Perry / Loudermilk

Question 1

5. Because of the effect of cyclic ovarian changes on the breast, the best time for breast self-examination (BSE)
   is:
   a. 5 to 7 days after menses ceases. c. Midmenstrual cycle.
   b. Day 1 of the endometrial cycle. d. Any time during a shower or bath.

Answer 1

ANS: A
The physiologic alterations in breast size and activity reach their minimal level about 5 to 7 days after
menstruation stops. All women should perform BSE during this phase of the menstrual cycle

Question 2

21. A fully matured endometrium that has reached the thickness of heavy, soft velvet describes the _____
    phase of the endometrial cycle.
    a. Menstrual c. Secretory
    b. Proliferative d. Ischemic

Answer 2

ANS: C
The secretory phase extends from the day of ovulation to approximately 3 days before the next menstrual
cycle. During this phase, the endometrium becomes fully mature. During the menstrual phase, the endometrium is being shed; the endometrium is fully mature again during the secretory phase. The proliferative phase is a period of rapid growth, but the endometrium becomes fully mature again during the secretory phase. During the ischemic phase, the blood supply is blocked, and necrosis develops. The endometrium is fully mature during the secretory phase.

Question 3

8. A 36-year-old woman has been given a diagnosis of uterine fibroids. When planning care for this patient, the
   nurse should know that:
   a. Fibroids are malignant tumors of the uterus that require radiation or chemotherapy
   b. Fibroids increase in size during the perimenopausal period.
   c. Menorrhagia is a common finding.
   d. The woman is unlikely to become pregnant as long as the fibroids are in her uterus.

Answer 3

ANS: C
The major symptoms associated with fibroids are menorrhagia and the physical effects produced by large
myomas. Fibroids are benign tumors of the smooth muscle of the uterus, and their etiology is unknown. Fibroids are estrogen sensitive and shrink as levels of estrogen.

Question 4

17. A woman currently uses a diaphragm and spermicide for contraception. She asks the nurse what the major
    differences are between the cervical cap and diaphragm. The nurses most appropriate response is:
    a. No spermicide is used with the cervical cap, so its less messy.
    b. The diaphragm can be left in place longer after intercourse.
    c. Repeated intercourse with the diaphragm is more convenient.
    d. The cervical cap can safely be used for repeated acts of intercourse without adding more
    spermicide later.

Answer 4

ANS: D
The cervical cap can be inserted hours before sexual intercourse without the need for additional spermicide
later. No additional spermicide is required for repeated acts of intercourse. Spermicide should be used inside
the cap as an additional chemical barrier. The cervical cap should remain in place for 6 hours after the last act
of intercourse. Repeated intercourse with the cervical cap is more convenient because no additional spermicide
is needed.

Question 5

18. A woman was treated recently for toxic shock syndrome (TSS). She has intercourse occasionally and uses
    over-the-counter protection. On the basis of her history, what contraceptive method should she and her partner avoid?

a. Cervical cap c. Vaginal film
b. Condom d. Vaginal sheath

Answer 5

ANS: A
Women with a history of TSS should not use a cervical cap. Condoms, vaginal films, and vaginal sheaths are
not contraindicated for a woman with a history of TSS.

Question 6

20. A woman is 16 weeks pregnant and has elected to terminate her pregnancy. The nurse knows that the most
    common technique used for medical termination of a pregnancy in the second trimester is:
    a. Dilation and evacuation (D&E).
    b. Instillation of hypertonic saline into the uterine cavity.
    c. Intravenous administration of Pitocin.
    d. Vacuum aspiration.

Answer 6

ANS: A
The most common technique for medical termination of a pregnancy in the second trimester is D&E. It is
usually performed between 13 and 16 weeks. Hypertonic solutions injected directly into the uterus account for
less than 1% of all abortions because other methods are safer and easier to use. Intravenous administration of
Pitocin is used to induce labor in a woman with a third-trimester fetal demise. Vacuum aspiration is used for
abortions in the first trimester.

