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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
Showing posts with label maternal drill answers. Show all posts
Showing posts with label maternal drill answers. Show all posts

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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Maternal/OB drill 6 answers

Question 1. Which of the following patterns of weight gain is normal for a client who weighed 100 pounds before becoming pregnant?

1. 110 pounds by 10 weeks' gestation
2. 112 pounds by 20 weeks' gestation
3. 115 pounds by 30 weeks' gestation
4. 135 pounds by 40 weeks' gestation

Looking for answers(s):4
Explanation: During pregnancy, the woman should gain 25 to 35 pounds. Thus, the client should weigh around 135 pounds at 40 weeks' gestation. By 12 weeks, the client typically should have gained 3.5 to 5 pounds. By 20 weeks, the client typically should have gained 10 pounds. By 30 weeks, the client typically should have gained 10 pounds. By 40 weeks, the client typically should have gained 10 pounds. Typical weight gain is 3.5 to 5 pounds during the first trimester, followed by an average gain of 1 pound per week during the last two trimesters.

Question 2. Which of the following nursing diagnoses would be most appropriate for a woman in her third trimester who tells her husband that she does not want to go out in public "while I'm this pregnant"?

1. Altered Role Performance
2. Anxiety
3. Body Image Disturbance
4. Ineffective Family Coping

Looking for answers(s):3
Explanation: Bodily changes during pregnancy often cause a negative body image. At the end of the pregnancy, the woman often feels "out of shape" and "fat," leading to a nursing diagnosis of body image disturbance. Altered role performance applies to the state in which an individual experiences or is at risk for experiencing a disruption in the way she perceives her role performance. There is no evidence in this situation to suggest this nursing diagnosis. Anxiety applies to a state in which an individual experiences feelings of uneasiness (apprehension) with activation of the autonomic nervous system in response to a vague, nonspecific threat. There is no evidence in this situation to suggest this nursing diagnosis. Ineffective family coping focuses on family, not on an individual problem.

Question 3. Which of the following contraceptive methods would the nurse identify as the least effective in preventing conception?

1. Coitus interruptus
2. Condoms with spermicides
3. Intrauterine devices
4. Hormonal contraceptives

Looking for answers(s):1
Explanation: A high percentage of conception (20% to 25%) occurs with coitus interruptus primarily because sperm exist in the preejaculatory fluid. This method also requires a great deal of self-control to withdraw in the midst of intercourse before ejaculation of semen. The use of spermicides with condoms has an effectiveness rate of 80% to 85% if the method is used consistently and correctly. Intrauterine devices have an efficacy of 98% to 99%. Hormonal contraceptives have a 97% effectiveness rate.


Question 4. Which of the following behaviors would the nurse expect to observe in a primipara client by the third postpartum day?

1. Greater interest in learning about infant care
2. Requests for help with her activities of daily living
3. Sleeping most of the time when the infant is not in the room
4. Very talkative about the birth experience to friends

Looking for answers(s):1
Explanation: A greater interest in learning about infant care reflects the "taking hold" phase of expressing interests outside of self and taking interest in the infant. Requests for help with activities of daily living reflect passive, dependent behavior characteristic of the "taking in" phase (1 to 2 days after delivery). Basic needs of the woman need to be met in the passive, dependent "taking in" phase (1 to 2 days after delivery). During the "taking in" phase (1 to 2 days after delivery), the client integrates the birth experience into her being by frequently reviewing the experience.

Question 5. Which of the following would the nurse use to explain the term quickeningto a client who is at 18 weeks' gestation?

1. A light fluttering sensation when the fetus moves
2. A vaginal infection caused by yeast
3. Descent of the fetus into the pelvis
4. Vascular congestion and tenderness of the breast tissue

Looking for answers(s):1
Explanation: Quickening is defined as maternal perception of fetal movement, usually as a light fluttering sensation when the fetus moves, typically between the 16th and 20th weeks of pregnancy. A vaginal yeast infection is candidiasis, a vaginitis caused by Candida albicans. Descent of the fetus into the pelvis is engagement and occurs in the last weeks of pregnancy. Vascular congestion and tenderness of the breast tissue is commonly called engorgement.

Question 6. Which of the following terms best describes the conscious process by which a couple decides on the number and spacing of children and the timing of births?

1. Emergency contraception
2. Family planning
3. Infertility management
4. Preconception planning

Looking for answers(s):2
Explanation: Family planning is allowing the couple to choose when they want to conceive and have children, not just the prevention of pregnancy. It empowers them to feel ready physically, emotionally, and financially for the roles and tasks of parenthood. Emergency contraception is a hormonal form of birth control given within 72 hours of unprotected sexual intercourse to prevent implantation and pregnancy. This is a situational crisis and it is not considered planning. Although family planning may involve management of infertility, this answer is not inclusive of all aspects of planning for a family. Preconception planning offers couples an opportunity to enhance the probability of having a healthy newborn by examining the health history of both partners and providing appropriate guidance and counseling.

Question 7. Which of the following would be most important for the nurse to determine if the prenatal blood panel of a primigravida reveals that she is Rh negative?

1. Blood type of the father of the baby
2. Hemoglobin and hematocrit levels
3. Her religious preference
4. Previous administration of RhoGAM

Looking for answers(s):1
Explanation: If the father is Rh positive (or if his blood type is unknown), an antibody screen is done to determine if the woman has developed isoimmunity to the Rh antigen. If the father is negative, there is less chance of this problem. Although hemoglobin and hematocrit are important in prenatal blood work, they are unrelated to the client's Rh status and possible Rh isoimmunization. Religious preference would only be pertinent if isoimmunization was severe enough to require exchange transfusion of the infant. RhoGAM is only administered during or following pregnancy with a fetus that is Rh positive (or an abortus in which the blood Rh is unknown). This is the client's first pregnancy.

Question 8. A client, who is 8 weeks pregnant, tells the nurse, "We wanted a baby, but I'm not sure this is the best time." The nurse would interpret that the client is expressing feelings of which of the following?

1. Acceptance
2. Ambivalence
3. Apathy
4. Attachment

Looking for answers(s):2
Explanation: Ambivalence refers to simultaneous occurrence of conflicting emotions, ideas, or wishes. The client is verbalizing the desire for a baby, but at a more convenient time. Acceptance is a belief that the woman is pregnant. Apathy is an indifference to or absence or suppression of emotion, feelings, or concern. Attachment is strong emotional ties as a result of parent-infant interaction.

Question 9. Which of the following factors would be most influential to the outcome of a class on human sexuality that includes both males and females ranging in age from adolescence through middle-aged adults?

1. Availability of written handouts to reinforce the content
2. Cognitive level of the information to be presented
3. Environmental setting where the class will take place
4. The nurse's comfort level in discussing the subject matter

Looking for answers(s):4
Explanation: The nurse must demonstrate comfort with human sexuality content to facilitate an effective presentation to a class. Although important in reinforcement of concepts, availability of written handouts is not the most important aspect to influence the outcome of the class. Although important, the cognitive level of the information to be presented is not the most important factor in the determination of the effectiveness of the class. The setting for the class presentation facilitates effectiveness, but it is not the primary factor in the determination of the client learning outcomes.

Question 10. For which of the following clients would the nurse understand that oral contraceptive agents are contraindicated?

1. A 29-year-old female with alcohol abuse
2. A 30-year-old female who had three spontaneous abortions
3. A 36-year-old female with a history of thrombophlebitis
4. A teenager with regular menses for the past 4 years

Looking for answers(s):3
Explanation: A client with a past medical history of blood clots is an absolute contraindication to the use of oral contraceptives because the estrogen contained in the pills may stimulate clot formation. Although the client with alcohol abuse may take the pills irregularly, alcohol abuse is not a contraindication to the use of oral contraceptives. Spontaneous abortion is not a reason to avoid oral contraceptive agents. The teenage years are not a contraindication for the use of oral contraceptive agents. It is recommended that the teenager have well-established menstrual cycles for at least 2 years before beginning oral contraceptives.



Question 11. Which of the following areas would be the priority for client education in the first trimester?

1. Constipation
2. Danger signs
3. Lactation
4. Leg cramps

Looking for answers(s):2
Explanation: Education in the first trimester should focus on the possible danger signs of pregnancy. In fact, this information should be addressed on the first health care visit. The signs signify impending danger and indicate a need for medical attention. Constipation most frequently occurs in the second and third trimesters and should be addressed then. Infant-feeding techniques should be introduced during the early prenatal period and discussed again nearer to the end of the pregnancy. Leg cramps occur most commonly in the third trimester and should be addressed just prior to the client beginning the third trimester.

Question 12. When questioning a client about the number of extra calories eaten per day, the nurse knows the client is receiving adequate calories when she states the following?

1. 1,000
2. 300
3. 500
4. 750

Looking for answers(s):2
Explanation: A pregnant client needs 300 extra calories per day for adequate nutrition. An intake of 1,000 extra calories per day is in excess of the recommended daily requirement of extra calories needed for pregnancy. An intake of 500 extra calories per day is in excess of the recommended daily requirement of extra calories needed for pregnancy. An intake of 750 extra calories per day is in excess of the recommended daily requirement of extra calories needed for pregnancy.

Question 13. The nurse determines that a client understands the natural cervical mucus contraceptive method when the client describes the cervical mucus during her fertile period as which of the following?

1. Clear, wet, and sticky
2. Cloudy, white, and sticky
3. Thick and cloudy
4. Yellow and sticky

Looking for answers(s):1
Explanation: In response to high estrogen and progesterone levels during the fertile period, the mucus is clear, wet, and sticky and slippery (like an egg white) and is more abundant. Cloudy white and sticky mucus occurs after ovulation. Thick cloudy mucus is present in the postovulatory phase. The mucus has a yellowish color in the preovulatory phase.

Question 14. Teenagers in a health class ask the nurse educator, "Do spermicidal jellies ever work?" Which of the following would be the nurse's best reply?

1. "Spermicides are effective for repeated intercourse for 24 hours."
2. "They are not effective unless used with a male or female condom."
3. "They are the least effective of all contraceptives."
4. "They must be placed within 30 minutes before intercourse to be effective."

Looking for answers(s):4
Explanation: For maximum effectiveness, spermicidal agents should be inserted about 30 minutes prior to intercourse. For most spermicides, effectiveness is limited to 1 hour. Spermicides are effective for only one episode of intercourse. Reapplication is essential prior to each subsequent intercourse. The efficacy of spermicides is improved when used with condoms, but they are 70% effective when used alone, if used consistently and correctly. Coitus interruptus is the least effective of all contraceptive methods.

Question 15. Which of the following denotes the correct technique for fundal massage for a postpartum client exhibiting a large amount of blood on the perineal pad?

1. Compressing the fundus on one side while supporting the other side of the uterus
2. Massaging above the symphysis pubis while one hand supports the uterine fundus
3. Pressing deeply into the abdomen while compressing the fundus with both hands
4. Supporting the fundus while massaging the uterus just above the symphysis pubis

Looking for answers(s):4
Explanation: Supporting the fundus while massaging the uterus just above the symphysis pubis provides support to the lower uterine segment while stimulating contraction of the fundus. It also prevents inversion of the uterus, which is an obstetric emergency. The top (fundus) of the uterus is massaged, not the sides. Massaging at the symphysis pubis would not provide effective uterine contractions. One hand is used to massage the fundus. It is not necessary to press deep into the abdomen.

Question 16. When teaching a childbirth education class on infection prevention after delivery, the nurse would instruct the woman to perform perineal care how often?

1. After each voiding or defecation
2. Every 8 hours
3. Once each day
4. When she has perineal pain



Looking for answers(s):1
Explanation: Cleansing the perineum reduces the number of perianal microorganisms present. It also removes lochia and moisture, favorable for the growth of bacteria. Every 8 hours is not frequent enough. Any excreta need to be removed quickly to prevent infection. Once-daily cleansing will not be effective in preventing bacterial growth. Perineal care provides cleanliness and promotes comfort, but it does not relieve pain. Additionally, pain is not an adequate indicator for the need to perform perineal care.

Question 17. A client tells the nurse, "I had my tubes tied 5 years ago. I want to get pregnant now. Is it possible to reverse the sterilization?" The nurse bases her response on the knowledge of which of the following?

1. Female reversal produces a pregnancy rate of 90%
2. Male sterilization reversal is easier than a female's
3. Reversal is possible with tubal reconstruction
4. Reversal of bilateral tubal ligation is not possible

Looking for answers(s):3
Explanation: Reversal is possible but it is expensive and difficult (requiring microsurgery), and the results are uncertain. Tubal reconstruction has a 50% to 70% success rate. The incidence of a successful pregnancy after reanastomosis ranges from 50% to 70%. Reversal of a vasectomy is more difficult with a success rate less than that of fallopian tubal reversal. It is possible with microsurgery to reverse a bilateral tubal ligation.

Question 18. Which of the following is the primary factor to consider when assisting a client in choosing the optimum contraceptive method?

1. Compatibility with cultural values
2. Consistent and correct use
3. Few side effects
4. Lowest failure rate

Looking for answers(s):2
Explanation: The efficacy of the method chosen by the partners is directly proportional to the consistent and correct use of the method chosen. The optimal contraceptive method, therefore, is the one that is most effective for that couple when used consistently and correctly. Although cultural compatibility is important, it is not the most important aspect of the choice of contraception. Although few side effects is important, this is not the most important aspect of the chosen method of contraception. No contraceptive method has been scientifically proven to be 100% effective in the prevention of contraception. Even with a low failure rate, if the method is not used consistently and correctly, optimal effectiveness will not be achieved.


Question 19. Which of the following would the nurse include in a client's teaching plan about the danger signs of pregnancy?

1. Backache
2. Blurred vision
3. Edematous feet
4. Quickening

Looking for answers(s):2
Explanation: Blurred vision is a sign of pregnancy-induced hypertension that requires further investigation. Backache is a common discomfort of pregnancy associated with the hormonal effects on the musculoskeletal system. Lower extremity edema is normally a sign of venous stasis, especially if there is no edema of the hands or face. Although it may be uncomfortable, edematous feet are not a danger sign. Quickening is fetal movement as perceived by the mother and is normal during pregnancy.

Question 20. Using the five-digit system, which of the following denotes the correct obstetric history for a client who is 6 weeks pregnant, and has a son born at 36 weeks' gestation and a daughter born at 40 weeks' gestation?

1. G2 T1 P1 A0 L2
2. G2 T2 P0 A0 L2
3. G3 T1 P1 A0 L2
4. G3 T2 P0 A0 L2

Looking for answers(s):3
Explanation: This is the client's third pregnancy (G3). One child was born at term (40 weeks; T1) and one was delivered prior to 38 weeks' gestation (preterm; P1). There is no history of abortions (A0) and both children are living (L2). G2 represents a client who has been pregnant two times. This client has been pregnant three times.

Question 21. Which of the following would the nurse include in the teaching plan for a high school class on human sexuality as a positive sign of pregnancy?



1. Abdominal enlargement
2. Persistent amenorrhea
3. Positive urine HCG
4. Presence of fetal heart tones

Looking for answers(s):4
Explanation: Fetal heart tones heard by the examiner are a positive sign of pregnancy. Abdominal enlargement can be caused by multiple factors, such as tumors or ascites. Amenorrhea can be caused by numerous conditions, including endocrine problems, stress, nutritional status, excessive exercise, or gynecologic problems. Urine HCG tests can be falsely positive owing to protein or blood in the urine or in a turbid specimen. HCG can also originate from a source other than a pregnancy (ie, tumors of the pancreas, ovaries, and breasts). Postmenopausal women may have low levels of circulating HCG.

Question 22. A client calls the clinic because she has forgotten to take her oral contraceptive for the past 2 days. Which of the following should the nurse advise the client to do?

