Post by Nursing Board 101 on Aug 18, 2010 13:44:10 GMT -5
51. Assessment of a pregnant client reveals that she feels very anxious because of a lack of knowledge about giving birth. The client is in her second trimester. Which nursing intervention is most appropriate for this client?
a.)Provide her with the information and teach her the skills she'll need to understand and cope during birth.
b.)Provide her with written information about the birthing process.
c.)Have a more experienced pregnant woman assist her.
d.)Do nothing in hopes that she'll begin coping as the pregnancy progresses.
A. RATIONALE: Because the client is in her second trimester, the nurse has ample time to establish a trusting relationship with her and to teach her in a style that fits her needs. Written information would be effective only in conjunction with teaching sessions. Introducing her to another pregnant client may be helpful, but the nurse still needs to teach the client about giving birth. Doing nothing won't address the client's needs.
52. The nurse is assessing a pregnant woman in the clinic. In the course of the assessment, the nurse learns that this woman smokes one pack of cigarettes per day. The first step the nurse should take to help the woman stop smoking is to:
a.)assess the client's readiness to stop.
b.)suggest that the client reduce the daily number of cigarettes smoked by one-half.
c.)provide the client with the telephone number of a formal smoking cessation program.
d.)help the client develop a plan to stop.
A. RATIONALE: Before planning any intervention with a client who smokes, it's essential to determine whether the client is willing or ready to stop smoking. Commonly, a pregnant woman will agree to stop smoking for the duration of the pregnancy. This gives the nurse an opportunity to work with her over time to help with permanent smoking cessation.
53. The nurse is recording an Apgar score for a neonate. The nurse should assess: a.)heart rate, respiratory effort, temperature, reflex irritability, and color.
b.)heart rate, respiratory effort, reflex irritability, and color.
c.)heart rate, respiratory effort, temperature, and color.
d.)heart rate, respiratory effort, temperature, sucking reflex, and color.
B. RATIONALE: When recording an Apgar score for a neonate, the nurse should assess heart rate, respiratory effort, reflex irritability, and color. The neonate's temperature and sucking reflex will be assessed shortly after birth, but they aren't components of the Apgar score.
54. The nurse is teaching the mother of a neonate about the importance of immunizations. The nurse should teach her that active immunity:
a.)develops rapidly and is temporary.
b.)occurs by antibody transmission.
c.)results from exposure of an antigen through immunization or disease contact. d.)may be transferred by mother to neonate.
C. RATIONALE: Active immunity results from direct exposure of an antigen by immunization or disease exposure. Passive immunity occurs from antibody transmission. It occurs rapidly but is temporary. Passive immunity may be transferred by the mother to the neonate.
55. When evaluating a client's knowledge of symptoms to report during her pregnancy, which statement would indicate to the nurse that the client understands the information given to her?
a.)"I'll report increased frequency of urination."
b.)"If I have blurred or double vision, I should call the clinic immediately."
c.)"If I feel tired after resting, I should report it immediately."
d.)"Nausea should be reported immediately."
B. RATIONALE: Blurred or double vision may indicate hypertension or preeclampsia and should be reported immediately. Urinary frequency is a common problem during pregnancy caused by increased weight pressure on the bladder from the uterus. Clients generally experience fatigue and nausea during pregnancy.
56. The nurse has a client at 30 weeks' gestation who has tested positive for the human immunodeficiency virus (HIV). What should the nurse tell the client when she says that she wants to breast-feed her neonate?
a.)Encourage breast-feeding so that she can get her rest and get healthier.
b.)Encourage breast-feeding because it's healthier for the neonate.
c.)Encourage breast-feeding to facilitate bonding.
d.)Discourage breast-feeding because HIV can be transmitted through breast milk.
D. RATIONALE: Transmission of HIV can occur through breast milk, so breast-feeding should be discouraged in this case.
57. A neonate of a client with type 1 diabetes mellitus is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is: a.)peripheral acrocyanosis.
b.)bradycardia.
c.)lethargy.
d.)jaundice.
C. RATIONALE: Lethargy in the neonate may be seen with hypoglycemia because of a lack of glucose in the nerve cells. Peripheral acrocyanosis is normal in the neonate because of immature capillary function. Tachycardia, not bradycardia, is seen with hypoglycemia. Jaundice isn't a sign of hypoglycemia.
58. The nurse is assessing a neonate. When maternal estrogen has been transferred to the fetus, which sign will the nurse see in the neonate?
a.)Weak sucking response
b.)Enlarged breast tissue
c.)Soft skin
d.)Vernix caseosa
B. RATIONALE: It's common to see enlarged breast tissue in both male and female neonates in their first few days of life due to maternal estrogen transmitted to the fetus. Weak sucking response isn't related to estrogen. Soft skin and vernix caseosa are signs of full-term, well-developed neonates and aren't related to estrogen.
59. A 20-year-old female's pregnancy is confirmed at a clinic. She says her husband will be excited but she's concerned because she isn't excited. She fears this may mean she'll be a bad mother. The nurse should respond by:
a.)referring her to counseling.
b.)telling her such feelings are normal in the beginning of pregnancy.
c.)exploring her feelings.
d.)recommending she talk her feelings over with her husband.
B. RATIONALE: Misgivings and fears are common in the beginning of pregnancy. It doesn't necessarily mean that she requires counseling at this time. Exploring her feelings may help her understand her concerns more deeply but won't provide reassurance that her feelings are normal. She may benefit by discussing her feelings with her husband, but the husband also needs to be reassured that these feelings are normal at this time.
60. A woman who is 10 weeks pregnant tells the nurse that she's worried about her fatigue and frequent urination. The nurse should:
a.)recognize these as normal early pregnancy signs and symptoms.
b.)question her further about these signs and symptoms.
c.)tell her that she'll need blood work and urinalysis.
d.)tell her that she may be excessively worried.
A. RATIONALE: Fatigue and frequent urination are early signs and symptoms of pregnancy that may continue through the first trimester. Questioning her about the signs and symptoms is helpful to complete the assessment but won't reassure her. Prenatal blood work and urinalysis is routine for this situation but doesn't address the client's concerns. Telling her that she may be excessively worried isn't therapeutic.
61. A client with hypotonic labor dysfunction has been started on oxytocin (Pitocin). Despite adequate contractions, the fetus doesn't descend lower than 0 station. The physician recommends cesarean delivery. The client and her husband are confused because she had given birth previously to an average-size neonate. They ask several questions about cesarean birth. What would be the most accurate nursing diagnosis for this client?
a.)Anger related to loss of planned birth experience
b.)Anxiety related to lack of knowledge about the need for cesarean birth
c.)Acute pain related to long, unproductive labor
d.)Fear related to the unknown
B. RATIONALE: The couple's questions indicate their lack of knowledge. Anxiety is expected because a cesarean delivery was unplanned. The other options aren't indicated by the stated assessment data.
62. The nurse is providing care for a pregnant woman. The woman asks the nurse how she can best deal with her fatigue. The nurse should instruct her to:
a.)take sleeping pills for a restful night's sleep.
b.)try to get more rest by going to bed earlier.
c.)take her prenatal vitamins.
d.)tell her not to worry because the fatigue will go away soon.
B. RATIONALE: She should listen to the body's way of telling her that she needs more rest and try going to bed earlier. Vitamins won't take away fatigue. False reassurance is inappropriate and doesn't help her deal with fatigue now. Sleeping pills shouldn't be consumed prenatally because they can harm the fetus.
63. The nurse is providing care for a pregnant 16-year-old client. The client says that she's concerned she may gain too much weight and wants to start dieting. The nurse should respond by saying:
a.)"Now isn't a good time to begin dieting because you are eating for two."
b.)"Let's explore your feelings further."
c.)"Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems."
d.)"The prenatal vitamins should ensure the baby gets all the necessary nutrients."
C. RATIONALE: Depriving the developing fetus of nutrients can cause serious problems, and the nurse should discuss this with the client. The client isn't eating for two; this is a misconception. Exploring feelings helps the client understand her concerns, but she needs to be aware of the risks at this time. The vitamins are supplements and don't contain everything a mother or neonate needs; they work in congruence with a balanced diet.
64. The nurse is providing care for a pregnant client in her second trimester. Glucose tolerance test results show a blood glucose level of 160 mg/dl. The nurse should anticipate that the client will need to:
a.)start using insulin.
b.)start taking an oral antidiabetic drug.
c.)monitor her urine for glucose.
d.)be taught about diet.
D. RATIONALE: The client's blood glucose level should be controlled initially by diet and exercise, rather than insulin. The client will need to watch her overall dietary intake to control her blood glucose level. Oral antidiabetic drugs aren't used in pregnant females. Urine sugars aren't an accurate indication of blood glucose levels.