Question 7

19. The _____ is/are responsible for oxygen and carbon dioxide transport to and from the maternal
    bloodstream.
    a. Decidua basalis c. Germ layer
    b. Blastocyst d. Chorionic villi

Answer 7

ANS: D
Chorionic villi are fingerlike projections that develop out of the trophoblast and extend into the blood-filled
spaces of the endometrium. The villi obtain oxygen and nutrients from the maternal bloodstream and dispose
of carbon dioxide and waste products into the maternal blood. The decidua basalis is the portion of the decidua
(endometrium) under the blastocyst where the villi attach. The blastocyst is the embryonic development stage
after the morula. Implantation occurs at this stage. The germ layer is a layer of the blastocyst.

Question 8

18. A woman asks the nurse, What protects my babys umbilical cord from being squashed while the babys
    inside of me? The nurses best response is:
    a. Your babys umbilical cord is surrounded by connective tissue called Wharton jelly, which prevents
    compression of the blood vessels and ensures continued nourishment of your baby.
    b. Your babys umbilical floats around in blood anyway.
    c. You dont need to worry about things like that.
    d. The umbilical cord is a group of blood vessels that are very well protected by the placenta.

Answer 8

ANS: A
Your babys umbilical cord is surrounded by connective tissue called Wharton jelly, which prevents
compression of the blood vessels and ensures continued nourishment of your baby is the most appropriate
response. Your babys umbilical floats around in blood anyway is inaccurate. You dont need to worry about
things like that is an inappropriate response. It negates the clients need for teaching and discounts her feelings. The placenta does not protect the umbilical cord. The cord is protected by the surrounding Wharton jelly.

Question 9

31. A new mother asks the nurse about the white substance covering her infant. The nurse explains that the
    purpose of vernix caseosa is to:
    a. Protect the fetal skin from amniotic fluid.
    b. Promote normal peripheral nervous system development.
    c. Allow transport of oxygen and nutrients across the amnion.
    d. Regulate fetal temperature

Answer 9

ANS: A
Prolonged exposure to amniotic fluid during the fetal period could result in breakdown of the skin without the
protection of the vernix caseosa. Normal development of the peripheral nervous system is dependent on
nutritional intake of the mother. The amnion is the inner membrane that surrounds the fetus. It is not involved
in the oxygen and nutrient exchange. The amniotic fluid aids in maintaining fetal temperature.

Question 10

3. The nurse teaches a pregnant woman about the presumptive, probable, and positive signs of pregnancy. The
   woman demonstrates understanding of the nurses instructions if she states that a positive sign of pregnancy is:
   a. A positive pregnancy test.
   b. Fetal movement palpated by the nurse-midwife.
   c. Braxton Hicks contractions.
   d. Quickening.

Answer 10

ANS: B
Positive signs of pregnancy are attributed to the presence of a fetus, such as hearing the fetal heartbeat or
palpating fetal movement. A positive pregnancy test and Braxton Hicks contractions are probable signs of
pregnancy. Quickening is a presumptive sign of pregnancy.

Question 11

4. A woman is at 14 weeks of gestation. The nurse would expect to palpate the fundus at which level?
   a. Not palpable above the symphysis at this time
   b. Slightly above the symphysis pubis
   c. At the level of the umbilicus
   d. Slightly above the umbilicus

Answer 11

ANS: B
In normal pregnancies, the uterus grows at a predictable rate. It may be palpated above the symphysis pubis
sometime between the twelfth and fourteenth weeks of pregnancy. As the uterus grows, it may be palpated
above the symphysis pubis sometime between the twelfth and fourteenth weeks of pregnancy. The uterus rises
gradually to the level of the umbilicus at 22 to 24 weeks of gestation.

Question 12

16. Human chorionic gonadotropin (hCG) is an important biochemical marker for pregnancy and the basis for
    many tests. A maternity nurse should be aware that:
    a. hCG can be detected 2.5 weeks after conception.
    b. The hCG level increases gradually and uniformly throughout pregnancy.
    c. Much lower than normal increases in the level of hCG may indicate a postdate pregnancy.
    d. A higher than normal level of hCG may indicate an ectopic pregnancy or Down syndrome.

Answer 12

ANS: D
Higher levels also could be a sign of multiple gestation. hCG can be detected 7 to 8 days after conception. The
hCG level fluctuates during pregnancy: peaking, declining, stabilizing, and increasing again. Abnormally slow
increases may indicate impending miscarriage.

Question 13

19. The mucous plug that forms in the endocervical canal is called the:
    a. Operculum. c. Funic souffle.
    b. Leukorrhea. d. Ballottement.

