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HI there....welcome To test visual acuity, the nurse should ask the patient to cover each eye separately and read the eye chart with glasses and without, as appropriate. Fundamental of Nursing Before teaching any procedure to the patient, the nurse must first assess the patient’s willingness to learn and his current knowledge. Fundamentals of Nursing A blood pressure cuff that is too narrow can cause a falsely elevated blood pressure reading. Fundamentals of Nursing When preparing a single injection for a patient who takes regular and NPH insulin, the nurse should draw the regular insulin into the syringe first because it is clear and can be measured more accurately than the NPH insulin, which is turbid. Fundamentals of Nursing Rhonchi refers to the rumbling sounds heard on lung auscultation; they are more pronounced during expiration than during inspiration. Fundamentals of Nursing Gavage refers to forced feeding, usually through a gastric tube (a tube passed into the stomach by way of the mouth). Fundamentals of Nursing According to Maslow’s hierarchy of needs, physiologic needs (air, water, food, shelter, sex, activity, and comfort) have the highest priority. Fundamentals of Nursing Checking the identification band on a patient’s wrist is the safest and surest way to verify a patient’s identity. Fundamentals of Nursing A patient’s safety is the priority concern in developing a therapeutic environment. Fundamentals of Nursing The nurse should place the patient with a Sengstaken-Blakemore tube in semi-Fowler’s position. Fundamentals of Nursing The nurse can elicit Trousseau’s sign by occluding the brachial or radial artery; hand and finger spasms during occlusion indicate Trousseau’s sign and suggest hypocalcemia. Fundamentals of Nursing For blood transfusion in an adult, the appropriate needle size is 16 to 20G. Fundamentals of Nursing Pain that incapacities a patient and can’t be relieved by drugs is called intractable pain. Fundamentals of Nursing In an emergency, consent for treatment can be obtained by fax, telephone, or other telegraphic transmission. Fundamentals of Nursing Decibel is the unit of measurement of sound. Fundamentals of Nursing Informed consent is required for any invasive procedure. Fundamentals of Nursing A patient who can’t write his or her name to give consent for treatment must have his or her X witnessed by two persons, such as a nurse, priest, or doctor. Fundamentals of Nursing The Z-track I.M. injection technique seals medication deep into the muscle, thereby minimizing skin irritation and staining. It requires a needle that is 1’’ (2.5 cm) or longer. Fundamentals of Nursing A registered nurse (RN) should assign a licensed vocational nurse (LVN) or licensed practical nurse (LPN) to perform bedside care, such as suctioning and medication administration. Fundamentals of Nursing The therapeutic purposed of a mist tent is to increase hydration of secretions. Fundamentals of Nursing If a patient can’t void, the first nursing action should be bladder palpation to assess for bladder distention. Fundamentals of Nursing The patient who uses a cane should carry it on the unaffected side and advance it at the same time as the affected extremity. Fundamentals of Nursing To fit a supine patient for crutches, the nurse should measure from the axilla to the sole and add 2” (5 cm) to that measurement. Fundamentals of Nursing Assessment begins with the nurse’s first encounter with the patient and continues throughout the patient’s stay. The nurse obtains assessment data through the health history, physical examination, and review of diagnostic studies. Fundamentals of Nursing The appropriate needle size for an insulin injection is 25G and ⅝" (1.5 cm) long. Fundamentals of Nursing Residual urine refers to urine that remains in the bladder after voiding. The amount of residual urine normally ranges from 50 to 100 ml. Fundamentals of Nursing The five stages of the nursing process are assessment, nursing diagnosis, planning, implementation, and evaluation. Fundamentals of Nursing Planning refers to the stage of the nursing process in which the nurse assigns priorities to nursing diagnoses, defines short-term and long-term goals and expected outcomes, and establishes the nursing care plan. Fundamentals of Nursing Implementation refers to the stage of the nursing process in which the nurse puts the nursing care plan into action, delegates specific nursing interventions to members of the nursing team, and charts patient responses to nursing interventions. Fundamentals of Nursing Evaluation refers to the stage of the nursing process in which the nurse compares objective and subjective data with the outcome criteria and, if needed, modifies the nursing care plan, making the nursing process circular. Fundamentals of Nursing In the event of fire, the nurse should (1) remove the patient, (2) call the fire department, (3) attempt to contain the fire by closing the door, and (4) extinguish the fire, if it can be done safely. Fundamentals of Nursing Before administering any as need pain medication, the nurse should ask the patient to indicate the pain’s location. Fundamentals of Nursing Jehovah’s Witnesses believe that they shouldn’t receive blood components donated by other people. Fundamentals of Nursing When providing oral care for an unconscious patient, the nurse should position the patient on the side to minimize the risk of aspiration. Fundamentals of Nursing During assessment of distance vision, the patient should stand 20’ (6.1 m) from the chart. Fundamentals of Nursing The ideal room temperature for a geriatric patient or one who is extremely ill ranges form 66º to 76º F (18.8º to 24.4º C). Fundamentals of Nursing Normal room humidity ranges from 30% to 60%. Fundamentals of Nursing Hand washing is the single best method of limiting the spread of microorganisms. Hands should be washed for 10 seconds after routine contact with a patient and after gloves are removed. Fundamentals of Nursing To catheterize a female patient, the nurse should place her in the dorsal recumbent position. Fundamentals of Nursing A positive Homan’s sign may indicate thrombophlebitis. Fundamentals of Nursing Electrolytes in a solution are measured in milliequivalents per liter (mEq/L). A milliequivalent equals the number of milligrams per 100 milliliters of a solution. Fundamentals of Nursing Metabolism takes a place in two phases: anabolism (the constructive phase) and catabolism (the destructive phase). Fundamentals of Nursing The basal metabolic rate represents the amount of energy needed to maintain essential body functions. It is measured when the patient is awake and resting, hasn’t eaten for 14 to 18 hours, and is in a comfortable, warm environment. Fundamentals of Nursing Dietary fiber (roughage), which is derived from cellulose, supplies bulk, maintains adequate intestinal motility, and helps establish regular bowel habits. Fundamentals of Nursing Alcohol is metabolized primarily in the liver. Smaller amounts are metabolized by the kidneys and lungs. Fundamentals of Nursing Petechiae refers to tiny, round, purplish red spots that appear on the skin and mucous membranes as a result of intradermal or submucosal hemorrhage. Fundamentals of Nursing Purpura refers to a purple skin discoloration caused by blood extravasation. Fundamentals of Nursing Glucose-6-phosphate dehydrogenase (C6PD) deficiency is an inherited metabolic disorder characterized by red blood cells that are