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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 7 answers

Question 1. Which of the following would denote a positive maternal-infant bonding interaction during the first 3 days?

1. Calling the infant "he" or "she" on the day of discharge
2. Carrying the infant slightly away from own body
3. Holding the infant in the "en-face" position
4. Laying the infant at the foot of the bed

Looking for answers(s):3
Explanation: Eye contact with the infant in the "en-face" position appears to have a cementing effect on the development of a trusting relationship. Calling the infant "he" or "she" at discharge indicates recognition of the infant's individuality and comes early in the postpartum period. Enfolding the infant in the parent's arms, not away from the body, signals feelings of closeness. Parents who are bonding want to have the infant close to them.

Question 2. After giving birth at 37 weeks' gestation, a new mother is transferred to the postpartum unit. The nursing action that best promotes attachment process between the mother and baby is:

1. Teaching the client to breastfeed the baby
2. Allowing the client extra visiting privileges in the newborn nursery
3. Encourage the client to room-in with her infant on a 24-hou basis
4. Arranging staffing so that one nurse is assigned to care for the client and her baby

Looking for answers(s):3
Explanation: 1. It is possible that the client does not want to breastfeed; attachment can be furthered by rooming-in 2. This may not be a judicious action; rooming-in is far more preferable. 3. Rooming-in provides time for the mother and infant to be together; the mother can become acquainted with the infant more quickly. 4. This will not promote bonding and attachment.

Question 3. A client in the midphase of labor becomes very uncomfortable and asks for medication.
Mepreidine (Demerol) 50 mg is ordered. This medication:

1. Acts to produce amnesia
2. Act as a preliminary anesthetic
3. Induces sleep until the time of delivery
4. Increases the client's pain threshold, resulting in pain reduction

Looking for answers(s):4
Explanation: Meperidine (Demerol) is classified as a narcotice analgesic drug and is effective for the relief of pain. Does not induce amnesia. Acts as an analgesics, not anesthetic. Induces sleep is an undesirable effect because the mother could not participate in the delivery process.

Question 4. A pregnant client develops thrombophlebitis of the left leg and is admitted to the hospital for bed rest and anticoagulant theraphy. The anticoagulant the nurse should expect to administer is:

1. Heparin
2. Dicumarol
3. Diphenadione (Dipaxin)
4. Warfarin (Coumadin)

Looking for answers(s):1
Explanation: Heparin is used because its molecular size is too large to pass the placental barrier. All of the 3 drugs can pass the placental barrier and cause hemorrhage in the fetus.

Question 5. A client who had a postpartum hemorrhage is to receive 1 unit of packed red blood cells. When observing the staff nurse administering the packed red blood cells without wearing gloves, the nurse manager correctly comes to the conclusion that the:

1. Client does not have an infection
2. Donor blood is free of bloodborne pathogens
3. Nurse should have worn gloves for self-protection
4. Nurse was skilled enough to prevent exposure to the blood

Looking for answers(s):3
Explanation: 1. Even if the client does not have an infection gloves are always worn when exposure to blood is a possibility. 2. All blood is considered to be potentially infectious. 3. According to the Centers for Disease Control (CDC) recommendations for isolation precautions, gloves should be worn when there is potential contact with blood or other body fluids. 4. Nurses are required to take precautions that limit exposure; gloves must be worn.

Question 6. The nurse correctly teaches that the most frequent side effect associated with the use of IUD's is:

1. Ectopic pregnancy
2. Expulsion of the IUD
3. Rupture of the uterus
4. Excessive menstrual flow

Looking for answers(s):4
Explanation: 1. There is no documentation of this. 2. This may occur but is not classified as a side effect. 3. This may occur upon insertion but is fairly uncommon. 4. Subsequent to IUD insertion, there may be an excessive menstrual flow for several cycles; this is because of an increase in the blood supply resulting from the inflammatory process because the IUD is really a foreign body.

Question 7. A client begins preterm labor and the physician orders terbutaline sulfate (Brethine). After its administration, the nurse assesses the client for the therapeutic effect of:

1. Reduction of pain in the perineal area
2. Decrease in blood pressure from 120/80 to 90/60
3. Decrease in frequency and duration of contractions
4. Dilation of the cervix from 1 to 1.5 cm for every hour of labor

Looking for answers(s):3
Explanation: Terbutaline sulfate (Brethine) is a beta-mimetic drug that acts on the smooth muscles of the uterus to reduce contractilitiy, which in turns inhibits dilation and contractions. It has no analgesic effects, does not act to decrease blood pressure, acts to arrest preterm labor by relaxing the uterus; this would result in stopping cervical dilation rather than increasing it.

