Unit 1 - Postpardum

Question 1

A nurse is describing how the fetus moves through the birth canal. Which component would the nurse identify as being most important in allowing the fetal head to move through the pelvis?

A. biparietal diameter

B. sutures

C. frontal bones

D. fontanelles

Answer 1

Sutures are important because they allow the cranial bones to overlap in order for the head to adjust in shape (elongate) when pressure is exerted on it by uterine contractions or the maternal bony pelvis. Fontanelles are the intersections formed by the sutures. The frontal bones, along with the parietal and occipital bones are bones of the cranium that are soft and pliable. The biparietal diameter is an important diameter that can affect the birth process.

Question 2

The fetus of a woman in labor is determined to be in persistent occiput posterior position. Which intervention would the nurse identify as the priority?

A. immediate cesarean birth

B. position changes

C. pain relief measures

D. oxytocin administration

Answer 2

Intense back pain is associated with persistent occiput posterior position. Therefore, a priority is to provide pain relief measures. Counterpressure and backrubs may be helpful. Position changes that can promote fetal head rotation are important after the nurse institutes pain relief measures. Additionally, the woman’s ability to cooperate and participate in these position changes is enhanced when she is experiencing less pain. Immediate cesarean birth is not indicated unless there is evidence of fetal distress. Oxytocin would add to the woman’s already high level of pain.

Question 3

A female sex trade worker has been diagnosed with secondary syphilis. Which findings would most likely correlate with this diagnosis?

A. sore throat and flu-like symptoms

B. pain-free crusty genital lesions

C. painful dysurea

D. yellow vaginal discharge

Answer 3

With a secondary infection of syphilis, there would be no evidence of vaginal lesions present. Present would be a maculopapular rash (hands and feet); a sore throat; lymphadenopathy; and flu-like symptoms. Dysurea is not seen in the secondary infection. A yellow vaginal discharge is for gonorrhea.

Question 4

A nurse is assisting with the delivery of a newborn. The fetal head has just emerged. Which action would be performed next?

A. clamping of the umbilical cord

B. checking for the cord around the neck

C. suctioning of the mouth and nose

D. drying of the newborn

Answer 4

Once the fetal head has emerged, the primary care provider explores the fetal neck to see if the umbilical cord is wrapped around it. If it is, the cord is slipped over the head to facilitate delivery. Then the health care provider suctions the newborn’s mouth first (because the newborn is an obligate nose breather) and then the nares with a bulb syringe to prevent aspiration of mucus, amniotic fluid, or meconium. Finally the umbilical cord is double-clamped and cut between the clamps. The newborn is placed under the radiant warmer, dried, assessed, wrapped in warm blankets, and placed on the woman’s abdomen for warmth and closeness.

Question 5

A public health nurse is teaching a group of parents about sexually transmitted infection (STIs) and discusses the vaccine available for their children to prevent the most prevalent STI. What vaccine prevents the most prevalent STI?

A. the human papillomavirus vaccination

B. the syphilis vaccination

C. the genital herpes vaccination

D. the trichomonas vaginalis vaccination

Answer 5

Vaccination is available to prevent the most prevalent strains of HPV infection and may lead to a decrease in the cancer associated with HPV. There are no approved vaccinations available presently to prevent the other STIs.

Question 6

After teaching the students about health and wellness, the nursing instructor identifies a need for further instruction when one of the students makes which of the following statements?

A. “Health is an active process.”

B. “Health is dynamic and ever-changing.”

C. “Health means the same to every person.”

D. “Health is more than just the absence of illness.”

Answer 6

Health is more than just the absence of illness; it is an active process in which a person moves toward his or her maximum potential. It also has different definitions for different people. It is not stagnant, but changes frequently.

Question 7

What puts a postpartum woman at risk for DVT?

Answer 7

Clotting factors that increased during pregnancy tend to remain elevated during the early postpartum period. Giving birth stimulates this hypercoagulability state further. As a result, these coagulation factors remain elevated for 2 to 3 weeks postpartum (Silver & Major, 2010). This hypercoagulable state, combined with vessel damage during birth and immobility, places the woman at risk for thromboembolism (blood clots) in the lower extremities and the lungs.