deficient in G6PD, a critical enzyme in aerobic glycolysis. Fundamentals of Nursing According to the standard precautions recommended by the Centers for Disease Control and Prevention, the nurse shouldn’t recap needles after use because most needle sticks result from missed needle recapping. Fundamentals of Nursing The nurse administers a drug by I.V. push by delivering the dose directly into a vein, I.V. tubing, or catheter with a needle and syringe. Fundamentals of Nursing When changing the ties on a tracheostomy tube, the nurse should leave the old ties in place until the new ones are applied. Fundamentals of Nursing A nurse should have assistance when changing the ties on a tracheostomy tube. Fundamentals of Nursing A filter is always used for blood transfusions. Fundamentals of Nursing A four-point (quad) cane is indicated when a patient needs more stability than a regular cane can provide. Fundamentals of Nursing The patient should carry a cane on the unaffected side to promote a reciprocal gait pattern and distribute weight away from the affected leg. Fundamentals of Nursing A good way to begin a patient interview is to ask “What made you seek medical help?” Fundamentals of Nursing The nurse should adhere to standard precautions for blood and body fluids when caring for all patients. Fundamentals of Nursing Potassium (K+) is the most abundant cation in intracellular fluid. Fundamentals of Nursing In the four-point gait (or alternating gait), the patient first moves the right crutch followed by the left foot and then the left crutch followed by the right foot. Fundamentals of Nursing In the three-point gait, the patient moves two crutches and the affected leg simultaneously and then moves the unaffected leg. Fundamentals of Nursing In the two-point gait, the patient moves the right leg and the left crutch simultaneously and then moves the left leg and the right crutch. Fundamentals of Nursing Vitamin B complex, the water-soluble vitamins essential for metabolism, include thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), and cyanocobalamin (B12). Fundamentals of Nursing When being weighed, an adult patient should be lightly dressed and shoeless. Fundamentals of Nursing Before taking an adult’s oral temperature, the nurse should ensure that the patient hasn’t smoked or consumed hot or cold substances in the past 15 minutes. Fundamentals of Nursing The nurse shouldn’t take a rectal temperature on an adult patient if the patient has a cardiac disorder; anal lesions, or bleeding hemorrhoids or has recently undergone rectal surgery. Fundamentals of Nursing In a patient with cardiac problems, rectal temperature measurement may stimulate a vagal response, leading to vasodilation and decreased cardiac output. Fundamentals of Nursing When recording pulse amplitude and rhythm, the nurse should use these descriptive measures: +3 indicates a bounding pulse (readily palpable and forceful); +2, a normal pulse (easily palpable); +1, a thready or weak pulse (difficult to detect); and 0, an absent pulse (not detectable). Fundamentals of Nursing The intraoperative period begins when a patient is transferred to the operating room bed and ends when the patient is admitted to the postanesthesia recovery unit. Fundamentals of Nursing On the morning of surgery, the nurse should ensure that the informed consent form has been signed; that the patient hasn’t taken anything by mouth since midnight, has taken a shower with antimicrobial soap, has had mouth care (without swallowing the water, has removed common jewelry, and has received preoperative medication as prescribed; and that vital signs have taken and recorded. Artificial limbs and other prostheses are usually removed. Fundamentals of Nursing Comfort measures, such as positioning the patient, performing backrubs, and providing a restful environment, may decrease the patient’s need for analgesics or may enhance their effectiveness. Fundamentals of Nursing A drug has three names: its generic name, which is used in official publications; its trade name or brand name (such as Tylenol), which is selected by the drug company; and its chemical name, which describes the drug’s chemical composition. Fundamentals of Nursing The patient should take a liquid iron preparation through a straw to avoid staining the teeth. Fundamentals of Nursing The nurse should use the Z-track method to administer an I.M. injection of iron dextran (Imferon). Fundamentals of Nursing An organism may enter the body through the nose, mouth, rectum, urinary or reproductive tract, or skin. Fundamentals of Nursing In descending order, the levels of consciousness are alertness, lethargy, stupor, light coma, and deep coma. Fundamentals of Nursing To turn a patient by logrolling, the nurse folds the patient’s arms across the chest; extends the patient’s legs and inserts a pillow between them, if indicated; places a draw sheet under the patient; and turns the patient by slowly and gently pulling on the draw sheet. Fundamentals of Nursing The diaphragm of the stethoscope is used to hear high-pitched sounds such as breath sounds. Fundamentals of Nursing A slight blood pressure difference (5 to 10 mm Hg) between right and left arms is normal. Fundamentals of Nursing The nurse should place the blood pressure cuff 1'' (2.5 cm) above the antecubital fossa. Fundamentals of Nursing When instilling ophthalmic ointments, waste the first bed of ointment and then apply from the inner canthus to the outer canthus; twist the medication tube to detach the ointment. Fundamentals of Nursing The nurse should use a leg cuff to measure blood pressure in an obese patient. Fundamentals of Nursing If the blood pressure cuff is applied too loosely, the reading will be falsely elevated. Fundamentals of Nursing Ptosis refers to eyelid drooping. Fundamentals of Nursing A tilt table is useful for a patient with a spinal cord injury, orthostatic hypotension, or brain damage because it can move the patient gradually from a horizontal to a vertical (upright) position. Fundamentals of Nursing To perform venipuncture with the least injury to the vessel, the nurse should turn the bevel upward when the vessel’s lumen is larger than the needle and turn it downward when the lumen is only slightly larger than the needle. Fundamentals of Nursing To move the patient to the edge of the bed for transfer, follow these steps: (1) Move the patient’s head and shoulders toward the edge of the bed. (2) Move the patient’s feet and legs to the edge of the bed (crescent position). (3) Place both the arms well under the patient’s hips and straighten the back while moving the patient toward the edge of the bed. Fundamentals of Nursing When being measured for crutches, a patient should wear his or her shoes. Fundamentals of Nursing The nurse should attach a restraint to a part of the bed frame that moves with the head, not to the mattress or side rails. Fundamentals of Nursing The mist in a mist tent should never become so dense that it obscures clear visualization of the patient’s respiratory pattern. Fundamentals of Nursing To administer heparin subcutaneously, the nurse should follow these steps: (1) Clean, but don’t rub, the site with alcohol. (2) Stretch the skin taut or pick up a well-defined skin fold. (3)Hold the shaft of the needle in a dart position. (4)Insert the needle into the skin at a right (90-degree) angle. (5)Firmly depress the plunger; but don’t aspirate. (6)Leave the needle in place for 10 seconds. (7)Withdraw the needle gently at the same angle