IV magnesium sulfate at 1 g per hour is infusing. How will the nurse know the drug is having the desired effect?
1. The contractions will increase in frequency to every three minutes, although there will be no further cervical changes.
2. Mrs. P. will be able to sleep through her contractions due to the sedative of the magnesium sulfate.
3. The contractions will diminish in frequency and finally disappear.
4. Mrs. P. will have diminished deep tendon reflexes and her body pressure will decrease.
#3.If the magnesium sulfate is effective you would expect the contractions to decrease and then disappear. You would not continue to perform vaginal exams if the desired result is occurring.
Magnesium sulfate is a central nervous system depressant. Smooth muscle relaxation will occur, hence contraction will not increase in frequency
Although magnesium sulfate is a central nervous system depressant, it is not a sedative. Therefore, you would not expect Mrs. P. to fall asleep.
Although magnesium sulfate is used to treat preeclampsia, diminished deep tendon reflexes and decreased blood pressure would not tell the nurse that the drug is having the desired effect in premature labor.
43. Mrs. K. has just received an epidural for anesthesia during her labor. What should the nurse include in the plan of care because of the anesthesia?
1. Assist Mr. K. in position changes and observe for signs of labor progress.
2. Administer 500-1000 m of a sugar-free crystalloid solution.
3. Place a Foley catheter as soon as the anesthesia has been administered.
4. Offer Mrs. K. a back rub to reduce the discomfort of her contractions.
#1. Epidural anesthesia may diminish Mrs. K.’s sensation of painful stimuli and movement. Assistance and frequent assessment are therefore essential.
A bolus infusion of fluid is usually administered prior to placement of an epidural. It is not a part of the plan after administration of the anesthesia.
Although patients receiving epidural anesthesia may have difficulty in voiding, that is not a reason to place a Foley.
If the epidural is working satisfactorily, Mrs. K. should experience minimal discomfort from her contractions. Although a back rub is not contraindicated, the rationale is not correct.
44. Mrs. K. delivered her infant so three hours ago. She had an episiotomy to facilitate delivery. As a nurse assigned to care for MRS. K., which of the following would be the most appropriate action?
1. Place an ice pack on the perineum.
2. Apply a heat lamp to perineum.
3. Take Mrs. K. for a sitz bath.
4. Administer analgesic medication as ordered.
#1. Ice during the first 12 hours after delivery causes vasoconstriction and thereby prevents edema. Ice also provides pain relief through numbing of the area.
Heat is not an appropriate initial action because it may increase edema formation and does not aid the early healing process.
Although sitz baths may be used later in the course of recovery, the heat is not desirable in the first 12 hours because it may enhance edema formation.
Although analgesic agents may be required for pain relief, this is not the most appropriate action based on the information available.
45. Mrs. C. is scheduled for a cesarean section delivery due to transverse fetal lie. What is the best way for nurse to evaluate that Mrs. C. understands the procedure?
1. Ask Mrs. C. about the help she will have at home after her delivery.
2. Give Mrs. C. diagram of the body and ask her to draw the procedure for you.
3. Ask Mrs. C. to tell you what she knows about the scheduled surgery.
4.Provide Mrs. C. with a booklet explaining cesarean deliveries when she arrives at the hospital.
#3. Asking for clarification of what Mrs. C. knows is the best way to evaluate what she understands of the procedure. If the client has additional questions, the nurse can then clarify or amplify the information.
Although it is important to have some help after discharge this question will not elicit information about her understanding of the procedure.
This technique is useful in preparing young children for surgery, but is inappropriate for a normal adult.
Although written information may be helpful to explain cesarean birth, providing it at the time of admission does not allow the nurse the opportunity to evaluate that the patient understands the procedures.
46. Which of the following observations in the postpartum period would be of the most concern to the nurse?
1. After the delivery, the mother touches the newborn with her fingertips.
2. The new parents asked the nurse to recommend a good baby care book.
3. A new father holds his son in the end face position while visiting.
4. A new mother sits in the bed while her newborn lies awake in the crib.
#4. During the early postpartum period, evidence of maladaptive mothering may include limited handling or smiling at the infant; studies have shown that a predictable group of reciprocal interactions, between mother and baby, should take place with each encounter to foster and reinforce attachment.
Shortly after birth, the new mother examines her baby’s body with her fingertips looking for cues from the infant; fingertip touch causes the newborn to turn toward the touch.
Concern for ability to care for their newborn is an indicator of positive bonding and attachment.
For parents, the need for the newborn to open its eyes is nearly universal. Babies held in the face-to-face (en face) position attempt to focus on the eyes of the holder; this strongly evokes parental feeling.
47. Mrs. N. has just delivered her first baby who will breast fed. The nurse should include which of the following instructions in the teaching plan?
1. Try to schedule feedings at least every three to four hours.
2. Wash nipples with soap and water before each feeding.
3. Avoid nursing bras with plastic lining.
4. Supplement with water between feedings when necessary.
#3. Successful lactation is fostered by feeding soon after delivery and then feeding when the newborn is ready to nurse; signs of infant readiness include a wakeful state and rooting and sucking motions.
Mothers are advised to simply wash their hands before breast feeding; washing the nipples is not necessary. The use of powders, creams, and soap is discouraged.
In a normal term infant who is being breast fed, supplemental water feedings are not needed; in fact; these feedings may impede breast feeding by decreasing the volume of breast milk required and also by feeding by creating “nipple confusion” in the infant.
48. A woman’s prenatal antibody titer shows that she is not immune to rubella and will receive the immunization after the delivery. The nurse would include which of the following instructions in the teaching plan?
1. Pregnancy must be avoided for the next three months.
2. Another immunization should be administered in the next pregnancy.
3. Breast feeding should be postponed for five days after the injection.
4. An injection will be needed after each succeeding pregnancy.
#1. To prevent intrauterine infection, which can result in miscarriage, stillbirth, and congenital rubella syndrome in the fetus, women who are immunized should be advised not to become pregnant for three months.
One immunization should result in the woman becoming immune to rubella; rubella vaccine is never administered during pregnancy because of the serious dangers to the fetus.
Receiving a rubella vaccination in the postpartum period is not a contraindication to breast feeding.
One immunization should result in the woman becoming immune to rubella; another antibody titer will be done in subsequent pregnancies for validation.
49. A woman had a normal vaginal delivery 12 hours ago and is to be discharged from the birthing center. The nurse evaluates that the woman understands the teaching related to episiotomy and perineal area when she states,
1. “I know the stitches will be removed at my postpartum clinic visit.”
2. “The ice pack should be removed for 10 minutes before replacing it.”
3. “The anesthetic spray, ten the heat lamp, will help lot.”