Note:

Red blood cell production ceases early in the puerperium, which leads to mean hemoglobin and hematocrit levels to decrease slightly in the first 24 hours and then rise slowly over the next 2 weeks.

Question 8

When describing the menstrual cycle to a group of young women, the nurse explains that estrogen levels are highest during which phase of the endometrial cycle?

A. proliferative

B. ischemic

C. secretory

D. menstrual

Answer 8

Estrogen levels are the highest during the proliferative phase of the endometrial cycle, when the endometrial glands enlarge in response to increasing amounts of estrogen. Progesterone is the predominant hormone of the secretory phase. Levels of estrogen and progesterone drop sharply during the ischemic phase and fall during the menstrual phase.

Question 9

A new mother is changing the diaper of her 12-hour-old newborn and asks why the stool is black and sticky. Which response by the nurse would be most appropriate?

Answer 9

Meconium is greenish-black and tarry and usually passed within 12 to 24 hours of birth. This is a normal finding. Iron can cause stool to turn black, but this would not be the case here. The stool is a normal occurrence and does not need to be checked for blood or reported.

Question 10

What is a normal WBC count?

Answer 10

4,000 - 11,000 /mCl

Question 11

A diabetes nurse educator is teaching a client, newly diagnosed with diabetes, about his disease process, diet, exercise, and medications. What is the goal of this education?

Answer 11

The basic purpose of educating and counseling is to help clients and families develop the self-care abilities (knowledge, attitude, skills) needed to maintain and improve health.

Question 12

After the nurse teaches a client about ways to reduce the symptoms of premenstrual syndrome, which client statement indicates a need for additional teaching?

A. “I will make sure to take my estrogen supplements a week before my period.”

B. “I quit smoking about a month ago, so that should help.”

C. “I’ve signed up for an aerobic exercise class three times a week.”

D. “I’ll cut down on the amount of coffee and colas I drink.”

Answer 12

Lifestyle changes such as exercising, avoiding caffeine, and smoking cessation are a key component for managing the signs and symptoms of premenstrual syndrome. Estrogen supplements are not used. If medication is necessary, NSAIDs may be used for painful physical symptoms; spironolactone may help with bloating and water retention.

Question 13

A child with persistent otitis media with effusion is to undergo insertion of pressure-equalizing tubes via a myringotomy. The child is to be discharged later that day. After teaching the parents about caring for their child after discharge, which statement indicates that the teaching was successful?

A. “He should wear earplugs when swimming in a pool or a lake.”

B. “His chances for ear infections now have dramatically decreased.”

C. “The tubes will stay in place for about a month and then fall out on their own.”

D. “We should keep the ears protected with cotton balls for the first 24 hours.”

Answer 13

When pressure-equalizing tubes are inserted, the surgeon may recommend avoiding water entry into the ears. Therefore, earplugs are suggested when the child is in the bathtub or swimming. When swimming in a lake, earplugs are especially important because lake water is contaminated with bacteria and entry of that water into the middle ear must be avoided. Typically, the tubes remain in place for at least several months and generally fall out on their own. Placement of pressure-equalizing tubes does not prevent middle ear infection. Other than earplugs for bathing and swimming, nothing else is placed in the child’s ear.

Question 14

The fetus of a nulliparous woman is in a shoulder presentation. The nurse would most likely prepare the client for which type of birth?

A. vaginal

B. forceps-assisted

C. vacuum extraction

D. cesarean

Answer 14

The fetus is in a transverse lie with the shoulder as the presenting part, necessitating a cesarean birth. Vaginal birth, forceps-assisted, and vacuum extraction births are not appropriate.

Question 15

When making a home visit, the nurse observes a newborn sleeping on his back in a bassinet. In one corner of the bassinet is some soft bedding material, and at the other end is a bulb syringe. The nurse determines that the mother needs additional teaching because:

Answer 15

The nurse should instruct the mother to remove all fluffy bedding, quilts, stuffed animals, and pillows from the crib to prevent suffocation. Newborns and infants should be placed on their backs to sleep. Having the bulb syringe nearby in the bassinet is appropriate. Although a crib is the safest sleeping location, a bassinet is appropriate initially.