it was inserted. (8)Apply pressure to the injection site with an alcohol pad. Fundamentals of Nursing For a sigmoidoscopy, the nurse should place the patient in a knee-chest or Sims’ position, depending on the doctor’s preference. Fundamentals of Nursing Maslow’s hierarchy of needs must be met in the following order: physiologic (oxygen, food, water, sex, rest, and comfort) safety and security, love and belonging, self-esteem and recognition, and self-actualization. Fundamentals of Nursing When caring for patient with a nasogastric tube, the nurse should apply a water-soluble lubricant to the nostril to prevent soreness. Fundamentals of Nursing During gastric lavage, a nasogastric tube is inserted, the stomach is flushed, and ingested substances are removed through the tube. Fundamentals of Nursing In documenting drainage on a surgical dressing, the nurse should include the size, color, and consistency of the drainage, for example, “10 mm of brown mucoid drainage noted on dressing.” Fundamentals of Nursing To elicit Babinski’s reflex, the nurse strokes the sole of the patient’s foot with a moderately sharp object, such as thumbnail. Fundamentals of Nursing In a positive Babinski’s reflex, the great toe dorsiflexes and the other toes fan out. Fundamentals of Nursing When assessing a patient for bladder distention, the nurse should check the contour of the lower abdomen for a rounded mass above the symphysis pubis. Fundamentals of Nursing The best way to prevent pressure ulcers is to reposition the bedridden patient at least every 2 hours. Fundamentals of Nursing Antiembolism stockings decompress the superficial blood vessels, thereby reducing the risk of thrombus formation. Fundamentals of Nursing The most convenient veins for venipuncture in a adult patient are the basilic and median cubital veins in the antecubital space. Fundamentals of Nursing From 2 to 3 hours before beginning a tube feeding, the nurse should aspirate the patient’s stomach contents to verify adequate gastric emptying. Fundamentals of Nursing People with type O blood are considered to be universal donors. Fundamentals of Nursing People with type AB blood are considered to be universal recipients. Fundamentals of Nursing Herts (Hz) refers to the unit of measurement of sound frequency. Fundamentals of Nursing Hearing protection is required when the sound intensity exceeds 84 dB; double hearing protection is required if it exceeds 104 dB. Fundamentals of Nursing Prothrombin, a clotting factor, is produced in the liver. Fundamentals of Nursing If a patient is menstruating when a urine sample is collected, the nurse should note this on the laboratory slip. Fundamentals of Nursing During lumbar puncture, the nurse must note the initial intracranial pressure and the cerebrospinal fluid color. Fundamentals of Nursing A patient who can’t cough to provide a sputum sample for culture may require a heated aerosol treatment to facilitate removal of a sample. Fundamentals of Nursing If eye ointment and eyedrops must be instilled in the same eye, the eyedrops should be instilled first. Fundamentals of Nursing When leaving an isolation room, the nurse should remove the gloves before the mask because fewer pathogens are on the mask. Fundamentals of Nursing Skeletal traction is applied to a bone using wire pins or tons. It is the most effective means of traction. Fundamentals of Nursing The total parenteral nutrition solution should be stored in a refrigerator and removed 30 to 60 minutes before use because delivery of a chilled solution can cause pain, hypothermia, venous spasm, and venous constriction. Fundamentals of Nursing Medication isn’t routinely injected I.M. into edematous tissue because it may not be absorbed. Fundamentals of Nursing When caring for a comatose patient, the nurse should explain each action to the patient in a normal voice. Fundamentals of Nursing When cleaning dentures, the sink should be lined with a washcloth. Fundamentals of Nursing A patient should void within 8 hours after surgery. Fundamentals of Nursing An EEG identifies normal and abnormal brain waves. Fundamentals of Nursing Stool samples for ova and parasite tests should be delivered to the laboratory without delay or refrigeration. Fundamentals of Nursing The autonomic nervous system regulates the cardiovascular and respiratory systems. Fundamentals of Nursing When providing tracheostomy care, the nurse should insert the catheter gently into the tracheostomy tube. When withdrawing the catheter, the nurse should apply intermittent suction for no more than 15 seconds and use a slight twisting motion. Fundamentals of Nursing A low-residue diet includes such as foods as roasted chicken, rice, and pasta. Fundamentals of Nursing A rectal tube should not be inserted for longer than 20 minutes; it can irritate the mucosa of the rectum and cause a loss of sphincter control. Fundamentals of Nursing A patient’s bed bath should proceed in this order: face, neck, arms, hands, chest, abdomen, back, legs, perineum. Fundamentals of Nursing When lifting and moving a patient, the nurse should use the upper leg muscles most to prevent injury. Fundamentals of Nursing Patient preparation for cholecystography includes ingestion of a contrast medium and a low-fat evening meal. Fundamentals of Nursing During occupied bed changes, the patient should be covered with a black blanket to promote warmth and prevent exposure. Fundamentals of Nursing Anticipatory grief refers to mourning that occurs for an extended time when one realizes that death is inevitable. Fundamentals of Nursing The following foods can alter stool color: beets (red), cocoa (dark red or brown), licorice (black), spinach (green), and meat protein (dark brown). Fundamentals of Nursing When preparing a patient for a skull X-ray, have the patient remove all jewelry and dentures. Fundamentals of Nursing The fight-or-flight response is a sympathetic nervous system response. Fundamentals of Nursing Bronchovesicular breath sounds in peripheral lung fields are abnormal and suggest pneumonia. Fundamentals of Nursing Wheezing refers to an abnormal, high-pitched breath sound that is accentuated on expiration. Fundamentals of Nursing Wax or a foreign body in the ear should be gently flushed out by irrigation with warm saline solution. Fundamentals of Nursing If a patient complains that his hearing aid is “not working,” the nurse should check the switch first to see if it’s turned on and then check the batteries. Fundamentals of Nursing The nurse should grade hyperactive biceps and triceps reflexes +4. Fundamentals of Nursing If two eye medications are prescribed for twice-daily instillation, they should be administered 5 minutes apart. Fundamentals of Nursing In a postoperative patient, forcing fluids helps prevent constipation. Fundamentals of Nursing The nurse must administer care in accordance with standards of care established by the American Nurses Association, state regulations, and facility policy. Fundamentals of Nursing The kilocalorie (kcal) is a unit of energy measurement that represents the amount of heat needed to raise the temperature of 1 kilogram of water 1º C. Fundamentals of Nursing As nutrients move through the body, they undergo ingestion, digestion, absorption, transport, cell metabolism, and excretion. Fundamentals of Nursing The body metabolizes alcohol at a fixed rate regardless of serum concentration. Fundamentals of Nursing In an alcoholic beverage, its proof reflects its percentage of alcohol multiplied by 2. For