MCN

Question 1

1. Mrs. Jimenez went to the health center for pre-natal check-up. the student nurse took her weight and revealed 142 lbs. She asked the student nurse how much should she gain weight in her pregnancy.

A. 20-30 lbs
B. 25-35 lbs
C. 30-40 lbs
D. 10-15 lbs

Answer 1

B. 25-35 lbs

ANSWER (B) 25-35 lbs. A weight gain of 11. 2 to 15.9 kg (25 to 35 lbs) is currently recommended as an average weight gain in pregnancy. This weight gain consists of the following: fetus- 7.5 lb; placenta- 1.5 lb; amniotic fluid-2 lb; uterus- 2.5 lb; breasts- 1.5 to 3 lb; blood volume- 4 lb; body fat- 7 lb; body fluid- 7 lb.

Question 2

2. The nurse is preparing Mrs. Jordan for cesarean delivery. Which of the following key concept should the nurse consider when implementing nursing care?

A. Explain the surgery, expected outcome and kind of anesthetics.
B. Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth.
C. Arrange for a staff member of the anesthesia department to explain what to expect post-operatively.
D. Instruct the mother’s support person to remain in the family lounge until after the delivery.

Answer 2

B. Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth.

ANSWER (B) Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth.

Question 3

3. Bettine Gonzales is hospitalized for the treatment of severe preecplampsia. Which of the following represents an unusual finding for this condition?

A. generalized edema
B. proteinuria 4+
C. blood pressure of 160/110
D. convulsions

Answer 3

D. convulsions

ANSWER (D) convulsions. Options A, B and C are findings of severe preeclampsia. Convulsions is a finding of eclampsia-an obstetrical emergency.

Question 4

4. During the first hours following delivery, the post partum client is given IVF with oxytocin added to them. The nurse understands the primary reason for this is:

A. To facilitate elimination
B. To promote uterine contraction
C. To promote analgesia
D. To prevent infection

Answer 4

B. To promote uterine contraction

ANSWER(B) To promote uterine contraction. Oxytocin is a hormone produced by the pituitary gland that produces intermittent uterine contractions, helping to promote uterine involution.

Question 5

5. Which of the following danger sings should be reported immediately during the antepartum period?

A. blurred vision
B. nasal stuffiness
C. breast tenderness
D. constipation

Answer 5

A. blurred vision

ANSWER (A) blurred vision. Danger signs that require prompt reporting are leaking of amniotic fluid, blurred vision, vaginal bleeding, rapid weight gain and elevated blood pressure. Nasal stuffiness, breast tenderness, and constipation are common discomforts associated with pregnancy.

Question 6

6. Which of the following is the most appropriate intervention to reduce stress in a preterm infant at 33 weeks’ gestation?

A. Sensory stimulation including several senses at a time
B. tactile stimulation until signs of over stimulation develop
C. An attitude of extension when prone or side lying
D. Kangaroo care

Answer 6

D. Kangaroo care

Question 7

7. A client in her third trimester tells the nurse, “I’m constipated all the time!” Which of the following should the nurse recommend?

A. Daily enemas
B. Laxatives
C. Increased fiber intake
D. Decreased fluid intake

Answer 7

C. Increased fiber intake

ANSWER (C). During the third trimester, the enlarging uterus places pressure on the intestines. This coupled with the effect of hormones on smooth muscle relaxation causes decreased intestinal motility (peristalsis). Increasing fiber in the diet will help fecal matter pass more quickly through the intestinal tract, thus decreasing the amount of water that is absorbed. As a result, stool is softer and easier to pass. Enemas could precipitate preterm labor and/or electrolyte loss and should be avoided. Laxatives may cause preterm labor by stimulating peristalsis and may interfere with the absorption of nutrients. Use for more than 1 week can also lead to laxative dependency. Liquid in the diet helps provide a semisolid, soft consistency to the stool. Eight to ten glasses of fluid per day are essential to maintain hydration and promote stool evacuation.

Question 8

8. Before assessing the postpartum client’s uterus for firmness and position in relation to the umbilicus and midline, which of the following should the nurse do first?