1. Continue to take the remaining pills for the rest of the cycle
2. Discontinue the pills for the rest of the cycle and use condoms
3. Take two pills for the next 2 days and use condoms the rest of the cycleTake two pills immediately and change to condoms for the rest of the cycle

Looking for answers(s):3
Explanation: To maintain hormone levels, the client should take the two pills for the next 2 days (to compensate for the missed pills) and then complete the rest of the pills. To decrease the risk of pregnancy, the client should also use an alternative method of contraception such as condoms for the rest of cycle. When two pills have been missed, an alternative form of contraception must be used. Discontinuing the pills for the rest of the cycle would cause a drop in estrogen and progesterone levels with resultant physiologic effects. Taking two pills immediately and then changing to condoms would cause a drop in the levels of estrogen and progesterone with resultant physiologic effects.

Question 23. The nurse informs the client who comes to the clinic for a subdermal implant of progesterone (Norplant) about its advantages. Which would the nurse include?

1. Effectiveness for 3 months
2. Noninvasive technique for insertion
3. Reversible and inexpensive
4. Very few complications or side effects

Looking for answers(s):3
Explanation: Subdermal implants may be removed at any time. Although the initial insertion is expensive, use of this method is inexpensive when one considers the length of time it is effective and that it requires little attention other than health care visits for problems. Subdermal implants are 96% effective until 5 years after insertion. It is recommended that they be replaced at this time to maintain maximum efficacy. Insertion, an invasive procedure, is through a half-inch surgical incision on the inside surface of the nondominant arm. Subdermal implants have multiple side effects, including tenderness and bruising at the insertion site, irregular bleeding, headaches, weight changes, and breast tenderness. Complications include infection, migration or breaking of rods, heavy bleeding, irregularity of menses, and abdominal pain.

Question 24. A client asks, "How will sitting in a sitz bath help me?" The nurse's best response would be which of the following?

1. "It is the best way to prevent you from getting a uterine and episiotomy infection."
2. "It will increase urinary bladder muscle tone and facilitate bladder emptying."
3. "Sitting in the water promotes muscle contraction and prevents hemorrhaging."
4. "The warmth of the water will help to facilitate the healing process."

Looking for answers(s):4
Explanation: Local moist heat, such as with a sitz bath, increases circulation, bringing white blood cells and removing waste products from the area, thus facilitating healing. Although warmth facilitates the healing process, there is no guarantee that infection will be prevented. Heat does not increase muscle tone and thus will not facilitate bladder emptying. Warmth promotes muscle relaxation. Heat would increase blood flow and increase bleeding—not prevent hemorrhaging.

Question 25. The nurse asks a client who is using the basal body temperature (BBT) method of contraception, "When do you and your partner have intercourse?" Which of the following replies is consistent with the BBT method?

1. "During the first few days after my period ends."
2. "From the last day of menses to the first day of temperature elevation."
3. "From the third day of temperature elevation until menses start."
4. "On any day my temperature is not elevated more than 1°."

Looking for answers(s):3
Explanation: When using the BBT method of birth control, coitus is limited to the postovulatory period. Body temperature rises under the influence of progesterone produced by the corpus luteum. The woman should assume that she might be fertile from the last day of menses until the temperature has remained elevated for 3 consecutive days. Intercourse should not occur during the preovulatory period. Although temperature is not elevated, preovulatory days for coitus are prohibited. Ovulation cannot be precisely predicted for all women.

Question 26. For which of the following contraceptive methods would the health care provider obtain a signed informed consent?

1. Cervical cap
2. Diaphragm
3. Symptothermal method
4. Vasectomy

Looking for answers(s):4
Explanation: A vasectomy is an invasive surgical procedure and requires signed informed consent. The cervical cap is a barrier method and does not require a signed informed consent. Measurement and application of a diaphragm is not an invasive procedure and does not require a signed informed consent. Symptothermal method determines the fertile period and is not an invasive procedure.

Question 27. At what point in the pregnancy would the nurse expect to administer a 1-hour, 50-gram glucose-screening test to low to moderate risk clients?

1. 12 and 20 weeks' gestation
2. 24 and 28 weeks' gestation
3. 34 and 38 weeks' gestation
4. 8 and 12 weeks' gestation

Looking for answers(s):2
Explanation: Beginning in the second trimester, many women have pregnancy-induced glucose intolerance. Early detection provides opportunity to prevent complications arising from the intolerance. Typically, a screening test for glucose is obtained between 24 and 28 weeks' gestation. At 12 and 20 weeks, it is too early for physiologic changes in carbohydrate metabolism to produce glucose intolerance. Signs of gestational diabetes commonly occur before 34 and 38 weeks' gestation. Waiting until this time would be too late. At 8 and 12 weeks, it is too early for physiologic changes in carbohydrate metabolism to produce glucose intolerance.

Question 28. Which of the following would be included in the teaching plan for a client who has just had an intrauterine device (IUD) implanted?

1. Consistent douching immediately after intercourse
2. Need to check for correct placement periodically
3. The estimated rate of pregnancy is 0% during the first year

Looking for answers(s):2
Explanation: To prevent pregnancy, the IUD must be in the intrauterine cavity. The woman must check for the IUD thread after menstruation to rule out expulsion of the device. Douching does not improve the efficacy of IUDs. A 0% pregnancy rate is unrealistic. The effectiveness rate varies between 93% and 97%. Spermicidal creams or jellies are never used with IUDs.

Question 29. Which of the following statements about the female sheath/condom is accurate?

1. A success rate of 99% if used consistently and correctly
2. Need to leave in place for at least 6 hours after intercourse
3. Provides female protection against sexually transmitted diseasesReusable after cleaning and inspecting for tears

Looking for answers(s):3
Explanation: The female should use the latex sheath along with a spermicidal jelly. The sheath protects the entire vagina and urethral area from contact with the shaft and base of the penis, reducing the risk of pregnancy and sexually transmitted infections. Although clinical trials show the female sheath/condom to be as effective as the diaphragm, it is only about 85% to 87% effective in preventing pregnancy. The female condom should be removed after male ejaculation takes place. It does not need to be left in place for effectiveness. Like all condoms, the female condom/sheath is disposable and intended for one-time use only.

Question 30. Which of the following would the nurse include in a teaching plan on sexuality and the major physiologic effects of hormonal contraceptives for teens in a local high school?

1. Decrease in sperm motility
2. Inhibition of the release of an ovum
3. Prevention of implantation
4. Production of thin cervical mucus

Looking for answers(s):2
Explanation: Hormonal contraceptives contain estrogen and progesterone, which inhibit follicle-stimulating hormone, thus inhibiting ovulation—the release of the ovum. Hormonal contraceptives have no affect on sperm. Without the release of an ovum, there is no fertilization and no need for implantation. The cervical mucus remains thick with hormonal contraceptive use, which becomes an unsuitable environment for the sperm.

Question 31. The nurse should recommend which of the following contraceptive methods for a 16-year-old female prostitute who has a history of tobacco, alcohol, and intravenous drug abuse?

1. Female condoms
2. Intrauterine device (IUD)
3. Oral contraceptives
4. Subdermal implants

Looking for answers(s):4
Explanation: Subdermal implants are 99% effective and require no effort to maintain contraception. Her age and history do not indicate that she would consistently use a female condom. As a prostitute, the client is at high risk for sexually transmitted diseases, which could cause pelvic inflammatory disease with the IUD in the uterine cavity. The client's age and substance abuse history make her a likely candidate for inconsistent use of the pill.

Question 32. The nurse recognizes that the client understands how to take her oral contraceptive when the nurse hears the client tell her friend which of the following?

1. "I have to take one pill each day at the same time."
2. "I will need to have a complete physical every 3 months."
3. "If I take antibiotics, I should stop taking my pills."
4. "The pills have practically few serious side effects."

Looking for answers(s):1
Explanation: To maintain a constant hormone level, the pill should be taken at the same time each day. The client will need to have a physical exam and Pap smear once a year. If antibiotic therapy is needed, it is best to continue the pills as usual. In addition, an alternative method of contraception should be used. Some of the adverse effects, such as blood clots and pulmonary embolism, are life-threatening.

Question 33. Which of the following should the nurse recommend to a client experiencing nausea and vomiting during the first trimester?

1. Consuming a few crackers before arising
2. Eating chicken noodle soup three times a day
3. Eating three regular large meals per day
4. Skipping meals when the nausea is present

Looking for answers(s):1
Explanation: Along with rising hormone levels, alterations in carbohydrate metabolism with a resultant decrease in blood glucose level are thought to contribute to nausea in pregnancy. Dry, starchy foods such as crackers supply complex carbohydrates to raise the blood glucose level and decrease nausea. Chicken noodle soup contains excess salt and fat and should be avoided in pregnancy. Small, frequent meals prevent overloading of the stomach, which can cause nausea or vomiting. Skipping meals may worsen the nausea and cause a low serum glucose level, which could harm the fetus.


Question 34. Which of the following questions would be most important to ask when obtaining a client's prenatal history?


1. "Are your immunizations up to date?"
2. "Do you regularly take any medication?"
3. "Have you ever had a sexually transmitted disease?"
4. "What is your usual prepregnant weight?"

Looking for answers(s):2
Explanation: Because any medication may be teratogenic to a fetus, it is most important for the nurse to question the client about medications that are taken regularly, including any and all prescribed and over-the-counter medications. Doing so minimizes the risk to the fetus. Any immunizations that may be needed by the client are not given during pregnancy unless a special need arises. A past history of sexually transmitted disease indicates high-risk behavior. Although this is important overall, this information is not the most crucial to obtain at this time. Knowing the client's prepregnant weight is important for nutritional assessment and teaching, but it is not the priority at this time.


Question 35. A client who is 24 hours postpartum has the following morning vital signs: Temperature 100° F; BP 124/78; P58; R16. The nurse should do which of the following?

1. Assess the vital signs hourly instead of every 4 hours.Recognize the client's vital signs are normal.
2. Report the changes in vital signs to the physician.
3. Retake the pulse rate after the client ambulates.
4. Recognize the client's vital signs are normal.

Looking for answers(s):4
Explanation: A temperature elevation greater than 100.4° F on any two consecutive readings is considered febrile. A temperature of 100° F reflects the body's normal response to tissue damage or repair and to slight dehydration from labor. Because the client's vital signs are within normal limits, there is no indication to assess vital signs more frequently. All of the vital signs are within normal limits and therefore do not need to be reported to the physician. As a result of the increased stroke volume from a large amount of venous blood returning to the heart (because it is no longer obstructed by the gravid uterus), the pulse rate may be 50 to 90 beats/minute the first 1 to 2 days after delivery. Counting the pulse rate after ambulation would not be necessary.

Question 36. When explaining to a client about the primary cause of constipation during pregnancy, the nurse would include which of the following?

1. Decreased water reabsorption
2. Delayed gastric emptying time
3. Increased peristalsis
4. Relaxation of GI tract muscle

Looking for answers(s):4
Explanation: During pregnancy, hormonal influences and subsequent relaxation of the smooth muscle lining the bowel lead to decreased motility and constipation. Decreased water reabsorption would cause liquid stools. Although present during pregnancy, decreased gastric emptying time does not cause constipation. Increased peristalsis would lead to decreased water absorption and liquid stools.

Question 37. While preparing a primigravida for her first pelvic exam, the client expresses fear and begins to cry. Which of the following would be the nurse's best response?

1."Can you tell me what is making you so afraid?"
2. "I will make sure that you are covered with a sheet at all times."
3. "The physician will tell you exactly what he is going to do."
4. "We'll postpone the exam until you are more comfortable."
Looking for answers(s):1
Explanation: Because the client is upset and verbalizing fear, the nurse needs to gather additional information for use in developing a plan for a most appropriate action. Although telling the client that the nurse will keep her covered is reassuring, the nurse is ignoring the client's anxiety and making assumptions about the cause of the client's upset. Although it is important to explain all procedures to the client, telling the client that the physician will tell her exactly what's going on ignores the client's fears and also makes assumptions about the cause of the client's upset. The pelvic examination at this time is important to obtain data to determine the client's risk status. Postponing the exam would possibly place the client at risk for complications. Additionally, this response doesn't address the client's feelings or the cause of her fears.

Question 38. When teaching a class at a clinic for homeless males, which of the following would the nurse relate as the most effective contraceptive for the prevention of sexually transmitted diseases (STDs)?

1. Condoms
2. Diaphragm
3. Sterilization
4. Vaginal Sponge

Looking for answers(s):1
Explanation: Condoms are a barrier method of contraception and provide the best protection available against STDs, including HIV. The effectiveness is increased when condoms are used with a spermicidal jelly. Although the diaphragm is a barrier method, STDs can still be introduced into the vagina. Sterilization is very effective in preventing pregnancy, but offers no protection against STDs. Although the vaginal sponge is considered a barrier method that traps and absorbs spermatozoa, it is ineffective in preventing STDs.

Question 39. When planning a teaching session for teenage girls on the use of a diaphragm for contraconception, which of the following would be included?

1. Having the diaphragm refitted after a weight loss or gain of 20 pounds
2. Inserting the diaphragm at least 8 hours prior to intercourse
3. Leaving the diaphragm in place for 24 hours after intercourse
4. Using a spermicidal jelly in the center and around the rim

Looking for answers(s):4
Explanation: Spermicidal preparations increase the efficacy of the diaphragm and should always be used. A diaphragm should be refitted after childbirth or after a weight loss or gain of 15 or more pounds. For maximum effectiveness, the diaphragm should be inserted no more than 2 hours before intercourse. The diaphragm should be left in place for at least 6 hours after coitus for maximum protection against pregnancy.

Question 40. When obtaining an intake history from a new client in the antepartum clinic, which of the following factors, if found in the multigravida's history, would identify her as being at increased risk for gestational diabetes?

1. Age of 25
2. Five living children
3. Prior birth of a large infant
4. Smoking two packs a day

Looking for answers(s):3
Explanation: An elevated glucose level stimulates the secretion of fetal insulin and results in macrosomia and an infant with a birth weight greater than 9 pounds. Thus, a history suggesting previous birth of a large infant would be a risk factor. Maternal age over 30 years is a risk factor for gestational diabetes. Increased number of pregnancies is not a risk factor for gestational diabetes. Smoking does not alter glucose metabolism. Because of the vasoconstrictive effects of nicotine, these infants usually have a low birth weight.

Question 41. Which of the following would be the nurse's best response to a client who asks the nurse to explain the purpose of a nonstress test (NST)?

1. "It determines how the baby's heart responds to uterine contractions."
2. "The test demonstrates the fetus's response to oxytocin."
3. "The test helps to give an accurate estimate of the gestational age."
4. "The test provides information about the size of the baby."

Looking for answers(s):1
Explanation: An NST demonstrates the fetal heart response to spontaneous or induced uterine contractions, which stress the fetus by decreasing uterine perfusion. If the fetus is already compromised, the contractions may alter the heart rate. Oxytocin is not used in an NST. An NST does not give information about the gestational age or the size of the infant.

Question 42. When advising the client who wants to discontinue hormonal contraceptives in order to become pregnant, the nurse would recommend stopping the hormonal contraceptive at least 3 months before conception for which of the following reasons?


1. To allow the client's hormone levels to return to normal
2. To permit healing of the uterine scar tissue
3. To prevent teratogenic effects on the fetus
4. To promote normalization of the endometrial lining

Looking for answers(s):1
Explanation: Hormonal contraceptives inhibit the release of follicle-stimulating hormone and luteinizing hormone to prevent the release of an ovum. Therefore, these agents should be stopped for approximately 3 months before conception to allow these hormone levels to return to normal. Using hormonal contraceptives does not cause uterine scars. Although any medication may be teratogenic to the fetus, this is not the rationale for stopping hormonal contraceptives prior to conception. Hormonal contraceptives inhibit ovulation, but do not alter the endometrial lining.

Question 43. Which of the following would be included in the nurse's explanation about the natural calendar method for a client whose religious preferences prevent the use of artificial contraception?

1. Including irregular bleeding episodes as menses
2. Planning for intercourse during her fertile periods
3. Practicing abstinence for 1 year
4. Recording the menstrual cycle for several months

Looking for answers(s):4
Explanation: The calendar method is based on the fact that ovulation occurs 14 days before the onset of menses. Recording cycles is necessary to calculate the fertile period. Irregular bleeding must not be confused with menses or the calculation of the fertile period will not be accurate. Use of the calendar method for contraception relies on avoidance of sexual intercourse during fertile periods. Although periods of abstinence may be essential for the prevention of pregnancy during the accurate calculation of the fertile period, a year of abstinence is unnecessary.