Question 8. A client at 26 weeks' gestation is admitted with an influenza infection. She is in labor. The physician's order that the nurse should question would be:

1. Bethamethasone 12 mg IV at 12am and 12pm
2. Vital signs and fetal heart tones every 30 minutes
3. Start IV loading dose of mangesium sulfate per protocol
4. Intake and output and IV Ringer's lactate at 500mL/24 hrs

Looking for answers(s):1
Explanation: 1. Antenatal glucocorticoid therapy is contraindicated when the client has an infection. 2. This is the usual monitoring for preterm labor. 3. Measures to halt labor should be started. 4. An available IV line should be maintained.

Question 9. A pregnant client with severe abdominal pain and heavy bleeding is prepared for a cesarean birth. Nursing care should include:

1. Teaching coughing and deep-breathing techniques
2. An abdominal prep and administration of a Fleet enema
3. Obtaining an informed consent and assessment of drug allergies
4. Inserting and indwelling catheter and administering a tap-water enema

Looking for answers(s):3
Explanation: 1. This is not a priority in an emergency such as this. 2. An enema is not given to a bleeding client; it may stimulate contractions and further bleeding. 3. In an emergency surgical situation when invasive techniques are necessary, it is important to have a consent signed as well as a history of the client's known allergies. 4. An enema is not given to a bleeding client; it may stimulate contractions and further bleeding.
Question 10. At 9pm visiting hours are officially over, but the relatives of one postpartum client remain at the bedside. The nurse's most appropriate intervention should be to

1. Firmly remind the client and visitors that visiting hours are over.
2. Call the evening nursing supervisor to tactfully handle the situation
3. Encourage the family members to participate in care as much s the client wishes.
4. Get written permission from the client's husband for the family members to remain.

Looking for answers(s):3
Explanation: 1. This would be an inappropriate intervention; family-centered maternity care focuses on the whole family, and the relatives should be permitted to take part in the care of the client. 2. The primary nurse should be able to handle this situation. 3. Family-centered maternity care focuses on the whole family; including the relatives in the care will be most therapeutic for the client. 4. The husband's permission is not required.

Question 11. The nurse recognizes that an expected change in the hematologic system that occurs during the second trimester of pregnancy is:

1. A decrease in WBCs
2. An icrease in blood volume
3. An increase in blood volume
4. A decrease in sedimanation rate

Looking for answers(s):3
Explanation: 1. White blood cell values remain stable during the antepartum period. 2. The hematocrit decreases as a result of hemodilution. 3. The blood volume increases by approximately 50% during pregnancy. Peak blood volume occurs between 30 and 34 weeks of gestation. 4. The sedimentation rate increases because of a decrease in plasma proteins.

Question 12In the 12th week of gestation, a client completely expels the products of conception. Because the client is Rh-negative, the nurse must:

1. Administer RhoGAM within 72 hours
2. Make certain she recieves RhoGAM on her first clinic visit
3. Not give RhoGAM, since it is not used with the birth of a stillborn
4. Make certain the client does not receive RhoGAM, since the gestation lasted only 12 weeks

Looking for answers(s):1
Explanation: 1. It is given within 72 hours postpartum if the client has not been sensitized previously. 2. It would be useless at this time. 3. RhoGAM is always indicated at the termination of a pregnancy, even with fetal demise. 4. RhoGAM is always indicated at the termination of a pregnancy, even with a short-term pregnancy.

Question 13. During prenatal development, fetal weight gain is greatest in the:

1. First Trimester
2. Third Trimester
3. Second Trimester
4. Implantation Period

Looking for answers(s):2
Explanation: 1. The first trimester is the period of organogenesis, when cells differentiate into major organ systems. 2. This is the period in which the fetus sores deposits of fat fetal weight gain is greatest. 3. Growth is occurring, but fat deposition does not occur in this period. 4. This is the period of the blastocyst, when initial cell division takes place.

Question 14. A client at 38 weeks' gestation is admitted for induction of labor. She has a history of ruptured membranes for the past 12 hours. She has no other symptoms of labor. The nurse is aware that if the proper conditions exist, the physician will prescribe:

1. Progesterone
2. Oxytocin (Pitocin)
3. Lututrin (Lutrexin)
4. Ergonovine maleate

Looking for answers(s):2
Explanation: Oxytocin is a small polypeptide hormone normally synthesized in the hypothalamus and secreted from the neurohypophysis during parturition or suckling; the synthetic form promotes powerful uterine (smooth muscle) contracitons and thus is used to induce labor. Progesterone builds up the endometrium; it does not initiate uterine contractions. Lututrin no drug by this name for this purpose. Ergonovine can lead to sustained contractions, which would be undesirable labor.