A. Assess the vital signs
B. Administer analgesia
C. Ambulate her in the hall
D. Assist her to urinate

Answer 8

D. Assist her to urinate

ANSWER (D). Before uterine assessment is performed, it is essential that the woman empty her bladder. A full bladder will interfere with the accuracy of the assessment by elevating the uterus and displacing to the side of the midline. Vital sign assessment is not necessary unless an abnormality in uterine assessment is identified. Uterine assessment should not cause acute pain that requires administration of analgesia. Ambulating the client is an essential component of postpartum care, but is not necessary prior to assessment of the uterus.

Question 9

9. Which of the following should the nurse do when a primipara who is lactating tells the nurse that she has sore nipples?

A. Tell her to breast feed more frequently
B. Administer a narcotic before breast feeding
C. Encourage her to wear a nursing brassiere
D. Use soap and water to clean the nipples

Answer 9

A. Tell her to breast feed more frequently

ANSWER (A). Feeding more frequently, about every 2 hours, will decrease the infant’s frantic, vigorous sucking from hunger and will decrease breast engorgement, soften the breast, and promote ease of correct latching-on for feeding. Narcotics administered prior to breast feeding are passed through the breast milk to the infant, causing excessive sleepiness. Nipple soreness is not severe enough to warrant narcotic analgesia. All postpartum clients, especially lactating mothers, should wear a supportive brassiere with wide cotton straps. This does not, however, prevent or reduce nipple soreness. Soaps are drying to the skin of the nipples and should not be used on the breasts of lactating mothers. Dry nipple skin predisposes to cracks and fissures, which can become sore and painful.

Question 10

10. The nurse assesses the postpartum vaginal discharge (lochia) on four clients. Which of the following assessments would warrant notification of the physician?

A. A dark red discharge on a 2-day postpartum client
B. A pink to brownish discharge on a client who is 5 days postpartum
C. Almost colorless to creamy discharge on a client 2 weeks after delivery
D. A bright red discharge 5 days after delivery

Answer 10

D. A bright red discharge 5 days after delivery

Question 11

11..A postpartum client has a temperature of 101.4°F, with a uterus that is tender when palpated, remains unusually large, and not descending as normally expected. Which of the following should the nurse assess next?

A. Lochia
B. Breasts
C. Incision
D. Urine

Answer 11

A. Lochia

ANSWER (A). The data suggests an infection of the endometrial lining of the uterus. The lochia may be decreased or copious, dark brown in appearance, and foul smelling, providing further evidence of a possible infection. All the client’s data indicate a uterine problem, not a breast problem. Typically, transient fever, usually 101°F, may be present with breast engorgement. Symptoms of mastitis include influenza-like manifestations. Localized infection of an episiotomy or C-section incision rarely causes systemic symptoms, and uterine involution would not be affected. The client data do not include dysuria, frequency, or urgency, symptoms of urinary tract infections, which would necessitate assessing the client’s urine.

Question 12

12. Which of the following is the priority focus of nursing practice with the current early postpartum discharge?

A. Promoting comfort and restoration of health
B. Exploring the emotional status of the family
C. Facilitating safe and effective self-and newborn care
D. Teaching about the importance of family planning

Answer 12

C. Facilitating safe and effective self-and newborn care

ANSWER (C) Because of early postpartum discharge and limited time for teaching, the nurse’s priority is to facilitate the safe and effective care of the client and newborn. Although promoting comfort and restoration of health, exploring the family’s emotional status, and teaching about family planning are important in postpartum/newborn nursing care, they are not the priority focus in the limited time presented by early post-partum discharge.

Question 13

13. Metoprolol tartrate a Beta-adrenergic antagonist may be administered to a client with heart failure because it acts to:

A. Reduce peripheral vascular resistance
B. Increase peripheral vascular resistance
C. Reduce fluid volume
D. Improve myocardial contractility

Answer 13

A. Reduce peripheral vascular resistance

ANSWER. (A). beta adrenergic antagonist antagonizes the action of sympathetic response. It works by reducing the force of contraction of heart muscles thereby reducing peripheral resistance and blood pressure.

Question 14

14. Which of the following should the nurse do when a primipara who is lactating tells the nurse that she has sore nipples?