4. “The water for the Sitz bath should be warm, about 102-1050 F.”
#2. To attain the maximum effect of reducing edema and providing numbness of the tissues, the ice pack should remain in place approximately 20 minutes and then be removed for about 10 minutes before replacing it.
Stitches used for an episiotomy are absorbable and do not require removal.
Because of the danger of tissue burns, a woman must be cautioned not to apply anethetic spray before using a heat lamp.
Recently, cool sitz baths have gained popularity because they are effective in reducing perineal edema; therefore; it may be best to offer the woman a choice.
50. Mrs. B. is bottle feeding her newborn. The nurse evaluates the client understands how to safely manage formula when Mrs. B. states,
1. “Prepared formula should be used within 48 hours.”
2. “All bottles, caps, and nipples must be sterilized.”
3. “A dishwasher is not sufficient for proper cleaning.”
4. “Prepared formula must be refrigerated until used.”
#4. Extra bottles of prepared formula are stored in the refrigerator and should be warmed slightly before feeding.
Bottles may be prepared individually, or up to one day’s supply of formula may be prepared at one time.
Cleanliness is essential, but sterilization is necessary only if the water source is questionable.
Bottles may be effectively prepared in dishwashers or washed thoroughly in warm soapy water and rinsed well; nipples should be washed and rinsed by hand.
51. Mrs. P. delivered her baby 12 hours ago. During the postpartum assessment, the uterus is found to be boggy with heavy lochia flow. The initial action of the nurse is to
1. notify the physician or nurse midwife.
2. administer prn oxytocin.
3. encourage the woman to increase ambulation.
4. massage the uterus until firm.
#4. A soft, boggy, uterus should be massaged until firm; clots may be expressed during massage and this often tends to contract the uterus more effectively.
If the uterus continues not to contract well or the bleeding is excessive, the physician or nurse midwife should be contacted; however, this is not the initial action of the nurse.
If the uterus continues to contract well or the bleeding is excessive, the physician or nurse midwife may order that oxytocin be administered; however, this is not the initial action of the nurse.
Ambulation is advised in the immediate postpartum period; however, this intervention is not related to the emergency situation described.
52. A breast feeding mother is visited by the home health nurse two weeks after the delivery. The woman is febrile with flulike symptoms; on assessment the nurse notes a warm, reddened, painful area of the right breast. The best initial action of the nurse is to
1. contact the physician for an order for antibiotics.
2. advise the mother to stop breast feeding and pumping.
3. assess the mother’s feeding technique and knowledge.
4. obtain a sample of breast milk for culture.
#1. These symptoms are signs of infectious mastitis, usually caused by Staphylococcus aureus; a 10-day course of antibiotics is indicated.
In mastitis, an improved outcome, a decreased duration of symptoms, and decreased incidence of breast abscess result if the breasts continue to be emptied by either nursing or pumping.
It is important that breast feeding technique and knowledge be assessed when mastitis has occurred because there have been found to be contributing factors for this complication; however, it is not the best initial action of the nurse.
Diagnosis and treatment of mastitis are usually based on symptoms and physical examination, even while waiting for laboratory results; if there is a recurrence of the mastitis, most experts agree that a culture should be obtained.
53. Mrs. P. had a vaginal delivery of her second child two days ago. She is breast feeding the baby without difficulty. During a postpartum assessment on Mrs. P., the nurse would expect the following normal finding.
1. Complaints of afterpains.
2. Pinkish to brownish vaginal discharge.
3. Voiding frequently, 50-57 ml per void.
4. Fundus 1 cm above the umbilicus.
#1. Afterpains occur more commonly in multiparas than in primiparas and are caused by intermittent uterine contractions. Because oxytocin is released when the infant suckles, breast feeding also increase the severity of the after pains.
Lochia (term for vaginal discharge after birth) serosa occurs from bout the third until the tenth day after delivery and would not be observed on the second day; it is a pinkish to brownish color.
Catheterization would be required when the bladder is distended and the woman cannot void or when she is voiding small amounts (<100 ml) frequently.
After birth, the top of the fundus remains at the level of the umbilicus for about half a day; it then descends approximately one fingerbreadth per day until it can no longer be palpated on about the tenth day.
54. A mother who had a vaginal delivery of her first baby six weeks ago is seen for her postpartum visit. She is feeling well and is bottle feeding her infant successfully. During the physical assessment, the nurse would expect to find the following normal data.
1. Fundus palpated 6 cm below the umbilicus.
2. Breasts tender, some milk expressed.
3. Striae pink but beginning to fade.
4. Creamy, yellow vaginal discharge.
#3. At two weeks postpartum, striae (stretch marks) are pink and obvious; by six weeks they are beginning to fade out but may not achieve a silvery appearance for several more weeks.
The uterus is no longer palpable abdominally by 10 days to two weeks postpartum.
In a non-nursing mother; breasts wound not be tender and no milk would be expressed by two weeks postpartum.
The final discharge, termed lochia alba, is creamy or yellowish and persists from about the tenth day to two to three weeks after delivery; by six weeks, there would be no vaginal discharge or menses may be resumed.
55. A nurse collects the following data on a woman 26 hours after a long labor and a vaginal delivery: temperature 1010 F (38.30 C), blood pressure 110/70, pulse 90, some diaphoresis, output 1000 ml per eight hours, ankle edema, lochia moderate rubra, fundus 1 cm above umbilicus and tender on palpation. The client also asks that the infant be brought back to the nursery. In the analysis of this data, the nurse would select which of the following priority nursing diagnoses?
1. Alteration in parenting related to material discomfort.
2. High risk for injury related to spread of infection.
3. Fluid volume excess related to urinary retention.
4. Knowledge deficit related to uterine subinvolution.
#2. The classic definition of puerperal morbidity resulting from infection is a temperature of 100.40F (38.00C) or higher on any of the first 10 days postpartum exclusive of the first 24 hours; additional signs are increased pulse rate, uterine tenderness, foul-smelling lochia, and subinvolution (uterus remains enlarged.)
The postpartum client needs additional rest and an isolated request for the newborn to be cared for in the nursery should not be interpreted as an alteration in parenting or bonding.
In the first 48 hours after birth, a postpartum diuresis takes place and the woman will frequently urinate as much as 3000 ml per day; there may also be profuse sweating (diaphoresis) and gradually diminishing of edema of the extremities.
After delivery, the uterus should descend below the umbilicus at the rate of 1-2 cm per day; failure to do so may be termed subinvolution and the cause must be determined. The client’s lack of knowledge about this condition would not be the first priority.
56. Which of the following findings in three-hour-old, full-term newborn would the nurse record as abnormal when assessing the head?