Answer 13

ANS: A
The operculum protects against bacterial invasion. Leukorrhea is the mucus that forms the endocervical plug
(the operculum). The funic souffle is the sound of blood flowing through the umbilical vessels. Ballottement is
a technique for palpating the fetus.

Question 14

20. To reassure and educate pregnant clients about changes in their breasts, nurses should be aware that:
    a. The visibility of blood vessels that form an intertwining blue network indicates full function of
    Montgomerys tubercles and possibly infection of the tubercles.
    b. The mammary glands do not develop until 2 weeks before labor.
    c. Lactation is inhibited until the estrogen level declines after birth.
    d. Colostrum is the yellowish oily substance used to lubricate the nipples for breastfeeding

Answer 14

ANS: C
Lactation is inhibited until after birth. The visible blue network of blood vessels is a normal outgrowth of a
richer blood supply. The mammary glands are functionally complete by midpregnancy. Colostrum is a creamy, white-to-yellow premilk fluid that can be expressed from the nipples before birth.

Question 15

21. To reassure and educate pregnant clients about changes in their cardiovascular system, maternity nurses
    should be aware that:
    a. A pregnant woman experiencing disturbed cardiac rhythm, such as sinus arrhythmia requires close
    medical and obstetric observation, no matter how healthy she otherwise may appear.
    b. Changes in heart size and position and increases in blood volume create auditory changes from 20
    weeks to term.
    c. Palpitations are twice as likely to occur in twin gestations.
    d. All of the above changes likely will occur.

Answer 15

ANS: B
Auscultatory changes should be discernible after 20 weeks of gestation. A healthy woman with no underlying
heart disease does not need any therapy. The maternal heart rate increases in the third trimester, but
palpitations may not occur. Auditory changes are discernible at 20 weeks

Question 16

25. Which statement about a condition of pregnancy is accurate?
    a. Insufficient salivation (ptyalism) is caused by increases in estrogen.
    b. Acid indigestion (pyrosis) begins early but declines throughout pregnancy.
    c. Hyperthyroidism often develops (temporarily) because hormone production increases.
    d. Nausea and vomiting rarely have harmful effects on the fetus and may be beneficial.

Answer 16

ANS: D
Normal nausea and vomiting rarely produce harmful effects, and nausea and vomiting periods may be less
likely to result in miscarriage or preterm labor. Ptyalism is excessive salivation, which may be caused by a
decrease in unconscious swallowing or stimulation of the salivary glands. Pyrosis begins in the first trimester
and intensifies through the third trimester. Increased hormone production does not lead to hyperthyroidism in
pregnant women.

Question 17

27. Which finding in the urine analysis of a pregnant woman is considered a variation of normal?
    a. Proteinuria c. Bacteria in the urine.
    b. Glycosuria d. Ketones in the urine

Answer 17

ANS: B
Small amounts of glucose may indicate physiologic spilling. The presence of protein could indicate kidney
disease or preeclampsia. Urinary tract infections are associated with bacteria in the urine. An increase in
ketones indicates that the patient is exercising too strenuously or has an inadequate fluid and food intake.

Question 18

2. Which meal would provide the most absorbable iron?
   a. Toasted cheese sandwich, celery sticks, tomato slices, and a grape drink
   b. Oatmeal, whole wheat toast, jelly, and low-fat milk
   c. Black bean soup, wheat crackers, orange sections, and prunes
   d. Red beans and rice, cornbread, mixed greens, and decaffeinated tea

Answer 18

ANS: C
Food sources that are rich in iron include liver, meats, whole grain or enriched breads and cereals, deep green
leafy vegetables, legumes, and dried fruits. In addition, the vitamin C in orange sections aids absorption. Dairy
products and tea are not sources of iron.

Question 19

8. A pregnant womans diet history indicates that she likes the following list of foods. The nurse would
   encourage this woman to consume more of which food to increase her calcium intake?
   a. Fresh apricots c. Spaghetti with meat sauce
   b. Canned clams d. Canned sardines

Answer 19

ANS: C
Food sources that are rich in iron include liver, meats, whole grain or enriched breads and cereals, deep green
leafy vegetables, legumes, and dried fruits. In addition, the vitamin C in orange sections aids absorption. Dairy
products and tea are not sources of iron.