A. Tell her to breast feed more frequently
B. Administer a narcotic before breast feeding
C. Encourage her to wear a nursing brassiereD. Use soap and water to clean the nipples

Answer 14

A. Tell her to breast feed more frequently

Question 15

15. The mother asks the nurse. “What’s wrong with my son’s breasts? Why are they so enlarged?” Whish of the following would be the best response by the nurse?

A. “The breast tissue is inflamed from the trauma experienced with birth”
B. “A decrease in material hormones present before birth causes enlargement,”
C. “You should discuss this with your doctor. It could be malignancy”
D. “The tissue has hypertrophied while the baby was in the uterus”

Answer 15

B. “A decrease in material hormones present before birth causes enlargement

ANSWER (B). The presence of excessive estrogen and progesterone in the maternal fetal blood followed by prompt withdrawal at birth precipitates breast engorgement, which will spontaneously resolve in 4 to 5 days after birth. The trauma of the birth process does not cause inflammation of the newborn’s breast tissue. Newborns do not have breast malignancy. This reply by the nurse would cause the mother to have undue anxiety. Breast tissue does not hypertrophy in the fetus or newborns.

Question 16

16. The nurse hears a mother telling a friend on the telephone about umbilical cord care. Which of the following statements by the mother indicates effective teaching?

A. “Daily soap and water cleansing is best”
B. ‘Alcohol helps it dry and kills germs”
C. “An antibiotic ointment applied daily prevents infection”
D. “He can have a tub bath each day”

Answer 16

B. ‘Alcohol helps it dry and kills germs”

ANSWER (B). Application of 70% isopropyl alcohol to the cord minimizes microorganisms (germicidal) and promotes drying. The cord should be kept dry until it falls off and the stump has healed. Antibiotic ointment should only be used to treat an infection, not as a prophylaxis. Infants should not be submerged in a tub of water until the cord falls off and the stump has completely healed.

Question 17

17. Immediately after birth the nurse notes the following on a male newborn: respirations 78; apical hearth rate 160 BPM, nostril flaring; mild intercostal retractions; and grunting at the end of expiration. Which of the following should the nurse do?

A. Call the assessment data to the physician’s attention
B. Start oxygen per nasal cannula at 2 L/min.
C. Suction the infant’s mouth and nares
D. Recognize this as normal first period of reactivity

Answer 17

D. Recognize this as normal first period of reactivity

ANSWER (D). The first 15 minutes to 1 hour after birth is the first period of reactivity involving respiratory and circulatory adaptation to extrauterine life. The data given reflect the normal changes durin time period. The infant’s assessment data reflect no

Question 18

18. The nurse hears a mother telling a friend on the telephone about umbilical cord care. Which of the following statements by the mother indicates effective teaching?

A. “Daily soap and water cleansing is best”
B. ‘Alcohol helps it dry and kills germs”
C. “An antibiotic ointment applied daily prevents infection”
D. con haye a tub bath each day”

Answer 18

B. ‘Alcohol helps it dry and kills germs

Question 19

19. When measuring a client’s fundal height, which of the following techniques denotes the correct method of measurement used by the nurse?

A. From the xiphoid process to the umbilicus
B. From the symphysis pubis to the xiphoid process
C. From the symphysis pubis to the fundus
D. From the fundus to the umbilicus

Answer 19

C. From the symphysis pubis to the fundus

ANSWER (C). The nurse should use a nonelastic, flexible, paper measuring tape, placing the zero point on the superior border of the symphysis pubis and stretching the tape across the abdomen at the midline to the top of the fundus. The xiphoid and umbilicus are not appropriate landmarks to use when measuring the height of the fundus (McDonald’s measurement).

Question 20

20. A client with severe preeclampsia is admitted with of BP 160/110, proteinuria, and severe pitting edema. Which of the following would be most important to include in the client’s plan of care?

A. Daily weights
B. Seizure precautions
C. Right lateral positioning
D. Stress reduction

Answer 20

B. Seizure precautions

ANSWER (B). Women hospitalized with severe preeclampsia need decreased CNS stimulation to prevent a seizure. Seizure precautions provide environmental safety should a seizure occur. Because of edema, daily weight is important but not the priority. Preclampsia causes vasospasm and therefore can reduce utero-placental perfusion. The client should be placed on her left side to maximize blood flow, reduce blood pressure, and promote diuresis. Interventions to reduce stress and anxiety are very important to facilitate coping and a sense of control, but seizure precautions are the priority.