65. The nurse is providing care for a pregnant client with gestational diabetes. The client asks the nurse if her gestational diabetes will affect her delivery. The nurse should know that:
a.)the delivery may need to be induced early.
b.)the delivery must be by cesarean.
c.)the mother will carry to term safely.
d.)it's too early to tell.
A. RATIONALE: Early induction or early cesarean delivery are possibilities if the mother has diabetes and euglycemia that hasn't been maintained during pregnancy. Cesarean delivery isn't always necessary.
66. A newly pregnant woman tells the nurse that she hasn't been taking her prenatal vitamins because they make her nauseated. In addition to stressing the importance of taking the vitamins, the nurse should advise the client to:
a.)switch brands.
b.)take the vitamin on a full stomach.
c.)take the vitamin with orange juice for better absorption.
d.)take the vitamin first thing in the morning.
B. RATIONALE: Prenatal vitamins commonly cause nausea and taking them on a full stomach may curb this. Switching brands may not be helpful and may be more costly. Orange juice tends to make pregnant women nauseated. The vitamins may be taken at night, rather than in the morning, to reduce nausea.
67. A neonate born 2 hours ago has just arrived in the nursery. Which nursing measure will prevent the neonate from losing heat due to evaporation?
a.)Keeping him away from drafts
b.)Putting a blanket between him and cold surfaces
c.)Putting a cap on his head
d.)Drying him thoroughly after a bath
D. RATIONALE: Neonates lose heat through evaporation as liquid is converted to a vapor. Drying a neonate after birth and following a bath prevents heat loss caused by evaporation. Keeping a neonate away from drafts prevents heat loss caused by convection. Keeping a neonate off a cold surface, such as a scale, prevents the heat loss caused by conduction. Placing a cap on the neonate's head preserves heat and prevents heat loss caused by radiation.
68. The nurse is caring for a neonate with a myelomeningocele. The priority nursing care of a neonate with a myelomeningocele is primarily directed toward:
a.)ensuring adequate nutrition.
b.)preventing infection.
c.)promoting neural tube sac drainage.
d.)conserving body heat.
B. RATIONALE: The nurse needs to provide special care to the neural tube sac to prevent infection. Allowing the sac to dry could result in cracks that allow microorganisms to enter. Pressure on the sac could cause it to rupture, creating a portal of entry for microorganisms. Administering antibiotics and keeping the sac free from urine and stool are other measures to prevent infection. Adequate nutrition is a concern for all neonates, including those with a myelomeningocele. Like all neonates, the neonate with a myelomeningocele must be kept warm, but care must be taken to avoid drying out the neural tube sac with a radiant heater or exerting pressure using a sheet or blanket over the sac.
69. nurse is conducting a neonate assessment of a boy, born 3 hours earlier. Which assessment would make the nurse suspect a congenital hip dislocation?
a.)Limited abduction of the affected leg
b.)Unequal gluteal folds
c.)Lengthening of the limb on the affected side
d.)Crepitus of the affected hip on movement
B. RATIONALE: Unequal gluteal folds are signs of congenital hip dislocation. Other signs include unequal thighs, limited adduction of the affected side, and shortening of the limb on the affected side. Crepitus of the affected hip isn't felt, but an audible click may be heard when the hip on the affected side is adducted.
70. The nurse has been teaching a new mother how to feed her infant son who was born with a cleft lip and palate. Which action by the mother would indicate that the teaching has been successful?
a.)Placing the neonate flat during feedings
b.)Providing fluids with a small spoon
c.)Placing the nipple in the cleft palate
d.)Burping the neonate frequently
D. RATIONALE: Because a neonate with a cleft lip and palate can't grasp a nipple securely, he may swallow a large amount of air during feedings and, therefore, require frequent burping. A neonate with a cleft lip and palate should be fed in an upright position to reduce the risk of aspiration. Spoons aren't used. A neonate with a cleft lip and palate may use specially prepared nipples for feeding. Placing the nipple in the cleft palate increases the risk of aspiration.
71. A client who is 34 weeks pregnant is experiencing bleeding caused by placenta previa. The fetal heart sounds are normal, and the client isn't in labor. Which nursing intervention should the nurse perform?
a.)Allow the client to ambulate with assistance.
b.)Perform a vaginal examination to check for cervical dilation.
c.)Monitor the amount of vaginal blood loss.
d.)Notify the physician for a fetal heart rate of 130 beats/minute.
C. RATIONALE: Estimate the amount of blood loss by such measures as weighing perineal pads or counting the amount of pads saturated over a period of time. The physician should be notified of continued blood loss, an increase in blood flow, or vital signs indicative of shock (hypotension and tachycardia). The woman should be placed on bed rest and not allowed to ambulate. A pelvic examination should never be performed when placenta previa is suspected because manipulation of the cervix can cause hemorrhage. A normal fetal heart rate is 120 to 160 beats/minute; therefore, the physician doesn't need to be notified of a fetal heart rate of 130 beats/minute.
72. A nurse in a prenatal clinic is assessing a 28-year-old who is 24 weeks pregnant. Which findings would lead this nurse to suspect that the client has mild preeclampsia? a.)Glycosuria, hypertension, seizures
b.)Hematuria, blurry vision, reduced urine output
c.)Burning on urination, hypotension, abdominal pain
d.)Hypertension, edema, proteinuria
D. RATIONALE: The typical findings of mild preeclampsia are hypertension, edema, and proteinuria. Abdominal pain, blurry vision, and reduced urine output are signs of severe preeclampsia. Seizures are a sign of eclampsia. The other findings aren't typically found in women with preeclampsia.
73. A client who is 24 weeks pregnant and diagnosed with preeclampsia is sent home with orders for bed rest and a referral for home health visits by a community health nurse. Which comment made by the client should indicate to the nurse that the client understands the reasons for home health visits?
a.)"The community health nurse will help fix my meals."
b.)"The community health nurse will give me my antihypertensive medication."
c.)"The community health nurse will check me and my baby and talk with my physician."
d.)"The community health nurse will give me prenatal care so that I won't have to see my physician."
C. RATIONALE: Community health nurses provide skilled nursing care, such as assessing and monitoring blood pressure, providing treatments and education, and communicating with the physician. For the prenatal client with preeclampsia, this may include monitoring the therapeutic effects of antihypertensive medications, assessing fetal heart tones, and providing nutrition counseling. The professional nurse doesn't fix meals in the home this service may be provided by a home health aide or housekeeper. The community health nurse teaches the client to take her own medications, including the proper time, dose, frequency, and adverse effects. The community health nurse doesn't replace the care provided by the client's physician.
74. A client who is 12 weeks pregnant is complaining of severe left lower quadrant pain and vaginal spotting. She's admitted for treatment of an ectopic pregnancy. Which nursing diagnosis takes the highest priority?
a.)Risk for deficient fluid volume
b.)Anxiety
c.)Acute pain
d.)Impaired gas exchange
A. RATIONALE: A ruptured ectopic pregnancy is a medical emergency due to the large quantity of blood that may be lost in the pelvic and abdominal cavities. Shock may develop from blood loss, and large quantities of I.V. fluids are needed to restore intravascular volume until the bleeding is surgically controlled. All the other nursing diagnoses are relevant for a woman with an ectopic pregnancy, but risk for deficient fluid volume through hemorrhage is the greatest threat to her physiological integrity and must be stopped. Anxiety may be due to such factors as the risk of dying and the fear of future infertility. Acute pain may be caused by a ruptured or distended fallopian tube or blood in the peritoneal cavity. Impaired gas exchange may result from the loss of oxygen-carrying hemoglobin through blood loss.
75. A client delivered a healthy full-term baby girl 2 hours ago by cesarean delivery. When assessing this client, which finding requires immediate nursing action?
a.)Tachycardia and hypotension
b.)Gush of vaginal blood when she stands up
c.)Blood stain (5.1 cm) in diameter on the abdominal dressing
d.)Complaints of abdominal pain
A. RATIONALE: A rising pulse rate and falling blood pressure may be signs of hemorrhage. Lochia pools in the vagina of a postpartal woman who has been sitting and may suddenly gush out when she stands up. A blood stain on a fresh surgical incision isn't a cause for immediate concern; however, the area of blood should be circled and timed. An increase in the size of the blood stain and oozing of the surgical incision should be promptly reported to the physician. It's normal for a woman who has had a cesarean section to feel pain at the incision site once her anesthesia has worn off.