1. Two “soft spots” between the cranial bones.
2. Asymmentry of the head with overriding bones.
3. Head circumference 32 cm, chest 34 cm.
4. A sharply outlined, spongy area of edema.
#3. The circumference of the newborn’s head should be approximately 2 cm greater than the circumference of the chest at birth and will remain in this proportion for the next few months. Any differences in head size may indicate microcephaly (abnormal smallness of head) or hydrocephalus (Increased cerebrospinal fluid within the ventricles of the brain).
Two “soft spots” (fontanels) may be palpated on the newborn’s head. These are openings at the juncture of the cranial bones; the anterior fontanel closes within 18 months, the posterior fontanel within 8-12 weeks.
The head may appear asymmetric in the newborn of a vertex delivery. This is called molding and is caused by overriding of the cranial bones during labor and birth; it diminishes within a few days.
Caput succedaneum is a localized, easily identifiable soft area of the scalp, generally resulting from a long and difficult labor or vacuum extraction; the fluid is reabsorbed within 12 hours to a few days after birth.
57. The nurse collects the following data while assessing the newborn: color pink with bluish hands and feet, some pale yellow papules with red base over trunk, small white spots on the nose, and a red area at the nape of the neck. The nurse’s next action would be to
1. document findings as within a normal range.
2. isolate infant pending diagnosis.
3. request a dermatology consultation.
4. document as indicators of malnutrition.
#1. These findings of acrocyanosis (bluish discoloration of the hands and feet), erytheeema toxicum (newborn rash), milia, and a nevus flammeus (port wine stain) are all within the normal range for a full-term newborn.
The findings described do not indicate that the infant has an infectious condition that would require isolation.
The findings described do not require further medical intervention.
Intrauterine malnutrition is mainly manifested by low birth weight and internal physiologic changes.
58. While performing the discharge assessment on a two-day-old newborn, the nurse finds that after blanching the skin on the fore head, the color turns yellow. The nurse knows that this indicates
1. a normal biologic response.
2. an infectious liver condition.
3. an Rh incompability problem.
4. jaundice related to breast feeding.
#1. Physiologic jaundice occurs after the first 24 hours of life and is caused by accelerated destruction of fetal blood cells (RBCs), impaired conjugaion of bilirubin, and increased reabsorption from the intestinal tract; there is no pathologic basis.
Hepatitis B virus (HBV), if transmitted to the fetus, increases the risk of prematurity and perinatal morbidity; infants who subsequently test positive for HBV surface antigen are rarely symptomatic.
Hemolytic disease of the newborn caused by Rh incompatibility with the mother’s blood may cause jaundice that most often appears at birth or in the first 24 hours of life.
Breast feeding jaundice, found in 1-5% of newborns being breast fed, appears after the first week of life when the mother’s mature milk has come in.
59. Baby Y. is two-days-old and is being breast fed. The nurse finds that yesterday her stool was thick and tarry, today it’s thinner and greenish; she voided twice since birth with some pink stains noted on the diaper. The nurse knows that these findings indicate
1. marked dehydration.
2. inadequate initial nutrition.
3. normal newborn elimination.
4. a need for medical consultation.
#3. Normal tern newborns pass meconium within 8-24 hours of life; meconium is formed in utero and is thick, tarry, black (or dark green) in appearance. Transitional stool is a thinner brown to green. Normal voiding is two to six times daily; there may be innocuous pink stains (“brick dust spots”) on the diaper from urates.
Dehydration in a newborn may be indicated by an increased temperature or a depressed fontanel; normal urinary output is often limited and the voidings may be scanty.
Following birth, caloric intake is often insufficient for weight gain and during this time there may be a weight loss of 5-10%; normal newborn elimination criteria takes this phenomenon into consideration.
The findings described here do not indicate a need for medical interventions.
60. The nurse notes the following behaviors in a six-hour-old, full-term newborn: occasional tremors of extremities, straightens arms and hands outward and flexes knees when disturbed, toes fan out when heel is stroked, and tries to walk when held upright. The nurse knows that these to walk when held upright. The nurse knows that these findings indicate
1. signs of drug withdrawal.
2. abnormal uncoordinated movements.
3. asymmetric muscle tone.
4. expected neurological development.
#4. Tremors are common in the full-term newborn; when a newborn is startled s/he will exhibit the Moro reflex, that is, s/he will straighten arms and hands outward while the knees flex; in a newborn the Babinski reflex is displayed by a fanning and extension of the toes (in adults the toes flex); and when held upright with feet lightly touching a surface, the newborn will put one foot in front of the other and “walk”.
The signs of drug withdrawal include hyperactivity, hyperirritabiity (persistent high-pitched cry), exaggerated tremors and reflexes, and seizures.
The movements of a newborn are normally uncoordinated; the findings described are not ones of uncoordination.
When awake the newborn may exhibit purposeless, uncoordinated bilateral movements of the extremities, if asymmetric (one-sided) neurologic dysfunction should be suspected; these are not the type of movements described.
61. While assessing a newborn, the nurse notes that the areola is flat with less than 0.5 cm of breast tissue. The finding indicates
1. that infant is male.
2. maternal hormonal depletion.
3. intrauterine growth retardation.
4. preterm gestational age.
#4. At term gestation, the breast bud tissue will measure between 0.5 and 1 cm (5-10 mm.)
At birth, both male and female newborns may have enlarged breasts from maternal estrogen; decreased breast tissue would not be expected in either male or female.
Maternal hormonal influences may cause the newborn’s breast to become engorged, but not reduced in size.
Intrauterine growth retardation (IUGR), or an infant who is small-for-gestational age (SGA), is a newborn at or below the tenth percentile for weight on the newborn classification chart.
62. The nurse’s initial care plan for the full-term newborn includes the nursing diagnosis “risk of fluid volume depletion related to absence of intestinal flora.” A related nursing intervention would be to
1. administer glucose water or put to breast.
2. assess first void and passing of meconium.
3. administer vitamin K injection.
4. send cord blood to lab for Coomb’s test.
#3. The newborn is at a high risk for hemorrhage due to an absence of intestinal flora (bacteria). Vitamin K, needed for the formation of prothrombin and proconvertin for blood coagulation, is usually synthesized by these bacteria in the colon; however, they are absent in the newborn’s sterile gut. This problem is prevented by the administration of vitamin K following birth.
Newborns should be fed by bottle or breast shortly after birth; however, this is not related to the newborn’s lack of intestinal flora.
Usually the first void and passing of meconium is noted in the first 24 hours of life and should be documented by the nurse; this is not related to the listed nursing diagnosis.
A Coomb’s test is performed on a newborn’s cored blood if hemolytic disease of the newborn is suspected, as I Rh incompatibility; this is not related to the listed diagnosis of fluid depletion.