Question 44. During the initial interview of a pregnant client, the nurse uses Nigele's rule to determine the estimated date of delivery (EDD). Which of the following questions would be essential to ask?

1. "On what day did your previous menstrual period stop?"
2. "What type of contraception are you using at this time?"
3. "When was the first day of your last menstrual period?"
4. "When was the last time that you had sexual intercourse?"

Looking for answers(s):3
Explanation: Nigele's rule assumes the woman has a 28-day cycle and that the pregnancy occurred on the 14th day. To calculate the EDD, the nurse must know the first day of the client's last menstrual period, add 7 days, and then subtract 3 months. Using the last day of the previous cycle and following Nigele's rule, conception would have occurred before ovulation. The question is unrelated to the determination of the EDD. Pregnancy has already been confirmed if the nurse is calculating the EDD. The client could have had intercourse after conception.



Question 45. For which of the following would the nurse be alert if the client is receiving medroxyprogesterone (Depo-Provera) injections?

1. Hepatitis B
2. Myocardial infarction
3. Venous thrombosis
4. Pelvic inflammatory disease

Looking for answers(s):3
Explanation: Medroxyprogesterone (Depo-Provera) carries an increased risk of venous thrombosis and thromboembolism. Hepatitis B is transmitted by contact with contaminated blood and body fluids. It is not associated with the use of Depo-Provera. Pelvic inflammatory disease is primarily caused by microorganisms that ascend from the vagina to the uterus and adnexa.

Question 46. When explaining to a male client about the advantages and disadvantages of vasectomy as a method of contraception, which of the following would be appropriate to include?

1. A vasectomy can be performed in the physician's office.
2. Contraception is 100% effective.Sperm in the semen are immediately eliminated.
3. Sperm in the semen are immediately eliminated.
4. Voluntary reversal is impossible.

Looking for answers(s):1
Explanation: A vasectomy is considered to be minor surgery, often performed as an outpatient procedure under local anesthesia. Although it is about 99% effective, there is an occasional failure associated with vasectomy. Sperm are not eliminated immediately from the reproductive tract. It takes almost 1 month for complete sperm elimination. Although reversal is possible, the clinical success of fertility following reversal is decreased.

Question 47. When measuring the fundal height of a client during a prenatal visit, the nurse finds the fundus at the level of the umbilicus. The nurse would document the approximate gestational age of the fetus as which of the following?

1. 10 weeks
2. 20 weeks
3. 30 weeks
4. 40 weeks

Looking for answers(s):2
Explanation: At 20 weeks' gestation, the fundus is normally at the level of the umbilicus. At 10 weeks, the fundus would be below the symphysis pubis and therefore unmeasurable. The uterus rises into the pelvis at about 12 weeks. At 30 weeks, the fundus would be above the umbilicus. At 40 weeks, the fundus would be at the level of the xiphoid process.

Question 48. Which of the following instructions would be included for a client who is scheduled to have an abdominal ultrasound?

1. Bathing with an antibacterial soap to remove bacteria from the skin
2. Drinking a quart or more of fluids 2 hours before the test and not voiding
3. Remaining in a fasting state from midnight until after the test is completed
4. Taking 2 ounces of mineral oil to facilitate bowel evacuation

Looking for answers(s):2
Explanation: A full bladder, accomplished with the intake of at least 1 quart of fluid, elevates the uterus and its contents out of the pelvis, facilitating better visualization. The full bladder also serves as a landmark in reading the ultrasound image. Ultrasonography is a noninvasive test. Bacteria on the skin will not affect the outcome. Ultrasonography does not require the client to fast. For an ultrasound, the bowel does not need to be evacuated for adequate visualization of the uterus and its contents.

Question 49. Which of the following statements by the nurse would be most appropriate for a client who smokes 1/2 to 1 pack of cigarettes per day?

1. "Here's some information on effective ways to quit smoking."
2. "Try to reduce the number of cigarettes you smoke per day."
3. "You should quit smoking immediately."
4. "Your smoking is harmful to you and to the infant."

Looking for answers(s):1
Explanation: Giving the client information on effective ways to quit smoking provides her with useful information that she may try. Although reducing the number of cigarettes per day is helpful, this does not prevent harm to the fetus—even a few cigarettes a day are too many. The client needs information about effective ways to quit smoking. Telling the client to quit smoking immediately does not provide her with the tools to quit. Merely telling the client that her smoking is harmful does not give her the necessary information or tools to quit. It is public knowledge that smoking during pregnancy is harmful to both the mother and fetus.

Question 50. A client reports swelling of her feet and hands on arising each morning. A 24-hour dietary recall reveals a salt intake in excess of 2 g/day. Which of the following should the nurse recommend?

1. Avoidance of high-sodium foods
2. Elimination of all salt from her diet
3. Request to the physician for a diuretic
4. Restriction of fluid intake

Looking for answers(s):1
Explanation: Avoiding foods high in sodium is recommended to prevent fluid retention while providing the recommended sodium requirements for pregnancy. Neither sodium nor fluid can be severely restricted without untoward effects. During pregnancy, sodium needs are slightly increased because the body water (ECF) is expanding. Therefore, elimination of all dietary salt intake is problematic. Diuretics are contraindicated in pregnancy unless they are essential for an accompanying medical problem. Water intake is essential for the expanding ECF and to facilitate renal perfusion.




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Maternal/OB drill 5 answers

MCN Test 5 –Answers & Rationales

1. Mr. And Mrs. W. recently arrived in the United States from East Asia. Mr. W. brings his wife to the hospital in late labor; his mother and Mrs. W.’s sister are also present. As the nurse directs Mr. W. to the dressing room to change into a scrub suit, Mrs. W. anxiously states, “No, he can’t come with me. Get my sister and mother-in-law.” The nurse’s best response is,
1. “I’m sorry, but out hospital only allows the father into the delivery.”
2. “I’ll ask the doctor if that’s OK.
3. “When I talk to your husband, I’m sure he’ll want to be with you.”
4. “That’s fine. I’ll show your husband the waiting area.

#4. One consideration is the East Asian husband’s lack of involment during pregnancy and birth; this is a mutually agreeable separation of men’s and women’s roles.
1. The client’s cultural background must be integrated into any management strategy; referring to policy does not ensure culturally sensitive care.
2. The nurse is responsible for assessing cultural factors and integrating strategies into the client’s plan of care.
3. Nursing profession, as the profession most involved in providing holistic care to individuals, must be knowledgeable about and skilled in values, beliefs, and health-illness practices of different cultures; omission of cultural factors is a major obstacle to providing quality care.

2. During an initial prenatal visit, a woman states that her last menstrual period began on November 21; she also reports some vaginal bleeding about December 19. The nurse would calculate that this client expected date of birth (EDB) would be:
1. July 21
2. August 28
3. September 26
4. October 1

#2. If a woman has a menstrual period every 28 days and was not taking oral contraceptives, Nagele’s rule may be a fairly accurate determiner of her predicted birth date. To use this method, begin with the first day of the last menstrual period, subtract three months, and add seven days.
To use Nagele’s rule, begin with the first day of the last menstrual period, subtract three months and add seven days.
To use Nagele’s rule, begin with the first day of the last regular menstrual period, subtract three months and add seven days; some women do experience some vaginal bleeding around the time of what would have been their next period even though they are pregnant.
3. A 24-year-old woman comes to the clinic because she thinks she is pregnant. Which of the following is a probable sign of pregnancy that the nurse would expect this client to have?
1. Fetal heart tones
2. Nausea and vomiting
3. Amenorrhea
4. Chadwick’s sign

#4. Probable signs of pregnancy are the result of physiologic changes in the pelvic organs and hormonal influences; for example, the mucous membranes of the vulva, vagina, and cervix become bluish (Chadwick’s sign) as a result of hyperemia and proliferation of cells.
Detection of fetal heart tomes is a positive sign (clearly demonstrates the presence of a fetus) of pregnancy that can be detected, with a Doppler instrument, as early as 10 weeks.
Nausea and vomiting is a presumptive symptom of pregnancy because it can be caused by factors other than pregnancy.
Amenorrhea is a presumptive symptom of pregnancy because it can be caused by factors other than pregnancy.

4. A married 25-year-old housewife is six weeks gestation and is being seen for her first prenatal visit. In relation to normal maternal acceptance of pregnancy, the nurse would expect that the client fills
1. some ambivalence now that the pregnancy is confirmed
2. overwhelmed by the thought of future changes.
3. much happiness and enjoyment in the event.
4. detached from the event until physical changes occur.

#1. During the first trimester of pregnancy, women normally experience ambivalence about being pregnant. It is estimated that around 80% of women initially reject the idea of pregnancy; even women who planned pregnancy may respond at first with surprise and shock.
Feelings of being overwhelmed by changes related to pregnancy (physical, lifestyle, etc.) are an indicator of lack of acceptance of the pregnancy and are not considered normal.
Feeling happiness and enjoyment about being pregnant does occur in some women initially; however, it is not the predominant finding.
By the end of the first trimester, most women accept pregnancy but research has not found a direct relationship between this acceptance
And the physical changes; these changes are related more to the reality of the fetus than the pregnancy.
5. A woman is entering the 20th week of pregnancy. Which normal change would the nurse expect to find on assessment?
1. Fundus just below diaphragm
2. Pigment changes in skin
3. Complaints of frequent urinatio
4. Blood pressure returning to prepregnancy level

#2. From 20-24 weeks gestation, pigment changes in skin may occur from actions of hormones. These include the linea nigra, melasma on the face, and striae gravidarum (stretch marks).
Uterine growth in pregnancy follows a pattern; by the 20th week the fundus should reach the umbilicus, at about the 38th week it is just below the diaphragm until lightening (uterus drops into true pelvis) occurs before labor.
Frequency of urination occurs in the first trimester (weeks 0-12) and again in the last trimester (weeks 28-40) from pressure of the gravid uterus on the bladder.
Blood pressure in the first 24 weeks usually decreases 5-10 mmHg systolic and 10-15 mmHg diastolic due to relaxation of the vascular smooth muscle and the formation of new peripheral vascular beds. The blood pressure usually rises to prepregnancy levels by the time labor begins.

6. Mrs. W., blood type A+, rubella negative, hemoglobin 12 g, hematocrit 35%, is a primigravida in the first trimester. During her second prenatal visit she complains of being very tired, experiencing frequent urination, and a white vaginal discharge; she also states that her nausea and occasional vomiting persists. Based on these findings, the nurse would select which of the following nursing diagnoses?
1. Activity intolerance related to nutritional deprivation.
2. Alteration in elimination related to a possible infection
3. High risk for injury related to hematologic incompatibility
4. Alteration in physiologic responses related to pregnancy

#4. All of the data stated are within the normal expected range for a first trimester pregnancy. These factors are related to hormonal changes and the growing uterus.
The findings of fatigue, nausea and vomiting, and the hemoglobin and hematocrit count are all within the norm for a first trimester pregnancy.
Frequency of urination, from pressure of the growing uterus on the bladder, and a white vaginal discharge, from increased activity of cervical and vaginal cells, are all normal findings for a first trimester pregnancy.
There are no data to support this nursing diagnosis; a blood type of 0, or if the woman was Rh negative, would increase the risk for this type of injury to the fetus

7. Ms. R. had her frequency confirmed and has completed her first prenatal visit. Considering that all data were found to be within normal limits, the nurse would plan that the next visit should be in
1. one week
2. two weeks
3. one month
4. two months

#3. In a low-risk pregnancy, the recommended frequency of prenatal visits is: every 4 weeks for the first 28 weeks, every 2 weeks until the 36th week, then every week until birth.
For low-risk pregnancy, this sequence of visits would be too frequent and unnecessary.
For a low-risk pregnancy in the early weeks, this sequence of visits would be too frequent and unnecessary.
Even in a low-risk pregnancy, this sequence of visits would be inadequate to detect danger signs of complications or administer needed care and assessments.

8. Which statement by a pregnant client would indicate to the nurse that diet teaching has been effective?
1. “The most important time to take my iron pills is during the early weeks when the baby is forming.”
2. “I don’t like milk, but I’ll increase my intake of cheese and yogurt.”
3. “I’ll be very careful about using salt while I’m pregnant.
4. “ Because I’m overweight to begin with, I can continue my weight loss diet.”

#2 To meet increased calcium needs, pregnant women need to increase their intake of dairy products or consider a calcium supplement that provides 600 mg of calcium per day; it is not necessary to drink milk.
The fetus stores iron during the last trimester of pregnancy; because of this, and other increased needs for iron during pregnancy, an additional daily supplement of 30-60 mg of ferrous salts is recommended beginning about 12 weeks gestation.
Because of the extra requirements for sodium storage in the body, sodium intake should not be restricted during pregnancy; rigid sodium restriction has been observed to lead to neonatal hyponatremia.
Although the ideal weight gain for obese pregnant women appears to be less than that recommended for normal-weight women, pregnancy is not the time to diet to lose weight; in weight loss, ketones are formed and these may lead to neurologic damage to the fetus.


9. Mrs. C., age 40, gravida 3 para 2 is eight weeks pregnant. She is a full-time office manager, states she “usually unwinds with a few glasses of wine” with dinner, smokes about five cigarettes a day, and was “surprised” by his pregnancy. After the assessment, which of the following would the nurse select as the priority nursing diagnosis?
1. High risk for an alteration in bonding related to an unplanned pregnancy
2. High risk for injury to the fetus related to advanced age.
3. Ineffective individual coping related to low self-esteem
4. Knowledge deficit related to effects of substance abuse.

#4. Evidence exists that smoking, consuming alcohol, or using social drugs during pregnancy may be harmful to the fetus.
Initially, even if the pregnancy is planned, there is an element of surprise that conception has occurred. This feeling of ambivalence does not, in itself, indicate that acceptance and normal bonding will not occur.
A major risk for the older expectant couple relates to the increased incidence of Down syndrome in children born to women over age 35 or 40; however, the risk for injury to the fetus is greater from substance abuse.
No data support this nursing diagnosis.

10. A young couple has just completed a preconception visit in the maternity clinic. Before leaving, the woman asks the nurse why she was instructed not to take any over-the-counter medications. The nurse should reply.
1. “Research has found that many of these drugs have been linked to problems with getting pregnant.”
2. “At conception, and in the first trimester, these drugs can be as dangerous to the fetus as prescription drugs.
3. “You should only take drugs that the physician has ordered during pregnancy.”
4. “Any drug is dangerous at this time; later on in pregnancy if won’t matter.”

#2. It is best to avoid any medication when planning a pregnancy and during the first trimester; the greatest potential for gross abnormalities in the fetus occurs during the first trimester, when fetal organs are first developing. The greatest danger extends from day 31 after the last menstrual period to day 71.
Problems with fertility have been linked to many areas, such as smoking, alcohol (in male infertility), and pelvic inflammatory disease; this connection has not been found with most common over-the-counter medications.
Even prescription drugs may have a teratogenic effect (cause serious defects) on the fetus; the rule to follow is that the advantage of using a particular medication must outweigh the risks.
Even thought he most dangerous time for the fetus is conception and the first trimester of pregnancy, some medications have teratogenic effects 9cause serious defects) when taken in the second and third trimesters.


11. The pregnant couple asks the nurse what is the purpose of prepared childbirth classes. The nurse’s best response would be.
1. “The main goal of most types of childbirth classes is to provide information that will help eliminate fear and anxiety.
2. “The desired goal is childbirth without the use of analgesics.”
3. “These classes help to reduce the pain of childbirth by exercise and relaxation methods.
4. “The primary aims is to keep you and your baby healthy during pregnancy and after!”

#1. All programs in prepared childbirth have some similarities; all have an educational component to help eliminate fear.
Expectant parents are taught that childbirth preparation classes do not exclude the use of analgesics but that they often reduce the amount necessary. To set childbirth without pain relief as a goal can be extremely destructive to the woman’s self-concept.
Most prepared childbirth classes do teach the mother coping strategies to deal with the pain and discomforts of birth; these may not directly reduce the pain itself and also other methods maybe used instead of exercises and relaxation, such as hypnosis.