Question 20

35. A pregnant patient would like to know a good food source of calcium other than dairy products. Your best answer is:
    a. Legumes c. Lean meat
    b. Yellow vegetables d. Whole grains

Answer 20

ANS: A
Although dairy products contain the greatest amount of calcium, it also is found in legumes, nuts, dried fruits, and some dark green leafy vegetables. Yellow vegetables are rich in vitamin A. Lean meats are rich in protein and phosphorus. Whole grains are rich in zinc and magnesium.

Question 21

5. At 35 weeks of pregnancy a woman experiences preterm labor. Tocolytics are administered and she is placed on bed rest, but she continues to experience regular uterine contractions, and her cervix is beginning to dilate and efface. What would be an important test for fetal well-being at this time?
   a. Percutaneous umbilical blood sampling (PUBS)
   b. Ultrasound for fetal size
   c. Amniocentesis for fetal lung maturity
   d. Nonstress test (NST)

Answer 21

ANS: C
Amniocentesis would be performed to assess fetal lung maturity in the event of a preterm birth. Indications for PUBS include prenatal diagnosis or inherited blood disorders, karyotyping of malformed fetuses, detection of fetal infection, determination of the acid-base status of a fetus with intrauterine growth restriction, and assessment and treatment of isoimmunization and thrombocytopenia in the fetus. Typically, fetal size is determined by ultrasound during the second trimester and is not indicated in this scenario. NST measures the fetal response to fetal movement in a noncontracting mother.

Question 22

10. When nurses help their expectant mothers assess the daily fetal movement counts, they should be aware that:
    a. Alcohol or cigarette smoke can irritate the fetus into greater activity.
    b. Kick counts should be taken every half hour and averaged every 6 hours, with every other 6-hour stretch off.
    c. The fetal alarm signal should go off when fetal movements stop entirely for 12 hours.
    d. Obese mothers familiar with their bodies can assess fetal movement as well as average-size women.

Answer 22

ANS: C
No movement in a 12-hour period is cause for investigation and possibly intervention. Alcohol and cigarette smoke temporarily reduce fetal movement. The mother should count fetal activity (kick counts) two or three times daily for 60 minutes each time. Obese women have a harder time assessing fetal movement.

Question 23

16. Compared with contraction stress test (CST), nonstress test (NST) for antepartum fetal assessment:
    a. Has no known contraindications.
    b. Has fewer false-positive results.
    c. Is more sensitive in detecting fetal compromise.
    d. Is slightly more expensive.

Answer 23

ANS: A
CST has several contraindications. NST has a high rate of false-positive results, is less sensitive than the CST, and is relatively inexpensive.

Question 24

20. Risk factors tend to be interrelated and cumulative in their effect. While planning the care for a laboring client with diabetes mellitus, the nurse is aware that she is at a greater risk for:
    a. Oligohydramnios. c. Postterm pregnancy.
    b. Polyhydramnios. d. Chromosomal abnormalities.

Answer 24

ANS: B
Polyhydramnios (amniotic fluid >2000 mL) is 10 times more likely to occur in diabetic compared with nondiabetic pregnancies. When a pregnant woman’s blood sugar levels are not well controlled, the baby’s urine output increases, leading, potentially, to excessive amounts of amniotic fluid. Polyhydramnios puts the mother at risk for premature rupture of membranes, premature labor, and postpartum hemorrhage. Prolonged rupture of membranes, intrauterine growth restriction, intrauterine fetal death, and renal agenesis (Potter syndrome) all put the client at risk for developing oligohydramnios. Anencephaly, placental insufficiency, and perinatal hypoxia all contribute to the risk for postterm pregnancy. Maternal age older than 35 and balanced translocation (maternal and paternal) are risk factors for chromosome abnormalities.