63. In the time immediately following birth, the nurse may delay instillation of eye medication primarily to
1. check prenatal record to determine if prophylatic treatment is needed.
2. ensure that initial eye saline irrigation is completed.
3. enable mother to breast feed the infant in the first hour of life.
4. facilitate eye contact and bonding between parents and newborn.
#4. The initial parental-newborn attachment period can be enhanced if the care providers keep routine investigations to a minimum, delay instillation of ophthalmic antibiotic for one hour, keep the room dim, and provide privacy; eye prophylaxis medication can cause chemical conjunctivitis, which may interfere with the baby’s ability to focus on the parent’s faces.
Prophylactic eye treatment for Neisseria gonorrhoea, which may have infected the infant of an infected mother during the birth process, is legally required for all newborns.
Before instillation of ophthalmic ointment, the eyes should be gently cleaned with a moist cotton ball; irrigations, before or after medication administration, should not be done.
Breast feeding of newborns should be encouraged as soon as possible after birth; however, this is not a reason to delay eye prophylaxis.
64. The nurses should include which of the following instructions in the care plan for a new mother who is breast feeding her full-term newborn?
1. Put to breast when infant shows readiness to feed.
2. Breast feed infant every three to four hours until discharge.
3. Offer water feedings between breast feedings.
4. Feed infant when he knows hunger by crying.
#1. It is important for the new mother to learn and respond to her infant’s early feeding cues. Early cues that indicate a newborn is interested in feeding include hand-to-hand or hand-passing-mouth motion, whimpering, sucking, and rooting.
In the past it was typical to establish artificial, every three to four hour schedules for feeding after the initial feeding; this schedule failed to recognize the individual needs of the newborn infant and presented difficulties for the new mother just establishing lactation.
Using supplementary bottle feedings for the breast feeding infant may weaken or confuse the sucking reflex or decrease the infant’s interest in nursing; bottles should be avoided until breast feeding is well established.
Crying is a late sign of hunger, it has also been shown to delay the transition to extrauterine life by causing unoxygenated blood to be shunted into systemic circulation through the foramen ovale and ductus arteriosus.
65. In the delivery area, after ensuring that the newborn has establishes respirations, the next priority of the nurse should be to
1. perform the Apgar score.
2. place plastic clamp on cord.
3. dry infant and provide warmth.
4. ensure correct identification.
After birth, the first priority is to maintain respirations, the second priority is to provide and maintain warmth; the newborn’s temperature may fall 2-300C after birth due mainly to evaporative losses; this triggers cold-induced metabolic responses and heat production.
The Apgar score, an immediate evaluation of the newborn’s physical condition, is rare one minute after birth and again in five minutes; however, it is not the second priority of care.
The cord is clamped with two Kelly clamps and then cut at delivery; it is not a priority to replace the clamps with a plastic clamp immediately.
To ensure correct identification, the nurse places ID bands on the mother and infant before they leave the birth area; however, this is not the second priority of care.
66. During the bath demonstration, Mrs. A. asks the nurse if it is OK to use baby powder because warm weather is coming. The nurse should respond
1. “Just dust in on the diaper area only.”
2. “It’s best not to use powder on infants.”
3. “ First use baby oil, then the powder.”
4. “If the baby is just in a diaper he’ll be cool.”
#2. Powders and oils are not recommended for the neonate’s skin; oils may clog the pores, and the small particles of powders may be inhaled by the neonate.
Powders are not recommended for the neonate because the small particles may be inhaled.
Powders and oils are not recommended for the neonate’s skin; oils may clog the pores, and the small particles of powders may be inhaled by the neonate.
Even in a hot environment, an infant should have a layer of clothing, so excess moisture will be absorbed and the body cooled.
67. Which of the following muscles would the nurse choose as the preferred site for a newborn’s vitamin K injection?
1. Gluteus medius.
2. Mid-deltoid.
3. Vastus lateralis.
4. Rectus femoris.
#3. The middle third of the vastus laterals muscle in the thigh is the preferred site for an intramuscular injection in the newborn.
Children below the age of three do not have sufficient muscle development in the gluteal muscle group (buttocks) to withstand injections at this site.
Children below the age of three do not have sufficient muscle development in the deltoid muscle group (upper arm) to withstand injections at this site.
The middle third of the rectus femoris in the thigh is an alternate site, but its proximity to major vessels and the sciatic nerve necessitates caution in using this site for injections in the newborn.
68. The nurse knows that Mrs. T. understands proper cord care for her newborn when the client
1. views a videotape on newborn hygiene care.
2. reads a booklet on care of the newborn’s cord stump.
3. says she will apply Bacitracin ointment three times per day.
4. cleans the cord and surrounding skin with an alcohol pad.
#4. Before discharge, parents should demonstrate proper cleaning of the cord stump by wiping it with an alcohol pad; they should know to do this two to three times a day until the cord falls off in 7-14 days.
Viewing a videotape does not indicate that learning or understanding has occurred.
Reading a booklet does not indicate that learning or understanding has occurred.
Various preparations such as triple dye, Betadine, and Bacitracin are used for newborn cord care in nurseries to promote drying and provide a bactericidal effect; this is not necessary after discharge.
69. The nurse knows that more instruction on care of the circumcised infant is needed when the mother states,
1. “I know to gently retract the foreskin after the area is healed.”
2. “At each diaper change I will squeeze water over the penis and pat dry.”
3. “I know not to disturb the yellow exudates that will form.”
4. “For the first day or so I’ll apply a little A&D ointment.”
#1. A circumcision is the surgical removal of the prepuce or foreskin from the tip of the penis; any foreskin that remains should not be retracted.
The parents should be instructed to squeeze water gently over the penis and pat it dry after each diaper change for two to three days or until healing has occurred.
A whitish yellow exudates that adhere to the glans is granuation tissue and should not be removed.
After the circumcision, A&D ointment is placed on the penis to keep the diaper from adhering to the site; new ointment is applied at each diaper change for at least 24-48 hours.
70. The nurse knows that Ms. Y. has a basic understanding of bottle feeding her infant when the client states,
1. “I know not to prop the bottle until my baby is older.”
2. “With these bottles, he should be able to finish them.”
3. “When I hold the bottle upside down, drops of milk should fall.”
4. “I should burp the baby about every 5-10 minutes.”
#3. The nipple should have a hole big enough to allow milk to flow in drops when the bottle is inverted; too large an opening may cause regurgitation, too small an opening can exhaust and upset the infant.
Bottles should always be held, not propped, positional otitis media may develop when the infant is fed horizontally because milk and nasal mucus may occlude the Eustachian tube.