Question 21

21. A postpartum primipara asks the nurse, “When can we have sexual intercourse again?” Which of the following would be the nurse’s best response?

A. “Anytime you both want to.”
B. “As soon as choose a contraceptive method.”
C. “When the discharge has stopped and the incision is healed.”
D. “After your 6 weeks examination.”

Answer 21

C. “When the discharge has stopped and the incision is healed.”

ANSWER C. Cessation of the lochial discharge signifies healing of the endometrium. Risk of hemorrhage and infection are minimal 3 weeks after a normal vaginal delivery. Telling the client anytime is inappropriate because this response does not provide the client with the specific information she is requesting. Choice of a contraceptive method is important, but not the specific criteria for safe resumption of sexual activity. Culturally, the 6- weeks’ examination has been used as the time frame for resuming sexual activity, but it may be resumed earlier.

Question 22

22. Calcium gluconate is being administered to a client with pregnancy induced hypertension (PIH). A nursing action that must be initiated as the plan of care throughout injection of the drug is:

A. Ventilator assistance
B. CVP readings
C. EKG tracings
D. Continuous CPR

Answer 22

C. EKG tracings

Answer: (C) EKG tracings. A potential side effect of calcium gluconate administration is cardiac arrest. Continuous monitoring of cardiac activity (EKG) throught administration of calcium gluconate is an essential part of care.

Question 23

23. When preparing to administer the vitamin K injection to a neonate, the nurse would select which of the following sites as appropriate for the injection?

A. Deltoid muscle
B. Anterior femoris muscle
C. Vastus lateralis muscle
D. Gluteus maximus muscle

Answer 23

C. Vastus lateralis muscle

ANSWER C. The middle third of the vastus lateralis is the preferred injection site for vitamin K administration because it is free of blood vessels and nerves and is large enough to absorb the medication. The deltoid muscle of a newborn is not large enough for a newborn IM injection. Injections into this muscle in a small child might cause damage to the radial nerve. The anterior femoris muscle is the next safest muscle to use in a newborn but is not the safest. Because of the proximity of the sciatic nerve, the gluteus maximus muscle should not be until the child has been walking 2 years.

Question 24

24. A client at 8 weeks’ gestation calls complaining of slight nausea in the morning hours. Which of the following client interventions should the nurse question?

A. Taking teaspoon of bicarbonate of soda in an 8-ounce glass of water
B. Eating a few low-sodium crackers before getting out of bed
C. Avoiding the intake of liquids in the morning hours
D. Eating six small meals a day instead of thee large meals

Answer 24

A. Taking teaspoon of bicarbonate of soda in an 8-ounce glass of water

sodium ingested, which can cause complications. Eating low-sodium crackers would be appropriate. Since liquids can increase nausea avoiding them in the morning hours when nausea is usually the strongest is appropriate. Eating six small meals a day would keep the stomach full, which often decrease nausea.

Question 25

25. The nurse documents positive ballottement in the client's prenatal record. The nurse understands that this indicates which of the following? A. Palpable contractions on the abdomen B. Passive movement of the unengaged fetus, C. Fetal kicking felt by the client D. Enlargement and softening of the uterus

Answer 25

B. Passive movement of the unengaged fetus, ANSWER (B). Ballottement indicates passive movement of the unengaged fetus. Ballottement is not a contraction. Fetal kicking felt by the client represents quickening. Enlargement and softening of the uterus is known as Piskacek's sign.

Question 26

26. During a pelvic exam the nurse notes a purple-blue tinge of the cervix. The nurse documents this as which of the following? A. Braxton-Hicks sign B. Chadwick's sign p C. Goodell's sign D. McDonald's sign

Answer 26

B. Chadwick's sign ANSWER B. Chadwick's sign refers to the purple-blue tinge of the cervix. Braxton Hicks contractions are painless contractions beginning around the 4th month. Goodell's sign indicates softening of the cervix. Flexibility of the uterus against the cervix is known as McDonald's sign.