Question 15. A client, whose husband is overseas in the military, is admitted to the hospital with vaginal staining but no pain. The client's history reveals amenorrhea for the last 2 months and pregnancy confirmation by her physician after her first missed period. She is admitted for observation with a possible diagnosis of :

1. Missed abortion
2. Ectopic pregnancy
3. Inevitable abortion
4. Threatened abortion

Looking for answers(s):4
Explanation: 1. This may not cause any outward symptoms, only the signs of pregnancy disappearing. 2. This is usually accompanied by severe pain radiating to the shoulder on the affected side. 3. This can be confirmed only if vaginal examination reveals cervical dilation. 4. Spotting in the firs trimester may indicate that the client may be having a threatened abortion; any client with the possibility of hemorrhage should not be left alone; therefore admitting this client for observation is safe medical practice; abortion is usually inevitable if accompanied by pain and cervical dilation.

Question 16. At about 5 cm dilation, a laboring client receives medication for pain. The nurse is aware that one of the medications given to women in labor that could cause respiratory depression of the newborn is:

1. Scopolamine
2. Promazine (Sparine)
3. Meperidine (Demerol)
4. Promethazine (Phenergan)

Looking for answers(s):3
Explanation: Respiratory depression occurs with the use of meperidine (Demerol) and produces significant depression of the infant at birth if circulating levels are high at time of birth. Scopolamine induces amnesia and forgetfulness in the mother but does not cause respiratory depression; this medication is not presently used. Prpmazine (Sparine), an anxiolytic, augments the effects of demerol, thereby lessening the amount of drug needed. Promethazine (Phenergan), an antihistamine, does not cause respiratory depression.

Question 17. When caring for a client who is having a prolonged labor, the nurse must be aware that the client is very concerned when her labor deviates from what she sees as the norm. A response conveying acceptance of the client's expressions of frustration and hostility would be:

1. "I'll rub your back; tell me if it helps."
2. "I'll leave as you can talk to your husband."
3. "All women get weary and frustrated during labor."
4. "Would you like to talk about what's bothering you?"

Looking for answers(s):1
Explanation: 1. This response provides the client with a comfort measure while giving her an opportunity to get verbalize her fears about having a prolonged labor. 2. This closes off communication with the client. 3. This is of no help to the client; she is concerned with what is happening to her. 4. This can be answered "yes" or "no" and leaves no further avenue for discussion.

Question 18. A pregnant woman is at term is admitted to the birthing unit in active labor. The client is excited about the anticipated birth because has three sons and the amniocentesis indicates that she will have a girl. The nurse recognizes that there are implications for newborn observations and care when the nursing history reveals that:

1. The membranes ruptured 2 hours ago
2. Her first child was diagnozed with hemophilia
3. She has taken NSAIDs for frequent sinus headaches
4. There was a placenta previa in a previous pregnancy
Looking for answers(s):3
Explanation: NSAID as well as other over-the counter drugs (OCT) taken during pregnancy may cause problems in the newborn during the neonatal period. The membranes ruptured 2 hours ago is not a cause of concern; if membranes ruptured over 24 hours before birth, infection may ensue. Hemophilia affects males; this fetus is known to be a female may be a carrier but would not have hemophilia. Placenta previa would have been diagnosed before active labor; a history of a placenta previa in an earlier pregnancy would not have implication for this newborn.

Question 19. A 16-year-old comes to the prenatal clinic because she has missed three menstrual periods. Before her physical examination, the client says. "I don't know what the problem is, but I can't be pregnant." The nurse's most therapeutic response to this statement would be:

1. "The doctor will let you know shortly."
2. "What brought you to the prenatal clinic then?"
3. "Many young women are irregular at your age."
4. "If you have had intercourse, you are probably pregnant."

Looking for answers(s):2
Explanation: 1. This response would close off any future communication with the client. 2. This response points out reality and allow the client to elaborate. 3. This may be true statement, but it does not allow for much discussion to follow. 4. This response sounds rather critical or judgmental and would probably cut off further discussion with the client.

Question 20. After an 8-hour, uneventful labor a client gives birth to a baby boy spontaneously under epidural block anesthesia. As the nurse places the baby in the mother's arms immediately after the birth, the mother asks, "is he normal?" The most appropriate response by the nurse would be:

1. "Most babies are normal; of course he is"
2. "He must be all right, he has such a good strong cry."
3. "Yes, because your pregnancy and labor were so normal."
4. "Shall we unwrap him so you can look him over for yourself?"