Parents should be encouraged to avoid overfeeding or feeding infants everytime they cry; infants should be allowed to set their own pace once feedings are established.
The infant should be burped at intervals, preferably at the middle and end of the feeding; too frequent burping may confuse a newborn who is attempting to coordinate sucking, swallowing, and breathing simultaneously.
71. Baby G. weighs 1450 g, has weak tone, with extremities extended position while at rest. The pinna is flat and does not readily recoil. Very little breast tissue is palpable. The soles have deep indentations over the upper one-third. Based on these data, what should the nurse know about Baby G.’s gestational age?
1. Full-term infant, 38-42 weeks gestation.
2. Premature infant, less than 24 weeks gestation.
3. Premature infant, 29-33 weeks gestation.
4. Post-term infant greater than 42 weeks gestation.
#3. A birth weight of 1450 g is the mean weight for an infant at 30 weeks gestation, but falls within the 10-90th percentiles for infants between 29 and 33 weeks gestation. The diminished muscle tone and extension of extremities at rest are also characteristic of this gestational age. The sole creases described are actually most characteristic of an infant between 32 and 34 weeks gestation.
Full-term infants generally have birth weights of greater than 3000 g, with a range of 2700-4000 g.
The infant cannot be less mature than 24 weeks gestation on all of the assessment data presented. Generally, at less than 24 weeks gestation, weight would be 500-700 g at most, breast tissue would be absent, and the areola might not be discernible. Sole creases would not be present.
The post-term infant would be expected to weight at least 2700 g, be tightly flexed at rest, and have abundant sole creases, large and well-defined breast buds, and a pinna that readily recoils.
72. A premature infant at six hours old, has respirations of 64, mild nasal flaring, and expiratory grunting. She is pink in room air, temperature is 36.50 C. The baby’s mother raptured membranes 36 hours prior to delivery. Which measures should the nurse include in the plan of care?
1. Have respiratory therapy set up a respirator since respiratory failure is imminent. Get blood gases every hour.
2. Encourage mother/infant interaction. Rooming in as soon as stable. Monitor vital signs every eight hours.
3. Observe the signs of sepsis. Cultures if ordered. Monitor vital signs at least every two hours for the first 24 hours. Encourage family interaction with infant.
4. Radiant warmer for first 48 hours. Vital signs every hour. Restrict visitation due to risk of infection.
#3. Prolonged rupture of membranes places this premature infant at risk for sepsis. Frequent monitoring of vital signs; color, activity level, and overall behavior is particularly important because changes may provide early cues to a developing infection. Family interaction with the infant should always be a part of the nursing plan.
Although the infant is exhibiting signs of mild respiratory distress, there is no sign that respiratory failure is imminent. Blood gas frequency is determined by physician order.
Although the infant will probably do very well, she must be monitored more frequently than every eight hours. Rooming in would not be a priority at this time.
Although the infant has some mild hypothermia, there is no evidence that a warmer will be needed for 48-hours. Vital signs should be monitored frequently, but are not required on an hourly basis. Limitation of visitors with obvious infections may be appropriate; however, restrictions are not needed.
73. During the assessment of two-day-old infant with bruising and cephalhematoma, the nurse notes jaundice of the face and trunk. The baby is also being breast fed. Bilirubin level is 10 mg/dl. What is the most likely interpretation of these findings?
1. Hyperbilirubinemia due to the bruising and cephalhematoma.
2. Pthologic jaundice requiring exchange transfusion.
3. Breast milk jaundice.
4. Hyperbilirubinemia due to blood group incompatibility.
#1. Although hyperbilirbinemia is common in newborns, certain factors increase the likelihood of early appearance of visible jaundice. Cold stress, brushing at delivery, cephalhematoma, asphyxiation, prematurity, breast feeding, and poor feedings are all factors that may lead to hyperbilirubinemia in otherwise normal infants.
Although jaundice at this age may be pathologic, exchange transfusion is reserved for situations that cannot be managed with more conservative measures such as continued monitoring, supplemental feeding, an/or phototherapy first.
Although the infant is being breast fed, true breast milk jaundice does not develop until four to seven days after birth.
There is no information to suggest blood group incompatibility.
74. A six-hour-old newborn has been diagnosed with erythroblastosis fetalis. The nurse understands that this condition is caused by
1. ABO blood group incompatibility between the father and infant.
2. Rh incompatibility between the mother and infant.
3. ABO blood group incompatibility between the mother and infant.
4. Rh incompatibility between father and infant.
#2. Erythroblastosis fetalis results when an Rh negative woman makes antibodies against her Rh positive fetus. The antibodies attack fetal red cells.
Although ABO blood group incompatibility may lead to jaundice, it does not result in erythroblastosis fetalis. Blood group incompatibility between father and infant will not produce problems for the infant.
ABO incompatibility will not lead to erythroblastosis fetalis although it may result in fetal hemolysis and jaundice of the newborn.
Although erythroblastosis is an Rh-related disorder, it is not produced by any relationship between the father’s and infant’s blood types.
75. Mrs. K. is an Rh negative mother who has just given birth to an Rh positive infant. She had a negative indirect Coombs’ test at 38 weeks gestations and her infant had a negative direct Coombs’ test. What should the nurse know about these tests?
1. Although Mrs. K.’s infant is Rh positive, she has no antibodies to the Rh factor. RhoGAM should be given.
2. Mrs. K. has demonstrated antibodies to the Rh factor. She should not have any more children.
3. Mrs. K. has formed antigens against the Rh factor. RhoGAM must be given to the infant.
4. Since Mrs. K.’s infant is Rh positive, the Coombs’ tests are meaningless.
#1. Since the indirect and direct Coomb’s tests were negative, antibodies to Rh have not developed. Mrs. K. should have RhGAM to prevent antibody formation.
Negative tests indicate that antibodies have not developed to the Rh factor.
Rh is an antigen. If Mrs. K. was sensitized, she would have developed antibodies to the Rh antigen. RhoGAM would be given to the mother to prevent antibody development.
The Coomb’s test indicate the presence or absence of antibodies to the Rh antigen. Since Mrs. K. is Rh negative and her infant is positive, these tests are important.
76. Baby G. was born at 38 weeks gestation to a heroin-addicted mother. At birth, baby G. had Apgar scores of 5 at one minute and 6 at five minutes. Birthweight was at 10th percentile for gestational age. What should the nurse include in Baby B.’s plan of care?
1. Administer methadone to diminish symptoms of heroin withdrawal.
2. Promote parent-infant attachment by encouraging rooming-in.
3. Observe for signs of jaundice because this is a common complication.
4. Place in a quiet area of the nursery and swaddle with hands near mouth to promote more organized behavioral state.
#4. Neonatal withdrawal is a common occurrence in heroin addition. Placing Baby G. in a quiet area and swaddling may promote state organization and minimize some symptoms. Medications may be needed to control hyperirritability.