Question 27

27. Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole. She is aware that one of the following is unassociated with this condition? A. Excessive fetal activity. B. Larger than normal uterus for gestational age. C. Vaginal bleeding D. Elevated levels of human chorionic gonadotropin.

Answer 27

A. Excessive fetal activity. Answer: (A) Excessive final activity. T most common signs and symptoms of hydatidiform mole includes elevated lives of human chorionic gonadotropin, vaginal bleeding, larger than normal useras for gestational age, failure to detect fetal heart activity even with sensitive instruments, excessive nausea and vomiting, and early development of pregnancy-induced hypertension. Fetal activity would not be noted.

Question 28

28. With a fetus in the left-anterior breech presentation, the nurse would expect the fetal heart rate would be most audible in which of the following areas? A. Above the maternal umbilicus and to the right of midline B. In the lower-left maternal abdominal quadrant C. In the lower-right maternal abdominal quadrant D. Above the maternal umbilicus and to the left of midline

Answer 28

D. Above the maternal umbilicus and to the left of midline ANSWER D. With this presentation, the fetal upper torso and back face the left upper maternal abdominal wall. The fetal heart rate would be most audible above the maternal umbilicus and to the left of the middle. The other positions would be incorrect.

Question 29

29. During vaginal examination of Janah who is in labor, the presenting part is at station plus two. Nurse, correctly interprets it as: A. Presenting part is 2 cm above the plane of the ischial spines. B. Biparietal diameter is at the level of the ischial spines. C. Presenting part in 2 cm below the plane of the ischial spines. D. Biparietal diameter is 2 cm above the ischial spines.

Answer 29

C. Presenting part in 2 cm below the plane of the ischial spines. Answer: (C) Presenting part in 2 cm below the plane of the ischial spines. Fetus at station plus two indicates that the presenting part is 2 cm below the plane of the ischial spines.

Question 30

30. Nurse Oliver is teaching a diabetic pregnant client about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy require: A. Decreased caloric intake B. Increased caloric intake C. Decreased Insulin D. Increase Insulin

Answer 30

B. Increased caloric intake Answer: (B) Increased caloric intale. Glucose crosses the placenta, but insulin does not. High fetal demands for glicose, combined with the insulin resistance caused by horrsonal changes in the last half of pregnancy can result in elevation of maternal blood glucose levels. This increases the mother's demand for insulin and is referred to as the diabetogenic effect of pregnancy.

Question 31

1. A trial for vaginal delivery after an earlier caesarean, would likely to be given to a gravida, who had: A. First low transverse cesarean was for active herpes type 2 infections; vaginal culture at 39 weeks pregnancy was positive. B. First and second caesareans were for cephalopelvic disproportion. C. First caesarean through a classic incision as a result of severe fetal distress. D. First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex presentation.

Answer 31

D. First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex presentation. Answer: (D) First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex presentation. This type of client has no obstetrical indication for a caesarean section as she did with her first caesarean delivery.

Question 32

32. During a prenatal class, the nurse explains the rationale for breathing techniques during preparation for labor based on the understanding that breathing techniques are most important in achieving which of the following? A. Eliminate pain and give the expectant parents something to do B. Reduce the risk of fetal distress by increasing uteroplacental perfusion C. Facilitate relaxation, possibly reducing the perception of pain D. Eliminate pain so that less analgesia and anesthesia are needed

Answer 32

C. Facilitate relaxation, possibly reducing the perception of pain ANSWER C. Breathing techniques can raise the pain threshold and reduce the perception of pain. They also promote relaxation. Breathing techniques do not eliminate pain, but they can reduce it. Positioning, not breathing, increases uteroplacental perfusion

Question 33

33. A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension (PIH). The clinical findings that would warrant use of the antidote, calcium gluconate is: A. Urinary output 90 cc in 2 hours. B. Absent patellar reflexes. C. Rapid respiratory rate above 40/min. D. Rapid rise in blood pressure.

Answer 33

B. Absent patellar reflexes. Answer: (B) Absent patellar reflexes. Absence of patellar reflexes is an indicator of hypermagnesemia, which inquires administration of calcium gluconate.