76. A nurse in the nursery is preparing to perform phenylketonuria (PKU) testing. Which neonate is ready for the nurse to test?
a.)A 3-day-old neonate who has been fed I.V. since birth
b.)A 2-day-old neonate who has been breast-fed
c.)A 1-day-old neonate receiving formula
d.)A breast-fed neonate being discharged within 24 hours of birth
B. RATIONALE: To test for PKU, a neonate must have had a sufficient intake of phenylalanine through the ingestion of either formula or breast milk for at least 2 days. A neonate who has been receiving I.V. fluids and hasn't yet received breast milk or formula isn't ready to be tested for PKU. A neonate who is discharged within 24 hours of delivery will need to see the physician for PKU testing after receiving formula or breast milk for 48 hours.
77. The nurse is teaching a client who is 28 weeks pregnant and has gestational diabetes how to control her blood glucose levels. Diet therapy alone has been unsuccessful in controlling her blood glucose levels, so she has started insulin therapy. The nurse should consider the teaching effective when the client says:
a.)"I won't use insulin if I'm sick."
b.)"I need to use insulin each day."
c.)"If I give myself an insulin injection, I don't need to watch what I eat."
d.)"I'll monitor my blood glucose levels twice a week."
B.RATIONALE: When dietary treatment for gestational diabetes is unsuccessful, insulin therapy is started and the client will need daily doses. The client shouldn't stop using the insulin unless first obtaining an order from the physician for insulin adjustments when ill. Diet therapy continues to play an important role in blood glucose control in the client who requires insulin. Diet therapy is important to achieve appropriate weight gain and to avoid periods of hypoglycemia and hyperglycemia when taking insulin. Fasting, postprandial, and bedtime blood glucose levels need to be checked daily.
78. A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and delivers a boy. Which priority intervention should be included in the care plan for the neonate during his first 24 hours?
a.)Administer insulin subcutaneously.
b.)Administer a bolus of glucose I.V.
c.)Provide frequent early feedings with formula.
d.)Avoid oral feedings.
C. RATIONALE: The neonate of a mother with diabetes may be slightly hyperglycemic immediately after birth because of the high glucose levels that cross the placenta from mother to fetus. During pregnancy, the fetal pancreas secretes increased levels of insulin in response to this increased glucose amount. However, during the first 24 hours of life, this combination of high insulin production in the neonate coupled with the loss of maternal glucose can cause severe hypoglycemia. Frequent, early feedings with formula can prevent hypoglycemia. Insulin shouldn't be administered because the neonate of a mother with diabetes is at risk for hypoglycemia. A bolus of glucose given I.V. may cause rebound hypoglycemia. If glucose is given I.V., it should be administered as a continuous infusion. Oral feedings shouldn't be avoided because early, frequent feedings can help avoid hypoglycemia.
79. A 28-year-old woman gave birth 1 hour ago to a full-term baby boy. Which finding should the nurse expect when palpating the client's fundus?
a.)Soft, at the level of the umbilicus
b.)Firm (1.9 cm) below the umbilicus
c.)Firm, at the level of the umbilicus
d.)Boggy, midway between the umbilicus and symphysis pubis
C. RATIONALE: Within 1 hour after delivery, the fundus should be firm and at the level of the umbilicus. A soft or boggy fundus isn't contracting well due to such factors as a full bladder or retained pieces of placenta and places the postpartum woman at risk for hemorrhage.
80. Which finding is considered normal in a neonate during the first few days after birth?
a.)Weight loss of 25%
b.)Birth weight of 2,000 to 2,500 g
c.)Weight loss then return to birth weight
d.)Weight gain of 25%
C. RATIONALE: Babies lose approximately 10% of their birth weight during the first 3 or 4 days, due to the loss of excess extracellular fluids and meconium as well as limited oral intake, until breast-feeding is established. Return to birth weight should occur within 10 days after birth. Normal birth weights range from 2,700 to 4,000 g.
81. The mother of a neonate expresses concern about how she'll continue to breast-feed when she returns to work in 6 weeks. What's the best response by the nurse?
a.)"Why don't you wait and see how things go? You may be tired of breast-feeding by then."
b.)"Let your daycare provider give the baby formula in a bottle and breast-feed when you're home."
c.)"Your baby won't need breast-feeding by then, so just switch completely to formula when you return to work."
d.)"You can continue breast-feeding after you go back to work. You can pump your breasts and put the milk in a bottle."
D. RATIONALE: Breast-feeding should continue for the first 6 months after birth when possible. Breast milk can be pumped at work to give to the neonate at daycare. This will also keep the mother's milk production up.
82. Early detection of an ectopic pregnancy is paramount in preventing a life-threatening rupture. Which symptoms should alert the nurse to the possibility of an ectopic pregnancy?
a.)Abdominal pain, vaginal bleeding, and a positive pregnancy test b.)Hyperemesis and weight loss
c.)Amenorrhea and a negative pregnancy test
d.)Copious discharge of clear mucus and prolonged epigastric pain
A. RATIONALE: Abdominal pain, vaginal bleeding, and a positive pregnancy test are cardinal signs of an ectopic pregnancy. Nausea and vomiting may occur prior to rupture, but significantly increase after rupture. Amenorrhea and a negative pregnancy test may indicate another type of metabolic disorder such as hypothyroidism. Discharge of clear mucus isn't indicative of an ectopic pregnancy, and referred shoulder pain, not epigastric pain, should be expected.
83. The client has just given birth to her first child, a healthy, full-term baby girl. The client is Rh (D)-negative and her neonate is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility?
a.)Administration of Rh (D) Immune Globulin I.M. to the neonate within 72 hours
b.)Administration of Rh (D) Immune Globulin I.M. to the mother within 72 hours
c.)Injection of Rh (D) Immune Globulin to the mother during her 6 week follow-up visit d.)Administration of Rh (D) Immune Globulin I.M. to the mother within 3 months
B. RATIONALE: When a mother is Rh (D)-negative and a neonate is Rh-positive, the mother forms antibodies against the D antigen. Most of the antibodies develop within the first 72 hours after she has given birth due to the exchange of maternal and fetal blood during delivery. If the mother becomes pregnant again, she'll have a high antibody D level that may destroy fetal blood cells during the second pregnancy. However, if the mother receives an injection of Rh (D) Immune Globulin within 72 hours, no antibodies will be formed. Rh (D) Immune Globulin may also be given to the mother during pregnancy, if the neonate is Rh-positive. The neonate isn't given Rh (D) Immune Globulin.
84. On the 9th postpartum day, a client breast-feeding her neonate experiences pain, redness, and swelling of her left breast. She's diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information? a.)Wear a loose-fitting bra to avoid constricting the milk ducts.
b.)Stop breast-feeding permanently.
c.)Take antibiotics until the pain is relieved.
d.)Use a warm moist compress over the painful area.
D. RATIONALE: Warm, moist compresses will reduce inflammation and edema of the infected breast tissue. The woman with mastitis should wear a proper fitting bra with good support. Breast-feeding may resume once the infection is treated. The client will need to pump the breast in the meantime to keep the breast empty of milk and to ensure an adequate milk supply. Antibiotics must be taken for the full course of therapy and not stopped when symptoms subside.
85. The nurse teaches a postpartum client about breast-feeding. Which statement best indicates that the client knows how to avoid breast engorgement?
a.)"I'll apply warm, moist compresses to my breasts."
b.)"I'll breast-feed every 1& to 3 hours."
c.)"I'll use an electric breast pump."
d.)"I'll wear a bra 24 hours per day."
B. RATIONALE: Frequent breast-feeding keeps the breasts relatively empty and increases circulation, thereby helping to remove fluid that may lead to engorgement. Applying warm compresses to the breasts stimulates the let-down reflex, filling the breasts and increasing engorgement. An electric breast pump usually isn't used if the neonate can breast-feed frequently. Although a bra supports the breasts, it can't prevent engorgement.
86. The nurse is assessing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus?
a.)One fingerbreadth above the umbilicus
b.)One fingerbreadth below the umbilicus
c.)At the level of the umbilicus
d.)Below the symphysis pubis
B. RATIONALE: After a client gives birth, the height of her fundus should decrease about one fingerbreadth (about 1 cm) each day. Immediately after birth, the fundus may be above the umbilicus. At 6 to 12 hours after birth, it should be at the level of the umbilicus. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. After 10 days, it should be below the symphysis pubis.
87. The nurse is helping to prepare a client for discharge following childbirth. During a teaching session, the nurse instructs the client to do Kegel exercises. What's the purpose of these exercises?
a.)To prevent urine retention
b.)To relieve lower back pain
c.)To tone the abdominal muscles
d.)To strengthen the perineal muscles
D. RATIONALE: Kegel exercises strengthen and increase the elasticity of the pubococcygeus muscle, which is the main perineal muscle. They also improve vaginal tone and help prevent stress incontinence and hemorrhoids. Kegel exercises can't prevent urine retention, relieve lower back pain, or tone abdominal muscles.