Question 16

What pulse rate should you expect in a postpartum woman?

Answer 16

60-80 bpm is normal during the first week after birth, and is called puerperal bradycardia.

A pulse rate over 100 bpm should be investigated further to rule out complications such as infection, cardiac problems, or hemorrhage.

Question 17

A nurse is conducting a class for a local woman’s group about recommendations for a Pap smear. One of the participants asks, “At what age should a woman have her first Pap smear?” The nurse responds by stating that a woman should have her first Pap smear at which age?

A. 21

B. 28

C. 25

D. 18

Answer 17

According to the American Cancer Society, a woman should have her first Pap smear at age 21.

Question 18

A nurse educator uses models of health and illness when teaching. Which model of health and illness places high-level health and death on opposite ends of a graduated scale?

A. Health Belief Model

B. Health-Illness Continuum

C. Agent-Host-Environment Model

D. Health Promotion Model

Answer 18

The Health-Illness Continuum views health as a constantly changing state, with high-level wellness and death being on opposite ends of a graduated scale. The Agent-Host-Environment Model is useful in examining the causes of disease in an individual. The Health Belief Model describes health behaviors. The Health Promotion Model incorporates individual characteristics and experiences, as well as behavior-specific knowledge and beliefs, to motivate healthy behavior.

Question 19

A new mother who is breast-feeding her newborn asks the nurse, “How will I know if my baby is drinking enough?” Which response by the nurse would be most appropriate?

(hint: how many diapers?)

Answer 19

Soaking 6 to 12 diapers a day indicates adequate hydration. Contentedness after feeding is not an indicator for adequate hydration.

Question 20

A nurse is caring for a stable toddler diagnosed with accidental poisoning, due to the ingestion of cleaning solution. What must be included in educating parents about how to protect a toddler from accidental poisoning?

A. Keep cleaning solutions locked up.

B. Label poisonous solutions.

C. Do not leave the toddler alone.

D. Closely monitor the toddler’s activity.

Answer 20

The parents should keep cleaning solutions locked up to protect the toddler from accidental poisoning. Accidental poisonings usually occur among toddlers and commonly involve substances located in bathrooms or kitchens. Labeling poisonous substances may not help as toddlers are unable to read. Not leaving the child alone and closely monitoring the child are important, but not feasible all the time.

Question 21

A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse prepares the client for this monitoring based on the understanding that which criterion must be present?

A. floating presenting fetal part

B. cervical dilation of 2 cm or more

C. a neonatologist to insert the electrode

D. intact membranes

Answer 21

For continuous internal electronic fetal monitoring, four criteria must be met: ruptured membranes, cervical dilation of at least 2 cm, fetal presenting part low enough to allow placement of the electrode, and a skilled practitioner available to insert the electrode.

Question 22

A client with trichomoniasis is to receive metronidazole. What should the nurse instruct the client to avoid while taking this drug?

A. chocolate

B. alcohol

C. caffeine

D. nicotine

Answer 22

The client should be instructed to avoid consuming alcohol when taking metronidazole because severe nausea and vomiting could occur. There is no need to avoid nicotine, chocolate, or caffeine when taking metronidazole.

Question 23

A client states that she is to have a test to measure bone mass to help diagnose osteoporosis. The nurse would most likely plan to prepare the client for:

A. pelvic X-ray.

B. ultrasound.

C. DEXA scan.

D. MRI.

Answer 23

The client most likely will be having a DEXA scan, which is a screening test that calculates the mineral content of the bone at the spine and hip. Ultrasound, MRI, and a pelvic X-ray would be of little help in determining bone mass.

Question 24

A nurse is reviewing the fetal heart rate pattern and observes abrupt decreases in FHR below the baseline, appearing as a U-shape. The nurse interprets these changes as reflecting which type of deceleration?