Question 25

Biophysical risks include factors that originate with either the mother or the fetus and affect the functioning of either one or both. The nurse who provides prenatal care should have an understanding of these risk factors. Match the specific pregnancy problem with the related risk factor.

a. Polyhydramnios
b. Intrauterine growth restriction (maternal cause)
c. Oligohydramnios
d. Chromosomal abnormalities
e. Intrauterine growth restriction (fetoplacental cause)
28. Premature rupture of membranes
29. Advanced maternal age
30. Fetal congenital anomalies
31. Abnormal placenta development
32. Smoking, alcohol, and illicit drug use

Answer 25

28 C
29 D
30 A
31 E
32 B

Question 26

34. When the pregnant diabetic woman experiences hypoglycemia while hospitalized, the nurse should intervene by having the patient:
    a. Eat six saltine crackers.
    b. Drink 8 oz of orange juice with 2 tsp of sugar added.
    c. Drink 4 oz of orange juice followed by 8 oz of milk.
    d. Eat hard candy or commercial glucose wafers.

Answer 26

ANS: A
Crackers provide carbohydrates in the form of polysaccharides. Orange juice and sugar will increase the blood sugar but not provide a slow-burning carbohydrate to sustain the blood sugar. Milk is a disaccharide and orange juice is a monosaccharide. They will provide an increase in blood sugar but will not sustain the level. Hard candy or commercial glucose wafers provide only monosaccharides.

Question 27

38. A woman has a history of drug use and is screened for hepatitis B during the first trimester. What is an appropriate action?
    a. Provide a low-protein diet.
    b. Offer the vaccine.
    c. Discuss the recommendation to bottle-feed her baby.
    d. Practice respiratory isolation.

Answer 27

ANS: B
A person who has a history of high risk behaviors should be offered the hepatitis B vaccine. Care is supportive and includes bed rest and a high-protein, low-fat diet. The first trimester is too early to discuss feeding methods with a woman in the high risk category. Hepatitis B is transmitted through blood.

Question 28

3. What laboratory marker is indicative of disseminated intravascular coagulation (DIC)?
   a. Bleeding time of 10 minutes c. Thrombocytopenia
   b. Presence of fibrin split products d. Hyperfibrinogenemia

Answer 28

ANS: B
Degradation of fibrin leads to the accumulation of fibrin split products in the blood. Bleeding time in DIC is normal. Low platelets may occur with but are not indicative of DIC because they may result from other coagulopathies. Hypofibrinogenemia would occur with DIC.

Question 29

10. A woman with severe preeclampsia has been receiving magnesium sulfate by intravenous infusion for 8 hours. The nurse assesses the woman and documents the following findings: temperature of 37.1 C, pulse rate of 96 beats/min, respiratory rate of 24 breaths/min, blood pressure (BP) of 155/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus. The nurse calls the physician, anticipating an order for:
    a. Hydralazine. c. Diazepam.
    b. Magnesium sulfate bolus. d. Calcium gluconate.

Answer 29

ANS: A
Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. Typically it is administered for a systolic BP greater than 160 mm Hg or a diastolic BP greater than 110 mm Hg. An additional bolus of magnesium sulfate may be ordered for increasing signs of central nervous system irritability related to severe preeclampsia (e.g., clonus) or if eclampsia develops. Diazepam sometimes is used to stop or shorten eclamptic seizures. Calcium gluconate is used as the antidote for magnesium sulfate toxicity. The client is not currently displaying any signs or symptoms of magnesium toxicity.

Question 30

28. A woman arrives for evaluation of her symptoms, which include a missed period, adnexal fullness, tenderness, and dark red vaginal bleeding. On examination the nurse notices an ecchymotic blueness around the womans umbilicus and recognizes this assessment finding as:
    a. Normal integumentary changes associated with pregnancy.
    b. Turners sign associated with appendicitis.
    c. Cullens sign associated with a ruptured ectopic pregnancy.
    d. Chadwicks sign associated with early pregnancy.

Answer 30

ANS: C
Cullens sign, the blue ecchymosis seen in the umbilical area, indicates hematoperitoneum associated with an undiagnosed ruptured intraabdominal ectopic pregnancy. Linea nigra on the abdomen is the normal integumentary change associated with pregnancy. It manifests as a brown, pigmented, vertical line on the lower abdomen. Turners sign is ecchymosis in the flank area, often associated with pancreatitis. Chadwicks sign is the blue-purple color of the cervix that may be seen during or around the eighth week of pregnancy.

Question 31

34. An abortion in which the fetus dies but is retained within the uterus is called a(n):
    a. Inevitable abortion c. Incomplete abortion
    b. Missed abortion d. Threatened abortion

Answer 31

ANS: B
Missed abortion refers to retention of a dead fetus in the uterus. An inevitable abortion means that the cervix is dilating with the contractions. An incomplete abortion means that not all of the products of conception were expelled. With a threatened abortion the woman has cramping and bleeding but not cervical dilation.