Looking for answers(s):4
Explanation: 1. This is false reassurance; this comment closes off communication with the mother at a very opportune moment. 2. Crying is not indicative of congenital defects; a strong cry does not ensure "normalcy". 3. The "normalcy" of the mother's pregnancy and labor does not always have a relationship to the "normalcy" of the infant. 4. Mothers need to explore their infants visually and through touch to assure themselves that the infants are normal in all respects.

Question 21. A young couple attends the prenatal clinic. The wife is 8 weeks' pregnant and asks the clinic nurse for information about an abortion. The nurse expresses the opinion that abortion is immoral and that many women have long-term guilt feelings after an abortion. The couple leave the clinic in a very disturbed state. Legally, the:

1. Client had a right to receive correct, unbiased information
2. Nurse's statements need not be based on scientific knowledge
3. Physician should have been called in, since nurses should not discuss abortion
4. Nurse had a right to state feelings as long as they were identified as the nurse's own

Looking for answers(s):1
Explanation: 1. Nurses with positive attitudes toward abortion should counsel women who are thinking of undergoing the procedure; they should know what services are available and the various methods that are used to induce abortion. 2. Nursing practice necessitates scientific knowledge; statements must be based on fact, not personal feelings or beliefs. 3. The nurse is capable of giving information about abortion and need not defer to the physician. 4. The nurse should give the client only the information requested and should not state personal feelings.

Question 22. A newly delivered mother with three young children at home comment to the nursery nurse that she cannot hold the baby for feedings once she gets home. She has just too much to do, and anyhow, it spoils the baby. The best response for the nurse to make is:

1. "You seem concerned about time. Let's talk about it."
2. "That's entirely up to you; you have to do what works for you."
3. "Holding the baby when feeding is important for development."
4. "It is very unsafe to prop a bottle. The baby could aspirate the fluid."

Looking for answers(s):1
Explanation: 1. This opens up an area of communication to get at what really is troubling the mother about feeding the baby. 2. Because the nurse is aware that this is not the best method, the problem of time should be explored with the mother. 3. Holding can be accomplished at times other than feeding periods; it does not explore the client's feelings. 4. This is true, but the mother should not be frightened; a more gentle explanation should be used.

Question 23. Which of the following is the most important nursing action when caring for a client who is 6 hours post cesarean birth?

1. Turning, coughing, and deep breathing every 4 hours
2. Applying anesthetic spray to her perineum
3. Assisting the client to the bathroom for a shower
4. Encouraging a sitz bath three times a day

Looking for answers(s):1
Explanation: A cesarean birth is a surgical procedure involving an abdominal incision. Immobility in the postoperative period causes secretions to pool. Also, abdominal incisions cause pain on deep breathing. Clients with abdominal incisions need to turn, cough, and deep breathe to mobilize secretions to prevent atelectasis and pneumonia. Anesthetic spray is applied to the episiotomy to provide local analgesia. Clients who have had a cesarean birth do not have a perineal incision. Six hours post cesarean birth is too soon for a shower. The client may be very weak for the first 24 hours. Safety might be an issue. Sitz baths provide cleansing and warmth to perineal areas for clients with episiotomies.

Question 24. The husband of a client who is in the transitional phase of labor becomes very tense and nervous during this period and asks the nurse, "Do you think it is best for me to leave, since I don't seem to do my wife much good?" The most appropriate response by the nurse would be:

1. "This is the time your wife needs you. Don't run out on her now."
2. "This is hard for you. Let me try to help you coach her during this difficult phase."
3. "I know this is hard for you. Why don't you go have a cup of coffee and relax and come back later if you feel like it?"
4. "If you feel that way, you'd bes go out and sit in the father's waitingroom for a while because you may transmit your anxiety to your wife."

Looking for answers(s):2
Explanation: 1. This statement is judgmental; this approach suggest that he will be failing his wife. 2. Both the father and the mother need additional support during the transitional stage of labor. 3. The husband should be present throughout labor to support his wife; he should be assisted in this role. 4. This does not encourage him to fulfill his role in supporting the mother during labor.