example, a 100-proof beverage contains 50% alcohol. Fundamentals of Nursing A living will is a witnessed document that states a patient’s desire for certain types of care and treatment, which depends on the patient’s wishes and views and quality of life. Fundamentals of Nursing The nurse should flush a peripheral heparin lock every 8 hours (if it wasn’t used during the previous 8 hours) and as needed with normal saline solution to maintain patency. Fundamentals of Nursing Quality assurance is a method of determining whether nursing actions and practices meet established standards. Fundamentals of Nursing The five rights of medication administration are the right patient, right medication, right dose, right route of administration, and the right time. Fundamentals of Nursing Outside of the hospital setting, only the sublingual and transligual forms of nitroglycerin should be used to relieve acute anginal attacks. Fundamentals of Nursing The implementation phase of the nursing process involves recording the patient’s response to the nursing plan, putting the nursing plan into action, delegating specific nursing interventions, and coordinating the patient’s activities. Fundamentals of Nursing The Patient’s Bill of Rights offers guidance and protection to patients by stating the responsibilities of the hospital and its staff toward patients and their families during hospitalization. Fundamentals of Nursing To minimize the omissions and distortion of facts, the nurse should record information as soon as it is gathered. Fundamentals of Nursing When assessing a patient’s health history, the nurse should record the current illness chronologically, beginning with the onset of the problem and continuing to the present. Fundamentals of Nursing Drug administration is a dependent activity. The nurse can administer or withhold a drug only with the doctor’s permission. Fundamentals of Nursing The nurse shouldn’t give false assurance to a patient. Fundamentals of Nursing After receiving preoperative medication, a patient isn’t competent to sign an informed consent form. Fundamentals of Nursing When lifting a patient, a nurse uses the weight of her body instead of the strength in her arms. Fundamentals of Nursing A nurse may clarify a doctor’s explanation to a patient about an operation or a procedure but must refer questions about informed consent to the doctor. Fundamentals of Nursing The nurse shouldn’t use her thumb to take a patient’s pulse rate because the thumb has a pulse of its own and may be confused with the patient’s pulse. Fundamentals of Nursing An inspiration and an expiration count as one respiration. Fundamentals of Nursing Normal respirations are known as eupnea. Fundamentals of Nursing During a blood pressure measurement, the patient should rest the arm against a surface because using muscle strength to hold up the arm may raise the blood pressure. Fundamentals of Nursing Major unalterable risk factors for coronary artery disease include heredity, sex, race, and age. Fundamentals of Nursing Inspection is the most frequently used assessment technique. Fundamentals of Nursing Family members of an elderly person in a long-term care facility should transfer some personal items (such as photographs, a favorite chair, and knickknacks) to the person’s room to provide a homey atmosphere. Fundamentals of Nursing The upper respiratory tract warms and humidifies inspired air and plays a role in taste, smell, and mastication. Fundamentals of Nursing Signs of accessory muscle use include shoulder elevation, intercostal muscle retraction, and scalene and sternocleidosmastoid muscle use during respiration. Fundamentals of Nursing When patients use axillary crutches, their palms should bear the brunt of the weight. Fundamentals of Nursing Activities of daily living include eating, bathing, dressing, grooming, toileting, and interacting socially. Fundamentals of Nursing Normal gait has two phases: the stance phase, in which the patient’s foot rests on the ground, and the swing phase, in which that patient’s foot moves forward. Fundamentals of Nursing The phases of mitosis are prophase, metaphase, anaphase, and telophase. Fundamentals of Nursing The nurse should follow standard precautions in the routine care of all patients. Fundamentals of Nursing The nurse should use the bell of the stethoscope to listen for venous hums and cardiac murmurs. Fundamentals of Nursing The nurse can assess a patient’s general knowledge by asking questions such as “Who is the president for the United States?” Fundamentals of Nursing Cold packs are applied for the first 20 to 48 hours after an injury; then heat is applied. During cold application, the pack is applied for 20 minutes and then removed for 10 to 15 minutes to prevent reflex dilation (rebound phenomenon) and frostbite injury. Fundamentals of Nursing The pons is located above the medulla and consists of white matter (sensory and motor tracts) and gray matter (reflex centers). Fundamentals of Nursing The autonomic nervous system controls the smooth muscles. Fundamentals of Nursing A correctly written patient goal expresses the desired patient behavior, criteria for measurement, time frame for achievement, and conditions under which the behavior will occur. It is developed in collaboration with the patient. Fundamentals of Nursing The optic disk is yellowish pink and circular with a distinct border. Fundamentals of Nursing A primary disability results from a pathologic process; a secondary disability, from inactivity. Nurses usually are held liable for failing to keep an accurate count of sponges and other devices during surgery. Fundamentals of Nursing The best dietary sources of vitamin B6 are liver, kidney, pork, soybeans, corn, and whole-grain cereals. Fundamentals of Nursing Iron-rich foods, such as organ meats, nuts, legumes, dried fruit, leafy vegetables, eggs, and whole gains, generally have low water content. Fundamentals of Nursing Collaboration refers to joint communication and decision making between nurses and doctors designed to meet patients’ needs by integrating the care regimens of both professions in one comprehensive approach. Fundamentals of Nursing Bradycardia refers to a heart rate of fewer than 60 beats/minute. Fundamentals of Nursing A nursing diagnosis is a statement of a patient’s actual or potential health problems that can be resolved, diminished, or otherwise changed by nursing interventions. Fundamentals of Nursing During the assessment phase of the nursing process, the nurse collects and analyzes three types of data: health history, physical examination, and laboratory and diagnostic test data. Fundamentals of Nursing The patient’s health history consists primarily of subjective data, information supplied by patient. Fundamentals of Nursing The physical examination includes objective data obtained by inspection, palpation, percussion, and auscultation. Fundamentals of Nursing When documenting patient care, the nurse should write legibly, use only standard abbreviations, and sign every entry. The nurse should never destroy or attempt to obliterate documentation or leave vacant lines. Fundamentals of Nursing Factors that affect body temperature include time of day, age, physical activity, phase of menstrual cycle, and pregnancy. Fundamentals of Nursing The most accessible and commonly used artery for measuring a patient’s pulse rate is the radial artery, which is compressed against the radius to take the pulse rate. Fundamentals of Nursing The normal pulse rate