A. variable decelerations

B. late decelerations

C. early decelerations

D. prolonged decelerations

Answer 24

Variable decelerations present as visually apparent abrupt decreases in FHR below baseline and have an unpredictable shape on the FHR baseline, possibly demonstrating no consistent relationship to uterine contractions. The shape of variable decelerations may be U, V, or W, or they may not resemble other patterns. Early decelerations are visually apparent, usually symmetrical and characterized by a gradual decrease in the FHR in which the nadir (lowest point) occurs at the peak of the contraction. They are thought to be a result of fetal head compression that results in a reflex vagal response with a resultant slowing of the FHR during uterine contractions. Late decelerations are visually apparent, usually symmetrical, transitory decreases in FHR that occur after the peak of the contraction. The FHR does not return to baseline levels until well after the contraction has ended. Delayed timing of the deceleration occurs, with the nadir of the uterine contraction. Late decelerations are associated with uteroplacental insufficiency. Prolonged decelerations are abrupt FHR declines of at least 15 bpm that last longer than 2 minutes but less than 10 minutes.

Question 25

A nurse is conducting an in-service program for a group of labor and birth unit nurses about about cesarean birth. The group demonstrates understanding of the information when they identify which condition as an appropriate indication? Select all that apply. A. placenta previa B. active genital herpes infection C. previous cesarean birth D. fetal distress E. prolonged labor

Answer 25

The leading indications for cesarean birth are previous cesarean birth, breech presentation, dystocia, and fetal distress. Examples of specific indications include active genital herpes, fetal macrosomia, fetopelvic disproportion, prolapsed umbilical cord, placental abnormality (placenta previa or abruptio placentae), previous classic uterine incision or scar, gestational hypertension, diabetes, positive HIV status, and dystocia. Fetal indications include malpresentation (nonvertex presentation), congenital anomalies (fetal neural tube defects, hydrocephalus, abdominal wall defects), and fetal distress.

Question 26

What is another name for stretch marks? Do they go away?

Answer 26

Striae - typically don't go away completely

Question 27

When assessing cervical effacement of a client in labor, the nurse assesses which characteristic? A. degree of thinning B. extent of opening to its widest diameter C. fetal presenting part D. passage of the mucous plug

Answer 27

Effacement refers to the degree of thinning of the cervix. Cervical dilation refers to the extent of opening at the widest diameter. Passage of the mucous plug occurs with bloody show as a premonitory sign of labor. The fetal presenting part is determined by vaginal examination and is commonly the head (cephalic), pelvis (breech), or shoulder.

Question 28

The nurse is caring for a child with widespread itching and has recommended bathing as a relief measure. After teaching the mother about this, which statement from the mother indicates a need for further instruction? A. “After bathing, I need to rub his skin everywhere to make sure he is completely dry.” B. “I must make sure I use lukewarm water instead of hot water.” C. “We should leave his skin moist before applying medication or moisturizer.” D. “Oatmeal baths are helpful; we can add Aveeno skin relief bath treatment.”

Answer 28

The nurse needs to emphasize to the mother that she must only pat the child dry and not rub his skin. Rubbing can cause further itching. Additionally, the skin should be left moist prior to applying medication or moisturizer. Lukewarm water and oatmeal baths are appropriate.

Question 29

A woman has been in labor for some time, but her membranes have not yet ruptured. Artificial rupture of membranes is being considered. Which assessment findings would support the decision to perform the procedure? Select all that apply. A. fetal head at -2 station B. vertex presentation C. cervical effacement 50% D. uterine contractions every 2 minutes E. cervical dilation of 4 cm

Answer 29

An amniotomy (artificial rupture of the fetal membranes) may be performed to augment or induce labor when the membranes have not ruptured spontaneously. Doing so allows the fetal head to have more direct contact with the cervix to dilate it. This procedure is performed with the fetal head at -2 station or lower, with the cervix dilated to at least 3 cm. Contractions, effacement, and presentation are not considerations for performing an amniotomy.

Question 30

A woman gave birth to a newborn via vaginal delivery with the use of a vacuum extractor. The nurse would be alert for which possible effect in the newborn? A. asphyxia B. clavicular fracture C. central nervous system injury D. cephalhematoma

Answer 30

Use of forceps or a vacuum extractor poses the risk of tissue trauma, such as ecchymoses, facial and scalp lacerations, facial nerve injury, cephalhematoma, and caput succedaneum. Asphyxia may be related to numerous causes, but it is not associated with use of a vacuum extractor. Clavicular fracture is associated with shoulder dystocia. Central nervous system injury is not associated with the use of a vacuum extractor.