Maintaining a healthy pregnancy with a positive outcome for mother and newborn is a goal of prenatal care by a physician, nurse midwife, or other qualified health care provider; childbirth education classes are not a substitute for this important intervention.

12. A woman in her 38th week of pregnancy is to have an amniocentesis to evaluate fetal maturity. The L/S (lecithin/sphingomyelin) ratio is 2:1. The nurse knows that this finding indicates.
1. fetal lung maturity
2. that labor can be induced.
3. the fetus is not viable
4. a non-stress test is indicated

#1. Lecithin and sphingomyelin are phosphilipids produced by the type II alveolar cells. The L/S ratio increases with gestation and a ratio of 2:1 indicates lung maturity.
An L/S ratio of 2:1 indicates lung maturity but there are several potential problems with this indicator; thus other parameters must also be measured. Meconium or blood in amniotic fluid alters the ratio and, despites a mature ratio in pregnancies complicated by diabetes, the neonate may still develop respiratory distress syndrome.
Viability refers to the fetus being capable of living outside the womb, now considered to be 25 weeks gestation due to advanced technology; L/S ratio is not used to measure viability.
A non-stress test is used to identify the fetus who may not be adapting well to the intrauterine environment; it does not indicate fetal maturity.

13. Mrs. T is having a contraction stress test (CST) in her last month of pregnancy. When assessing the fetal monitor strip, the nurse notices that with most of the contractions, the fetal heart rate uniformly slows at mid-contraction and then returns to baseline about 20 seconds after the contraction is over. The nurse would interpret the test result to be
1. negative: normal
2. reactive: negative
3. positive: abnormal
4. unsatisfactory

#3. The CST subjects the fetus to uterine that compress the arteries supplying the placenta, thus reducing placental blood flow an the flow of oxygen to the fetus; the fetus with minimal metabolic reserve will have late decelerations where the fetal heart rate does not return to the baseline until the contraction ends. Fetal compromise is therefore suggested.
In a negative normal CST there are no late decelerations occurring with contractions. This indicates fetal well-being related to uteroplacental function.
A reactive negative result refers to a normal non-stress test in which the fetal heart rate accelerates with fetal movement.
This term refers to a test that cannot be read adequately, for example, inability to stimulate at least three contractions in 10 minutes or unsatisfactory tracings related to positioning or fetal movement.

14. Mrs. P., 36 weeks gestation, is having a CST with an oxytocin IV infusion pump. After two contractions, the uterus stays contracted. The best initial action of the nurse is to
1. help the client turn on her left side.
2. turn off the infusion pump
3. wait three minutes for the uterus to relax.
4. administer prn terbutaline sulfate (Brethine)

#2. When IV oxytocin is being used to stimulate uterine contractions in a contraction stress test, the oxytocin infusion si stopped if contractions occur more often than every two minutes or last longer than 60 seconds, if uterine tetany (remains contracted) takes place, or if continued fetal heart rate decelerations are noted.
Turning a client, in late pregnancy, on her left side will relieve pressure of the gravid uterus on the inferior vena cava; it will have no effect on a contracted uterus.
A contracted uterus reduces placental blood flow and the flow of oxygen to the fetus; this condition can result in fetal hypoxia so it must be resolved immediately.
It is possible that this tocholytic drug may be given to inhibit uterine contractions, but first the cause of the contraction must be eliminated.

15. A pregnant woman, in the first trimester, is to have a transabdominal ultrasound. The nurse would include which of the following instructions
1. Nothing by mouth (NPO) from6:00 A.M. the morning of the test.
2. Drink one to two quarts of water and do not urinate before the test.
3. Come to the clinic first for injection of the contrast dye.
4. No special instructions are needed for this test.

#2. To obtain clearer images during the first trimester, women are required to drink one to two quarts of clear fluid to fill the urinary bladder and thereby push the uterus higher into the abdomen where it can be more accurately scanned.
There are not diet restrictions necessary to prepare for an ultrasound.
Ultrasound is a technique that involved the sue of high-frequency sound waves; the sound waves bounce off tissues of differing acoustic density. No contrast dye is needed.
There are special instructions needed when a woman in the first trimester is to have a transabdominal ultrasound.

16. Mrs. F., pregnant for the first time, calls the clinic to say she is bleeding. To obtain important information, the nurse should next ask,
1. “When did you last feel the baby move.”
2. “How long have you been pregnant.”?
3. “When was your pregnancy test done?”
4. “Are you having any uterine cramping?”

#2. When a pregnant woman is bleeding vaginally, the nurse should first ask her how many weeks or months pregnant she is; management of bleeding differs in an early pregnancy contrasted with bleeding in late pregnancy. Additional information would include if tissue amniotic fluid was discharged and what other symptoms, such as cramps or pain, are present.
Feeling fetal movement is a good indicator of fetal well-being in late pregnancy. If this client were in the third trimester, this would be additional information obtained.
The actual timing of a pregnancy test does not relate to the length of pregnancy; testing can be done at any time.
Careful assessment is required to determine whether the cause of the bleeding is a threatened abortion; this would include other symptoms, such as cramps or abdominal pain, that maybe present. The nurse must first determine the length of gestation.
17. Ms. Y. is hospitalized with a possible ectopic pregnancy. In addition to the classic symptoms of abdominal pain, amenorrhea, and abnormal vaginal bleeding, the nurse knows that which of the following factors in Ms. Y. history may be associated with this condition.?
1. Multiparity
2. Age under 20
3. Pelvic inflammatory disease (PID)
4. Habitual spontaneous abortions

#3. The incidence of ectopic pregnancy in the Untied States has increased by a factor of 4.9 during recent years. This is attributed primarily to the growing number of women of childbearing age who experience PID and endometriosis, who use intrauterine devices, or who have had tubal surgery.
Multiparity (having had two or more children) has not been found to be a factor in the incidence of ectopic pregnancy; infertile women treated with assisted reproductive technology are at higher risk.
The incidence of ectopic pregnancy increases with age; youth is not an individual factor.
A history of therapeutic abortions has been found to be a factor in extopic pregnancy, not spontaneous abortions (miscarriage).


18. Ms. C is being discharged after treatment for a hydatidiform mole. The nurse should include which of the following in the discharge teaching plan?
1. Do not become pregnant for at least one year.
2. Have blood pressure checked weekly for six months.
3. RhoGAM must be received with next pregnancy and delivery
4. An amniocentesis can detect a recurrence of this disorder in the future.

#1. The follow-up protocol of critical importance after a molar pregnancy is the assessment of serum chorionic gonadotropin (hCG); hCG is considered a highly specific tumor marker for gestational trophoblastic disease (GTD). The hCG levels are assayed at intervals for one year; a rise or plateau necessitates further diagnostic assessment and usually treatment. Pregnancy would obscure the evidence of choriocarcinoma by the normal secretion of hCG.
Pregnancy-induced hypertension (PIH) may be seen earlier than the usual 20 weeks of gestation when there is a molar pregnancy; after evacuation of the mole there is no need for long-term blood pressure assessment.
The administration of RhoGAM is indicated to prevent hemolytic disease of the newborn as seen in a Rh-negative pregnancy.
In a molar pregnancy, cell differentiation is halted and trophoblastic tissue proliferates; the disorder becomes evident in the first trimester. An amniocentesis, usually performed at 16+ weeks of pregnancy, is not related to this disorder.


19. Mrs. T., 40 weeks gestation, is admitted to the labor and delivery unit with possible placenta previa. On the admission assessment, the nurse would expect to find
1. signs of a Couvelaire uterus
2. severe lower abdominal pain
3. painless vaginal bleeding
4. a board-like abdomen

#3. Placenta previa, when the placenta is implanted in the lower uterine segment, often is characterized by the sudden onset of bright red bleeding in the third trimester. Usually this bleeding is painless and may or may not be accompanied by contractions.
A Couvelaire uterus can occur in severe abruptio placentae when blood extravasates into the uterine musculature and prevents contraction of the uterus after delivery.
Severe lower abdominal pain, especially in a woman in labor, can be a sign of a ruptured uterus.
This sign can be part of the classic presentation of abruptio placenta, which also includes constant abdominal pain and uterine tenderness on palpation.


20. Mrs. S., 30 weeks gestation, is being discharged to home care with a diagnosis of placenta previa. The nurse knows that the client understanding her care at home when the client states,
1. “As I get closer to my due date I will have to remain in bed.”
2. “ I can continue with my office job because it’s mostly sitting
3. “My husband won’t be too happy with this ‘no sex’ order.”
4. “I’m disappointed that I will need a cesarean section.

#3. In placenta previa, any sexual arousal is contraindicated because it can cause the release of oxytocin, which can cause the cervix to pull away from the low-lying placenta; this results in bleeding and potential jeopardy to the fetus.
For women with placenta previa whose condition is stable, but the fetus is premature, a regimen of restricted activity and bedrest is indicated.
For women with placenta previa whose condition is stable, but the fetus is premature, a regimen of restricted activity and bedrest is indicated.
In placenta previa, if the woman’s condition is stable, and the previa is less than 30% (a partial or marginal previa), a vaginal delivery may be possible with careful monitoring.


21. A teenage patient, 38 weeks gestation, is admitted with a diagnosis of pregnancy-induced hypertension (PIH). Data include: blood pressure 160/100, generalized edema, weigh gain of 10 pounds in last 2 weeks, and proteinuria of +3; the patient is also complaining of a headache and nausea. In planning care for this client, the nurse would set the following priority goal. The client will
1. demonstrate a decreased blood pressure within 48 hours
2. not experience a seizure prior to delivery.
3. maintain a strict diet prior to delivery
4. comply with medical and nutritional regimen.

#2. Preeclampsia may progress to eclampsia, the convulsive phase of PIH. Symptoms that herald the progression include headache, visual disturbances, epigastric pain, nausea or vomiting, hyperreflexia, and oliguria; classical signs of PIH also intensify.
In this disorder, placental perfusion is already compromised, decreasing maternal blood pressure can further reduce perfusion and stress the fetus; if the diastolic pressure exceeds 110 mmHg, an antihypertensive drug maybe administered.
Weight gain in advancing PIH is an indication of progressive water retention and not a sign of an inappropriate diet; a weight gain exceeding 1.5 kg per week during the third trimester is a sign of PIH.
The signs described here are indicators of progressive PIH; the data do not support noncompliance.


22. Mrs. S., 32 weeks gestation, has developed mild PIH. The nurse evaluates that the client understands her treatment regimen when the client states,
1. “it is most important not to miss any of my blood pressure medication.”
2. I will watch my diet restrictions very carefully.”
3. “I will spend most of my time in bed, on my left side.
4. “I’m happy that this only happens during a first pregnancy.

#3. Modified bedrest in the left lateral position may be advised for the client with mild PIH. This position improves venous return and placental and renal perfusion; urine output increases, and blood pressure may stabilize or decrease.
If diastolic pressure exceed 110 mmHg, an antihypertensive drug may be administered IV in more severe PIH; in PIH, placental perfusion is already compromised and lowering maternal blood pressure can further reduce perfusion and stress the fetus.
Dietary restrictions are no longer advised, and the client may follow a regular, well-balanced diet as tolerated.
Previous PIH predisposes to recurrence of PIH.


23. A pregnant client with class 3 cardiac disease is seen during an initial prenatal visit. The nurse selects which of the following priority nursing diagnoses”
1. Knowledge deficit related to self-care during pregnancy.
2. Fear, client and family, related to pregnancy outcome
3. Alteration in nutrition related to sodium-restricted diet.
4. Activity intolerance related to compromised cardiac status

#4. Once pregnancy is established, the focus of management is on minimizing any extra cardiac demands on the pregnant woman. In class 3 cardiac disease, the client experiences fatigue, palpitation, dyspnea, or angina when she undertakes less than ordinary activity. Physical activity is markedly restricted; this includes bedrest throughout the pregnancy.
Pregnant women with cardiac disease do need to learn self-care to minimize the risk of complications; this, however, does not take priority over physiologic safety.
Pregnancies with serious complications instill fear in the client and family; however, physiological needs take priority.
Pregnant women with cardiac disease are likely to be placed on a sodium-restricted diet; however, this does not take priority over the risk of cardiac decompensation.


24. The nurse includes the importance of self-monitoring of glucose in the care plan for a diabetic client planning a pregnancy. The goal of this monitoring is to prevent
1. congenital malformations in the fetus
2. maternal vasculopathy
3. accelerated growth of the fetus.
4. delayed maturation of fetal lungs.

#1. There is increasing evidence that the degree of control for an insulin-dependent diabetic woman prior to conception greatly affects the fetal outcome. Studies find that poor maternal glucose control underlies the incidence of congenital malformations in the infants of diabetic mothers.
In diabetic woman with vascular disease, White’s class D, or one who has had diabetes for at least 20 years, even careful control of glucose at this point will not prevent these cardiovascular changes.
Macrosomia, excessive fetal growth, can occur in infants of diabetic mothers from hyperinsulinism; however, this is a concern in alter pregnancy, not at conception.
Infants of diabetic mothers have a higher incidence of respiratory distress syndrome because hypersulinism has a delaying effect on fetal lung maturation; however, this is a concern in later pregnancy.


25. After a prenatal class on healthy behaviors during pregnancy, the nurse can evaluate that learning has occurred when a client states,
1. “Alcohol in the first trimester of pregnancy is very dangerous, later it’s OK.”
2. “Drinking alcohol during pregnancy is the most preventable cause of mental retardation”
3. “Alcohol is bad during pregnancy, but a little with breast feeding helps with let-down
4. “problems for the baby usually only occur with heavy drinking of alcohol.

#2. Prenatal alcohol exposure is a preventable cause of birth defects and neurodevelopmental deficits; it is the leading most preventable cause of mental retardation.
Research confirms that infants suffer more severe abnormalities the earlier alcohol consumption occurs during gestation; but alcohol consumption in late pregnancy is also associated with intrauterine growth retardation and preterm delivery.
Women should not drink any alcohol when breast feeding. It can cause drowsiness, weakness, decrease in linear growth, and abnormal weight gain in the infant; it may also decrease milk ejection.
No safe level has been determined for alcohol consumption during pregnancy.


26. Mrs. D. is 36 weeks gestation and the nurse is talking with her during a prenatal visit. Which statement indicates that Mrs. D. understands the onset of labor?
1. “I need to go to the hospital as soon as the contractions become painful.”
2. “If I experience bright red vaginal bleeding I know that I am about to deliver.”
3. “I need to go to the hospital when I am having regular contractions and bloody show.”
4. “My labor will not start until after my membranes rupture and I gush fluid.”

#3. Regular contractions coupled with bloody show suggest that cervical changes are occurring as a result of contractions.
Perception of pain with contractions is not a reliable indicator of true labor.
Bright red vaginal leading is a sign of a complication, not the onset of labor.
Rupture of membranes does not necessarily occur prior to the onset of labor.


27. Using Leopold’s maneuvers to determine fetal position, the nurse finds that Mrs. L’s fetus is in a vertex position with the back on the left side. Where is the best place for the nurse to listen for fetal heart tones?
1. In the right upper quadrant of the mother’s abdomen.
2. In the left upper quadrant of the mother’s abdomen.
3. In the right lower quadrant of the mother’s abdomen.
4. In the left lower quadrant of the mother’s abdomen.


#4. The left lower quadrant is the correct location since the back is on the left and the vertex is in the pelvis.
The right upper quadrant would be the place to auscultate if the back were on the right and the breech were in the pelvis.
The left upper quadrant would be the place to auscultate if the back were on the left and the breech were in the pelvis.
The right lower quadrant would be the place to auscultate if the back were on the right side.


28. Which of the following is the best way for the nurse to assess contractions in a client presenting to the labor and delivery area?
1. Place the client on the electronic fetal monitor with the labor toco at the fudus.
2. As the client to describe the frequency, duration, and strength of her contractions.
3. Use Leopold’s maneuvers to determine the quality of the uterine contractions.
4. Place the fingertips of one hand on the fundus to determine frequency, duration, and strength of contractions.