Question 34

34. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that warrant the nurse in-charge to discontinue I.V. infusion of Pitocin is: A. Contractions every 1½ minutes lasting 70-80 seconds. B. Maternal temperature 101.2 C. Early decelerations in the fetal heart rate. D. Fetal heart rate baseline 140-160 bpm.

Answer 34

A. Contractions every 1½ minutes lasting 70-80 seconds. Answer: (A) Contractions every 1½ minutes lasting 70-80 seconds. Contractions every 1½ minutes lasting 70-80 seconds, is indicative of hyperstimulation of the uterus, which could result in injury to the mother and the fetus if Pitocin is not discontinued.

Question 35

35. For the client who is using oral contraceptives, the nurse informs the client about the need to take the pill at the same time each day to accomplish which of the following? A. Decrease the incidence of nausea B. Maintain hormonal levels C. Reduce side effects D. Prevent drug interactions

Answer 35

B. Maintain hormonal levels Answer B. Regular timely ingestion of oral contraceptives is necessary to maintain hormonal levels of the drugs to suppress the action of the hypothalamus and anterior pituitary leading to inappropriate secretion of FSH and LH. Therefore, follicles do not mature, ovulation is inhibited, and pregnancy is prevented. The estrogen content of the oral site contraceptive may cause the nausea, regardless of when the pill is taken. Side effects and drug interactions may occur with oral contraceptives regardless of the time the pill is taken.

Question 36

36. After 4 hours of active labor, the nurse notes that the contractions of a primigravida client are not strong enough to dilate the cervix. Which of the following would the nurse anticipate doing? A. Obtaining an order to begin IV oxytocin infusion B. Administering a light sedative to allow the patient to rest for several hour C. Preparing for a cesarean section for failure to progress D. increasing the encouragement to the patient when pushing begins

Answer 36

A. Obtaining an order to begin IV oxytocin infusion ANSWER A. The client's labor is hypotonic. The nurse should call the physical and obtain an order for an infusion of oxytocin, which will assist the uterus to contact more forcefully in an attempt to dilate the cervix. Administering light sedative would be done for hypertonic uterine contractions. Preparing for cesarean section is unnecessary at this time. Oxytocin would increase the uterine contractions and hopefully progress labor before a cesarean would be necessary. t is too early to anticipate client pushing with contractions.

Question 37

37. The client tells the nurse that her last menstrual period started on January 14 and ended on January 20. Using Nagele's rule, the nurse determines her EDD to be which of the following? A. September 27 B. October 21 C. November 7 D. December 27

Answer 37

B. October 21 Answer B. To calculate the EDD by Nagele's rule, add 7 days to the first day of the last menstrual period and count back 3 months, changing the year appropriately

Question 38

38. A client in her third trimester tells the nurse, "I'm constipated all the time!" Which of the following should the nurse recommend? A. Daily enemas B. Laxatives C. Increased fiber intake D. Decreased fluid intake

Answer 38

C. Increased fiber intake Answer C. During the third trimester, the enlarging uterus places pressure on the intestines. This coupled with the effect of hormones on smooth muscle relaxation causes decreased intestinal motility (peristalsis). Increasing fiber in the diet will help tecal matter pass more quickly through the intestinal tract, thus decreasing the amount of water that is absorbed. As a result, stool is softer and easier to pass. Enemas could precipitate preterm labor and/or electrolyte loss and should be avoided. Laxatives may cause preterm labor by stimulating peristalsis and may interfere with the absorption of nutrients.

Question 39

39. The nurse understands that the fetal head is in which of the following positions with a face presentation? A. Completely flexed B. Completely extended C. Partially extended D. Partially flexed

Answer 39

B. Completely extended ANSWER B. With a face presentation, the head is completely extended. With a vertex presentation, the head is completely or partially flexed. With a brow (forehead) presentation, the head would be partially extended.

Question 40

40. Which of the following would the nurse use as the basis for the teaching plan when caring for a pregnant teenager concerned about gaining too much weight during pregnancy? A. 10 pounds per trimester B. I pound per week for 40 weeks C. ½ pound per week for 40 wooks D. A total gain of 25 to 30 pounds

Answer 40

D. A total gain of 25 to 30 pounds Answer D. To ensure adequate fetal growth and development during the 40 weeks of a pregnancy, a total weight gain 25 to 30 pounds is recommended: 1.5 pounds in the first 10 weelis; 9 pounds by 30 weeks and 27.5 pounds by 40 weeks. The pregnant woman should gain less weight in the first and second trimester than in the third. During the first trimester, the client should only gain 1.5 pounds in the first 10 weeks, not 1 pound per week. A weight gain of pound per week would be 20 pounds for the total pregnancy, less than the recommended amount.