88. The nurse is using Doppler ultrasound to assess a pregnant woman. When should the nurse expect to hear fetal heart tones?
a.)7 weeks
b.)11 weeks
c.)17 weeks
d.)21 weeks
B. RATIONALE: Using Doppler ultrasound, fetal heart tones may be heard as early as the 11th week of pregnancy. Using a stethoscope, fetal heart tones may be heard between 17 and 20 weeks of gestation.
89. The nurse is planning care for a 16-year-old client in the prenatal clinic. Adolescents are prone to which complication during pregnancy?
a.)Iron deficiency anemia
b.)Varicosities
c.)Nausea and vomiting
d.)Gestational diabetes
A. RATIONALE: Iron deficiency anemia is a common complication of adolescent pregnancies. Adolescent girls may already be anemic. The need for iron during pregnancy, for fetal growth and an increased blood supply, compounds the anemia even further. Varicosities are a complication of pregnancy more likely seen in women over age 35. An adolescent pregnancy doesn't increase the risk of nausea and vomiting or gestational diabetes.
90. The nurse is caring for a 16-year-old pregnant client. The client is taking an iron supplement. What should this client drink to increase the absorption of iron?
a.)A glass of milk
b.)A cup of hot tea
c.)A liquid antacid
d.)A glass of orange juice
D. RATIONALE: Increasing vitamin C enhances the absorption of iron supplements. Taking an iron supplement with milk, tea, or an antacid reduces the absorption of iron.
91. The nurse is caring for a client who is on ritodrine therapy to halt premature labor. What condition indicates an adverse reaction to ritodrine therapy?
a.)Hypoglycemia
b.)Crackles
c.)Bradycardia
d.)Hyperkalemia
B. RATIONALE: Use of ritodrine can lead to pulmonary edema. Therefore, the nurse should assess for crackles and dyspnea. Blood glucose levels may temporarily rise, not fall, with ritodrine. Ritodrine may cause tachycardia, not bradycardia. Ritodrine may also cause hypokalemia, not hyperkalemia.
92. The nurse is caring for a client in her 34th week of pregnancy who wears an external monitor. Which statement by the client would indicate an understanding of the nurse's teaching?
a.)"I'll need to lie perfectly still."
b.)"You won't need to come in and check on me while I'm wearing this monitor."
c.)"I can lie in any comfortable position, but I should stay off my back."
d.)"I know that the external monitor increases my risk of a uterine infection."
C. RATIONALE: A woman with an external monitor should lie in the position that's most comfortable to her, although the supine position should be discouraged. A woman should be encouraged to change her position as often as necessary; however, the monitor may need to be repositioned after a position change. The nurse still needs to frequently assess and provide emotional support to a woman in labor who is wearing an external monitor. Because an external monitor isn't invasive and is worn around the abdomen, it doesn't increase the risk of uterine infection.
93. The nurse is developing a care plan for a client in her 34th week of gestation who is experiencing premature labor. What nonpharmacologic intervention should the plan include to halt premature labor?
a.)Encouraging ambulation
b.)Serving a nutritious diet
c.)Promoting adequate hydration
d.)Performing nipple stimulation
D. RATIONALE: Providing adequate hydration to the woman in premature labor may help halt contractions. The client should be placed on bed rest so that the fetus exerts less pressure on the cervix. A nutritious diet is important in pregnancy, but it won't halt premature labor. Nipple stimulation activates the release of oxytocin, which promotes uterine contractions.
94. A client treated for premature labor is ready for discharge. Which instruction should the nurse include in the discharge teaching plan?
a.)Report a heart rate greater than 120 beats/minute to the physician.
b.)Take terbutaline every 4 hours, during waking hours only.
c.)Call the physician if the fetus moves 10 times in 1 hour.
d.)Increase activity daily if not fatigued.
A. RATIONALE: Because terbutaline can cause tachycardia, the woman should be taught to monitor her radial pulse and call the physician for a heart rate greater than 120 beats/minute. Terbutaline must be taken every 4 to 6 hours around-the-clock to maintain an effective serum level that will suppress labor. A fetus normally moves 10 to 12 times per hour. The client experiencing premature labor must maintain bed rest at home.
95. The nurse is caring for a client in labor. Which assessment finding indicates fetal distress?
a.)Lack of meconium staining
b.)Early decelerations in fetal heart rate during contractions
c.)An increase in fetal heart rate with fetal scalp stimulation
d.)Fetal blood pH less than 7.20
D. RATIONALE: A fetal blood pH less than 7.20 is an indication of fetal hypoxia. During labor, a fetal pH range of 7.20 to 7.30 is considered normal. Fetal blood is sampled from the fetal scalp through a dilated cervix. The other options are normal findings.
96. The nurse is assessing a woman in labor. Her cervix is dilated 8 cm. Her contractions are occurring every 2 minutes. She's irritable and in considerable pain. What type of breathing should the nurse instruct the woman to use during the peak of a contraction?
a.)Deep breathing
b.)Shallow chest breathing
c.)Deep, cleansing breaths
d.)Chest panting
B. RATIONALE: Shallow chest breathing is used during the peak of a contraction during the transitional phase of labor. Deep breathing can cause a woman to hyperventilate and feel light-headed, with numbness or tingling in her fingers or toes. A deep, cleansing breath taken at the beginning and end of each breathing exercise can help prevent hyperventilation. Chest panting may be used to prevent a woman from pushing before the cervix is fully dilated.
97. The nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension?
a.)Administer ephedrine to raise her blood pressure.
b.)Administer oxygen using a mask.
c.)Place the woman flat on her back with her legs raised.
d.)Ensure adequate hydration before the anesthetic is administered.
D. RATIONALE: Because the woman is in a state of relative hypovolemia, administering fluids I.V. before the epidural anesthetic is given may prevent hypotension. Administration of an epidural anesthetic may lead to hypotension because blocking the sympathetic fibers in the epidural space reduces peripheral resistance. Ephedrine may be administered after an epidural block if a woman becomes hypotensive and shows evidence of cardiovascular decompensation. However, ephedrine isn't administered to prevent hypotension. Oxygen is administered to a woman who becomes hypotensive, but it won't prevent hypotension. Placing a pregnant woman in a supine position can contribute to hypotension because of uterine pressure on the great vessels.
98. A woman in labor shouts to the nurse, "My baby is coming right now! I feel like I have to push!" An immediate nursing assessment reveals that the head of the fetus is crowning. After asking another staff member to notify the physician and setting up for delivery, which nursing intervention is most appropriate?
a.)Gently pulling at the neonate 's head as it's delivered
b.)Holding the neonate 's head back until the physician arrives
c.)Applying gentle pressure to the neonate 's head as it's delivered
d.)Placing the mother in a Trendelenburg position until the physician arrives
C. RATIONALE: Gentle pressure applied to the neonate's head as it's delivered prevents rapid expulsion, which can cause brain damage to the neonate and perineal tearing in the mother. Never pull at the neonate 's head or hold the head back. Placing the mother in the Trendelenburg position won't halt labor and may cause respiratory difficulties.
99. The nurse is caring for a client who is in labor. The physician still isn't present. After the neonate's head is delivered, which nursing intervention would be most appropriate?
a.)Checking for the umbilical cord around the neonate 's neck
b.)Placing antibiotic ointment in the neonate 's eyes
c.)Turning the neonate's head to the side, to drain secretions
d.)Assessing the neonate for respirations
A. RATIONALE: After the neonate 's head is delivered, the nurse should check for the cord around the neonate 's neck. If the cord is around the neck, it should be gently lifted over the neonate 's head. Antibiotic ointment, to prevent gonorrheal conjunctivitis, is administered to the neonate after birth, not during delivery of the head. The neonate's head isn't turned during delivery. After delivery, the neonate is held with his head lowered to help with drainage of secretions. If a bulb syringe is available, it can be used to gently suction the neonate's mouth. Assessing the neonate's respiratory status should be done immediately after delivery.
100. The nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do?
a.)Apply an ice pack to her perineum.
b.)Take a Sitz bath.
c.)Perform perineal care after voiding or a bowel movement.
d.)Drink plenty of fluids.