#4. The fingertips of one hand allow the nurse to feel when the contraction begins and ends and to determine the strength of by the firmness of the uterus.
Although the electronic fetal monitor can yield useful information as the patient continues to labor, it is not the best way for initial assessment to occur.
Self-report by the patient may be used to supplement the nurse’s assessment, but should not replace it.
Leopold’s maneuverses are used to determine fetal position prior to auscultation of heart rate. They do not provide information about contractions.


29. As the nurse assigned to Mrs. Q. you are listening to fetal heart tones. Which of the following findings would you consider abnormal for a patient in active labor?
1. A rate of 160 with no significant changes through a contraction
2. A rate of 130 with accelerations to 150 with fetal movement
3. A rate that varies between 120 and 130
4. A rate of 170 with a drop to 140 during a contraction

#4. A rate of 170 is suggestive of fetal tachycardia. A drop to 140 during a contraction represents some periodic change, which is not a normal finding.
A rate of 160 is normal. The absence of changes during contractions is a reassuring finding.
A rate of 130 is normal. Accelerations with fetal movement are a reassuring finding.
Baseline variability between 120 and 130is a normal finding.


30. Ms. K. arrives at the birthing center in active labor. On examination, the cervix is 5 cm dilated membranes intact and bulging, and the presenting part at – 1 station. Ms. K asks if she can go for a walk. What is the best response for the nurse to give?
1. “I think it would be best for you to remain in bed at this time because of the risk of cord prolapse.”
2. “It’s fine for you to walk, but please stay nearby. If you feel a gush of fluid, I will need to check you and your baby.”
3. “It will be fine for you to walk because that will assist the natural body forces to bring the baby down the birth canal.
4. “I would be glad to get you a bean bag chair or rocker instead.”

#2. Although there is always some risk of complications when membranes rupture, it is safe for Ms. K. to ambulate as long as she is rechecked if rupture of membranes occur.
Although cord prolapse can occur when the presenting part is not fully engaged, the incidence is highest with malpresentation, grand multiparity, multiple gestation, and low birthweight.
Although ambulation does support natural labor progress, this response is not the best one without anticipatory guidance.
Although the nurse may not feel comfortable allowing Ms. K. to walk, this response does not provide the client with any rationale for the nurse’s response and is therefore inappropriate.


31. Mrs. M., a primigravida, presents to the labor room with rupture of membranes at 40 weeks gestation. Her cervix is 2 cm dilated and 100% effaced. Contractions are every 10 minutes. What should the nurse include in the plan of care?
1. Allow Mrs. M. to ambulate as desired as long as the presenting part is engaged.
2. Assessed fetal heart tones and maternal status every five minutes.
3. Place Mrs. M. on an electronic fetal monitor for continuous assessment of labor.
4. Send Mrs. M. home with instructions to return when contractions are every five minutes.

#1. Ambulation will help Mrs. M.’s contractions more effectively dilate the cervix. As long as the presenting part is engaged, there is not increased risk of cord prolapse.
Assessments every five minutes are made during the second stage of labor. They are not required during the latent phase of first stage labor.
Although periodic assessments of mother and fetus are required, continuous monitoring is not indicated.
Although many patients in latent phase are sent home with instructions to return when contractions become more frequent, Mrs. M.’s ruptured membranes are a contraindication to that action.


32. Mrs. B. is in active labor at 4 cm dilated, 100% effaced, and 0 station. As she is ambulating she experiences a gush of fluid. What is the most appropriate initial action for the nurse to take?
1. Send a specimen of the amniotic fluid to the laboratory for analysis.,
2. Have Mrs. B. return to her room and place her in Trendelenburg position to prevent cord prolapse.
3. Have Mrs. B. return to her room so that you can assess fetal status, including auscultation of fetal heart tones for one full minute.
4. Call Mrs. B.’s physician because a cesarean delivery will be required.

#3. The most important nursing action after rupture of the membranes is careful fetal assessment, including fetal heart tones counted for one minute.
There is no known reason based on the available information to request amniotic fluid analysis. Therefore, not only is this not an appropriate initial action, it is not required at all.
The presenting part is at 0 station. At this station, it is unlikely that a cord prolapse would occur. Trendelenburg would be sued only if an assessment confirmed this complication.
There is no information suggesting that Mrs. B. will require operative delivery. It is more important to assess the client than anything else at this time.


33. The nurse is providing care to Ms. C. During the most recent vaginal examination the nurse feels the cervix 6 cm dilated, 100% effaced, with the vertex at – 1 station. What is the best interpretation of this information? The woman is in
1. transition with the head as presenting part not yet engaged.
2. transition with the backside as presenting part fully engaged.
3. latent phase labor with the backside as presenting part fully engaged.
4. active labor with the head as presenting part fully engaged.

#1. At 6 cm dilation and complete effacement, active labor is occurring. A station of –1 indicates that the vertex is above the ischial spines and not fully engaged.
Transition does not begin until 8 cm of cervical dilation. The vertex is the head, not backside and – 1 station is above the ischial spines and not fully engaged.
Latent phase ends by the time the cervix is 4 cm dilated. The vertex is the head, not backside and 1 – station is above the ischial spines and not fully engaged.
Although Ms. C. is in active labor with the head as presenting part, a – 1 station is not fully engaged since the head is above the ischial spines.


34. Mrs. M. is completely dilated and at +2 station. Her contractions are strong and last 50-70 seconds. Based on this information, the nurse should know that Mrs. M. is in which stage of labor?
1. First stage
2. Second stage
3. Third stage
4. Fourth stage

#2. The second stage of labor extends from complete cervical dilation to delivery of the infant.
The first stage of labor extent until the cervix is fully dilated.
The third stage of labor extends from delivery of the fetus to delivery of the placenta.
The fourth stage of labor extends from delivery placenta through the early postpartum period.


35. A 28-year primigravida is admitted to the labor room. She is 2 cm dilated, 90% effaced, and the head is at 0 station. Contractions are every 10 minutes lasting 20-30 seconds. Membranes are intact. Admitting vital signs are: blood pressure 110/70, pulse 78, respirations 16, temperature 98.80F, and fetal heart rate 144. The nurse plans to monitor
1. blood pressure and contractions hourly and fetal heart rate every 15 minutes
2. temperature, blood pressure, and contractions every 4 hours and fetal heart rte hourly.
3. contractions, effacement, and dilation of cervix, and fetal heart rte every hour.
4. contractions, blood pressure, and fetal heart rate every 15 minutes.

#1. During early labor, blood pressure and contractions should be monitored hourly and fetal heart rate every 15 minutes.
During early labor, temperature is monitored every 4 hours, blood pressure every hour and contractions every half hour to hour. Fetal hear rate is monitored every 15 minutes.
During early labor, contractions are monitored every half hour or hour, cervical effacement and dilation are assessed when there is a change in condition. Fetal heart rate is monitored every 15 minutes.
During early labor, contractions are monitored every half hour to hour and blood pressure is monitored hourly. Fetal heart rate is monitored every 15 minutes.


36. Mrs. H.’s cervix is completely dilated with the head at –2 station. The head has not descended in the past hour. What is the most appropriate initial assessment for the nurse to make?
1. Assess to determine if Mrs. H’s bladder is distended.
2. Send Mrs. H. for x-rays to determine fetal size.
3. Notify the surgical team so that an operative delivery can be planned
4. Assessed fetal status, including fetal heart tones, and scalp pH.

#1. A full bladder may prevent the head from moving down into the pelvic inlet. Often clients do not have the sensation of a full bladder late in labor, despite significant distention.
Although fetal size may contribute to failure of the head to descend, this is not the initial assessment required.
Notification of a surgical team is not an assessment. There is also no evidence that an operative delivery is required at this time.
Although continuous assessment of felt well-being is important, there is no indication for scalp pH. Therefore, these assessments are not the most appropriate ones to be made.

37. Ms. N. has been in labor for six hours. She is now 9 cm dilated and has intense contractions every one to two minutes. Ms. N. is anxious and feels the need to bear down with her contractions. What is the best action for the nurse to take?
1. Allow Ms. N. to push so that delivery can be expedited.
2. Encourage panting breathing through contractions to prevent pushing
3. Reposition Ms. N. in a squatting position to make her more comfortable.
4. Provide back rubs during contractions to distract Ms. N.

#2. Since Ms. N. is still in transition and not ready to deliver, encouraging her to pant will diminish the urge to push.
Pushing prior to complete dilation of the cervix may increase edema and make delivery more difficult.
Although a squatting position maybe useful as delivery approaches, it will not help diminish the urge to push prior to complete cervical dilation.
During transition, many women do not like to be touched, even if this action was perceived as helpful earlier in labor.

38. A newborn, at one minute after vaginal delivery, is pink with blue hands and feet, has a lusty cry, heart rate 140, prompt response to stimulation with crying, and maintains minimal flexion, with sluggish movement. The nurse should know that this newborn’s Apgar score is:
1. ten
2. nine
3. eight
4. seven

#3. This infant has two point for heart rate, respiratory effort and reflex irritability. One point is awarded for color and muscle tone for a total of eight.
A score of 10 would result if all five criteria received a maximum of two points. This infant does not have two points for color or for muscle tone.
A score of nine would result if four criteria received a maximum of two points and one received one point. This infant does not have two points for color or for muscle tone.
A score of seven would result if there was a total of three points off from the five criteria. This infant has a total of two points off.


39. Mrs. G. delivered a 7 lb boy by spontaneous vaginal delivery 30 minutes ago. Her fundus is firm at the umbilicus and she has moderate lochia rubra. Which nursing diagnosis is highest priority as the nurse plans care?
1. Risk for infection related to episiotomy
2. Constipation related to fear of pain
3. Potential for altered urinary elimination related to perineal edema
4. Knowledgeable regarding newborn care.
5.

#3. Perineal edema may affect urinary elimination. If allowed to continue, it may also lead to excessive postpartum bleeding because the uterus cannot firmly contracted when the bladder is excessively full.
Although this diagnosis may be appropriate during the postpartum period, it is not the highest priority.
Concerns about constipation are more often seen after the first 24 hours.
There is no information to suggest that this client has a knowledge deficit regarding newborn care. Even if she does, physiologic needs are of higher priority during the first hour after birth.


40. Mrs. G. is in the fourth stage of labor. She and her new daughter are together in the room. What assessments are essential for the nurse to make during this time?
1. Assess the pattern and frequency of contractions and the infant’s vital signs.
2. Assess Mrs. G’s vital signs, fundus, bladder, perineal condition, and lochia.
3. Assess Mrs. G.’s vital signs, fundus, bladder, perineal condition, and lochia. Return the infant to the nursery.
4. Assess the infant for obvious abnormalities. Assess Mrs.G for blood loss and firm uterine contraction.

#2. Assessment of the mother during fourth stage includes elements related to her recovery from childbirth. Infant assessment focuses on stability and transition to extrauterine life.
This information is not appropriate to fourth stage for the mother. She should not experience a pattern of contraction after delivery, although afterpains are a part of the involutional process. Infant assessment information is correct.
Although the information related to maternal assessment is correct, there is no reason to return the infant to the nursery.
These assessments would be appropriate during the third stage of labor.


41. Mrs. P. G3 P2, was admitted at 32 weeks gestation contracting every 7-10 minutes. Her cervix is 2 cm dilated and 70% effaced. What should the nurse include in the plan of care for this client?
1. Discuss with Mrs. P. the need to stop working after her discharge from the hospital.
2. Monitor Mrs. P. and her fetus for response to impending delivery.
3. Assess Mrs. P’s past pregnancy history to determine if she has experienced preterm labor in the past.
4. Start oral terbutaline to stop the contractions.

#3. As a G3P2, Mrs. P.’s past pregnancy history may provide some important information that may shape the care rendered at this time.
Although Mrs. P. may need to reduce her activity level if she continues with preterm labor, this is not the most appropriate plan at this time.
Although the nurse should monitor Mrs. P. and her fetus, this is not with the expectation of impending delivery.
Although tocolytic agents may be required, a physician’s order is necessary. The IV therapy is usually initiated first, with a switch to oral agents after contraction cease.


42. Mrs. P. was admitted in premature labor contracting every five minutes. Her cervix is 3 cm dilated and 100% effaced, IV magnesium sulfate at 1 g per hour is infusing. How will the nurse know the drug is having the desired effect?
1. The contractions will increase in frequency to every three minutes, although there will be no further cervical changes.
2. Mrs. P. will be able to sleep through her contractions due to the sedative of the magnesium sulfate.
3. The contractions will diminish in frequency and finally disappear.
4. Mrs. P. will have diminished deep tendon reflexes and her body pressure will decrease.

#3.If the magnesium sulfate is effective you would expect the contractions to decrease and then disappear. You would not continue to perform vaginal exams if the desired result is occurring.
Magnesium sulfate is a central nervous system depressant. Smooth muscle relaxation will occur, hence contraction will not increase in frequency
Although magnesium sulfate is a central nervous system depressant, it is not a sedative. Therefore, you would not expect Mrs. P. to fall asleep.
Although magnesium sulfate is used to treat preeclampsia, diminished deep tendon reflexes and decreased blood pressure would not tell the nurse that the drug is having the desired effect in premature labor.

43. Mrs. K. has just received an epidural for anesthesia during her labor. What should the nurse include in the plan of care because of the anesthesia?
1. Assist Mr. K. in position changes and observe for signs of labor progress.
2. Administer 500-1000 m of a sugar-free crystalloid solution.
3. Place a Foley catheter as soon as the anesthesia has been administered.
4. Offer Mrs. K. a back rub to reduce the discomfort of her contractions.

#1. Epidural anesthesia may diminish Mrs. K.’s sensation of painful stimuli and movement. Assistance and frequent assessment are therefore essential.
A bolus infusion of fluid is usually administered prior to placement of an epidural. It is not a part of the plan after administration of the anesthesia.
Although patients receiving epidural anesthesia may have difficulty in voiding, that is not a reason to place a Foley.
If the epidural is working satisfactorily, Mrs. K. should experience minimal discomfort from her contractions. Although a back rub is not contraindicated, the rationale is not correct.


44. Mrs. K. delivered her infant so three hours ago. She had an episiotomy to facilitate delivery. As a nurse assigned to care for MRS. K., which of the following would be the most appropriate action?
1. Place an ice pack on the perineum.
2. Apply a heat lamp to perineum.
3. Take Mrs. K. for a sitz bath.
4. Administer analgesic medication as ordered.

#1. Ice during the first 12 hours after delivery causes vasoconstriction and thereby prevents edema. Ice also provides pain relief through numbing of the area.
Heat is not an appropriate initial action because it may increase edema formation and does not aid the early healing process.
Although sitz baths may be used later in the course of recovery, the heat is not desirable in the first 12 hours because it may enhance edema formation.
Although analgesic agents may be required for pain relief, this is not the most appropriate action based on the information available.


45. Mrs. C. is scheduled for a cesarean section delivery due to transverse fetal lie. What is the best way for nurse to evaluate that Mrs. C. understands the procedure?
1. Ask Mrs. C. about the help she will have at home after her delivery.
2. Give Mrs. C. diagram of the body and ask her to draw the procedure for you.
3. Ask Mrs. C. to tell you what she knows about the scheduled surgery.
4.Provide Mrs. C. with a booklet explaining cesarean deliveries when she arrives at the hospital.

#3. Asking for clarification of what Mrs. C. knows is the best way to evaluate what she understands of the procedure. If the client has additional questions, the nurse can then clarify or amplify the information.
Although it is important to have some help after discharge this question will not elicit information about her understanding of the procedure.
This technique is useful in preparing young children for surgery, but is inappropriate for a normal adult.
Although written information may be helpful to explain cesarean birth, providing it at the time of admission does not allow the nurse the opportunity to evaluate that the patient understands the procedures.


46. Which of the following observations in the postpartum period would be of the most concern to the nurse?
1. After the delivery, the mother touches the newborn with her fingertips.
2. The new parents asked the nurse to recommend a good baby care book.
3. A new father holds his son in the end face position while visiting.
4. A new mother sits in the bed while her newborn lies awake in the crib.