Question 41

41. For which of the following clients would the nurse expect that an intrauterine device would not be recommended? A. Woman over age 35 B. Nulliparous woman C. Promiscuous young adult D. Postpartum client

Answer 41

C. Promiscuous young adult Answer C. An IUD may increase the risk of pelvic inflammatory disease, especially in women with more than one sexual partner, because of the increased risk of sexually transmitted infections. An UID should not be used if the woman has an active or chronic pelvic infection, postpartum infection, endometrial hyperplasia or carcinoma, or uterine abnormalities. Age is not a factor in determining the risks associated with IUD use, Most IUD users are over the age of 30. Although there is a slightly higher risk for infertility in women who have never been pregnant, the IUD is an acceptable option as long as the risk-benefit ratio is discussed. IUDs may be inserted immediately after delivery, but this is not recommended because of the increased risk and rate of expulsion at this time

Question 42

42.. When preparing a woman who is 2 days postpartum for discharge, recommendations for which of the following contraceptive methods would be avoided? A. Diaphragm B. Female condom C. Oral contraceptives D. Rhythm method

Answer 42

A. Diaphragm Answer A. The diaphragm must be fitted individually to ensure effectiveness. Because of the changes to the reproductive structures during pregnancy and following delivery, the diaphragm must be refitted, usually at the 6 weeks' examination following childbirth or after a weight loss of 15 lbs or more. In addition, for maximum effectiveness, spermicidal jelly should be placed in the dome and around the rim.

Question 43

43. When teaching a client about contraception. Which of the following would the nurse include as the most effective method for preventing sexually transmitted infections? A. Spermicides B. Diaphragm C. Condoms D. Vasectomy

Answer 43

C. Condoms Answer C. Condoms, when used correcily and consistently, are the most effective contraceptive method or barrier again bacterial and viral sexually transmitted infections. Although spermicides kill sperm, they do not provide reliable protection against the spread of sexually transmitted infections, especially intracellular organisms such as HIV. Insertion and removal of the diaphragm along with the use of the spermicides may cause vaginal irritations, which could place the client at risk for infection transmission. Male sterilization eliminates spermatozoa from the ejaculate, but it does not eliminate bacterial and/or viral microorganisms that can cause sexually transmitted infections.

Question 44

44. Nurse Hazel is preparing to care for a client who is newly admitted to the hospital with a possible diagnosis of ectopic pregnancy. Nurse Hazel develops a plan of care for the client and determines that which of the following nursing actions is the priority? A. Monitoring weight B. Assessing for edema C. Monitoring apical pulse D. Monitoring temperature

Answer 44

C. Monitoring apical pulse Answer: (C) Monitoring apical pulse. Morning care for the client with a possible ectopic pregnancy is focused on preventing or identifying hypovolemic shock and controlling pain. An elevated pulse rate is an indicator of shock.

Question 45

45. Nurse Reese is reviewing the record of a pregnant client for her first prenatal visit. Which of the following data, if noted on the client's record, would alert the nurse that the client is at risk for a spontaneous abortion? A. Age 36 years B. History of syphilis C. History of genital herpes D. History of diabetes mellitus

Answer 45

B. History of syphilis Answer: (B) History of syphilis. Matemal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion.

Question 46

46. When preparing to listen to the fetal heart rate at 12 weeks' gestation, the nurse would use which of the following? A. Stethoscope placed midline at the umbilicus B. Doppler placed midline at the suprapubic region C. Fetoscope placed midway between the umbilicus and the xiphoid process D. External electronic fetal monitor placed at the umbilicus

Answer 46

B. Doppler placed midline at the suprapubic region Answer B. At 12 weeks gestation, the uterus rises out of the pelvis and is palpable above the symphysis pubis."