of a resting adult is 60 to 100 beats/minute. The rate is slightly faster in women than in men and much faster in children than in adults. Fundamentals of Nursing Laboratory test results are an objective form of assessment data. Fundamentals of Nursing The measurement systems most often used in clinical practice are the metric system, apothecaries’ system, and household system. Fundamentals of Nursing Before signing an informed consent, a patient should know whether other treatment options are available and should understand what will occur during the preoperative, intraoperative, and postoperative phase; the risk involved; and the possible complications. The patient also should have a general idea of the time required from surgery to recovery and should have an opportunity to ask questions. Fundamentals of Nursing A patient must sign a separate informed consent form for each procedure. Fundamentals of Nursing During percussion, the nurse uses quick, sharp tapping of the fingers or hands against body surfaces to produce sounds (that helps determine the size, shape, position, and density of underlying organs and tissues), elicit tenderness, or assess reflexes. Fundamentals of Nursing Ballottement is a form of light palpation involving gentle, repetitive bouncing of tissues against the hand and feeling their rebound. Fundamentals of Nursing A foot cradle keeps bed linen off the patient’s feet, which prevent skin irritation and breakdown, especially in a patient with peripheral vascular disease or neuropathy. Fundamentals of Nursing If the patient is a married minor, permission to perform a procedure can be obtained form the patient’s spouse. Fundamentals of Nursing Gastric lavage is the flushing of the stomach and removal of ingested substances through a nasogastric tube. It can be used to treat poisoning or drug overdose. Fundamentals of Nursing During the evaluation step of the nursing process, the nurse assesses the patient’s response to therapy. Fundamentals of Nursing Bruits commonly indicate a life- or limb-threatening vascular disease. Fundamentals of Nursing O.U. means each eye; O.D., right eye; and O.S, left eye. Fundamentals of Nursing To remove a patient’s artificial eye, the nurse depresses the lower lid. Fundamentals of Nursing The nurse should use a warm saline solution to clean an artificial eye. Fundamentals of Nursing A thready pulse is very fine and scarcely perceptible. Fundamentals of Nursing Axillary temperature usually is 1º F lower than oral temperature. Fundamentals of Nursing After suctioning a tracheostomy tube, the nurse must document the color, amount, consistency, and odor of secretions. Fundamentals of Nursing On a medication prescription, the abbreviation p.c. means that the medication should be administered after meals. Fundamentals of Nursing After bladder irrigation, the nurse should document the amount, color, and clarity of the urine and the presence of clots or sediment. Fundamentals of Nursing Laws regarding patient self-determination vary from state to state. Therefore, the nurse must be familiar with the laws of the state in which she works. Fundamentals of Nursing Gauge refers to the inside diameter of a needle. The smaller the gauge, the larger the diameter. Fundamentals of Nursing An adult normally has 32 permanent teeth. Fundamentals of Nursing After turning a patient, the nurse should document the position used, time turned, and skin assessment findings. Fundamentals of Nursing PERRLA is an abbreviation for normal pupil assessment findings: pupils equal, round, and reactive to light with accommodation. Fundamentals of Nursing When purcussing a patient’s chest for postural drainage, the nurse’s hands should be cupped. Fundamentals of Nursing When measuring a patient’s pulse, the nurse should assess the rate, rhythms, quality, and strength. Fundamentals of Nursing Before transferring a patient from a bed to a wheelchair, the nurse should push the wheelchair’s footrests to the sides and lock its wheels. Fundamentals of Nursing When assessing respirations, the nurse should document the rate, rhythm, depth, and quality. Fundamentals of Nursing For a subcutaneous injection, the nurse should use a ⅝" 25G needle. Fundamentals of Nursing The notation “AA & O x 3” indicates that the patient is awake, alert, and oriented to person (knows who he is), place (knows where he is), and time (knows the date and time). Fundamentals of Nursing Fluid intake includes all fluids taken by mouth, including foods that are liquid at room temperature, such as gelatin, custard, and ice cream; I.V. fluids; and fluids administered in feeding tubes. Fluid output includes urine, vomitus, and drainage (such as from a nasogastric tube or from a wound) as well as blood loss, diarrhea or stool, and perspiration. Fundamentals of Nursing After administering an intradermal injection, the nurse shouldn’t massage the area because massage can irritate the site and interfere with results. Fundamentals of Nursing When administering an intradermal injection, the nurse should hold the syringe almost flat against the patient’s skin (at about a 15-degree angle) with the bevel up. Fundamentals of Nursing To obtain an accurate blood pressure, the nurse should inflate the manometer 20 to 30 mm Hg above the disappearance of the radial pulse before releasing the cuff pressure. Fundamentals of Nursing The nurse should count an irregular pulse for 1 full minute. Fundamentals of Nursing A patient who is vomiting while lying down should be placed in a lateral position to prevent aspiration of vomitus. Fundamentals of Nursing Prophylaxis is disease prevention. Fundamentals of Nursing Body alignment is achieved when the body parts are in proper relation to their natural position. Fundamentals of Nursing Trust is the foundation of a nurse-patient relationship. Fundamentals of Nursing Blood pressure in the force exerted by the circulating volume of blood on arterial walls. Fundamentals of Nursing Malpractice refers to the professional’s wrongful conduct, improper discharge of duties, or failure to meet standers of care, which causes harm to another. Fundamentals of Nursing As a general rule, nurses can’t refuse a patient care assignment; however, they may refuse to participate in abortions in most states. Fundamentals of Nursing A nurse can be found negligent if a patient is injured because the nurse failed to perform a duty that a reasonable and prudent person would perform or because the nurse performed an act that a reasonable and prudent person wouldn’t perform. Fundamentals of Nursing States have enacted Good Samaritan laws to encourage professionals to provide medical assistance at the scene of an accident without fear of a lawsuit arising from such assistance. These laws don’t apply to care provided in a health care facility. Fundamentals of Nursing A doctor should sign verbal and telephone orders within the time established by institutional policy, usually within 24 hours. Fundamentals of Nursing A competent adult has the right to refuse lifesaving medical treatment; however, the individual should be fully informed of the consequences of this refusal. Fundamentals of Nursing Although a patient’s health record or chart is the health care facility’s physical property, its contents belong to the patient. Fundamentals of Nursing Before a patient’s record can be released to a third party, the patient or patient’s legal guardian must give written consent. Fundamentals of Nursing Under the Controlled Substances Act, every dose of a