#4. During the early postpartum period, evidence of maladaptive mothering may include limited handling or smiling at the infant; studies have shown that a predictable group of reciprocal interactions, between mother and baby, should take place with each encounter to foster and reinforce attachment.
Shortly after birth, the new mother examines her baby’s body with her fingertips looking for cues from the infant; fingertip touch causes the newborn to turn toward the touch.
Concern for ability to care for their newborn is an indicator of positive bonding and attachment.
For parents, the need for the newborn to open its eyes is nearly universal. Babies held in the face-to-face (en face) position attempt to focus on the eyes of the holder; this strongly evokes parental feeling.


47. Mrs. N. has just delivered her first baby who will breast fed. The nurse should include which of the following instructions in the teaching plan?
1. Try to schedule feedings at least every three to four hours.
2. Wash nipples with soap and water before each feeding.
3. Avoid nursing bras with plastic lining.
4. Supplement with water between feedings when necessary.

#3. Successful lactation is fostered by feeding soon after delivery and then feeding when the newborn is ready to nurse; signs of infant readiness include a wakeful state and rooting and sucking motions.
Mothers are advised to simply wash their hands before breast feeding; washing the nipples is not necessary. The use of powders, creams, and soap is discouraged.
In a normal term infant who is being breast fed, supplemental water feedings are not needed; in fact; these feedings may impede breast feeding by decreasing the volume of breast milk required and also by feeding by creating “nipple confusion” in the infant.


48. A woman’s prenatal antibody titer shows that she is not immune to rubella and will receive the immunization after the delivery. The nurse would include which of the following instructions in the teaching plan?
1. Pregnancy must be avoided for the next three months.
2. Another immunization should be administered in the next pregnancy.
3. Breast feeding should be postponed for five days after the injection.
4. An injection will be needed after each succeeding pregnancy.

#1. To prevent intrauterine infection, which can result in miscarriage, stillbirth, and congenital rubella syndrome in the fetus, women who are immunized should be advised not to become pregnant for three months.
One immunization should result in the woman becoming immune to rubella; rubella vaccine is never administered during pregnancy because of the serious dangers to the fetus.
Receiving a rubella vaccination in the postpartum period is not a contraindication to breast feeding.
One immunization should result in the woman becoming immune to rubella; another antibody titer will be done in subsequent pregnancies for validation.


49. A woman had a normal vaginal delivery 12 hours ago and is to be discharged from the birthing center. The nurse evaluates that the woman understands the teaching related to episiotomy and perineal area when she states,
1. “I know the stitches will be removed at my postpartum clinic visit.”
2. “The ice pack should be removed for 10 minutes before replacing it.”
3. “The anesthetic spray, ten the heat lamp, will help lot.”
4. “The water for the Sitz bath should be warm, about 102-1050 F.”

#2. To attain the maximum effect of reducing edema and providing numbness of the tissues, the ice pack should remain in place approximately 20 minutes and then be removed for about 10 minutes before replacing it.
Stitches used for an episiotomy are absorbable and do not require removal.
Because of the danger of tissue burns, a woman must be cautioned not to apply anethetic spray before using a heat lamp.
Recently, cool sitz baths have gained popularity because they are effective in reducing perineal edema; therefore; it may be best to offer the woman a choice.


50. Mrs. B. is bottle feeding her newborn. The nurse evaluates the client understands how to safely manage formula when Mrs. B. states,
1. “Prepared formula should be used within 48 hours.”
2. “All bottles, caps, and nipples must be sterilized.”
3. “A dishwasher is not sufficient for proper cleaning.”
4. “Prepared formula must be refrigerated until used.”

#4. Extra bottles of prepared formula are stored in the refrigerator and should be warmed slightly before feeding.
Bottles may be prepared individually, or up to one day’s supply of formula may be prepared at one time.
Cleanliness is essential, but sterilization is necessary only if the water source is questionable.
Bottles may be effectively prepared in dishwashers or washed thoroughly in warm soapy water and rinsed well; nipples should be washed and rinsed by hand.


51. Mrs. P. delivered her baby 12 hours ago. During the postpartum assessment, the uterus is found to be boggy with heavy lochia flow. The initial action of the nurse is to
1. notify the physician or nurse midwife.
2. administer prn oxytocin.
3. encourage the woman to increase ambulation.
4. massage the uterus until firm.

#4. A soft, boggy, uterus should be massaged until firm; clots may be expressed during massage and this often tends to contract the uterus more effectively.
If the uterus continues not to contract well or the bleeding is excessive, the physician or nurse midwife should be contacted; however, this is not the initial action of the nurse.
If the uterus continues to contract well or the bleeding is excessive, the physician or nurse midwife may order that oxytocin be administered; however, this is not the initial action of the nurse.
Ambulation is advised in the immediate postpartum period; however, this intervention is not related to the emergency situation described.


52. A breast feeding mother is visited by the home health nurse two weeks after the delivery. The woman is febrile with flulike symptoms; on assessment the nurse notes a warm, reddened, painful area of the right breast. The best initial action of the nurse is to
1. contact the physician for an order for antibiotics.
2. advise the mother to stop breast feeding and pumping.
3. assess the mother’s feeding technique and knowledge.
4. obtain a sample of breast milk for culture.


#1. These symptoms are signs of infectious mastitis, usually caused by Staphylococcus aureus; a 10-day course of antibiotics is indicated.
In mastitis, an improved outcome, a decreased duration of symptoms, and decreased incidence of breast abscess result if the breasts continue to be emptied by either nursing or pumping.
It is important that breast feeding technique and knowledge be assessed when mastitis has occurred because there have been found to be contributing factors for this complication; however, it is not the best initial action of the nurse.
Diagnosis and treatment of mastitis are usually based on symptoms and physical examination, even while waiting for laboratory results; if there is a recurrence of the mastitis, most experts agree that a culture should be obtained.


53. Mrs. P. had a vaginal delivery of her second child two days ago. She is breast feeding the baby without difficulty. During a postpartum assessment on Mrs. P., the nurse would expect the following normal finding.
1. Complaints of afterpains.
2. Pinkish to brownish vaginal discharge.
3. Voiding frequently, 50-57 ml per void.
4. Fundus 1 cm above the umbilicus.

#1. Afterpains occur more commonly in multiparas than in primiparas and are caused by intermittent uterine contractions. Because oxytocin is released when the infant suckles, breast feeding also increase the severity of the after pains.
Lochia (term for vaginal discharge after birth) serosa occurs from bout the third until the tenth day after delivery and would not be observed on the second day; it is a pinkish to brownish color.
Catheterization would be required when the bladder is distended and the woman cannot void or when she is voiding small amounts (<100 ml) frequently.
After birth, the top of the fundus remains at the level of the umbilicus for about half a day; it then descends approximately one fingerbreadth per day until it can no longer be palpated on about the tenth day.


54. A mother who had a vaginal delivery of her first baby six weeks ago is seen for her postpartum visit. She is feeling well and is bottle feeding her infant successfully. During the physical assessment, the nurse would expect to find the following normal data.
1. Fundus palpated 6 cm below the umbilicus.
2. Breasts tender, some milk expressed.
3. Striae pink but beginning to fade.
4. Creamy, yellow vaginal discharge.

#3. At two weeks postpartum, striae (stretch marks) are pink and obvious; by six weeks they are beginning to fade out but may not achieve a silvery appearance for several more weeks.
The uterus is no longer palpable abdominally by 10 days to two weeks postpartum.
In a non-nursing mother; breasts wound not be tender and no milk would be expressed by two weeks postpartum.
The final discharge, termed lochia alba, is creamy or yellowish and persists from about the tenth day to two to three weeks after delivery; by six weeks, there would be no vaginal discharge or menses may be resumed.


55. A nurse collects the following data on a woman 26 hours after a long labor and a vaginal delivery: temperature 1010 F (38.30 C), blood pressure 110/70, pulse 90, some diaphoresis, output 1000 ml per eight hours, ankle edema, lochia moderate rubra, fundus 1 cm above umbilicus and tender on palpation. The client also asks that the infant be brought back to the nursery. In the analysis of this data, the nurse would select which of the following priority nursing diagnoses?
1. Alteration in parenting related to material discomfort.
2. High risk for injury related to spread of infection.
3. Fluid volume excess related to urinary retention.
4. Knowledge deficit related to uterine subinvolution.

#2. The classic definition of puerperal morbidity resulting from infection is a temperature of 100.40F (38.00C) or higher on any of the first 10 days postpartum exclusive of the first 24 hours; additional signs are increased pulse rate, uterine tenderness, foul-smelling lochia, and subinvolution (uterus remains enlarged.)
The postpartum client needs additional rest and an isolated request for the newborn to be cared for in the nursery should not be interpreted as an alteration in parenting or bonding.
In the first 48 hours after birth, a postpartum diuresis takes place and the woman will frequently urinate as much as 3000 ml per day; there may also be profuse sweating (diaphoresis) and gradually diminishing of edema of the extremities.
After delivery, the uterus should descend below the umbilicus at the rate of 1-2 cm per day; failure to do so may be termed subinvolution and the cause must be determined. The client’s lack of knowledge about this condition would not be the first priority.


56. Which of the following findings in three-hour-old, full-term newborn would the nurse record as abnormal when assessing the head?
1. Two “soft spots” between the cranial bones.
2. Asymmentry of the head with overriding bones.
3. Head circumference 32 cm, chest 34 cm.
4. A sharply outlined, spongy area of edema.

#3. The circumference of the newborn’s head should be approximately 2 cm greater than the circumference of the chest at birth and will remain in this proportion for the next few months. Any differences in head size may indicate microcephaly (abnormal smallness of head) or hydrocephalus (Increased cerebrospinal fluid within the ventricles of the brain).
Two “soft spots” (fontanels) may be palpated on the newborn’s head. These are openings at the juncture of the cranial bones; the anterior fontanel closes within 18 months, the posterior fontanel within 8-12 weeks.
The head may appear asymmetric in the newborn of a vertex delivery. This is called molding and is caused by overriding of the cranial bones during labor and birth; it diminishes within a few days.
Caput succedaneum is a localized, easily identifiable soft area of the scalp, generally resulting from a long and difficult labor or vacuum extraction; the fluid is reabsorbed within 12 hours to a few days after birth.


57. The nurse collects the following data while assessing the newborn: color pink with bluish hands and feet, some pale yellow papules with red base over trunk, small white spots on the nose, and a red area at the nape of the neck. The nurse’s next action would be to
1. document findings as within a normal range.
2. isolate infant pending diagnosis.
3. request a dermatology consultation.
4. document as indicators of malnutrition.


#1. These findings of acrocyanosis (bluish discoloration of the hands and feet), erytheeema toxicum (newborn rash), milia, and a nevus flammeus (port wine stain) are all within the normal range for a full-term newborn.
The findings described do not indicate that the infant has an infectious condition that would require isolation.
The findings described do not require further medical intervention.
Intrauterine malnutrition is mainly manifested by low birth weight and internal physiologic changes.


58. While performing the discharge assessment on a two-day-old newborn, the nurse finds that after blanching the skin on the fore head, the color turns yellow. The nurse knows that this indicates
1. a normal biologic response.
2. an infectious liver condition.
3. an Rh incompability problem.
4. jaundice related to breast feeding.

#1. Physiologic jaundice occurs after the first 24 hours of life and is caused by accelerated destruction of fetal blood cells (RBCs), impaired conjugaion of bilirubin, and increased reabsorption from the intestinal tract; there is no pathologic basis.
Hepatitis B virus (HBV), if transmitted to the fetus, increases the risk of prematurity and perinatal morbidity; infants who subsequently test positive for HBV surface antigen are rarely symptomatic.
Hemolytic disease of the newborn caused by Rh incompatibility with the mother’s blood may cause jaundice that most often appears at birth or in the first 24 hours of life.
Breast feeding jaundice, found in 1-5% of newborns being breast fed, appears after the first week of life when the mother’s mature milk has come in.


59. Baby Y. is two-days-old and is being breast fed. The nurse finds that yesterday her stool was thick and tarry, today it’s thinner and greenish; she voided twice since birth with some pink stains noted on the diaper. The nurse knows that these findings indicate
1. marked dehydration.
2. inadequate initial nutrition.
3. normal newborn elimination.
4. a need for medical consultation.

#3. Normal tern newborns pass meconium within 8-24 hours of life; meconium is formed in utero and is thick, tarry, black (or dark green) in appearance. Transitional stool is a thinner brown to green. Normal voiding is two to six times daily; there may be innocuous pink stains (“brick dust spots”) on the diaper from urates.
Dehydration in a newborn may be indicated by an increased temperature or a depressed fontanel; normal urinary output is often limited and the voidings may be scanty.
Following birth, caloric intake is often insufficient for weight gain and during this time there may be a weight loss of 5-10%; normal newborn elimination criteria takes this phenomenon into consideration.
The findings described here do not indicate a need for medical interventions.


60. The nurse notes the following behaviors in a six-hour-old, full-term newborn: occasional tremors of extremities, straightens arms and hands outward and flexes knees when disturbed, toes fan out when heel is stroked, and tries to walk when held upright. The nurse knows that these to walk when held upright. The nurse knows that these findings indicate
1. signs of drug withdrawal.
2. abnormal uncoordinated movements.
3. asymmetric muscle tone.
4. expected neurological development.

#4. Tremors are common in the full-term newborn; when a newborn is startled s/he will exhibit the Moro reflex, that is, s/he will straighten arms and hands outward while the knees flex; in a newborn the Babinski reflex is displayed by a fanning and extension of the toes (in adults the toes flex); and when held upright with feet lightly touching a surface, the newborn will put one foot in front of the other and “walk”.
The signs of drug withdrawal include hyperactivity, hyperirritabiity (persistent high-pitched cry), exaggerated tremors and reflexes, and seizures.
The movements of a newborn are normally uncoordinated; the findings described are not ones of uncoordination.
When awake the newborn may exhibit purposeless, uncoordinated bilateral movements of the extremities, if asymmetric (one-sided) neurologic dysfunction should be suspected; these are not the type of movements described.


61. While assessing a newborn, the nurse notes that the areola is flat with less than 0.5 cm of breast tissue. The finding indicates
1. that infant is male.
2. maternal hormonal depletion.
3. intrauterine growth retardation.
4. preterm gestational age.

#4. At term gestation, the breast bud tissue will measure between 0.5 and 1 cm (5-10 mm.)
At birth, both male and female newborns may have enlarged breasts from maternal estrogen; decreased breast tissue would not be expected in either male or female.
Maternal hormonal influences may cause the newborn’s breast to become engorged, but not reduced in size.
Intrauterine growth retardation (IUGR), or an infant who is small-for-gestational age (SGA), is a newborn at or below the tenth percentile for weight on the newborn classification chart.


62. The nurse’s initial care plan for the full-term newborn includes the nursing diagnosis “risk of fluid volume depletion related to absence of intestinal flora.” A related nursing intervention would be to
1. administer glucose water or put to breast.
2. assess first void and passing of meconium.
3. administer vitamin K injection.
4. send cord blood to lab for Coomb’s test.

#3. The newborn is at a high risk for hemorrhage due to an absence of intestinal flora (bacteria). Vitamin K, needed for the formation of prothrombin and proconvertin for blood coagulation, is usually synthesized by these bacteria in the colon; however, they are absent in the newborn’s sterile gut. This problem is prevented by the administration of vitamin K following birth.
Newborns should be fed by bottle or breast shortly after birth; however, this is not related to the newborn’s lack of intestinal flora.
Usually the first void and passing of meconium is noted in the first 24 hours of life and should be documented by the nurse; this is not related to the listed nursing diagnosis.
A Coomb’s test is performed on a newborn’s cored blood if hemolytic disease of the newborn is suspected, as I Rh incompatibility; this is not related to the listed diagnosis of fluid depletion.


63. In the time immediately following birth, the nurse may delay instillation of eye medication primarily to
1. check prenatal record to determine if prophylatic treatment is needed.
2. ensure that initial eye saline irrigation is completed.
3. enable mother to breast feed the infant in the first hour of life.
4. facilitate eye contact and bonding between parents and newborn.