Although neonatal withdrawal may be a problem, methadone is contraindicated because it may cause addiction in the newborn.
Although parent-infant attachment is important, this infant is not stable enough for rooming-in.
Infants born to hereoin-addicted mothers experience early liver maturation and a lower incidence of jaundice than other newborns.
77. Baby L. is a 36-week-gestation infant who had tachypnea, nasal flaring, and intercostals retractions that increased over the first six hours of life. Baby l. was treated with IV fluids oxygen. Which of the following assessments suggests to the nurse that Baby L. was improving?
1. Baby L. has see-saw respirations with coarse breath sounds.
2. Baby L.’s respiratory rate is 50 and pulse is 136, no nasal flaring is observed.
3. Baby l. has a pH of 6.97 and pO2 of 61 on 40% oxygen.
4. Baby L. has gained 150 g in the 12 hours since birth.
#2. Baby L.’s respiratory rate and pulse are within normal limits and the nasal flaring is no longer present.
See-saw respirations and coarse breath sounds suggest that Baby L., continues with significant respiratory distress.
A pH of 6.97 suggests significant acidosis. A pO2 of 61 on 40% oxygen is suggestive of significant hypoxia. Neither of these findings suggests improvement.
A weight gain of 150 g in the first 12 hours of life is suggestive of edema. Edema often accompanies
78. You are caring for an infant. During your assessment you note a flattened philtrum, short palpebral fissures, and birth weight and head circumference below the fifth percentile for gestation age. The infant has a poor suck. Which of the following is the best interpretation of this data?
1. Down syndrome.
2. Fetal alcohol syndrome.
3. Turner’s syndrome.
4. Congenital syphilis.
#2. Although a medical diagnosis cannot be made from the assessment data, all of the findings noted are commonly seen in infants with fetal alcohol syndrome.
Infants with Down syndrome do not exhibit the flattened philtrum or short palpebral fissures. Most do not manifest any growth abnormalities at birth.
Turner’s syndrome is very rarely identified in infants due to the limited manifestations until later in childhood.
Although infants with congenital syphilis may have intrauterine growth retardation, the other symptoms described are not usually present.
79. A two-week-old premature infant with abdominal distention, significant gastric aspirate prior to feeding, and bloody stools ha also had episodes of apnea and bradycardia and temperature instability. What should the nurse include in the plan care for this infant?
1. Increase feeding frequency to every two hours.
2. Place the infant to seizure precautions.
3. Place the infant in strict isolation ti prevent infection of other infants.
4. Monitor infant carefully including blood pressure readings and measurements of abdominal girth.
#4. The infant’s prematurity is the major risk factor for necrotizing enterocolitis, which effects 1-15% of all infants in NICU. Usual nonsurgical treatment includes antibiotic therapy, making the infant NPO, frequent monitoring and respiratory and circulatory support as needed.
The infant described most likely has a condition known as necrotizing enterocolitis. In this situation the infant is placed NPO. Continued feedings may lead to perforation of the intestines.
The infant described most likel has a condition known as necrrotizing enterocolitis. These infants are not at increased risk for seizures, hence, seizure precautions are not needed.
Necrotizing enterocolitis is not directly transmitted from one infant to the next; therefore, isolation is not required.
80. Mrs. L. is taking her newborn home from the hospital at 18 hours after birth. As the nurse giving discharge instructions, which response by Mrs. L. best her understanding of PKU testing?
1. “I know you stuck my baby’s heel today for the PKU test and that my doctor will recheck the test when I bring her for her one month appointment.”
2. “After I start my baby on cereal, I will return for a follow-up blood test.”
3. “I will have a visiting nurse come to the house each dayfor the first week to check the PKU test.”
4. “I will bring my baby back to the hospital or doctor’s office to have a repeat PKU no later than one week from today.”
#4. One additional PKU test within the first week of life will validate whether PKU disease is present. The infant should have been on breast milk or formula for 48 hours prior to the test.
Although Mrs. . understand that one test has already been done, waiting until one month of age would be too late if the infant had this disorder.
PKU is a disease of abnormal protein metabolism. Waiting until the infant starts cereal would be of no use. If PKU exists, the milk feedings of the first months of life would produce brain damage.
The PKU test needs to be repeated only once after the infant has been on milk feedings for at least 48 hours.
81. Mr. and Mrs. A. have come to your clinic because they have not been able to achieve a pregnancy after trying for two years without using any form of birth control. Which of the following tests could determine that Mrs. A is ovulating regularly?
1. Hysterosalpingogram.
2. Serial basal body temperature graph.
3. Postcoital test.
4. Semen analysis.
#2. Serial basal body temperature graphs are a baseline for determining when ovulation has taken place during a menstrual cycle. If ovulation has occurred, the temperature will be higher the second half of the cycle and lower the first half.
Hysterosalphingogram is an X-ray visualization of the uterus and fallopian tubes with the aid of a dye to determine tubal patency.
The postcoital test determines the effects of the cervical environment on the sperm.
Semen analysis determines the number, motility, and condition of sperm at ejaculation.
82. Mrs. J. is preparing to take Clomid to induce ovulation so she can have an in vitro fertilization. She asks if she should expect any side-effects from the drug. Your best answer should include which of the following?
1. Weight gain with increased appetite and constipation.
2. Tingling of the hands and feet.
3. Alopecia (hair loss).
4. Stuffy nose and cold-like symptoms.
#1. Weight gain associated with increased appetite and constipation are fairly common side-effects of Clomid.
There is no connection between Clomid and changes in sensation of hands and feet.
Alopecia is associated with chemotherapy not ovulatory therapy.
Stuffy nose and cold-like symptoms are associated with allergies, not Clomid.
83. Mr. and Mrs. M. have been using a diaphragm for contraception. Which of the following statements indicates they are using it correctly?
1. “We use K-Y jelly around the rim to help with insertion.”
2. “I wash the diaphragm each time and hold it up to the light to look for any holes.”
3. “I take the diaphragm out about one hour after the intercourse because it feels funny.”
4. “I dounche right away after intercourse.”
#2. The diaphragm should be washed and dried and inspected for holes before being put away.
A spermicide should be used in the center of the diaphragm as well as around the rim for added protection as well as insertion ease.
The diaphragm should be left in place six hours after intercourse. If it feels “funny” it should be checked by the healthcare provider for proper fit.
Douching, even with the diaphragm in place, will lessen its effectiveness. Douching after intercourse is unnecessary.