Question 25. A decision to withhold "extraordinary care" for a newborn with severe abnormalities is actually:

1. A decision to let the newborn die
2. The same as pediatric euthanasia
3. Presuming that the newborn has no rights
4. Unethical and illegal medical nursing practice

Looking for answers(s):1
Explanation: 1. Based on the family's decision, extraordinary care does not have to be employed; the infant's basic needs are met, and nature is allowed to take its course. 2. Euthanasia is a deliberate intervention to cause death. 3. If the infant's physical needs are met and comfort is provided, the infant's rights are not ignored; "extraordinary," not "all," care is being withheld. 4. It is neither unethical or illegal to withhold extraordinary treatments; once such treatment is started, it becomes a legal issue.

Question 26. In dealing with a couple identified as having an infertility problem, the nurse knows that:

1. Infertility is usually psycholigic in origin
2. Infertility and sterilty are essentially the same problem
3. The couple have been unable to have a child after trying for a year
4. One partner has a problem that makes that person unable to have children

Looking for answers(s):3
Explanation: 1. Infertility may be psychogenic; however, statistics show that physiologic problems are more often the cause. 2. This is untrue; infertility may be corrected, but sterility is irreversible. 3. Infertility is the inability of a couple to conceive after at least 1 year of adequate exposure to the possibility of pregnancy. 4. This may or may not be true; it is possible that there is a problem with both.

Question 27. Which of the following assessment findings about the uterus would the nurse expect to find in a primipara client 6 hours post delivery of an average-for-gestational-age infant?

1. Fundus firm, midline, 2 fingerbreadths below the umbilicus
2. Fundus firm, midline, at the level of the umbilicus
3. Fundus firm, to the right of the midline, at the umbilical level
4. Fundus soft, to the right of the midline, 2 fingerbreadths above the umbilicus

Looking for answers(s):2
Explanation: One hour after birth, the fundus rises to the level of the umbilicus, where it remains for approximately 24 hours. It should be firm and in the middle. The fundus should be firm and midline, but should not be 2 fingerbreadths below the umbilicus on the day of delivery. A fundus that is to the right of the midline denotes urinary bladder distention. The fundus should be firm to provide hemostasis. The fundus is up too far in the abdomen and is deviated to the right, denoting a distended bladder.

Question 28. An amniocentesis done on a client at 16 weeks' gestation reveals a fetus with Down syndrome. The client and her husband elect to have the pregnancy terminated. The nurse giving care to a client whose pregnancy is surgically terminated should be aware that:

1. The client is emotionally unstable at this time
2. There is a high risk for a postoperative infection
3. Contraceptive counseling should be deferred to a later time
4. The client needs to express her feeling of guilt, anger, and frustration

Looking for answers(s):4
Explanation: 1. This is a false assumption. 2. This is a sterile procedure and should not predispose the client to postoperative infection. 3. Studies show that contraceptive counseling at this time is most important, because the client may not return after the abortion. 4. The client must feel comfortable enough to verbalize her feelings of guilt; this helps to complete the grieving process.

Question 29. A couple in the fertility clinic have become very discouraged regarding their efforts to conceive. The nurse can best support them by understanding that the most stressful aspect of the process is:

1. Obtaining the necessary specimens
2. Visitng the fertility clinic frequently
3. Discovering which partner is infertile
4. Planning when intercourse should take place

Looking for answers(s):4
Explanation: 1. Obtaining and delivering the necessary specimens may be inconvenient but should not be stressful. 2. The number of office visits and examinations that are required may be cumbersome but should not be stressful. 3. The couple probably knows that one of them has a fertility problem; it may be helpful knowing that the problem is so that measures can be taken to correct it. 4. A strategy for increasing the chances of conceiving requires the couple to plan intercourse only while the woman is ovulating; this removes spontaneity and is often stressful.

Question 30. During the taking-hold phase, the nurse would expect the new mother to:

1. Talk about the baby
2. Call the baby by name
3. Touch the baby with her fingertips
4. Be passively involved with the baby

Looking for answers(s):2
Explanation: 1. This may occur in either phase. 2. The mother has completed the taking-in phase (the mother's needs predominate) and has moved into taking-hold the taking-hold phase (active maternal involvement with self and infant) when she calls the baby by name. 3. This is the initial early action of the taking-in phase. 4. This is part of the taking-in phase.

Question 31. An infant is born with a bilateral cleft palate. Plans are made to begin reconstruction immediately. Nursing intervention to promote parent-infant bonding should include:

1. Demonstrating a positive acceptance of the infant.
2. Placing the baby in a nursery away from view of the general public.
3. Explaining to the parents that the infant will look normal after the surgery.
4. Encouraging the parents to limit contact with the infant until after surgery.