Question 31

A nurse is conducting a refresher program for a group of nurses working in the newborn nursery. After teaching the group about variations in newborn head size and appearance, the nurse determines that the teaching was successful when the group identifies which variation as normal? Select all that apply. A. closed fontanels B. posterior fontanel diameter 1.5 cm C. caput succedaneum D. cephalhematoma E. molding

Answer 31

Normal variations in newborn head size and appearance include cephalhematoma, molding, and caput succedaneum. Microcephaly, closed fontanels, or a posterior fontanel diameter greater than 1 cm are considered abnormal.

Question 32

Which of the following statements illustrates the effect of the sociocultural dimension on health and illness? A. "Why shouldn't I drink and drive? Everyone else does." B. "I used biofeedback to lower my blood pressure." C. "I know I have heart problems, so I have changed my diet." D. "My mother has sickle cell anemia, and so do I."

Answer 32

Health practices and beliefs are strongly influenced by one's sociocultural dimension, including lifestyle, family, and culture. These factors are involved in patterns of living (such as drinking and driving) and values about health and illness. Sickle cell anemia involves the physical dimension; changing one's diet involves the intellectual dimension; and biofeedback involves the emotional dimension.

Question 33

A client comes to the clinic with abdominal pain. Based on her history the nurse suspects endometriosis. The nurse expects to prepare the client for which evaluatory method to confirm this suspicion? A. transvaginal ultrasound B. pelvic examination C. laparoscopy D. hysterosalpingogram

Answer 33

The only certain method of diagnosing endometriosis is by seeing it. Therefore, the nurse would expect to prepare the client for a laparoscopy to confirm the diagnosis. A pelvic examination and transvaginal ultrasound are done to assess for endometriosis but do not confirm its presence. Hysterosalpingography aids in identifying tubal problems resulting in infertility.

Question 34

In which patients might breastfeeding be contraindicated?

Answer 34

HIV, *active* TB, herpes, chemo, drug/alcohol abuse

Question 35

A postpartum woman who is bottle-feeding her newborn asks the nurse, "About how much should my newborn drink at each feeding?" The nurse responds by saying that to feel satisfied, the newborn needs which amount at each feeding?

Answer 35

2-4 ounces ## Footnote Newborns need about 108 cal/kg or approximately 650 cal/day. Therefore, a newborn will need to 2 to 4 ounces to feel satisfied at each feeding.

Question 36

A woman has opted to use the basal body temperature method for contraception. The nurse instructs the client that a rise in basal body temperature indicates which event? A. safe period for intercourse B. pregnancy C. ovulation D. onset of menses

Answer 36

Basal body temperatures typically rise within a day or two after ovulation and remain elevated for approximately 2 weeks, at which point bleeding usually begins. Basal body temperature is not a means for determining pregnancy. Having intercourse while the temperature is elevated would increase the risk of pregnancy.

Question 37

What respirations should you expect to find in a postpartum woman?

Answer 37

The normal range of 12-20 can be expected at rest. Once the organs return to their normal positions after birth, pulmonary function should return to normal.

Question 38

Cytotec

Answer 38

Misopristol - Prostaglandin - Used to control postpartum bleeding not controlled by other medications *Note: Can also induce labor or abortion of pregnancy* Dosage: Intravaginally: 25 mcg q3-6, if necessary

Question 39

Why should a new mom be encouraged to ambulate?

Answer 39

To prevent DVT and PE

Question 40

What would be an expected finding for hematocrit during the postpartum period?

Answer 40

Hematocrit should remain relatively stable or even slightly increase due to the loss of plasma from diuresis. An acute decrease in hematocrit would *not* be an expected finding in postpartum women, and may indicate hemmorhage. ## Footnote *Normal hematocrit for women is 42% (+/- 5%)*

Question 41

When educating parents of preschoolers, what is most important to include in your presentation? A. Keep chemicals in a locked cabinet B. Use wrist guards with rollerblades C. Teach preschoolers to tread water D. Strict discipline with potty training

Answer 41

Increasing mobility, lack of life experience and judgment, and immature musculoskeletal and neurologic systems lead to potentially hazardous encounters for toddlers and preschoolers.