Question 32

43. The nurse caring for a woman hospitalized for hyperemesis gravidarum should expect that initial treatment to involve:
    a. b. c. d.
    Corticosteroids to reduce inflammation.
    IV therapy to correct fluid and electrolyte imbalances.
    An antiemetic, such as pyridoxine, to control nausea and vomiting. Enteral nutrition to correct nutritional deficits.

Answer 32

ANS: B
Initially, the woman who is unable to keep down clear liquids by mouth requires IV therapy for correction of fluid and electrolyte imbalances. Corticosteroids have been used successfully to treat refractory hyperemesis gravidarum; however, they are not the expected initial treatment for this disorder. Pyridoxine is vitamin B6, not an antiemetic. Promethazine, a common antiemetic, may be prescribed. In severe cases of hyperemesis gravidarum, enteral nutrition via a feeding tube may be necessary to correct maternal nutritional deprivation. This is not an initial treatment for this patient.

Question 33

22. Which occurrence is associated with cervical dilation and effacement?
    a. Bloody show c. Lightening
    b. False labor d. Bladder distention

Answer 33

As the cervix begins to soften, dilate, and efface, expulsion of the mucous plug that sealed the cervix during pregnancy occurs. This causes rupture of small cervical capillaries. Cervical dilation and effacement do not occur with false labor. Lightening is the descent of the fetus toward the pelvic inlet before labor. Bladder distention occurs when the bladder is not emptied frequently. It may slow down the descent of the fetus during labor.

Question 34

33. The priority nursing care associated with an oxytocin (Pitocin) infusion is:
    a. Measuring urinary output.
    b. Increasing infusion rate every 30 minutes. c. Monitoring uterine response.
    d. Evaluating cervical dilation.

Answer 34

ANS: C
Because of the risk of hyperstimulation, which could result in decreased placental perfusion and uterine rupture, the nurses priority intervention is monitoring uterine response. Monitoring urinary output is also important; however, it is not the top priority during the administration of Pitocin. The infusion rate may be increased after proper assessment that it is an appropriate interval to do so. Monitoring labor progression is the standard of care for all labor patients.

Question 35

5. Two days ago a woman gave birth to a full-term infant. Last night she awakened several times to urinate and noted that her gown and bedding were wet from profuse diaphoresis. One mechanism for the diaphoresis and diuresis that this woman is experiencing during the early postpartum period is:
   a. Elevated temperature caused by postpartum infection.
   b. Increased basal metabolic rate after giving birth.
   c. Loss of increased blood volume associated with pregnancy.
   d. Increased venous pressure in the lower extremities.

Answer 35

ANS: C
Within 12 hours of birth women begin to lose the excess tissue fluid that has accumulated during pregnancy. One mechanism for reducing these retained fluids is the profuse diaphoresis that often occurs, especially at night, for the first 2 or 3 days after childbirth. Postpartal diuresis is another mechanism by which the body rids itself of excess fluid.
An elevated temperature would cause chills and may cause dehydration, not diaphoresis and diuresis. Diaphoresis and diuresis sometimes are referred to as reversal of the water metabolism of pregnancy, not as the basal metabolic rate. Postpartal diuresis may be caused by the removal of increased venous pressure in the LE’s.

Question 36

27. Which documentation on a womans chart on postpartum day 14 indicates a normal involution process?
    a. Moderate bright red lochial flow
    b. Breasts firm and tender
    c. Fundus below the symphysis and not palpable
    d. Episiotomy slightly red and puffy

Answer 36

ANS: C
The fundus descends 1 cm/day, so by postpartum day 14 it is no longer palpable. The lochia should be changed by this day to serosa. Breasts are not part of the involution process. The episiotomy should not be red or puffy at this stage.

Question 37

26. The nurse caring for the postpartum woman understands that breast engorgement is caused by:
    a. Overproduction of colostrum.
    b. Accumulation of milk in the lactiferous ducts and glands.
    c. Hyperplasia of mammary tissue.
    d. Congestion of veins and lymphatics.