Looking for answers(s):1
Explanation: 1. By demonstrating acceptance of the infant, without regard for the defect, the nurse acts as a role model for the parents, thus enhancing their acceptance. 2. Infants with cleft palates can remain in the newborn nursery; they should not be hidden. 3. This is false reassurance; it does not promote parent-infant bonding. 4. The parents should be encouraged to have frequent contact with their infant to promote bonding.

Question 32. A pregnant client's labor is to be induced at 39 week's gestation. The nurse is aware that several drugs are currently utilized for inducing labor. Select all that apply.

1. Oxytocin (Pitocin)
2. Misprostol (Cytotec)
3. Ergonovine (Ergotrate)
4. Carboprost (Hemabate)
5. Dinoprostone (Prepidil)
1 2

Explanation: Pitocin is an oxytocic used for labor induction. Cytotec is a prostaglandin used for cervical ripening and labor induction. Ergotrate is an oxytocis used for postpartum or postabortion hemorrhage, not labor induction. Hemobate is a prostaglandin used for pospartum hemmorrhage, not labor induction. Prepidil is used for cervical ripening, not labor induction.

Question 33. It is important for the nurse to support the parent's decision to abort a fetus with a birth defect because:

1. Supporting them will eliminate feelings of guilt
2. The parents are legally responsible for the decision
3. It is essential for maintenance of family equilibrium
4. The nurse's support will relieve the pressure associated with decision making

Looking for answers(s):3
Explanation: 1. Support may help, but it does not completely alleviate guilt feelings. 2. Support does not affect the legal responsibility of the parents. 3. Although support will help minimize guilt, it will not eliminate it; however will sustain family cohesion and unity. 4. This may help, but it cannot completely relieve pressure.

Question 34. During the first hours following delivery, the postpartum client is given intravenous fluids with oxytocin (Pitocin) added to them. The nurse understands the primary reason for this is:

1. To facilitate elimination
2. To prevent infection
3. To promote analgesia
4. To promote uterine contraction

Looking for answers(s):4
Explanation: Oxytocin is a hormone produced by the pituitary gland that produces intermittent uterine contractions, helping to promote uterine involution. The intravenous fluid may facilitate elimination, but oxytocin does not affect bowel or bladder elimination. Oxytocin has no antibacterial or analgesic action.

Question 35. During the postpartum period, while considering nursing measures to help parent-child relationships, the nurse should be aware that the most important factor at this time is the:

1. Anesthesia during labor
2. Duration and difficulty of labor
3. Physical condition of the infant
4. Health status during pregnancy

Looking for answers(s):3
Explanation: 1. Though the effect of an anesthesia is a factor, the most important factor is the physical condition of the infant. 2. Though the duration and difficulty of labor is a factor, the most important factor is the physical condition of the infant. 3. Bonding between parent and baby is most successful when interaction is possible right after birth; if the child is ill, contact is limited. 4. Health status during pregnancy may be a factor, but the most important factor is the physical condition of the infant.

Question 36. The uterus rise out of the pelvis and becomes an abdominal organ at about the:

1. 10th week of pregnancy
2. 8th week of pregnancy
3. 12th week of pregnancy
4. 18th week of pregnancy

Looking for answers(s):3
Explanation: 1. The uterus is still within the pelvic area. 2. The uterus is still within the pelvic area. 3. By this time the fetus and placenta have grown, expanding the size of the uterus. The extended uterus expands into the abdominal cavity. 4. The uterus has already risen out of the pelvis and is expanding farther into the abdominal area.

Question 37. A client suspects that she is pregnant, but because she is the only wage earner in her family, she is ambivalent about continuing the pregnancy. The nurse recognizes that the client is in crisis and also remembers that pregnancy and birth are considered crises because:

1. There are mood changes during pregnancy
2. They are periods of change and adjustment to change
3. There are hormonal and physiologic changes in the mother
4. Narcissism is the mother affects the husband wife relationship

Looking for answers(s):2
Explanation: 1. These are transient; they are similar to previous mood changes and should not affect the mother's ability to cope. 2. Expected periods of marked change and adjustment are called developmental crises and predispose the woman to a situational crisis. 3. These occur throughout the life cycle of a mature woman and should not now be classified as a crisis. 4. It becomes a crisis only if the husband withdraws support.

Question 38. When caring for a family on a postpartum unit, the nurse must be aware that all the tasks, responsibilities, and attitudes that make up child care can be called parenting and that either parent can exhibit these qualities. A person is able to perform parenting because of:

1. A marriage with flexible roles
2. An inborn ability based on instinct
3. Positive childhood roles and concepts
4. A good education in growth and development

Looking for answers(s):3
Explanation: 1. Marriage is not essential for good parenting. 2. Parenting is learned, not inborn. 3. Parenting is not an inborn instinct rather a learned behavior based on past experiences or current instruction. 4. This knowledge does not ensure the ability to parent.