controlled drug dispensed by the pharmacy must be counted for, whether the dose was administered to a particular patient or discarded accidentally. Fundamentals of Nursing A nurse can’t perform duties that violate a rule or regulation established by a state licensing board even if it is authorized by a health care facility or doctor. Fundamentals of Nursing The nurse should select a private room, preferably with a door that can be closed, to minimize interruptions during a patient interview. Fundamentals of Nursing In categorizing nursing diagnosis, the nurse should address actual life-threatening problems first, followed by potentially life-threatening concerns. Fundamentals of Nursing The major components of a nursing care plan are outcome criteria (patient goals) and nursing interventions. Fundamentals of Nursing Standing orders, or protocols, establish guidelines for treating a particular disease or set of symptoms. Fundamentals of Nursing In assessing a patient’s heart, the nurse normally finds the point of maximal impulse at the fifth intercostals space near the apex. Fundamentals of Nursing The S1 sound heard on auscultation is caused by closure of the mitral and tricuspid valves. Fundamentals of Nursing To maintain package sterility, the nurse should open the wrapper’s top flap away from the body, open side flap by touching only the outer part of the wrapper, and open the final flap by grasping the turned-down corner and pulling it toward the body. Fundamentals of Nursing The nurse shouldn’t use a cotton-tipped applicator to dry a patient’s ear canal or remove wax because it may force cerumen against the tympanic membrane. Fundamentals of Nursing A patient’s identification bracelet should remain in place until the patient has been discharged from the health care facility and has left the premises. Fundamentals of Nursing The Controlled Substances Act designated five categories, or schedules, that classify controlled drugs according to their abuse liability. Fundamentals of Nursing Schedule I drugs, such as heroin, have a high abuse potential and have no currently accepted medical use in the United States. Fundamentals of Nursing Schedule II drugs, such as morphine, opium, and meperidine (Demerol), have a high abuse potential but have currently accepted medical uses. Their use may lead to physical or psychological dependence. Fundamentals of Nursing Schedule III drugs, such as paregoric and butabarbital (Butisol), have a lower abuse potential than Schedule I or II drugs. Abuse of Schedule III drugs may lead to moderate or low physical or psychological dependence, or both. Fundamentals of Nursing Schedule IV drugs, such as chloral hydrate, have a low abuse potential compared with Schedule III drugs. Fundamentals of Nursing Schedule V drugs, such as cough syrups that contain codeine, have the lowest abuse potential of the controlled substances. Fundamentals of Nursing Activities of daily living are actions that the patient must perform every day to provide self-care and interact with society. Fundamentals of Nursing Testing of the six cardinal fields of gaze evaluates the function of all extraocular muscles and cranial nerves III, IV, and VI. Fundamentals of Nursing The six types of heart murmurs are graded from 1 to 6. A grade 6 heart murmur can be heard with stethoscope slightly raised from the chest. Fundamentals of Nursing The most important goal to include in a care plan is the patient’s goal. Fundamentals of Nursing Fruits are high in fiber and low in protein and should be omitted from a low-residue diet. Fundamentals of Nursing The nurse should use an objective scale to assess and quantify pain because postoperative pain varies greatly among individuals. Fundamentals of Nursing Postmortem care includes cleaning and preparing the deceased patient for family viewing, arranging transportation to the morgue or funeral home, and determining the disposition of belongings. Fundamentals of Nursing The nurse should provide honest answers to the patient’s questions. Fundamentals of Nursing Milk shouldn’t be included in a clear liquid diet. Fundamentals of Nursing Consistency in nursing personnel is paramount when caring for a child, and infant, or a confused patient. Fundamentals of Nursing The hypothalamus secretes vasopressin and oxytocin, which are stored in the pituitary gland. Fundamentals of Nursing The three membranes that enclose that brain and spinal cord are the dura mater, pia mater, and arachnoid. Fundamentals of Nursing A nasogastric tube is used to remove fluid and gas from the small intestine preoperatively or postoperatively. Fundamentals of Nursing Psychologists, physical therapists, and chiropractors aren’t authorized to write prescriptions for medication. Fundamentals of Nursing The area around a stoma should be cleaned with mild soap and water. Fundamentals of Nursing Vegetables have a high fiber content. Fundamentals of Nursing The nurse should use a tuberculin syringe to administer an S.C. injection of less than 1 ml. Fundamentals of Nursing For adults, S.C. injections require a 25G 1" needle; for infants, children, elderly, or very thin patients, they require a 25G to 27G ½" needle. Fundamentals of Nursing Before administering medication, the nurse should identify the patient by checking the identification band and asking the patient to state his name. Fundamentals of Nursing To clean the skin before an injection, the nurse should use a sterile alcohol swab and wipe from the center of the site outward in a circular motion. Fundamentals of Nursing The nurse always should inject heparin deep into S.C. tissue at a 90-degree angle (perpendicular to the skin) to prevent skin irritation. Fundamentals of Nursing If blood is aspirated into the syringe before an I.M. injection, the nurse should withdraw the needle, prepare another syringe, and repeat the procedure. Fundamentals of Nursing The nurse shouldn’t cut the patient’s hair without written consent from the patient or an appropriate relative. Fundamentals of Nursing If bleeding occurs after an injection, the nurse should apply pressure until the bleeding stops; if bruising occurs, the nurse should monitor the site for an enlarging hematoma. Fundamentals of Nursing When providing hair and scalp care, the nurse should begin combing at the end of the hair and work toward the head. Fundamentals of Nursing Frequency of patient hair care depends on the length and texture of the hair, duration of hospitalization, and patient’s condition. Fundamentals of Nursing Proper hearing aid function requires careful handling during insertion and removal, regular cleaning of the ear piece to prevent wax buildup, and prompt replacement of dead batteries. Fundamentals of Nursing The hearing aid marked with a blue dot is for the left ear; the one with the red dot is for the right ear. Fundamentals of Nursing A hearing aid shouldn’t be exposed to heat or humidity and shouldn’t be immersed in water. Fundamentals of Nursing The nurse should instruct a patient not to use hair spray while wearing a hearing aid. Fundamentals of Nursing The five branches of pharmacology are pharmacokinetics, pharmacodynamics, pharmacotherapeutics, toxicology, and pharmacognosy. Fundamentals of Nursing The nurse should remove heel protectors every 8 hours to inspect the foot for signs of skin breakdown. Fundamentals of Nursing The purpose of heat application is to promote vasodilation, which reduces pain caused by inflammation. Fundamentals of Nursing A sutured surgical incision is an