A. RATIONALE: A cold pack applied to an episiotomy during the first 24 hours after delivery may reduce edema and tension on the incision line, thereby reducing pain. After the first 24 hours, a Sitz bath may reduce discomfort by promoting circulation and healing. While perineal care should be performed after each voiding and bowel movement, its purpose is to prevent infection not reduce discomfort. Drinking plenty of fluids is also important, especially for the breast-feeding woman, but it doesn't relieve perineal discomfort.
a.)Provide her with the information and teach her the skills she'll need to understand and cope during birth.
b.)Provide her with written information about the birthing process.
c.)Have a more experienced pregnant woman assist her.
d.)Do nothing in hopes that she'll begin coping as the pregnancy progresses.
A. RATIONALE: Because the client is in her second trimester, the nurse has ample time to establish a trusting relationship with her and to teach her in a style that fits her needs. Written information would be effective only in conjunction with teaching sessions. Introducing her to another pregnant client may be helpful, but the nurse still needs to teach the client about giving birth. Doing nothing won't address the client's needs.
52. The nurse is assessing a pregnant woman in the clinic. In the course of the assessment, the nurse learns that this woman smokes one pack of cigarettes per day. The first step the nurse should take to help the woman stop smoking is to:
a.)assess the client's readiness to stop.
b.)suggest that the client reduce the daily number of cigarettes smoked by one-half.
c.)provide the client with the telephone number of a formal smoking cessation program.
d.)help the client develop a plan to stop.
A. RATIONALE: Before planning any intervention with a client who smokes, it's essential to determine whether the client is willing or ready to stop smoking. Commonly, a pregnant woman will agree to stop smoking for the duration of the pregnancy. This gives the nurse an opportunity to work with her over time to help with permanent smoking cessation.
53. The nurse is recording an Apgar score for a neonate. The nurse should assess: a.)heart rate, respiratory effort, temperature, reflex irritability, and color.
b.)heart rate, respiratory effort, reflex irritability, and color.
c.)heart rate, respiratory effort, temperature, and color.
d.)heart rate, respiratory effort, temperature, sucking reflex, and color.
B. RATIONALE: When recording an Apgar score for a neonate, the nurse should assess heart rate, respiratory effort, reflex irritability, and color. The neonate's temperature and sucking reflex will be assessed shortly after birth, but they aren't components of the Apgar score.
54. The nurse is teaching the mother of a neonate about the importance of immunizations. The nurse should teach her that active immunity:
a.)develops rapidly and is temporary.
b.)occurs by antibody transmission.
c.)results from exposure of an antigen through immunization or disease contact. d.)may be transferred by mother to neonate.
C. RATIONALE: Active immunity results from direct exposure of an antigen by immunization or disease exposure. Passive immunity occurs from antibody transmission. It occurs rapidly but is temporary. Passive immunity may be transferred by the mother to the neonate.
55. When evaluating a client's knowledge of symptoms to report during her pregnancy, which statement would indicate to the nurse that the client understands the information given to her?
a.)"I'll report increased frequency of urination."
b.)"If I have blurred or double vision, I should call the clinic immediately."
c.)"If I feel tired after resting, I should report it immediately."
d.)"Nausea should be reported immediately."
B. RATIONALE: Blurred or double vision may indicate hypertension or preeclampsia and should be reported immediately. Urinary frequency is a common problem during pregnancy caused by increased weight pressure on the bladder from the uterus. Clients generally experience fatigue and nausea during pregnancy.
56. The nurse has a client at 30 weeks' gestation who has tested positive for the human immunodeficiency virus (HIV). What should the nurse tell the client when she says that she wants to breast-feed her neonate?
a.)Encourage breast-feeding so that she can get her rest and get healthier.
b.)Encourage breast-feeding because it's healthier for the neonate.
c.)Encourage breast-feeding to facilitate bonding.
d.)Discourage breast-feeding because HIV can be transmitted through breast milk.
D. RATIONALE: Transmission of HIV can occur through breast milk, so breast-feeding should be discouraged in this case.
57. A neonate of a client with type 1 diabetes mellitus is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is: a.)peripheral acrocyanosis.
b.)bradycardia.
c.)lethargy.
d.)jaundice.
C. RATIONALE: Lethargy in the neonate may be seen with hypoglycemia because of a lack of glucose in the nerve cells. Peripheral acrocyanosis is normal in the neonate because of immature capillary function. Tachycardia, not bradycardia, is seen with hypoglycemia. Jaundice isn't a sign of hypoglycemia.
58. The nurse is assessing a neonate. When maternal estrogen has been transferred to the fetus, which sign will the nurse see in the neonate?
a.)Weak sucking response
b.)Enlarged breast tissue
c.)Soft skin
d.)Vernix caseosa
B. RATIONALE: It's common to see enlarged breast tissue in both male and female neonates in their first few days of life due to maternal estrogen transmitted to the fetus. Weak sucking response isn't related to estrogen. Soft skin and vernix caseosa are signs of full-term, well-developed neonates and aren't related to estrogen.
59. A 20-year-old female's pregnancy is confirmed at a clinic. She says her husband will be excited but she's concerned because she isn't excited. She fears this may mean she'll be a bad mother. The nurse should respond by:
a.)referring her to counseling.
b.)telling her such feelings are normal in the beginning of pregnancy.
c.)exploring her feelings.
d.)recommending she talk her feelings over with her husband.
B. RATIONALE: Misgivings and fears are common in the beginning of pregnancy. It doesn't necessarily mean that she requires counseling at this time. Exploring her feelings may help her understand her concerns more deeply but won't provide reassurance that her feelings are normal. She may benefit by discussing her feelings with her husband, but the husband also needs to be reassured that these feelings are normal at this time.
60. A woman who is 10 weeks pregnant tells the nurse that she's worried about her fatigue and frequent urination. The nurse should:
a.)recognize these as normal early pregnancy signs and symptoms.
b.)question her further about these signs and symptoms.
c.)tell her that she'll need blood work and urinalysis.
d.)tell her that she may be excessively worried.
A. RATIONALE: Fatigue and frequent urination are early signs and symptoms of pregnancy that may continue through the first trimester. Questioning her about the signs and symptoms is helpful to complete the assessment but won't reassure her. Prenatal blood work and urinalysis is routine for this situation but doesn't address the client's concerns. Telling her that she may be excessively worried isn't therapeutic.
61. A client with hypotonic labor dysfunction has been started on oxytocin (Pitocin). Despite adequate contractions, the fetus doesn't descend lower than 0 station. The physician recommends cesarean delivery. The client and her husband are confused because she had given birth previously to an average-size neonate. They ask several questions about cesarean birth. What would be the most accurate nursing diagnosis for this client?
a.)Anger related to loss of planned birth experience
b.)Anxiety related to lack of knowledge about the need for cesarean birth
c.)Acute pain related to long, unproductive labor
d.)Fear related to the unknown
B. RATIONALE: The couple's questions indicate their lack of knowledge. Anxiety is expected because a cesarean delivery was unplanned. The other options aren't indicated by the stated assessment data.
62. The nurse is providing care for a pregnant woman. The woman asks the nurse how she can best deal with her fatigue. The nurse should instruct her to:
a.)take sleeping pills for a restful night's sleep.
b.)try to get more rest by going to bed earlier.
c.)take her prenatal vitamins.
d.)tell her not to worry because the fatigue will go away soon.
B. RATIONALE: She should listen to the body's way of telling her that she needs more rest and try going to bed earlier. Vitamins won't take away fatigue. False reassurance is inappropriate and doesn't help her deal with fatigue now. Sleeping pills shouldn't be consumed prenatally because they can harm the fetus.
63. The nurse is providing care for a pregnant 16-year-old client. The client says that she's concerned she may gain too much weight and wants to start dieting. The nurse should respond by saying:
a.)"Now isn't a good time to begin dieting because you are eating for two."
b.)"Let's explore your feelings further."
c.)"Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems."
d.)"The prenatal vitamins should ensure the baby gets all the necessary nutrients."
C. RATIONALE: Depriving the developing fetus of nutrients can cause serious problems, and the nurse should discuss this with the client. The client isn't eating for two; this is a misconception. Exploring feelings helps the client understand her concerns, but she needs to be aware of the risks at this time. The vitamins are supplements and don't contain everything a mother or neonate needs; they work in congruence with a balanced diet.
64. The nurse is providing care for a pregnant client in her second trimester. Glucose tolerance test results show a blood glucose level of 160 mg/dl. The nurse should anticipate that the client will need to:
a.)start using insulin.
b.)start taking an oral antidiabetic drug.
c.)monitor her urine for glucose.
d.)be taught about diet.
D. RATIONALE: The client's blood glucose level should be controlled initially by diet and exercise, rather than insulin. The client will need to watch her overall dietary intake to control her blood glucose level. Oral antidiabetic drugs aren't used in pregnant females. Urine sugars aren't an accurate indication of blood glucose levels.