Question 42

What is Hemabate?

Answer 42

Carboprost tromethamine - prostaglandin - used to control postpartum bleeding (also able to induce labor) *Note: also used to induce abortion of pregnancy* Dosage: For bleeding: IM Test dose of 100 mcg, then 250 mcg every 15-90 min (up to 2 mg/2000 mcg)

Question 43

Bioterrorism has become a commonly used term. What is the definition of bioterrorism? A. The deliberate spread of pathogens into a community B. A worldwide plan to produce illness and injury C. A verbal threat by those wishing to harm specific individuals D. A written threat calculated to produce terror in a family

Answer 43

Bioterrorism involves the deliberate spread of pathogenic organisms into a community.

Question 44

During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as what? (What are some other markings you may find?)

Answer 44

Mongolian spots are blue or purple splotches that appear on the lower back and buttocks of newborns. Milia are unopened sebaceous glands frequently found on a newborn's nose. Stork bites are superficial vascular areas found on the nape of the neck and eyelids and between the eyes and upper lip. Birth trauma would be manifested by bruising, swelling, and possible deformity.

Question 45

The nurse is caring for an 8-year-old boy hospitalized for a bone marrow transplant. His parents are in and out of his room throughout the day. Which behaviors of the child would alert the nurse that he is in the second stage of separation anxiety? A. He forms superficial relationships with his caregivers. B. He sits quietly and is uninterested in playing and eating. C. He cries uncontrollably whenever they leave. D. He ignores his parents when they return to his room.

Answer 45

Separation anxiety consists of three stages—protest, despair, and detachment. In the protest stage, the child reacts aggressively to separation and exhibits great distress by crying, expressing agitation, and rejecting others who attempt to offer comfort. In the despair phase the child displays hopelessness by withdrawing from others, becoming quiet without crying, and exhibiting apathy, depression, lack of interest in play and food, and overall feelings of sadness. In the detachment stage the child shows interest in the environment, starts to play again, and forms superficial relationships with the nurses and other children. If the parents return, the child ignores them. A child in this phase of separation anxiety exhibits resignation, not contentment.

Question 46

A nurse is conducting an in-service program for a group of nurses working in the labor and birth suite of the facility. After teaching the group about the factors affecting the labor process, the nurse determines that the teaching was successful when the group identifies which component as part of the true pelvis? Select all that apply. A. pelvic inlet B. vagina C. mid pelvis D. pelvic floor muscles E. cervix F. pelvic outlet

Answer 46

The true pelvis is made up of three planes: the pelvic inlet, mid pelvis, and pelvic outlet. The cervix, vagina, and pelvic floor muscles are the soft tissues of the passageway.

Question 47

Which finding would the nurse expect in a client with bacterial vaginosis? A. fish-like odor of discharge B. cervical bleeding on contact C. yellowish-green discharge D. vaginal pH of 3

Answer 47

Manifestations of bacterial vaginosis include a thin, white, homogenous vaginal discharge with a characteristic stale fishy odor, vaginal pH greater than 4.5, and clue cells on wet-mount examination. A yellowish-green discharge with cervical bleeding on contact would be characteristic of trichomoniasis.

Question 48

What would the nurse include when teaching parents how to prevent otitis externa? A. Using a hair dryer on high to dry the ear canals B. Wearing ear plugs when swimming C. Using hydrogen peroxide to dry the canal skin D. Daily ear cleaning with cotton swabs

Answer 48

To prevent otitis externa, the nurse would teach parents and children to wear earplugs when swimming and to avoid use of cotton swabs, headphones, and earphones. A hair dryer on a low setting can be used to dry the ear canals. A mixture of half rubbing alcohol and half vinegar can be used to dry the canal and alter the pH to discourage organism growth.

Question 49

What is a LATCH assessment and what is the total possible score?

Answer 49

Assesses the five key components of breastfeeding: Latch, audible swallowing, type of nipple, comfort, hold Each component is rated 0-2, with a maximum possible score of 10.