example of healing by first intention (healing directly, without granulation). Fundamentals of Nursing Healing by secondary intention (healing by granulation) is closure of the wound by the granulation tissue filling the defect and allowing reepithelialization to occur, beginning at the wound edges and continuing to the center, until the entire wound is covered. Fundamentals of Nursing Keloid formation is an abnormality in healing characterized by overgrowth of scar tissue at the wound site. Fundamentals of Nursing The nurse should administer procaine penicillin by deep I.M. injection in the upper outer portion of the buttocks in the adult or in the midlateral thigh in the child. The nurse shouldn’t massage the injection site. Fundamentals of Nursing The ascending colostomy drains fluid feces; the descending colostomy drains solid fecal matter. Fundamentals of Nursing A folded towel (called a scrotal bridge) can provide scrotal support for the patient with scrotal edema caused by vasectomy, epididymitis, or orchitis. Fundamentals of Nursing When giving an injection to the patient with a bleeding disorder, the nurse should use a small-gauge needle and apply pressure to the site for 5 minutes after the injection. Fundamentals of Nursing Platelets are the smallest and most fragile formed element of the blood and are essential for coagulation. Fundamentals of Nursing To insert a nasogastric tube, the nurse should first instruct the patient to tilt the head back slightly and then insert the tube. When the tube is felt curving at the pharynx, the nurse should tell the patient to tilt the head forward to close the trachea and open the esophagus by swallowing. (Sips of water can facilitate this action.) Fundamentals of Nursing According to families whose loved ones are in intensive care units, their four most important needs are to have questions answered honestly, to be assured that the best possible car is being provided, to know the prognosis, and to feel there is hope. Fundamentals of Nursing A double-bind communication when the verbal message contradicts the nonverbal message and the receiver is unsure of which message to respond to. Fundamentals of Nursing A nonjudgmental attitude displayed by the nurse demonstrates that she neither approves nor disapproves of the patient. Fundamentals of Nursing Target symptoms are those that the patient and others find most distressing. Fundamentals of Nursing Advise the patient to take aspirin on an empty stomach with a full glass of water and to avoid foods with acid such as coffee, citrus fruits, and cola. Fundamentals of Nursing For every patient problem, there is a nursing diagnosis; for every nursing diagnosis, there is a goal; and for every goal, there are interventions designed to make the goal a reality. The keys to answering examination questions correctly are identifying the problem presented, formulating a goal for that specific problem, and then selecting the intervention from the choices provided that will enable the patient to reach that goal. Fundamentals of Nursing Fidelity means loyalty and can be shown as a commitment to the profession of nursing and to the patient. Fundamentals of Nursing Giving an I.M. injection against the patient’s will and without legal authority is battery. Fundamentals of Nursing An example of a third-party payor is an insurance company. Fundamentals of Nursing On-call medication should be given within 5 minutes of receipt of the call. Fundamentals of Nursing Generally, the best method to determine the cultural or spiritual needs of the patient is to ask him. Fundamentals of Nursing An incident report shouldn’t be made part of the patient’s record but is an in-house document for the purpose of correcting the problem. Fundamentals of Nursing Critical pathways are a multidisciplinary guideline for patient care. Fundamentals of Nursing When prioritizing nursing diagnoses, use this hierarchy: (1) problems associated with airway, (2) those concerning breathing, and (3) those related to circulation. Fundamentals of Nursing The two nursing diagnoses with the highest priority that the nurse can assign are Ineffective airway clearance and Ineffective breathing pattern. Fundamentals of Nursing A subjective sign that a sitz bath has been effective is that patient expresses a decrease in pain or discomfort. Fundamentals of Nursing For the nursing diagnosis Diversional activity deficit to be valid, the patient must make the statement that he’s “bored, there is nothing to do” or words to that effect. Fundamentals of Nursing The most appropriate nursing diagnosis for an individual who doesn’t speak English is Communication, impaired, related to inability to speak dominant language (English). Fundamentals of Nursing The family of the patient who has been diagnosed as hearing impaired should be instructed to face the individual when they speak to him. Fundamentals of Nursing Up to age 3, the pinna should be pulled down and back to straighten the eustachian tube before instilling medication. Fundamentals of Nursing When administering eyedrops, the nurse should waste the first drop and instill the medication in the lower conjunctival sac to prevent injury to the cornea. Fundamentals of Nursing When administering eye ointment, the nurse should waste the first bead of medication and then apply the medication from the inner to the outer canthus. Fundamentals of Nursing When removing gloves and mask, the gloves, which most likely contain pathogens and are soiled, should be removed first. Fundamentals of Nursing Crutches should placed 6" (15 cm) in front of the patient and 6" to the side to assume a tripod position. Fundamentals of Nursing Listening is the most effective communication technique. Fundamentals of Nursing Process recording is a method of evaluating one’s communication effectiveness. Fundamentals of Nursing When feeding the elderly, limit high-carbohydrate foods because of the risk of glucose intolerance. Fundamentals of Nursing Passive range of motion maintains joint mobility whereas resistive exercises increase muscle mass. Fundamentals of Nursing Isometric exercises are performed on an extremity in a cast. Fundamentals of Nursing A back rub is an example of the gate-control theory of pain. Fundamentals of Nursing Anything below the waist is considered unsterile, a sterile field becomes unsterile when it comes in contact with nay unsterile item, a sterile field must be continuously monitored, and the 1" (2.5 cm) border around a sterile field is considered unsterile. Fundamentals of Nursing A “shift to the left” is evident when there is an increase in immature cells (bands) in the blood to fight an infection. Fundamentals of Nursing A “shift to the right” is evident when there is an increase in mature cells in the blood as seen in advanced liver diseases and pernicious anemia. Fundamentals of Nursing Before administering preoperative medication, make sure that an informed consent form has been signed and attached to the patient’s record. Fundamentals of Nursing The nurse should spend no more than 30 minutes per 8-hour shift in providing care to the patient with a radiation implant. Fundamentals of Nursing The nurse should stand near the patient’s shoulders for cervical implants and at the foot of the bed for head and neck implants. Fundamentals of Nursing The nurse should never be assigned to care for more than one patient with radiation implants. Fundamentals of Nursing Long-handled forceps and a lead-lined container should be in the room of the