65. The nurse is providing care for a pregnant client with gestational diabetes. The client asks the nurse if her gestational diabetes will affect her delivery. The nurse should know that:
a.)the delivery may need to be induced early.
b.)the delivery must be by cesarean.
c.)the mother will carry to term safely.
d.)it's too early to tell.
A. RATIONALE: Early induction or early cesarean delivery are possibilities if the mother has diabetes and euglycemia that hasn't been maintained during pregnancy. Cesarean delivery isn't always necessary.
66. A newly pregnant woman tells the nurse that she hasn't been taking her prenatal vitamins because they make her nauseated. In addition to stressing the importance of taking the vitamins, the nurse should advise the client to:
a.)switch brands.
b.)take the vitamin on a full stomach.
c.)take the vitamin with orange juice for better absorption.
d.)take the vitamin first thing in the morning.
B. RATIONALE: Prenatal vitamins commonly cause nausea and taking them on a full stomach may curb this. Switching brands may not be helpful and may be more costly. Orange juice tends to make pregnant women nauseated. The vitamins may be taken at night, rather than in the morning, to reduce nausea.
67. A neonate born 2 hours ago has just arrived in the nursery. Which nursing measure will prevent the neonate from losing heat due to evaporation?
a.)Keeping him away from drafts
b.)Putting a blanket between him and cold surfaces
c.)Putting a cap on his head
d.)Drying him thoroughly after a bath
D. RATIONALE: Neonates lose heat through evaporation as liquid is converted to a vapor. Drying a neonate after birth and following a bath prevents heat loss caused by evaporation. Keeping a neonate away from drafts prevents heat loss caused by convection. Keeping a neonate off a cold surface, such as a scale, prevents the heat loss caused by conduction. Placing a cap on the neonate's head preserves heat and prevents heat loss caused by radiation.
68. The nurse is caring for a neonate with a myelomeningocele. The priority nursing care of a neonate with a myelomeningocele is primarily directed toward:
a.)ensuring adequate nutrition.
b.)preventing infection.
c.)promoting neural tube sac drainage.
d.)conserving body heat.
B. RATIONALE: The nurse needs to provide special care to the neural tube sac to prevent infection. Allowing the sac to dry could result in cracks that allow microorganisms to enter. Pressure on the sac could cause it to rupture, creating a portal of entry for microorganisms. Administering antibiotics and keeping the sac free from urine and stool are other measures to prevent infection. Adequate nutrition is a concern for all neonates, including those with a myelomeningocele. Like all neonates, the neonate with a myelomeningocele must be kept warm, but care must be taken to avoid drying out the neural tube sac with a radiant heater or exerting pressure using a sheet or blanket over the sac.
69. nurse is conducting a neonate assessment of a boy, born 3 hours earlier. Which assessment would make the nurse suspect a congenital hip dislocation?
a.)Limited abduction of the affected leg
b.)Unequal gluteal folds
c.)Lengthening of the limb on the affected side
d.)Crepitus of the affected hip on movement
B. RATIONALE: Unequal gluteal folds are signs of congenital hip dislocation. Other signs include unequal thighs, limited adduction of the affected side, and shortening of the limb on the affected side. Crepitus of the affected hip isn't felt, but an audible click may be heard when the hip on the affected side is adducted.
70. The nurse has been teaching a new mother how to feed her infant son who was born with a cleft lip and palate. Which action by the mother would indicate that the teaching has been successful?
a.)Placing the neonate flat during feedings
b.)Providing fluids with a small spoon
c.)Placing the nipple in the cleft palate
d.)Burping the neonate frequently
D. RATIONALE: Because a neonate with a cleft lip and palate can't grasp a nipple securely, he may swallow a large amount of air during feedings and, therefore, require frequent burping. A neonate with a cleft lip and palate should be fed in an upright position to reduce the risk of aspiration. Spoons aren't used. A neonate with a cleft lip and palate may use specially prepared nipples for feeding. Placing the nipple in the cleft palate increases the risk of aspiration.
71. A client who is 34 weeks pregnant is experiencing bleeding caused by placenta previa. The fetal heart sounds are normal, and the client isn't in labor. Which nursing intervention should the nurse perform?
a.)Allow the client to ambulate with assistance.
b.)Perform a vaginal examination to check for cervical dilation.
c.)Monitor the amount of vaginal blood loss.
d.)Notify the physician for a fetal heart rate of 130 beats/minute.
C. RATIONALE: Estimate the amount of blood loss by such measures as weighing perineal pads or counting the amount of pads saturated over a period of time. The physician should be notified of continued blood loss, an increase in blood flow, or vital signs indicative of shock (hypotension and tachycardia). The woman should be placed on bed rest and not allowed to ambulate. A pelvic examination should never be performed when placenta previa is suspected because manipulation of the cervix can cause hemorrhage. A normal fetal heart rate is 120 to 160 beats/minute; therefore, the physician doesn't need to be notified of a fetal heart rate of 130 beats/minute.
72. A nurse in a prenatal clinic is assessing a 28-year-old who is 24 weeks pregnant. Which findings would lead this nurse to suspect that the client has mild preeclampsia? a.)Glycosuria, hypertension, seizures
b.)Hematuria, blurry vision, reduced urine output
c.)Burning on urination, hypotension, abdominal pain
d.)Hypertension, edema, proteinuria
D. RATIONALE: The typical findings of mild preeclampsia are hypertension, edema, and proteinuria. Abdominal pain, blurry vision, and reduced urine output are signs of severe preeclampsia. Seizures are a sign of eclampsia. The other findings aren't typically found in women with preeclampsia.
73. A client who is 24 weeks pregnant and diagnosed with preeclampsia is sent home with orders for bed rest and a referral for home health visits by a community health nurse. Which comment made by the client should indicate to the nurse that the client understands the reasons for home health visits?
a.)"The community health nurse will help fix my meals."
b.)"The community health nurse will give me my antihypertensive medication."
c.)"The community health nurse will check me and my baby and talk with my physician."
d.)"The community health nurse will give me prenatal care so that I won't have to see my physician."
C. RATIONALE: Community health nurses provide skilled nursing care, such as assessing and monitoring blood pressure, providing treatments and education, and communicating with the physician. For the prenatal client with preeclampsia, this may include monitoring the therapeutic effects of antihypertensive medications, assessing fetal heart tones, and providing nutrition counseling. The professional nurse doesn't fix meals in the home this service may be provided by a home health aide or housekeeper. The community health nurse teaches the client to take her own medications, including the proper time, dose, frequency, and adverse effects. The community health nurse doesn't replace the care provided by the client's physician.
74. A client who is 12 weeks pregnant is complaining of severe left lower quadrant pain and vaginal spotting. She's admitted for treatment of an ectopic pregnancy. Which nursing diagnosis takes the highest priority?
a.)Risk for deficient fluid volume
b.)Anxiety
c.)Acute pain
d.)Impaired gas exchange
A. RATIONALE: A ruptured ectopic pregnancy is a medical emergency due to the large quantity of blood that may be lost in the pelvic and abdominal cavities. Shock may develop from blood loss, and large quantities of I.V. fluids are needed to restore intravascular volume until the bleeding is surgically controlled. All the other nursing diagnoses are relevant for a woman with an ectopic pregnancy, but risk for deficient fluid volume through hemorrhage is the greatest threat to her physiological integrity and must be stopped. Anxiety may be due to such factors as the risk of dying and the fear of future infertility. Acute pain may be caused by a ruptured or distended fallopian tube or blood in the peritoneal cavity. Impaired gas exchange may result from the loss of oxygen-carrying hemoglobin through blood loss.
75. A client delivered a healthy full-term baby girl 2 hours ago by cesarean delivery. When assessing this client, which finding requires immediate nursing action?
a.)Tachycardia and hypotension
b.)Gush of vaginal blood when she stands up
c.)Blood stain (5.1 cm) in diameter on the abdominal dressing
d.)Complaints of abdominal pain
A. RATIONALE: A rising pulse rate and falling blood pressure may be signs of hemorrhage. Lochia pools in the vagina of a postpartal woman who has been sitting and may suddenly gush out when she stands up. A blood stain on a fresh surgical incision isn't a cause for immediate concern; however, the area of blood should be circled and timed. An increase in the size of the blood stain and oozing of the surgical incision should be promptly reported to the physician. It's normal for a woman who has had a cesarean section to feel pain at the incision site once her anesthesia has worn off.