Answer 37

ANS: D
Breast engorgement is caused by the temporary congestion of veins and lymphatics.
Breast engorgement is not the result of overproduction of colostrum. Accumulation of milk in the lactiferous ducts and glands does not cause breast engorgement. Hyperplasia of mammary tissue does not cause breast engorgement.

Question 38

14. The nurse should be aware that a pessary would be most effective in the treatment of what disorder?
    a. Cystocele c. Rectocele
    b. Uterine prolapse d. Stress urinary incontinence

Answer 38

ANS: B
A fitted pessary may be inserted into the vagina to support the uterus and hold it in the correct position. A pessary is not used for a cystocele, a rectocele, or stress urinary incontinence.

Question 39

34. If nonsurgical treatment for late postpartum hemorrhage is ineffective, which surgical procedure is appropriate to correct the cause of this condition?
    a. Hysterectomy c. Laparotomy
    b. Laparoscopy d. D&C

Answer 39

ANS: D
D&C allows examination of the uterine contents and removal of any retained placental fragments or blood clots. Hysterectomy is the removal of the uterus and is not indicated for this condition. A laparoscopy is the insertion of an endoscope through the abdominal wall to examine the peritoneal cavity. It is not the appropriate treatment for this condition. A laparotomy is also not indicated for this condition. A laparotomy is a surgical incision into the peritoneal cavity to explore it.

Question 40

40. Infants in whom cephalhematomas develop are at increased risk for:
    a. Infection. c. Caput succedaneum.
    b. Jaundice. d. Erythema toxicum.

Answer 40

ANS: B
Cephalhematomas are characterized by bleeding between the bone and its covering, the periosteum. Because of the breakdown of the red blood cells within a hematoma, the infants are at greater risk for jaundice. Cephalhematomas do not increase the risk for infections. Caput is an edematous area on the head from pressure against the cervix.

Question 41

4. A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper back. Information given to the infants parents should be based on the knowledge that petechiae:
   a. Are benign if they disappear within 48 hours of birth.
   b. Result from increased blood volume.
   c. Should always be further investigated.
   d. Usually occur with forceps delivery.

Answer 41

ANS: A
Petechiae, or pinpoint hemorrhagic areas, acquired during birth may extend over the upper portion of the trunk and face. These lesions are benign if they disappear within 2 days of birth and no new lesions appear. Petechiae may result from decreased platelet formation. In this situation the presence of petechiae is most likely a soft-tissue injury resulting from the nuchal cord at birth. Unless they do not dissipate in 2 days, there is no reason to alarm the family. Petechiae usually occur with a breech presentation vaginal birth.

Question 42

26. At 1 minute after birth, the nurse assesses the infant and notes a heart rate of 80 beats/minute, some flexion of the extremities, a weak cry, grimacing, and a pink body with blue extremities. The nurse would calculate an Apgar score of: ________

Answer 42

ANS: 5

Question 43

31. To prevent nipple trauma, the nurse should instruct the new mother to:
    a. Limit the feeding time to less than 5 minutes.
    b. Position the infant so the nipple is far back in the mouth.
    c. Assess the nipples before each feeding.
    d. Wash the nipples daily with mild soap and water.

Answer 43

ANS: B
If the infants mouth does not cover as much of the areola as possible, the pressure during sucking will be applied to the nipple, thus causing trauma to the area. Stimulating the breast for less than 5 minutes will not produce the extra milk the infant may need. This will also limit access to the higher-fat hindmilk. Assessing the nipples for trauma is important; however, this action alone will not prevent sore nipples. Soap can be drying to the nipples and should be avoided during breastfeeding.

Question 44

7. When providing an infant with a gavage feeding, which of the following should be documented each time?
   a. The infants abdominal circumference after the feeding
   b. The infants heart rate and respirations
   c. The infants suck and swallow coordination
   d. The infants response to the feeding

Answer 44

ANS: D
Documentation of a gavage feeding should include the size of the feeding tube, the amount and quality of the residual from the previous feeding, the type and quantity of the fluid instilled, and the infants response to the procedure. Abdominal circumference is not measured after a gavage feeding. Vital signs may be obtained before feeding. However, the infants response to the feeding is more important. Some older infants may be learning to suck, but the important factor to document would be the infants response to the feeding (including attempts to suck).