patient who has a radiation implant. Fundamentals of Nursing Generally, patients who have the same infection and are in strict isolation can share the same room. Fundamentals of Nursing Diseases requiring strict isolation include chickenpox, diphtheria, and viral hemorrhagic fever such as Marburg virus disease. Fundamentals of Nursing For the patient abiding by Jewish custom, milk and meat shouldn’t be served in the same meal. Fundamentals of Nursing Whether the patient can perform a procedure (psychomotor domain of learning) is a better indicator of the effectiveness of patient teaching than whether the patient can simply state the steps of the procedure (cognitive domain of learning). Fundamentals of Nursing Developmental stages according to Erik Erikson are trust versus mistrust (birth to 18 months), autonomy versus shame and doubt (18 months to 3 years), initiative versus guilt (3 to 5 years), industry versus inferiority (5 to 12 years), identity versus identity diffusion (12 to 18 years), intimacy versus isolation (18 to 25 years), generativity versus stagnation (25 to 60 years), and ego integrity versus despair (older than 60 years). Fundamentals of Nursing Face the hearing impaired patient when communicating with him. Fundamentals of Nursing A proper nursing intervention for the spouse of the patient who has suffered a serious incapacitating disease is to assist him in mobilizing a support system. Fundamentals of Nursing Hyperpyrexia refers to extreme elevation in temperature above 106º F (41.1º C). Fundamentals of Nursing

Maternal/OB drill 5

Post-Test –OB

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
2. 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.

3. 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

4. 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

5. 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.

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

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

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

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.”

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.

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.”

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!”

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

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

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)

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.

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?”

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

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.

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

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.

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.

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.

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

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.

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.

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.”

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.

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.

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

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.”

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.

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.

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.

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

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.

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.

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.

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

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.

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.



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.

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.

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.

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.

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.

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.

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.



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.

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.”

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.”

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.

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.

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.

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.



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.

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.

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.

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.

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.

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.

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.



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.

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.

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.

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.

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.”

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.

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.

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.”

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.”

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.

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.

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.

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.

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.



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.

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.

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.

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.

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.”

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.



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.

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.”

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?”

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.”

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.

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.

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.



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.”

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.

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.

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.

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.

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.

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.

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.

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.

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.”

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.

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.

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1 comment:

  1. UnknownJuly 30, 2012 at 11:46 PM

    Excellent blog very nice and unique information related to nurses. Thanks for sharing this information.
    Brethine

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