#4. The initial parental-newborn attachment period can be enhanced if the care providers keep routine investigations to a minimum, delay instillation of ophthalmic antibiotic for one hour, keep the room dim, and provide privacy; eye prophylaxis medication can cause chemical conjunctivitis, which may interfere with the baby’s ability to focus on the parent’s faces.
Prophylactic eye treatment for Neisseria gonorrhoea, which may have infected the infant of an infected mother during the birth process, is legally required for all newborns.
Before instillation of ophthalmic ointment, the eyes should be gently cleaned with a moist cotton ball; irrigations, before or after medication administration, should not be done.
Breast feeding of newborns should be encouraged as soon as possible after birth; however, this is not a reason to delay eye prophylaxis.


64. The nurses should include which of the following instructions in the care plan for a new mother who is breast feeding her full-term newborn?
1. Put to breast when infant shows readiness to feed.
2. Breast feed infant every three to four hours until discharge.
3. Offer water feedings between breast feedings.
4. Feed infant when he knows hunger by crying.

#1. It is important for the new mother to learn and respond to her infant’s early feeding cues. Early cues that indicate a newborn is interested in feeding include hand-to-hand or hand-passing-mouth motion, whimpering, sucking, and rooting.
In the past it was typical to establish artificial, every three to four hour schedules for feeding after the initial feeding; this schedule failed to recognize the individual needs of the newborn infant and presented difficulties for the new mother just establishing lactation.
Using supplementary bottle feedings for the breast feeding infant may weaken or confuse the sucking reflex or decrease the infant’s interest in nursing; bottles should be avoided until breast feeding is well established.
Crying is a late sign of hunger, it has also been shown to delay the transition to extrauterine life by causing unoxygenated blood to be shunted into systemic circulation through the foramen ovale and ductus arteriosus.


65. In the delivery area, after ensuring that the newborn has establishes respirations, the next priority of the nurse should be to
1. perform the Apgar score.
2. place plastic clamp on cord.
3. dry infant and provide warmth.
4. ensure correct identification.

After birth, the first priority is to maintain respirations, the second priority is to provide and maintain warmth; the newborn’s temperature may fall 2-300C after birth due mainly to evaporative losses; this triggers cold-induced metabolic responses and heat production.
The Apgar score, an immediate evaluation of the newborn’s physical condition, is rare one minute after birth and again in five minutes; however, it is not the second priority of care.
The cord is clamped with two Kelly clamps and then cut at delivery; it is not a priority to replace the clamps with a plastic clamp immediately.
To ensure correct identification, the nurse places ID bands on the mother and infant before they leave the birth area; however, this is not the second priority of care.


66. During the bath demonstration, Mrs. A. asks the nurse if it is OK to use baby powder because warm weather is coming. The nurse should respond
1. “Just dust in on the diaper area only.”
2. “It’s best not to use powder on infants.”
3. “ First use baby oil, then the powder.”
4. “If the baby is just in a diaper he’ll be cool.”

#2. Powders and oils are not recommended for the neonate’s skin; oils may clog the pores, and the small particles of powders may be inhaled by the neonate.
Powders are not recommended for the neonate because the small particles may be inhaled.
Powders and oils are not recommended for the neonate’s skin; oils may clog the pores, and the small particles of powders may be inhaled by the neonate.
Even in a hot environment, an infant should have a layer of clothing, so excess moisture will be absorbed and the body cooled.


67. Which of the following muscles would the nurse choose as the preferred site for a newborn’s vitamin K injection?
1. Gluteus medius.
2. Mid-deltoid.
3. Vastus lateralis.
4. Rectus femoris.

#3. The middle third of the vastus laterals muscle in the thigh is the preferred site for an intramuscular injection in the newborn.
Children below the age of three do not have sufficient muscle development in the gluteal muscle group (buttocks) to withstand injections at this site.
Children below the age of three do not have sufficient muscle development in the deltoid muscle group (upper arm) to withstand injections at this site.
The middle third of the rectus femoris in the thigh is an alternate site, but its proximity to major vessels and the sciatic nerve necessitates caution in using this site for injections in the newborn.


68. The nurse knows that Mrs. T. understands proper cord care for her newborn when the client
1. views a videotape on newborn hygiene care.
2. reads a booklet on care of the newborn’s cord stump.
3. says she will apply Bacitracin ointment three times per day.
4. cleans the cord and surrounding skin with an alcohol pad.

#4. Before discharge, parents should demonstrate proper cleaning of the cord stump by wiping it with an alcohol pad; they should know to do this two to three times a day until the cord falls off in 7-14 days.
Viewing a videotape does not indicate that learning or understanding has occurred.
Reading a booklet does not indicate that learning or understanding has occurred.
Various preparations such as triple dye, Betadine, and Bacitracin are used for newborn cord care in nurseries to promote drying and provide a bactericidal effect; this is not necessary after discharge.


69. The nurse knows that more instruction on care of the circumcised infant is needed when the mother states,
1. “I know to gently retract the foreskin after the area is healed.”
2. “At each diaper change I will squeeze water over the penis and pat dry.”
3. “I know not to disturb the yellow exudates that will form.”
4. “For the first day or so I’ll apply a little A&D ointment.”

#1. A circumcision is the surgical removal of the prepuce or foreskin from the tip of the penis; any foreskin that remains should not be retracted.
The parents should be instructed to squeeze water gently over the penis and pat it dry after each diaper change for two to three days or until healing has occurred.
A whitish yellow exudates that adhere to the glans is granuation tissue and should not be removed.
After the circumcision, A&D ointment is placed on the penis to keep the diaper from adhering to the site; new ointment is applied at each diaper change for at least 24-48 hours.


70. The nurse knows that Ms. Y. has a basic understanding of bottle feeding her infant when the client states,
1. “I know not to prop the bottle until my baby is older.”
2. “With these bottles, he should be able to finish them.”
3. “When I hold the bottle upside down, drops of milk should fall.”
4. “I should burp the baby about every 5-10 minutes.”

#3. The nipple should have a hole big enough to allow milk to flow in drops when the bottle is inverted; too large an opening may cause regurgitation, too small an opening can exhaust and upset the infant.
Bottles should always be held, not propped, positional otitis media may develop when the infant is fed horizontally because milk and nasal mucus may occlude the Eustachian tube.
Parents should be encouraged to avoid overfeeding or feeding infants everytime they cry; infants should be allowed to set their own pace once feedings are established.
The infant should be burped at intervals, preferably at the middle and end of the feeding; too frequent burping may confuse a newborn who is attempting to coordinate sucking, swallowing, and breathing simultaneously.


71. Baby G. weighs 1450 g, has weak tone, with extremities extended position while at rest. The pinna is flat and does not readily recoil. Very little breast tissue is palpable. The soles have deep indentations over the upper one-third. Based on these data, what should the nurse know about Baby G.’s gestational age?
1. Full-term infant, 38-42 weeks gestation.
2. Premature infant, less than 24 weeks gestation.
3. Premature infant, 29-33 weeks gestation.
4. Post-term infant greater than 42 weeks gestation.

#3. A birth weight of 1450 g is the mean weight for an infant at 30 weeks gestation, but falls within the 10-90th percentiles for infants between 29 and 33 weeks gestation. The diminished muscle tone and extension of extremities at rest are also characteristic of this gestational age. The sole creases described are actually most characteristic of an infant between 32 and 34 weeks gestation.
Full-term infants generally have birth weights of greater than 3000 g, with a range of 2700-4000 g.
The infant cannot be less mature than 24 weeks gestation on all of the assessment data presented. Generally, at less than 24 weeks gestation, weight would be 500-700 g at most, breast tissue would be absent, and the areola might not be discernible. Sole creases would not be present.
The post-term infant would be expected to weight at least 2700 g, be tightly flexed at rest, and have abundant sole creases, large and well-defined breast buds, and a pinna that readily recoils.


72. A premature infant at six hours old, has respirations of 64, mild nasal flaring, and expiratory grunting. She is pink in room air, temperature is 36.50 C. The baby’s mother raptured membranes 36 hours prior to delivery. Which measures should the nurse include in the plan of care?
1. Have respiratory therapy set up a respirator since respiratory failure is imminent. Get blood gases every hour.
2. Encourage mother/infant interaction. Rooming in as soon as stable. Monitor vital signs every eight hours.
3. Observe the signs of sepsis. Cultures if ordered. Monitor vital signs at least every two hours for the first 24 hours. Encourage family interaction with infant.
4. Radiant warmer for first 48 hours. Vital signs every hour. Restrict visitation due to risk of infection.

#3. Prolonged rupture of membranes places this premature infant at risk for sepsis. Frequent monitoring of vital signs; color, activity level, and overall behavior is particularly important because changes may provide early cues to a developing infection. Family interaction with the infant should always be a part of the nursing plan.
Although the infant is exhibiting signs of mild respiratory distress, there is no sign that respiratory failure is imminent. Blood gas frequency is determined by physician order.
Although the infant will probably do very well, she must be monitored more frequently than every eight hours. Rooming in would not be a priority at this time.
Although the infant has some mild hypothermia, there is no evidence that a warmer will be needed for 48-hours. Vital signs should be monitored frequently, but are not required on an hourly basis. Limitation of visitors with obvious infections may be appropriate; however, restrictions are not needed.


73. During the assessment of two-day-old infant with bruising and cephalhematoma, the nurse notes jaundice of the face and trunk. The baby is also being breast fed. Bilirubin level is 10 mg/dl. What is the most likely interpretation of these findings?
1. Hyperbilirubinemia due to the bruising and cephalhematoma.
2. Pthologic jaundice requiring exchange transfusion.
3. Breast milk jaundice.
4. Hyperbilirubinemia due to blood group incompatibility.

#1. Although hyperbilirbinemia is common in newborns, certain factors increase the likelihood of early appearance of visible jaundice. Cold stress, brushing at delivery, cephalhematoma, asphyxiation, prematurity, breast feeding, and poor feedings are all factors that may lead to hyperbilirubinemia in otherwise normal infants.
Although jaundice at this age may be pathologic, exchange transfusion is reserved for situations that cannot be managed with more conservative measures such as continued monitoring, supplemental feeding, an/or phototherapy first.
Although the infant is being breast fed, true breast milk jaundice does not develop until four to seven days after birth.
There is no information to suggest blood group incompatibility.

74. A six-hour-old newborn has been diagnosed with erythroblastosis fetalis. The nurse understands that this condition is caused by
1. ABO blood group incompatibility between the father and infant.
2. Rh incompatibility between the mother and infant.
3. ABO blood group incompatibility between the mother and infant.
4. Rh incompatibility between father and infant.

#2. Erythroblastosis fetalis results when an Rh negative woman makes antibodies against her Rh positive fetus. The antibodies attack fetal red cells.
Although ABO blood group incompatibility may lead to jaundice, it does not result in erythroblastosis fetalis. Blood group incompatibility between father and infant will not produce problems for the infant.
ABO incompatibility will not lead to erythroblastosis fetalis although it may result in fetal hemolysis and jaundice of the newborn.
Although erythroblastosis is an Rh-related disorder, it is not produced by any relationship between the father’s and infant’s blood types.


75. Mrs. K. is an Rh negative mother who has just given birth to an Rh positive infant. She had a negative indirect Coombs’ test at 38 weeks gestations and her infant had a negative direct Coombs’ test. What should the nurse know about these tests?
1. Although Mrs. K.’s infant is Rh positive, she has no antibodies to the Rh factor. RhoGAM should be given.
2. Mrs. K. has demonstrated antibodies to the Rh factor. She should not have any more children.
3. Mrs. K. has formed antigens against the Rh factor. RhoGAM must be given to the infant.
4. Since Mrs. K.’s infant is Rh positive, the Coombs’ tests are meaningless.

#1. Since the indirect and direct Coomb’s tests were negative, antibodies to Rh have not developed. Mrs. K. should have RhGAM to prevent antibody formation.
Negative tests indicate that antibodies have not developed to the Rh factor.
Rh is an antigen. If Mrs. K. was sensitized, she would have developed antibodies to the Rh antigen. RhoGAM would be given to the mother to prevent antibody development.
The Coomb’s test indicate the presence or absence of antibodies to the Rh antigen. Since Mrs. K. is Rh negative and her infant is positive, these tests are important.


76. Baby G. was born at 38 weeks gestation to a heroin-addicted mother. At birth, baby G. had Apgar scores of 5 at one minute and 6 at five minutes. Birthweight was at 10th percentile for gestational age. What should the nurse include in Baby B.’s plan of care?
1. Administer methadone to diminish symptoms of heroin withdrawal.
2. Promote parent-infant attachment by encouraging rooming-in.
3. Observe for signs of jaundice because this is a common complication.
4. Place in a quiet area of the nursery and swaddle with hands near mouth to promote more organized behavioral state.

#4. Neonatal withdrawal is a common occurrence in heroin addition. Placing Baby G. in a quiet area and swaddling may promote state organization and minimize some symptoms. Medications may be needed to control hyperirritability.
Although neonatal withdrawal may be a problem, methadone is contraindicated because it may cause addiction in the newborn.
Although parent-infant attachment is important, this infant is not stable enough for rooming-in.
Infants born to hereoin-addicted mothers experience early liver maturation and a lower incidence of jaundice than other newborns.


77. Baby L. is a 36-week-gestation infant who had tachypnea, nasal flaring, and intercostals retractions that increased over the first six hours of life. Baby l. was treated with IV fluids oxygen. Which of the following assessments suggests to the nurse that Baby L. was improving?
1. Baby L. has see-saw respirations with coarse breath sounds.
2. Baby L.’s respiratory rate is 50 and pulse is 136, no nasal flaring is observed.
3. Baby l. has a pH of 6.97 and pO2 of 61 on 40% oxygen.
4. Baby L. has gained 150 g in the 12 hours since birth.

#2. Baby L.’s respiratory rate and pulse are within normal limits and the nasal flaring is no longer present.
See-saw respirations and coarse breath sounds suggest that Baby L., continues with significant respiratory distress.
A pH of 6.97 suggests significant acidosis. A pO2 of 61 on 40% oxygen is suggestive of significant hypoxia. Neither of these findings suggests improvement.
A weight gain of 150 g in the first 12 hours of life is suggestive of edema. Edema often accompanies


78. You are caring for an infant. During your assessment you note a flattened philtrum, short palpebral fissures, and birth weight and head circumference below the fifth percentile for gestation age. The infant has a poor suck. Which of the following is the best interpretation of this data?
1. Down syndrome.
2. Fetal alcohol syndrome.
3. Turner’s syndrome.
4. Congenital syphilis.

#2. Although a medical diagnosis cannot be made from the assessment data, all of the findings noted are commonly seen in infants with fetal alcohol syndrome.
Infants with Down syndrome do not exhibit the flattened philtrum or short palpebral fissures. Most do not manifest any growth abnormalities at birth.
Turner’s syndrome is very rarely identified in infants due to the limited manifestations until later in childhood.
Although infants with congenital syphilis may have intrauterine growth retardation, the other symptoms described are not usually present.


79. A two-week-old premature infant with abdominal distention, significant gastric aspirate prior to feeding, and bloody stools ha also had episodes of apnea and bradycardia and temperature instability. What should the nurse include in the plan care for this infant?
1. Increase feeding frequency to every two hours.
2. Place the infant to seizure precautions.
3. Place the infant in strict isolation ti prevent infection of other infants.
4. Monitor infant carefully including blood pressure readings and measurements of abdominal girth.

#4. The infant’s prematurity is the major risk factor for necrotizing enterocolitis, which effects 1-15% of all infants in NICU. Usual nonsurgical treatment includes antibiotic therapy, making the infant NPO, frequent monitoring and respiratory and circulatory support as needed.
The infant described most likely has a condition known as necrotizing enterocolitis. In this situation the infant is placed NPO. Continued feedings may lead to perforation of the intestines.
The infant described most likel has a condition known as necrrotizing enterocolitis. These infants are not at increased risk for seizures, hence, seizure precautions are not needed.
Necrotizing enterocolitis is not directly transmitted from one infant to the next; therefore, isolation is not required.