Question 39. During labor a client who has been receiving epidural anesthesia has a sudden episode of severe nausea, and her skin becomes pale and clammy. The nurse's immediate reaction should be to:

1. Notify the physician
2. Elevate the client's legs
3. Check for vaginal bleeding
4. Monitor the FHR every 3 minutes

Looking for answers(s):2
Explanation: 1. If signs and symptoms do not abate after elevation of the legs, the physician should be notified. 2. Maternal hypotension is a common complication of this anesthesia for labor, and nausea is one of the first clues that this has occurred. Elevating the extremities restores blood to the central circulation. 3. This is not a specific observation after caudal anesthesia; it is part of the general nursing care during labor. 4. If the FHR is being monitored, it is a constant process; if not, the FHR should be monitored every 15 minutes.

Question 40. After ovulation has occurred, the ovum is believed to remain viable for:

1. 1 to 6 hours
2. 12 to 18 hours
3. 24 to 36 hours
4. 48 to 72 hours

Looking for answers(s):3
Explanation: 1. The ovum is viable a longer time. 2. The ovum is viable a longer time. 3. The ovum is capable of being fertilized for only 24 to 36 hours following ovulation; after this time it travels a variable distance between the fallopian tube and uterus, disintegrates, and is phagocytized by leukocytes. 4. The ovum is not fertilizable after 36 hours.

Question 41. Supportive nursing care in the beginning mother-infant relationship should include:

1. Requiring the mother to assist with simple aspects of her infant's care
2. Encouraging the mother to decide between breastfeeding and formula feeding
3. Allowing the mother ample time to undress and to carefully inspect her infant
4. Unobtrusive observation of the mother and her infant to watch for a disturbed relationship

Looking for answers(s):3
Explanation: 1. The client will proceed at her own rate; requiring her to do things is not supportive. 2. The mother should have made this decision before delivery. 3. Allowing the mother time to inspect the child permits viewing, touching, and holding, promoting bonding. 4. This can be done only by allowing the mother ample time to interact with her baby.

Question 42. A client undergoing treatment for infertility is diagnosed as having endometriosis. The nurse is aware that one of the drugs that may be used to treat this condition is:

1. Relaxin (Releasin)
2. Leuprolide (Lupron)
3. Ergonovine (Ergotrate)
4. Esterfied estrogen (Climestrone)

Looking for answers(s):2
Explanation: Continuous administration of Lupron decreases LH and FSH, as well as hormone-dependent tissue. Relaxin is used for dysmenorrhea; it causes relaxation of the symphysis pubis. Ergotrate is used to contract the uterus. Esterfied estrogen (Climestrone) is an estrogen that affects release of pituitary gonadotropins and inhibits ovulation.

Question 43. Research concerning the emotional factors of pregnancy indicates:

1. A rejected pregnancy will result in a rejeted infant
2. Ambivalence and anxiety about mothering are common
3. Maternal love is fully developed within the first week after birth
4. An effective mother experiences neither ambivalence nor anxiety about mothering

Looking for answers(s):2
Explanation: 1. Frequently the maternal instinct is nurtured by the sight of the infant. 2. Because mothering is not an inborn instinct, almost all mothers, including multiparas, report some ambivalence and anxiety about their ability to be good mothers. 3. It may take a much longer time. 4. Ambivalent feelings are universal in response to a neonate.

Question 44. Which of the following instructions would be included in a client's postpartum teaching plan about performing Kegel exercises to restore perineal muscle tone?

1. Alternately flexing and extending each foot while raising her leg 6 inches off the bed
2. Contracting and relaxing perineal muscles as if stopping and starting a urinary stream
3. Contracting the abdominal muscles while raising her legs 1 inch off the bed
4. Taking deep breaths and slowly exhaling while compressing the buttocks together

Looking for answers(s):2
Explanation: Kegel exercises require contracting the pubococcygeal muscle, the major muscle of the pelvic floor, to increase muscle tone and provide support to the vaginal wall, bladder, and rectum. Alternate flexing and extending the foot with raising will facilitate venous return and help prevent thrombophlebitis. However, this exercise will not affect perineal muscle tone. Contracting the abdominal muscles with leg raises will increase abdominal, but not perineal, muscle tone. Deep breathing expands the lungs. Contracting gluteal muscles will not affect the perineal, muscle tone.