Question 47

47. May arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. She also tells the nurse that a home pregnancy test was positive but she began to have mild cramps and is now having moderate vaginal bleeding. During the physical examination of the client, the nurse notes that May has a dilated cervix. The nurse determines that May is experiencing which type of abortion? A. Inevitable B. Incomplete C. Threatened D. Septic

Answer 47

A. Inevitable Answer: (A) Inevitable. An inevitable abortion is termination of pregnancy that cannot be prevented. Moderate to severe bleeding with mild cramping and cervical dilation would be noted in this type of abortion

Question 48

48. When taking an obstetrical history on a pregnant client who states, "I had a son born at 38 weeks gestation, a daughter born at 30 weeks gestation and I lost a baby at about 8 weeks," the nurse should record her obstetrical history as which of the following? A. G2 T2 PO A0 1.2 B. G3 TI PI A0 L2 C. G3 T2 PO A0 L2 D. G4 TI PI A1 L2

Answer 48

D. G4 TI PI A1 L2 Answer D. The client has been pregnant fou unes, including current pregnancy (G). Birth at 38 weeks' gestations considered full term (T). while birth form 20 weeks to 38 weeks is considered preterm (P). A spontaneous abortion occurred at 8 weeks (A). She has two living children (L).

Question 49

49. Which of the following drugs is the antidote for magnesium toxicity? A. Calcium gluconate (Kalcinate) B. Hydralazine (Apresoline) C. Naloxone (Narcan) D. Rho (D) immune globulin (RhoGAM)

Answer 49

A. Calcium gluconate (Kalcinate) Answer: (A) Calcium gluconate (Kalcinate). Calcium gluconate is the antidote for magnesium toxicity. Ten milliliters of 10% calcium gluconate is given L.V. push over 3 to 5 minutes. Hydralazine is given for sustained elevated blood pressure in preeclamptic clients. Rho (D) immune globulin is given to women with Rh-negative blood to prevent antibody formation from RH-positive conceptions. Naloxone is used to correct narcotic toxicity.

Question 50

50. Marlyn is screened for tuberculosis during her first prenatal visit. An intradermal injection of purified protein derivative (PPD) of the tuberculin bacilli is given. She is considered to have a positive test for which of the following results? A. An indurated wheal under 10 mm in diameter appears in 6 to 12 hours. B. An indurated wheal over 10 mm in diameter appears in 48 to 72 hours. C. A flat circumcised area under 10 mm in diameter appears in 6 to 12 hours. D. A flat circumcised area over 10 mm in diameter appears in 48 to 72 hours.

Answer 50

B. An indurated wheal over 10 mm in diameter appears in 48 to 72 hours. Answer: (B) An indurated wheal over 10 mm in diameter appears in 48 to 72 hours. A positive PPD result would be an indurated wheal over 10 mm in diameter that appears in 48 to 72 hours. The area must be a raised wheal, not a flat circumcised area to be considered positive

Question 51

51. Dianne, 24 year-old is 27 weeks' pregnant arrives at her physician's office with complaints of fever, nausea, vomiting, malaise, unilateral flank pain, and costovertebral angle tenderness. Which of the following diagnoses is most likely? A. Asymptomatic bacteriuria B. Bacterial vaginosis C. Pyelonephritis D. Urinary tract infection (UTI)

Answer 51

C. Pyelonephritis Answer: (C) Pyelonephritis. The symptoms indicate acute pyelonephritis, a serious condition in a pregnant client. UTI symptoms include dysuria, urgency, frequency, and suprapubic tenderness. Asymptomatic bacteriuria doesn't cause symptoms, Bacterial vaginosis causes milky white vaginal discharge but no systemic symptoms.

Question 52

52. When developing a plan of care for a client newly diagnosed with gestational diabetes, which of the following instructions would be the priority? A. Dietary intake B. Medication C. Exercise D. Glucose monitoring

Answer 52

A. Dietary intake Answer A. Although all of the choices are important in the management of diabetes, diet therapy is the mainstay of the treatment plan and should always be the priority. Women diagnosed with gestational diabetes generally need only diet therapy without medication to control their blood sugar levels. Exercise, is important for all pregnant women and especially for diabetic women, because it burns up glucose, thus decreasing blood sugar.