80. Mrs. L. is taking her newborn home from the hospital at 18 hours after birth. As the nurse giving discharge instructions, which response by Mrs. L. best her understanding of PKU testing?
1. “I know you stuck my baby’s heel today for the PKU test and that my doctor will recheck the test when I bring her for her one month appointment.”
2. “After I start my baby on cereal, I will return for a follow-up blood test.”
3. “I will have a visiting nurse come to the house each dayfor the first week to check the PKU test.”
4. “I will bring my baby back to the hospital or doctor’s office to have a repeat PKU no later than one week from today.”

#4. One additional PKU test within the first week of life will validate whether PKU disease is present. The infant should have been on breast milk or formula for 48 hours prior to the test.
Although Mrs. . understand that one test has already been done, waiting until one month of age would be too late if the infant had this disorder.
PKU is a disease of abnormal protein metabolism. Waiting until the infant starts cereal would be of no use. If PKU exists, the milk feedings of the first months of life would produce brain damage.
The PKU test needs to be repeated only once after the infant has been on milk feedings for at least 48 hours.


81. Mr. and Mrs. A. have come to your clinic because they have not been able to achieve a pregnancy after trying for two years without using any form of birth control. Which of the following tests could determine that Mrs. A is ovulating regularly?
1. Hysterosalpingogram.
2. Serial basal body temperature graph.
3. Postcoital test.
4. Semen analysis.

#2. Serial basal body temperature graphs are a baseline for determining when ovulation has taken place during a menstrual cycle. If ovulation has occurred, the temperature will be higher the second half of the cycle and lower the first half.
Hysterosalphingogram is an X-ray visualization of the uterus and fallopian tubes with the aid of a dye to determine tubal patency.
The postcoital test determines the effects of the cervical environment on the sperm.
Semen analysis determines the number, motility, and condition of sperm at ejaculation.


82. Mrs. J. is preparing to take Clomid to induce ovulation so she can have an in vitro fertilization. She asks if she should expect any side-effects from the drug. Your best answer should include which of the following?
1. Weight gain with increased appetite and constipation.
2. Tingling of the hands and feet.
3. Alopecia (hair loss).
4. Stuffy nose and cold-like symptoms.

#1. Weight gain associated with increased appetite and constipation are fairly common side-effects of Clomid.
There is no connection between Clomid and changes in sensation of hands and feet.
Alopecia is associated with chemotherapy not ovulatory therapy.
Stuffy nose and cold-like symptoms are associated with allergies, not Clomid.


83. Mr. and Mrs. M. have been using a diaphragm for contraception. Which of the following statements indicates they are using it correctly?
1. “We use K-Y jelly around the rim to help with insertion.”
2. “I wash the diaphragm each time and hold it up to the light to look for any holes.”
3. “I take the diaphragm out about one hour after the intercourse because it feels funny.”
4. “I dounche right away after intercourse.”

#2. The diaphragm should be washed and dried and inspected for holes before being put away.
A spermicide should be used in the center of the diaphragm as well as around the rim for added protection as well as insertion ease.
The diaphragm should be left in place six hours after intercourse. If it feels “funny” it should be checked by the healthcare provider for proper fit.
Douching, even with the diaphragm in place, will lessen its effectiveness. Douching after intercourse is unnecessary.


84. Mrs. B., who is 25-years old, wishes to take oral contraceptives. When taking her history, which of the following questions would determine if she is an appropriate candidate for this form of birth control?
1. “Do you currently smoke cigarettes and, if so, how many?”
2. “Have you had any recent weight gain or loss?”
3. “Do you douche regularly after intercourse?
4. “Is there any family history of kidney or gallbladder disease?”



#1. Cigarette smoking significantly increases a woman’s risk for circulatory complications and may contraindicate oral contraceptive use.
Weight gain or loss is insignificant for oral contraceptive users but important for diaphragm users.
Douching is unrelated to oral contraceptive use but may indicate a lack of knowledge regarding other forms of birth control.
Kidney or gallbladder disease is not a contraindication for oral contraceptive use, although diabetes, liver disease, and heart disease are.


85. Ms. K., who is 18-weeks pregnant, is scheduled for saline injection to terminate her pregnancy. She asks the nurse what she should expect. Your best answer is,
1. “Contractions will begin immediately after the instillation of saline and will be mild.”
2. “An amniocentesis will be performed with amniotic fluid removal and saline replacement.”
3. “A tube will be inserted through the cervix and warm saline will be administered by continuous drip.”
4. “The baby will be born alive but die a short time later.”

#2. The procedure begins with an amniocentesis where amniotic fluid is withdrawn and replaced with saline solution.
Contractions begin 24-48 hours after saline is administered and then contractions are very strong.
Insertion of fluid through the cervix is done for amnioinfusion, not saline injection.
Saline injection causes death to the fetus before contractions begin, usually in one to two hours.


86. Mrs. C. comes to the office complaining of the following symptoms: fatigue, weight gain, pelvic pain related to menstruation, heartburn, and constipation. Which of the above symptoms might indicate a diagnosis of endrometriosis?
1. Weight gain and fatigue.
2. Heartburn.
3. Constipation.
4. Pelvic pain related to menstruation.

#4. Pelvic pain related to menstruation is the most common symptom of endometriosis. The pain usually ends following cessation of menses.
Weight gain and fatigue have no relationship to endometriosis.
Heartburn has no relationship to endometriosis, which is bleeding of endometrial tissue located outside the uterus.
Some women complain of pain with defecation, but not constipation.


87. Miss D. has been diagnosed with Candida albicans. Which of the following types of vaginal dioscharge would you expect to find?
1. Thin, greenish yellow with foul odor.
2. Either a yellowish discharged or none at all.
3. Thick and white. Like cottage cheese.
4. Thin, grayish white with a fishy odor.

#3. Thick, white cottage cheese-like discharge is consistent with Candida albicans
Thin, greenish yellow discharge with a foul odor is consistent with trichomoniasis.
Yellowish discharge or no discharge is consistent with gonorrhea.
Thin, grayish white discharge with a fishy odor is consistent with bacterial vaginosis.


88. Mrs. G. has just been diagnosed with genital herpes for the first time. You can expect which of the following treatments to be part of her plan of care?
1. Vaginal soaks with saline to keep the area moist.
2. acyclovir 200 mg five times daily for 7-10 days.
3. Ceftriaxone 125 mg IM times 1 dose.
4. Topical application of podophyllin to the lesions.

#2. This is the correct drug and dosage for an initial infection of genital herpes.
The area should be kept as possible to promote drying of the lesions.
This is an antibiotic and is used as part of the treatment for gonorrhea.
Podophyllin is used to remove venereal warts (condyloma acuminata)


89. Mrs. E. is 10 weeks pregnant and tested positive for syphilis but has no symptoms. She asks you why she needs to be treated since she feels fine? Your best response to her would include which of the following?
1. “Syphilis can be transmitted to the baby and may cause it to die before birth if you are not treated.”
2. “If you do not receive treatment before the baby is born, your baby could become blind.”
3. “If syphilis is untreated, the baby may be mentally retarded at birth.”
4. “Syphilis may cause your baby to have a heart problem when it is born.”

#1. Syphilis is associated with stillbirth, premature birth, and neonatal death.
Blindness in infants is most often caused by untreated gonorrhea when prophylactic eye care is not given.
Mental retardation is associated with cytomegalovirus but not syphilis.


90. Miss H. has been diagnosed with fibrocystic breast disease. Which of the following should be included in the teaching plan for her?
1. Limiting breast self-examinations to every three because it may be painful.
2. Wearing a bra as little as possible because pressure on the breast may be painful.
3. Limiting caffeine and salt intake.
4. Using heat to the tender areas of the breast.

#3. Most women benefit from caffeine and salt restriction because this reduces fluid retention and increases comfort.
Breast self-examination should be done every month so the woman can become more familiar with her breasts and, therefore, more readily identify any irregularities.
A supportive bra that fits well should be worn both day and night because support will relieve symptoms.
Ice is more beneficial when breasts are sore than is heat.


91. The local YMCA is having a series of seminars on health-related topics. You are invited to discuss breast self-examination (BSE) with the group. Which of the following would be appropriate to teach regarding when BSE should be performed by women of reproductive age?
1. At the end of each menstrual cycle.
2. At the beginning of each menstrual cycle.
3. About 7-10 days after the beginning of each menstrual cycle.
4. About 7-10 days before the end of the menstrual cycle.

#3. The breast are softer, less tender, and swelling is reduced about a week after the beginning of the menstrual cycle.
The end of the menstrual cycle is the beginning of menses when the breasts are the most tender and edematous.
The beginning of the menstrual cycle is the beginning of menses when the breasts are the most tender and edematous.
As the end of the menstrual cycle approaches, the breasts become more tender and edematous.


92. You have been discussing breast self-examination (BSE) with Miss N. Which of the following statements would best indicate she is doing BSE correctly?
1. begin to examine my breasts by placing the palm of my right hand on the nipple of the left breast.”
2. I don’t like to press very hard because my breasts are very tender.”


3. “I use the tips of the middle three fingers of each to feel each breasts.”
4. “I feel for lumps in my breasts standing in front of a mirror.

#3. The ends of the three middle fingers are the most sensitive and should be used for BSE.
The palms of the hands are not at all sensitive and will be very inaccurate.
If the breasts are very tender, the exam is being done at the wrong time of the menstrual cycle. She should be pressing firmly to feel the deep tissue.
She should be lying down for palpation or standing in the shower. It is important to inspect the breasts in the mirror for changes in shape, nipples, and dimpling of the skin.


93. Ms. I., who is 32-years-old, had a simple mastectomy this morning. Which of the following should be included in your plan for her care?
1. Complete bedrest for the first 24 hours.
2. NPO with IV fluids for the first 48 hours.
3. Positioning on the operative side for the first 24 hours.
4. Keep patient-controlled anesthesia (PCA) controller within easy reach for the first 48 hours.

#4. Adequate pain relief is important and the use of PCA allows the client to control her own pain relief.
Ambulation is encouraged as soon as the effects of anesthesia are gone and fluids are tolerated.
Fluids are encouraged as soon as the effects of the anesthesia have worn off.
Positioning should be changed frequently and should not include the operative side.


94. The nurse is teaching a woman who had a simple mastectomy. Which of the following would be appropriate to tell her?
1. She should wait to be fitted for a permanent prosthesis until the wound is completely healed.
2. Since she had a simple mastectomy, she will probably not feel the need to attend Reach for Recovery meetings.
3. She will have very little pain and the incision will heal very quickly.
4. She should refrain from seeking male companionship since she will be seen as less than a woman.

#1. The incisional site may change with time and healing, so a permanent prosthesis should be purchased only after complete healing has occurred.
Reach to Recovery is a support group that will help her in many ways and should be encouraged.
Many women are surprised at the amount of incisional pain and the length of time required for healing.
She should continue her relationships with both men and women because mastectomy does not change who she is. With the help of a prosthesis, no one will know of her mastectomy unless she reveals it.

95. A group of woman have gathered at the local library for a series of seminars about women’s health issues. In discussing cancer of the cervix, which of the following would be
1. This cancer is very rapid growing, so early detection is difficult to achieve.
2. A cervical biopsy is the screening test of choice for early detection of cervical cancer.
3. All women have an equal chance to develop cervical cancer because there are no high risk factors.
4. An annual Pap smear may detect cervical dysplasia, a frequent precursor of cervical cancer.

#4. Cervical dysplasia is frequently a forerunner of cervical smears allow for early detection and treatment of cervical cancer.
Cervical cancer is a slow-growing disease, so regular Pap smears have a good chance to detect it before it becomes invasive.
A cervical biopsy may be required to confirm or rule out cancer from suspicious cervical tissue identified by culposcopy
There are numerous high-risk factors for cervical cancer such as multiple sex partners, history of STDs and dysplasia, and intrauterine DES (diethylstibesterol) exposure.


96. The nurse is talking to a woman who has been diagnosed with cancer of the ovary. She asks you what she could have done so that the cancer would have been found earlier. The best response should include which of the following?
1. She should have had more frequent, twice a year, Pap smears.
2. A yearly complete blood count (CBC) could have provided valuable clues to detect ovarian cancer.
3. Detection of ovarian cancer is earlier if a yearly proctoscopy is done.
4. There is little more she could have done for earlier detection.

#4. Detection of ovarian cancer is very difficult because it gives only vague, subtle symptoms and there are no diagnostic screening.
Biannual pelvic exams may be recommended for women with a family history of ovarian cancer. Pap smears only detect cervical changes.
There are no cancer markers identifiable with a CBC.
While vague gastrointestinal symptoms may be early symptoms, a proctoscopy will not visualize the ovaries.


97. The nurse is caring for a woman who has had a vaginal hysterectomy and an indwelling Foley catheter. After removal of the catheter, she is unable to void and has little sensation of bladder fullness. She is also constipated and is experiencing some perineal pain. The most appropriate nursing diagnosis is altered urinary elimination related to
1. infection as evidenced by inability to void with frequency and urgency.
2. retention as evidenced by inability to void and urinary distention.
3. gastrointestinal functioning as evidenced by inability to void and constipation.
4. dysuria as evidenced by inability to void and loss of bladder sensation.

#2. Retention of urine is common following vaginal hysterectomy due to stretching of musculature and proximity of the surgery to the bladder and its enervation.
Although infection is a potential problem, there is no evidence such as urgency or frequency, that the client has an infection.
The constipation experienced by the client may be related to the surgery, but is not related to the urinary problem.
There is no evidence that the client has dysuria, pain when urinating. The perineal pain is related to the surgery, but no the urinary retention.


98. Mrs. F., age 42, has had a simple vaginal hysterectomy without oophorectomy, due to uterine fibroids. You have completed your discharge teaching and she is preparing to go home. Which of the following statements indicates Mrs. F. understands the physical changes she will experience.
1. “I hope my husband will still love me since we can’t have sexual intercourse anymore.”
2. “I was hoping to stop having periods, but I guess that will need to wait a few more years.”
3. “It will be so nice to not need to use birth control any more.”
4. “I just don’t think I will ever feel feminine again since I can no longer experience orgasm.”

#3. After the loss of the uterus, pregnancy is unachievable and birth control is not needed even if the ovaries remain.
Intercourse may be resumed after the tissues in the vaginal area have healed and an active satisfying sex life may continue, although there may be some changes in sensations.
Mrs. F. will never have a menstrual period again since there is no uterine lining to be shed.
Orgasm is a function of the clitoris, not the uterus, so organs is still possible following hysterectomy.


99. The nurse has been discussing menopause with a 50-year-old woman who is experiencing some bodily changes indicative of the perimenopausal period. Which of the following statements indicates the client understands what is happening to her body?”
1. “Even though I am only having periods every few months, I should continue to use birth control until at least six months after my periods have stopped.”
2. “I am very upset to think that I will continue to have these hot flashes for the rest of my lfie.”
3. “Now that I am an old woman, I guess I’ll be sick most of the time, so I should plan to move to a retirement home.”
4. “I may continue to bleed on and off throughout the next 25 years.

#1. Even though ovulation is erratic and many periods are anovulatory, birth control should be continued for at least six months after the last menses.
Symptoms of menopause such as hot flashes and mood swings gradually subside and disappear by the time menses have stopped for a full year.
Menopause is not an illness and most women do not experience a decline in health related to this process.
Menopause has stopped for a full year is considered abnormal and requires evaluation.


100. A 55-year old woman who has ceased having menses has a family history of osteoporosis and increasing cholestrerol levels over the past several years. Hormone replacement therapy (HRT) has been prescribed with estrogen and progesterone. She asks you why she should take the pills since she feels quiet well. The nurse’s answer would be.
1. HRT is thought to help protect women from heart disease and osteoporosis.
2. HRT will help to reestablish the menstrual cycle, thus providing natural protection against heart disease and osteoporosis.
3. even though she feels well now, she will soon begin having major health problems and HRT will protect her against those problems.
4. she will be protected from breast cancer by HRT.

#1. HRT appears to help protect many women from heart disease and osteopororis if used with exercise and calcium supplements.
HRT may cause spotting and some bleeding for the first six months, but will not reestablish the menstrual cycle.
There is no indication of declining health in the menopausal woman with or without HRT.
Actually, the risk of breast cancer increases in susceptible women with the use of HRT.
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