84. Mrs. B., who is 25-years old, wishes to take oral contraceptives. When taking her history, which of the following questions would determine if she is an appropriate candidate for this form of birth control?
1. “Do you currently smoke cigarettes and, if so, how many?”
2. “Have you had any recent weight gain or loss?”
3. “Do you douche regularly after intercourse?
4. “Is there any family history of kidney or gallbladder disease?”
#1. Cigarette smoking significantly increases a woman’s risk for circulatory complications and may contraindicate oral contraceptive use.
Weight gain or loss is insignificant for oral contraceptive users but important for diaphragm users.
Douching is unrelated to oral contraceptive use but may indicate a lack of knowledge regarding other forms of birth control.
Kidney or gallbladder disease is not a contraindication for oral contraceptive use, although diabetes, liver disease, and heart disease are.
85. Ms. K., who is 18-weeks pregnant, is scheduled for saline injection to terminate her pregnancy. She asks the nurse what she should expect. Your best answer is,
1. “Contractions will begin immediately after the instillation of saline and will be mild.”
2. “An amniocentesis will be performed with amniotic fluid removal and saline replacement.”
3. “A tube will be inserted through the cervix and warm saline will be administered by continuous drip.”
4. “The baby will be born alive but die a short time later.”
#2. The procedure begins with an amniocentesis where amniotic fluid is withdrawn and replaced with saline solution.
Contractions begin 24-48 hours after saline is administered and then contractions are very strong.
Insertion of fluid through the cervix is done for amnioinfusion, not saline injection.
Saline injection causes death to the fetus before contractions begin, usually in one to two hours.
86. Mrs. C. comes to the office complaining of the following symptoms: fatigue, weight gain, pelvic pain related to menstruation, heartburn, and constipation. Which of the above symptoms might indicate a diagnosis of endrometriosis?
1. Weight gain and fatigue.
2. Heartburn.
3. Constipation.
4. Pelvic pain related to menstruation.
#4. Pelvic pain related to menstruation is the most common symptom of endometriosis. The pain usually ends following cessation of menses.
Weight gain and fatigue have no relationship to endometriosis.
Heartburn has no relationship to endometriosis, which is bleeding of endometrial tissue located outside the uterus.
Some women complain of pain with defecation, but not constipation.
87. Miss D. has been diagnosed with Candida albicans. Which of the following types of vaginal dioscharge would you expect to find?
1. Thin, greenish yellow with foul odor.
2. Either a yellowish discharged or none at all.
3. Thick and white. Like cottage cheese.
4. Thin, grayish white with a fishy odor.
#3. Thick, white cottage cheese-like discharge is consistent with Candida albicans
Thin, greenish yellow discharge with a foul odor is consistent with trichomoniasis.
Yellowish discharge or no discharge is consistent with gonorrhea.
Thin, grayish white discharge with a fishy odor is consistent with bacterial vaginosis.
88. Mrs. G. has just been diagnosed with genital herpes for the first time. You can expect which of the following treatments to be part of her plan of care?
1. Vaginal soaks with saline to keep the area moist.
2. acyclovir 200 mg five times daily for 7-10 days.
3. Ceftriaxone 125 mg IM times 1 dose.
4. Topical application of podophyllin to the lesions.
#2. This is the correct drug and dosage for an initial infection of genital herpes.
The area should be kept as possible to promote drying of the lesions.
This is an antibiotic and is used as part of the treatment for gonorrhea.
Podophyllin is used to remove venereal warts (condyloma acuminata)
89. Mrs. E. is 10 weeks pregnant and tested positive for syphilis but has no symptoms. She asks you why she needs to be treated since she feels fine? Your best response to her would include which of the following?
1. “Syphilis can be transmitted to the baby and may cause it to die before birth if you are not treated.”
2. “If you do not receive treatment before the baby is born, your baby could become blind.”
3. “If syphilis is untreated, the baby may be mentally retarded at birth.”
4. “Syphilis may cause your baby to have a heart problem when it is born.”
#1. Syphilis is associated with stillbirth, premature birth, and neonatal death.
Blindness in infants is most often caused by untreated gonorrhea when prophylactic eye care is not given.
Mental retardation is associated with cytomegalovirus but not syphilis.
90. Miss H. has been diagnosed with fibrocystic breast disease. Which of the following should be included in the teaching plan for her?
1. Limiting breast self-examinations to every three because it may be painful.
2. Wearing a bra as little as possible because pressure on the breast may be painful.
3. Limiting caffeine and salt intake.
4. Using heat to the tender areas of the breast.
#3. Most women benefit from caffeine and salt restriction because this reduces fluid retention and increases comfort.
Breast self-examination should be done every month so the woman can become more familiar with her breasts and, therefore, more readily identify any irregularities.
A supportive bra that fits well should be worn both day and night because support will relieve symptoms.
Ice is more beneficial when breasts are sore than is heat.
91. The local YMCA is having a series of seminars on health-related topics. You are invited to discuss breast self-examination (BSE) with the group. Which of the following would be appropriate to teach regarding when BSE should be performed by women of reproductive age?
1. At the end of each menstrual cycle.
2. At the beginning of each menstrual cycle.
3. About 7-10 days after the beginning of each menstrual cycle.
4. About 7-10 days before the end of the menstrual cycle.
#3. The breast are softer, less tender, and swelling is reduced about a week after the beginning of the menstrual cycle.
The end of the menstrual cycle is the beginning of menses when the breasts are the most tender and edematous.
The beginning of the menstrual cycle is the beginning of menses when the breasts are the most tender and edematous.
As the end of the menstrual cycle approaches, the breasts become more tender and edematous.
92. You have been discussing breast self-examination (BSE) with Miss N. Which of the following statements would best indicate she is doing BSE correctly?
1. begin to examine my breasts by placing the palm of my right hand on the nipple of the left breast.”
2. I don’t like to press very hard because my breasts are very tender.”
3. “I use the tips of the middle three fingers of each to feel each breasts.”
4. “I feel for lumps in my breasts standing in front of a mirror.
#3. The ends of the three middle fingers are the most sensitive and should be used for BSE.
The palms of the hands are not at all sensitive and will be very inaccurate.
If the breasts are very tender, the exam is being done at the wrong time of the menstrual cycle. She should be pressing firmly to feel the deep tissue.
She should be lying down for palpation or standing in the shower. It is important to inspect the breasts in the mirror for changes in shape, nipples, and dimpling of the skin.
93. Ms. I., who is 32-years-old, had a simple mastectomy this morning. Which of the following should be included in your plan for her care?