Question 45. A client visiting the prenatal clinic for the first time asks the nurse about the probability of having twins because her husband is one of a pair of fraternal twins. The nurse should explain that:

1. The probability of having twins is 25%
2. She will be monitored closely for the presence of twins
3. Her husband's history of being a twin raises the probability of having twins
4. There is no greater probability of having twins than in the general population

Looking for answers(s):4
Explanation: 1. If there is no maternal family history of twin pregnancies, it would be a chance occurrence that is equal to the probability found in the general population. 2. Pregnant women are routinely monitored for multiple pregnancies; this client needs information about her risk for having twins. 3. If there is no maternal family history of twin pregnancies, it would be a chance occurrence that is equal to the probability found in the general population. 4. Fraternal twins may occur as a result of a hereditary trait, but is related to the ovaries releasing two eggs during one ovulation; the fact that the father is a fraternal twin would not influence the female to release two eggs during one ovulation.

Question 46. During the process of gametogenesis, the male and female sex cells divide, and each mature sex cell contains:

1. 24 pairs of autosomes in their nuclei
2. 46 pairs of chromosomes in their nuclei
3. A diploid number of chromosomes in their nuclei
4. A haploid number of chromosomes in their nuclei

Looking for answers(s):4
Explanation: 1. They each have one set of chromosomes (23). 2. There are only 23 pairs of chromosomes in the nuclei. 3. The diploid number (46 chromosomes) is reached when fertilization occurs. 4. This is the result of a reduced chromosome number, from 46 to 23, readying the sex cells for fertilizaiton.

Question 47. During the postpartum period, a cardiac client with type 2 diabetes asks the nurse, "Which contraceptives will I be able to use to prevent pregnancy in the near future?" The nurse's best response would be:

1. "You may use oral contraceptives. They are almost 100% effective in preventing pregnancy."
2. "You may want to use a foam and a condom to prevent pregnancy until you consult with your doctor at your postpartum visit."
3. "The intrauterine device is best for you because it does not allow a fertilized ovum to become implanted in the urerine lining."
4. "You do not need to worry about becoming pregnant in the near future. Clients with cardiac conditions usually become infertile."

Looking for answers(s):2
Explanation: 1. Oral contraceptives are not recommended for this client because of their tendency to alter glucose tolerance. 2. Some type of a barrier contraceptive (condom) is usually recommended for the client with diabetes mellitus and a cardiac condition. 3. An IUD is not recommended because it may predispose this client to infection. 4. This is untrue; clients with a cardiac condition can become pregnant again in the future.

Question 48. A client at 6 weeks' gestation is receiving antibiotic theraphy for pyelonephritis. The nurse is aware that the safest antibitioc for administration during pregnancy is:

1. Gantrisin
2. Ampicillin
3. Tetracycline
4. Nitrofurantoin

Looking for answers(s):2
Explanation: Ampicillin has no know tertogenic effect associated with penicillin. Gantrisin sulfonamides may cause hemolysis in the fetus. Tetracycline causes permanent yellow staining of teeth in children whose mothers receive the drug during pregnancy. Nitrofurantion is contraindicated in severe renal disease.

Question 49. A client with multiple sclerosis has just confirmed her pregnancy. She states she is taking ACTH and wonders whether she can continue taking it. The best response by the nurse would be:

1. ACTH is safe to take during pregnancy
2. ACTH may make you prone to nausea and vomiting
3. This medication is untested in pregnancy. Check with your physician.
4. This is used during plasmapheresis and should be safe to continue taking.

Looking for answers(s):1
Explanation: Although ACTH is a pregnancy category C drug and it is not known whether it is harmful to the fetus, the client's health must be considered as well as the life of the fetus; it acts to strengthen nerve conduction. Nausea and vomiting are not side effects of ACTH. ACTH has been tested in pregnancy. Used during plasmapheresis is not the reason ACTH has been prescribed; the client has multiple sclerosis.

Question 50. After the first 3 months of pregnancy, the chief source of estrogen and progesterone is the:

1. Placenta
2. Adrenal Cortex
3. Corpus luteum
4. Anterior hypophysis

Looking for answers(s):1
Explanation: 1. When placental formation is complete, around the 12th week of pregnancy, it produces progesterone and estrogen. 2. This is not the chief source of progesterone and estrogen; only small amounts are secreted. 3. The corpus luteum supplies the estrogen and progesterone needed to sustain the pregnancy until the placenta is ready to take over. 4. FSH is secreted by the anterior hypophysis, but it is not secreted during pregnancy.
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