Question 45

15. In the assessment of a preterm infant, the nurse notices continued respiratory distress even though oxygen and ventilation have been provided. The nurse should suspect:
    a. Hypovolemia and/or shock. c. Central nervous system injury.
    b. A nonneutral thermal environment. d. Pending renal failure.

Answer 45

ANS: A
The nurse should suspect hypovolemia and/or shock. Other symptoms could include hypotension, prolonged capillary refill, and tachycardia followed by bradycardia. Intervention is necessary.

Question 46

21. Necrotizing enterocolitis (NEC) is an acute inflammatory disease of the gastrointestinal mucosa that can progress to perforation of the bowel. Approximately 2% to 5% of premature infants succumb to this fatal disease. Care is supportive; however, known interventions may decrease the risk of NEC. To develop an optimal plan of care for this infant, the nurse must understand which intervention has the greatest effect on lowering the risk of NEC:
    a. Early enteral feedings c. Exchange transfusion
    b. Breastfeeding d. Prophylactic probiotics

Answer 46

ANS: B
A decrease in the incidence of NEC is directly correlated with exclusive breastfeeding. Breast milk enhances maturation of the gastrointestinal tract and contains immune factors that contribute to a lower incidence or severity of NEC, Crohns disease, and celiac illness. The neonatal intensive care unit nurse can be very supportive of the mother in terms of providing her with equipment to pump breast milk, ensuring privacy, and encouraging skin-to-skin contact with the infant. Early enteral feedings of formula or hyperosmolar feedings are a risk factor known to contribute to the development of NEC. The mother should be encouraged to pump or feed breast milk exclusively. Exchange transfusion may be necessary; however, it is a known risk factor for the development of NEC. Although still early, a study in 2005 found that the introduction of prophylactic probiotics appeared to enhance the normal flora of the bowel and therefore decrease the severity of NEC when it did occur. This treatment modality is not as widespread as encouraging breastfeeding; however, it is another strategy that the care providers of these extremely fragile infants may have at their disposal.

Question 47

24. A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate (FHR) before birth is 180 beats/min with limited variability. At birth the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. On the basis of the maternal history, the cause of this newborns distress is most likely to be:
    a. Hypoglycemia. c. Respiratory distress syndrome.
    b. Phrenic nerve injury. d. Sepsis.

Answer 47

ANS: D
The prolonged rupture of membranes and the tachypnea (before and after birth) both suggest sepsis. An FHR of 180 beats/min is also indicative. This infant is at high risk for sepsis.

Question 48

32. With regard to injuries to the infants plexus during labor and birth, nurses should be aware that:
    a. If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months.
    b. Erb palsy is damage to the lower plexus.
    c. Parents of children with brachial palsy are taught to pick up the child from under the axillae.
    d. Breastfeeding is not recommended for infants with facial nerve paralysis until the condition resolves.

Answer 48

ANS: A
If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months. However, if the ganglia are disconnected completely from the spinal cord, the damage is permanent. Erb palsy is damage to the upper plexus and is less serious than brachial palsy. Parents of children with brachial palsy are taught to avoid picking up the child under the axillae or by pulling on the arms. Breastfeeding is not contraindicated, but both the mother and infant will need help from the nurse at the start.

Question 49

35. Near the end of the first week of life, an infant who has not been treated for any infection develops a copper-colored, maculopapular rash on the palms and around the mouth and anus. The newborn is showing signs of:
    a. Gonorrhea. c. Congenital syphilis.
    b. Herpes simplex virus infection. d. Human immunodeficiency virus.

Answer 49

ANS: C

The rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities

Question 50

45. An infant with severe meconium aspiration syndrome (MAS) is not responding to conventional treatment. Which highly technical method of treatment may be necessary for an infant who does not respond to conventional treatment?
    a. Extracorporeal membrane oxygenation
    b. Respiratory support with a ventilator
    c. Insertion of a laryngoscope and suctioning of the trachea
    d. Insertion of an endotracheal tube

Answer 50

ANS: A
Extracorporeal membrane oxygenation is a highly technical method that oxygenates the blood while bypassing the lungs, thus allowing the infants lungs to rest and recover. The infant is likely to have been first connected to a ventilator. Laryngoscope insertion and tracheal suctioning are performed after birth before the infant takes the first breath.