1. Complete bedrest for the first 24 hours.
2. NPO with IV fluids for the first 48 hours.
3. Positioning on the operative side for the first 24 hours.
4. Keep patient-controlled anesthesia (PCA) controller within easy reach for the first 48 hours.
#4. Adequate pain relief is important and the use of PCA allows the client to control her own pain relief.
Ambulation is encouraged as soon as the effects of anesthesia are gone and fluids are tolerated.
Fluids are encouraged as soon as the effects of the anesthesia have worn off.
Positioning should be changed frequently and should not include the operative side.
94. The nurse is teaching a woman who had a simple mastectomy. Which of the following would be appropriate to tell her?
1. She should wait to be fitted for a permanent prosthesis until the wound is completely healed.
2. Since she had a simple mastectomy, she will probably not feel the need to attend Reach for Recovery meetings.
3. She will have very little pain and the incision will heal very quickly.
4. She should refrain from seeking male companionship since she will be seen as less than a woman.
#1. The incisional site may change with time and healing, so a permanent prosthesis should be purchased only after complete healing has occurred.
Reach to Recovery is a support group that will help her in many ways and should be encouraged.
Many women are surprised at the amount of incisional pain and the length of time required for healing.
She should continue her relationships with both men and women because mastectomy does not change who she is. With the help of a prosthesis, no one will know of her mastectomy unless she reveals it.
95. A group of woman have gathered at the local library for a series of seminars about women’s health issues. In discussing cancer of the cervix, which of the following would be
1. This cancer is very rapid growing, so early detection is difficult to achieve.
2. A cervical biopsy is the screening test of choice for early detection of cervical cancer.
3. All women have an equal chance to develop cervical cancer because there are no high risk factors.
4. An annual Pap smear may detect cervical dysplasia, a frequent precursor of cervical cancer.
#4. Cervical dysplasia is frequently a forerunner of cervical smears allow for early detection and treatment of cervical cancer.
Cervical cancer is a slow-growing disease, so regular Pap smears have a good chance to detect it before it becomes invasive.
A cervical biopsy may be required to confirm or rule out cancer from suspicious cervical tissue identified by culposcopy
There are numerous high-risk factors for cervical cancer such as multiple sex partners, history of STDs and dysplasia, and intrauterine DES (diethylstibesterol) exposure.
96. The nurse is talking to a woman who has been diagnosed with cancer of the ovary. She asks you what she could have done so that the cancer would have been found earlier. The best response should include which of the following?
1. She should have had more frequent, twice a year, Pap smears.
2. A yearly complete blood count (CBC) could have provided valuable clues to detect ovarian cancer.
3. Detection of ovarian cancer is earlier if a yearly proctoscopy is done.
4. There is little more she could have done for earlier detection.
#4. Detection of ovarian cancer is very difficult because it gives only vague, subtle symptoms and there are no diagnostic screening.
Biannual pelvic exams may be recommended for women with a family history of ovarian cancer. Pap smears only detect cervical changes.
There are no cancer markers identifiable with a CBC.
While vague gastrointestinal symptoms may be early symptoms, a proctoscopy will not visualize the ovaries.
97. The nurse is caring for a woman who has had a vaginal hysterectomy and an indwelling Foley catheter. After removal of the catheter, she is unable to void and has little sensation of bladder fullness. She is also constipated and is experiencing some perineal pain. The most appropriate nursing diagnosis is altered urinary elimination related to
1. infection as evidenced by inability to void with frequency and urgency.
2. retention as evidenced by inability to void and urinary distention.
3. gastrointestinal functioning as evidenced by inability to void and constipation.
4. dysuria as evidenced by inability to void and loss of bladder sensation.
#2. Retention of urine is common following vaginal hysterectomy due to stretching of musculature and proximity of the surgery to the bladder and its enervation.
Although infection is a potential problem, there is no evidence such as urgency or frequency, that the client has an infection.
The constipation experienced by the client may be related to the surgery, but is not related to the urinary problem.
There is no evidence that the client has dysuria, pain when urinating. The perineal pain is related to the surgery, but no the urinary retention.
98. Mrs. F., age 42, has had a simple vaginal hysterectomy without oophorectomy, due to uterine fibroids. You have completed your discharge teaching and she is preparing to go home. Which of the following statements indicates Mrs. F. understands the physical changes she will experience.
1. “I hope my husband will still love me since we can’t have sexual intercourse anymore.”
2. “I was hoping to stop having periods, but I guess that will need to wait a few more years.”
3. “It will be so nice to not need to use birth control any more.”
4. “I just don’t think I will ever feel feminine again since I can no longer experience orgasm.”
#3. After the loss of the uterus, pregnancy is unachievable and birth control is not needed even if the ovaries remain.
Intercourse may be resumed after the tissues in the vaginal area have healed and an active satisfying sex life may continue, although there may be some changes in sensations.
Mrs. F. will never have a menstrual period again since there is no uterine lining to be shed.
Orgasm is a function of the clitoris, not the uterus, so organs is still possible following hysterectomy.
99. The nurse has been discussing menopause with a 50-year-old woman who is experiencing some bodily changes indicative of the perimenopausal period. Which of the following statements indicates the client understands what is happening to her body?”
1. “Even though I am only having periods every few months, I should continue to use birth control until at least six months after my periods have stopped.”
2. “I am very upset to think that I will continue to have these hot flashes for the rest of my lfie.”
3. “Now that I am an old woman, I guess I’ll be sick most of the time, so I should plan to move to a retirement home.”
4. “I may continue to bleed on and off throughout the next 25 years.
#1. Even though ovulation is erratic and many periods are anovulatory, birth control should be continued for at least six months after the last menses.
Symptoms of menopause such as hot flashes and mood swings gradually subside and disappear by the time menses have stopped for a full year.
Menopause is not an illness and most women do not experience a decline in health related to this process.
Menopause has stopped for a full year is considered abnormal and requires evaluation.
100. A 55-year old woman who has ceased having menses has a family history of osteoporosis and increasing cholestrerol levels over the past several years. Hormone replacement therapy (HRT) has been prescribed with estrogen and progesterone. She asks you why she should take the pills since she feels quiet well. The nurse’s answer would be.
1. HRT is thought to help protect women from heart disease and osteoporosis.
2. HRT will help to reestablish the menstrual cycle, thus providing natural protection against heart disease and osteoporosis.
3. even though she feels well now, she will soon begin having major health problems and HRT will protect her against those problems.
4. she will be protected from breast cancer by HRT.
#1. HRT appears to help protect many women from heart disease and osteopororis if used with exercise and calcium supplements.
HRT may cause spotting and some bleeding for the first six months, but will not reestablish the menstrual cycle.
There is no indication of declining health in the menopausal woman with or without HRT.
Actually, the risk of breast cancer increases in susceptible women with the use of HRT.
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