76. A nurse in the nursery is preparing to perform phenylketonuria (PKU) testing. Which neonate is ready for the nurse to test?
a.)A 3-day-old neonate who has been fed I.V. since birth
b.)A 2-day-old neonate who has been breast-fed
c.)A 1-day-old neonate receiving formula
d.)A breast-fed neonate being discharged within 24 hours of birth
B. RATIONALE: To test for PKU, a neonate must have had a sufficient intake of phenylalanine through the ingestion of either formula or breast milk for at least 2 days. A neonate who has been receiving I.V. fluids and hasn't yet received breast milk or formula isn't ready to be tested for PKU. A neonate who is discharged within 24 hours of delivery will need to see the physician for PKU testing after receiving formula or breast milk for 48 hours.
77. The nurse is teaching a client who is 28 weeks pregnant and has gestational diabetes how to control her blood glucose levels. Diet therapy alone has been unsuccessful in controlling her blood glucose levels, so she has started insulin therapy. The nurse should consider the teaching effective when the client says:
a.)"I won't use insulin if I'm sick."
b.)"I need to use insulin each day."
c.)"If I give myself an insulin injection, I don't need to watch what I eat."
d.)"I'll monitor my blood glucose levels twice a week."
B.RATIONALE: When dietary treatment for gestational diabetes is unsuccessful, insulin therapy is started and the client will need daily doses. The client shouldn't stop using the insulin unless first obtaining an order from the physician for insulin adjustments when ill. Diet therapy continues to play an important role in blood glucose control in the client who requires insulin. Diet therapy is important to achieve appropriate weight gain and to avoid periods of hypoglycemia and hyperglycemia when taking insulin. Fasting, postprandial, and bedtime blood glucose levels need to be checked daily.
78. A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and delivers a boy. Which priority intervention should be included in the care plan for the neonate during his first 24 hours?
a.)Administer insulin subcutaneously.
b.)Administer a bolus of glucose I.V.
c.)Provide frequent early feedings with formula.
d.)Avoid oral feedings.
C. RATIONALE: The neonate of a mother with diabetes may be slightly hyperglycemic immediately after birth because of the high glucose levels that cross the placenta from mother to fetus. During pregnancy, the fetal pancreas secretes increased levels of insulin in response to this increased glucose amount. However, during the first 24 hours of life, this combination of high insulin production in the neonate coupled with the loss of maternal glucose can cause severe hypoglycemia. Frequent, early feedings with formula can prevent hypoglycemia. Insulin shouldn't be administered because the neonate of a mother with diabetes is at risk for hypoglycemia. A bolus of glucose given I.V. may cause rebound hypoglycemia. If glucose is given I.V., it should be administered as a continuous infusion. Oral feedings shouldn't be avoided because early, frequent feedings can help avoid hypoglycemia.
79. A 28-year-old woman gave birth 1 hour ago to a full-term baby boy. Which finding should the nurse expect when palpating the client's fundus?
a.)Soft, at the level of the umbilicus
b.)Firm (1.9 cm) below the umbilicus
c.)Firm, at the level of the umbilicus
d.)Boggy, midway between the umbilicus and symphysis pubis
C. RATIONALE: Within 1 hour after delivery, the fundus should be firm and at the level of the umbilicus. A soft or boggy fundus isn't contracting well due to such factors as a full bladder or retained pieces of placenta and places the postpartum woman at risk for hemorrhage.
80. Which finding is considered normal in a neonate during the first few days after birth?
a.)Weight loss of 25%
b.)Birth weight of 2,000 to 2,500 g
c.)Weight loss then return to birth weight
d.)Weight gain of 25%
C. RATIONALE: Babies lose approximately 10% of their birth weight during the first 3 or 4 days, due to the loss of excess extracellular fluids and meconium as well as limited oral intake, until breast-feeding is established. Return to birth weight should occur within 10 days after birth. Normal birth weights range from 2,700 to 4,000 g.
81. The mother of a neonate expresses concern about how she'll continue to breast-feed when she returns to work in 6 weeks. What's the best response by the nurse?
a.)"Why don't you wait and see how things go? You may be tired of breast-feeding by then."
b.)"Let your daycare provider give the baby formula in a bottle and breast-feed when you're home."
c.)"Your baby won't need breast-feeding by then, so just switch completely to formula when you return to work."
d.)"You can continue breast-feeding after you go back to work. You can pump your breasts and put the milk in a bottle."
D. RATIONALE: Breast-feeding should continue for the first 6 months after birth when possible. Breast milk can be pumped at work to give to the neonate at daycare. This will also keep the mother's milk production up.
82. Early detection of an ectopic pregnancy is paramount in preventing a life-threatening rupture. Which symptoms should alert the nurse to the possibility of an ectopic pregnancy?
a.)Abdominal pain, vaginal bleeding, and a positive pregnancy test b.)Hyperemesis and weight loss
c.)Amenorrhea and a negative pregnancy test
d.)Copious discharge of clear mucus and prolonged epigastric pain
A. RATIONALE: Abdominal pain, vaginal bleeding, and a positive pregnancy test are cardinal signs of an ectopic pregnancy. Nausea and vomiting may occur prior to rupture, but significantly increase after rupture. Amenorrhea and a negative pregnancy test may indicate another type of metabolic disorder such as hypothyroidism. Discharge of clear mucus isn't indicative of an ectopic pregnancy, and referred shoulder pain, not epigastric pain, should be expected.
83. The client has just given birth to her first child, a healthy, full-term baby girl. The client is Rh (D)-negative and her neonate is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility?
a.)Administration of Rh (D) Immune Globulin I.M. to the neonate within 72 hours
b.)Administration of Rh (D) Immune Globulin I.M. to the mother within 72 hours
c.)Injection of Rh (D) Immune Globulin to the mother during her 6 week follow-up visit d.)Administration of Rh (D) Immune Globulin I.M. to the mother within 3 months
B. RATIONALE: When a mother is Rh (D)-negative and a neonate is Rh-positive, the mother forms antibodies against the D antigen. Most of the antibodies develop within the first 72 hours after she has given birth due to the exchange of maternal and fetal blood during delivery. If the mother becomes pregnant again, she'll have a high antibody D level that may destroy fetal blood cells during the second pregnancy. However, if the mother receives an injection of Rh (D) Immune Globulin within 72 hours, no antibodies will be formed. Rh (D) Immune Globulin may also be given to the mother during pregnancy, if the neonate is Rh-positive. The neonate isn't given Rh (D) Immune Globulin.
84. On the 9th postpartum day, a client breast-feeding her neonate experiences pain, redness, and swelling of her left breast. She's diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information? a.)Wear a loose-fitting bra to avoid constricting the milk ducts.
b.)Stop breast-feeding permanently.
c.)Take antibiotics until the pain is relieved.
d.)Use a warm moist compress over the painful area.
D. RATIONALE: Warm, moist compresses will reduce inflammation and edema of the infected breast tissue. The woman with mastitis should wear a proper fitting bra with good support. Breast-feeding may resume once the infection is treated. The client will need to pump the breast in the meantime to keep the breast empty of milk and to ensure an adequate milk supply. Antibiotics must be taken for the full course of therapy and not stopped when symptoms subside.
85. The nurse teaches a postpartum client about breast-feeding. Which statement best indicates that the client knows how to avoid breast engorgement?
a.)"I'll apply warm, moist compresses to my breasts."
b.)"I'll breast-feed every 1& to 3 hours."
c.)"I'll use an electric breast pump."
d.)"I'll wear a bra 24 hours per day."
B. RATIONALE: Frequent breast-feeding keeps the breasts relatively empty and increases circulation, thereby helping to remove fluid that may lead to engorgement. Applying warm compresses to the breasts stimulates the let-down reflex, filling the breasts and increasing engorgement. An electric breast pump usually isn't used if the neonate can breast-feed frequently. Although a bra supports the breasts, it can't prevent engorgement.
86. The nurse is assessing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus?
a.)One fingerbreadth above the umbilicus
b.)One fingerbreadth below the umbilicus
c.)At the level of the umbilicus
d.)Below the symphysis pubis
B. RATIONALE: After a client gives birth, the height of her fundus should decrease about one fingerbreadth (about 1 cm) each day. Immediately after birth, the fundus may be above the umbilicus. At 6 to 12 hours after birth, it should be at the level of the umbilicus. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. After 10 days, it should be below the symphysis pubis.
87. The nurse is helping to prepare a client for discharge following childbirth. During a teaching session, the nurse instructs the client to do Kegel exercises. What's the purpose of these exercises?
a.)To prevent urine retention
b.)To relieve lower back pain
c.)To tone the abdominal muscles
d.)To strengthen the perineal muscles
D. RATIONALE: Kegel exercises strengthen and increase the elasticity of the pubococcygeus muscle, which is the main perineal muscle. They also improve vaginal tone and help prevent stress incontinence and hemorrhoids. Kegel exercises can't prevent urine retention, relieve lower back pain, or tone abdominal muscles.
88. The nurse is using Doppler ultrasound to assess a pregnant woman. When should the nurse expect to hear fetal heart tones?
a.)7 weeks
b.)11 weeks
c.)17 weeks
d.)21 weeks
B. RATIONALE: Using Doppler ultrasound, fetal heart tones may be heard as early as the 11th week of pregnancy. Using a stethoscope, fetal heart tones may be heard between 17 and 20 weeks of gestation.
89. The nurse is planning care for a 16-year-old client in the prenatal clinic. Adolescents are prone to which complication during pregnancy?
a.)Iron deficiency anemia
b.)Varicosities
c.)Nausea and vomiting
d.)Gestational diabetes
A. RATIONALE: Iron deficiency anemia is a common complication of adolescent pregnancies. Adolescent girls may already be anemic. The need for iron during pregnancy, for fetal growth and an increased blood supply, compounds the anemia even further. Varicosities are a complication of pregnancy more likely seen in women over age 35. An adolescent pregnancy doesn't increase the risk of nausea and vomiting or gestational diabetes.
90. The nurse is caring for a 16-year-old pregnant client. The client is taking an iron supplement. What should this client drink to increase the absorption of iron?
a.)A glass of milk
b.)A cup of hot tea
c.)A liquid antacid
d.)A glass of orange juice
D. RATIONALE: Increasing vitamin C enhances the absorption of iron supplements. Taking an iron supplement with milk, tea, or an antacid reduces the absorption of iron.
91. The nurse is caring for a client who is on ritodrine therapy to halt premature labor. What condition indicates an adverse reaction to ritodrine therapy?
a.)Hypoglycemia
b.)Crackles
c.)Bradycardia
d.)Hyperkalemia
B. RATIONALE: Use of ritodrine can lead to pulmonary edema. Therefore, the nurse should assess for crackles and dyspnea. Blood glucose levels may temporarily rise, not fall, with ritodrine. Ritodrine may cause tachycardia, not bradycardia. Ritodrine may also cause hypokalemia, not hyperkalemia.
92. The nurse is caring for a client in her 34th week of pregnancy who wears an external monitor. Which statement by the client would indicate an understanding of the nurse's teaching?
a.)"I'll need to lie perfectly still."
b.)"You won't need to come in and check on me while I'm wearing this monitor."
c.)"I can lie in any comfortable position, but I should stay off my back."
d.)"I know that the external monitor increases my risk of a uterine infection."
C. RATIONALE: A woman with an external monitor should lie in the position that's most comfortable to her, although the supine position should be discouraged. A woman should be encouraged to change her position as often as necessary; however, the monitor may need to be repositioned after a position change. The nurse still needs to frequently assess and provide emotional support to a woman in labor who is wearing an external monitor. Because an external monitor isn't invasive and is worn around the abdomen, it doesn't increase the risk of uterine infection.
93. The nurse is developing a care plan for a client in her 34th week of gestation who is experiencing premature labor. What nonpharmacologic intervention should the plan include to halt premature labor?
a.)Encouraging ambulation
b.)Serving a nutritious diet
c.)Promoting adequate hydration
d.)Performing nipple stimulation
D. RATIONALE: Providing adequate hydration to the woman in premature labor may help halt contractions. The client should be placed on bed rest so that the fetus exerts less pressure on the cervix. A nutritious diet is important in pregnancy, but it won't halt premature labor. Nipple stimulation activates the release of oxytocin, which promotes uterine contractions.
94. A client treated for premature labor is ready for discharge. Which instruction should the nurse include in the discharge teaching plan?
a.)Report a heart rate greater than 120 beats/minute to the physician.
b.)Take terbutaline every 4 hours, during waking hours only.
c.)Call the physician if the fetus moves 10 times in 1 hour.
d.)Increase activity daily if not fatigued.
A. RATIONALE: Because terbutaline can cause tachycardia, the woman should be taught to monitor her radial pulse and call the physician for a heart rate greater than 120 beats/minute. Terbutaline must be taken every 4 to 6 hours around-the-clock to maintain an effective serum level that will suppress labor. A fetus normally moves 10 to 12 times per hour. The client experiencing premature labor must maintain bed rest at home.
95. The nurse is caring for a client in labor. Which assessment finding indicates fetal distress?
a.)Lack of meconium staining
b.)Early decelerations in fetal heart rate during contractions
c.)An increase in fetal heart rate with fetal scalp stimulation
d.)Fetal blood pH less than 7.20
D. RATIONALE: A fetal blood pH less than 7.20 is an indication of fetal hypoxia. During labor, a fetal pH range of 7.20 to 7.30 is considered normal. Fetal blood is sampled from the fetal scalp through a dilated cervix. The other options are normal findings.
96. The nurse is assessing a woman in labor. Her cervix is dilated 8 cm. Her contractions are occurring every 2 minutes. She's irritable and in considerable pain. What type of breathing should the nurse instruct the woman to use during the peak of a contraction?
a.)Deep breathing
b.)Shallow chest breathing
c.)Deep, cleansing breaths
d.)Chest panting
B. RATIONALE: Shallow chest breathing is used during the peak of a contraction during the transitional phase of labor. Deep breathing can cause a woman to hyperventilate and feel light-headed, with numbness or tingling in her fingers or toes. A deep, cleansing breath taken at the beginning and end of each breathing exercise can help prevent hyperventilation. Chest panting may be used to prevent a woman from pushing before the cervix is fully dilated.
97. The nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension?
a.)Administer ephedrine to raise her blood pressure.
b.)Administer oxygen using a mask.
c.)Place the woman flat on her back with her legs raised.
d.)Ensure adequate hydration before the anesthetic is administered.
D. RATIONALE: Because the woman is in a state of relative hypovolemia, administering fluids I.V. before the epidural anesthetic is given may prevent hypotension. Administration of an epidural anesthetic may lead to hypotension because blocking the sympathetic fibers in the epidural space reduces peripheral resistance. Ephedrine may be administered after an epidural block if a woman becomes hypotensive and shows evidence of cardiovascular decompensation. However, ephedrine isn't administered to prevent hypotension. Oxygen is administered to a woman who becomes hypotensive, but it won't prevent hypotension. Placing a pregnant woman in a supine position can contribute to hypotension because of uterine pressure on the great vessels.
98. A woman in labor shouts to the nurse, "My baby is coming right now! I feel like I have to push!" An immediate nursing assessment reveals that the head of the fetus is crowning. After asking another staff member to notify the physician and setting up for delivery, which nursing intervention is most appropriate?
a.)Gently pulling at the neonate 's head as it's delivered
b.)Holding the neonate 's head back until the physician arrives
c.)Applying gentle pressure to the neonate 's head as it's delivered
d.)Placing the mother in a Trendelenburg position until the physician arrives
C. RATIONALE: Gentle pressure applied to the neonate's head as it's delivered prevents rapid expulsion, which can cause brain damage to the neonate and perineal tearing in the mother. Never pull at the neonate 's head or hold the head back. Placing the mother in the Trendelenburg position won't halt labor and may cause respiratory difficulties.
99. The nurse is caring for a client who is in labor. The physician still isn't present. After the neonate's head is delivered, which nursing intervention would be most appropriate?
a.)Checking for the umbilical cord around the neonate 's neck
b.)Placing antibiotic ointment in the neonate 's eyes
c.)Turning the neonate's head to the side, to drain secretions
d.)Assessing the neonate for respirations
A. RATIONALE: After the neonate 's head is delivered, the nurse should check for the cord around the neonate 's neck. If the cord is around the neck, it should be gently lifted over the neonate 's head. Antibiotic ointment, to prevent gonorrheal conjunctivitis, is administered to the neonate after birth, not during delivery of the head. The neonate's head isn't turned during delivery. After delivery, the neonate is held with his head lowered to help with drainage of secretions. If a bulb syringe is available, it can be used to gently suction the neonate's mouth. Assessing the neonate's respiratory status should be done immediately after delivery.
100. The nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do?
a.)Apply an ice pack to her perineum.
b.)Take a Sitz bath.
c.)Perform perineal care after voiding or a bowel movement.
d.)Drink plenty of fluids.
A. RATIONALE: A cold pack applied to an episiotomy during the first 24 hours after delivery may reduce edema and tension on the incision line, thereby reducing pain. After the first 24 hours, a Sitz bath may reduce discomfort by promoting circulation and healing. While perineal care should be performed after each voiding and bowel movement, its purpose is to prevent infection not reduce discomfort. Drinking plenty of fluids is also important, especially for the breast-feeding woman, but it doesn't relieve perineal discomfort.