Question 50

A nurse is teaching a postpartum client how to do muscle-clenching exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response?

Answer 50

Muscle clenching perineal exercises help to improve pelvic floor tone, strengthen perineal muscles, and promote healing, ultimately helping to prevent urinary incontinence later in life. Kegel exercises have no effect on lochia, involution, or pain.

Question 51

Aside from actual blood loss, what else contributes to a blood plasma volume reduction in postpartum women?

Answer 51

Diuresis, which occurs during the early postpartum period.

Question 52

What is an *episiotomy*?

Answer 52

A surgical cut made to aid delivery and prevent tissue rupture.

Question 53

When teaching new parents about the sensory capabilities of their newborn, which sense would the nurse identify as being the least mature?

Answer 53

Vision is the least mature sense at birth. Hearing is well developed at birth, evidenced by the newborn's response to noise by turning. Touch is evidenced by the newborn's ability to respond to tactile stimuli and pain. A newborn can distinguish between sweet and sour by 72 hours of age.

Question 54

When can intercourse safely resume after childbirth?

Answer 54

Typically, sexual intercourse can be resumed once bright-red bleeding has stopped and the perineum is healed from an episiotomy or lacerations. This is usually by the third to the sixth week postpartum. Fluctuations in sexual interest are normal. In addition, breast-feeding women may notice a let-down reflex during orgasm and find that breasts are very sensitive when touched by the partner. Precoital vaginal lubrication may be impaired during the postpartum period, especially in women who are breast-feeding. Use of water-based gel lubricants can help.

Question 55

Where would you expect the fundus to be 12 hours after delivery?

Answer 55

At the umbilicus

Question 56

Which type of medications are not indicated for asthmatics, when possible? Which medications does this include?

Answer 56

Prostaglandins - Hemabate and Cytotec

Question 57

What causes postpartum diuresis?

Answer 57

Postpartum diuresis occurs as a result of several mechanisms: the large amounts of IV fluids given during labor, a decreasing antidiuretic effect of oxytocin as its level declines, the buildup and retention of extra fluids during pregnancy, and a decreasing production of aldosterone—the hormone that decreases sodium retention and increases urine production. All these factors contribute to rapid filling of the bladder within 12 hours of birth. Diuresis begins within 12 hours after childbirth and continues throughout the first week postpartum.

Question 58

The mother of a toddler with asthma seeks support from the parents of other children with asthma. The nurse recognizes that seeking and utilizing support systems is an example of which human dimension? A. Sociocultural dimension B. Environmental dimension C. Intellectual and spiritual dimension D. Physical dimension

Answer 58

Communicating with others and the use of support systems relate to the sociocultural dimension. An individual's relationship with others, being connected to a community, and feeling accepted and loved by others are also related to the sociocultural dimension.

Question 59

A pregnant woman comes to the labor and birth unit in labor. The woman tells the nurse, "Yesterday, I had this burst of energy and cleaned everything in site, but I don't know why," Which response by the nurse would be most appropriate? A. "You were looking forward to the birth of your baby." B. "You had a burst of adrenalin, which is common before labor." C. "You were trying to get everything ready for your baby." D. "You felt your mind telling you that you were about to go into labor."

Answer 59

Some women report a sudden increase in energy before labor. This is sometimes referred to as nesting because many women will focus this energy toward childbirth preparation by cleaning, cooking, preparing the nursery, and spending extra time with other children in the household. The increased energy level usually occurs 24 to 48 hours before the onset of labor. It is thought to be the result of an increase in epinephrine (adrenalin) release caused by a decrease in progesterone. The burst of energy is unrelated to getting everything ready, the mind telling the woman that she will be going into labor, or looking forward to the birth.

Question 60

What is the average blood loss associated with giving birth?

Answer 60

500 mL vaginal 1,000 mL cesarean

Question 61

What might indicate Vitamin A Toxicity

Answer 61

Lethargy, headaches, orange hue to skin

Question 62

When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes?

Answer 62

Although all the body systems of the newborn undergo changes, respiratory gas exchange along with circulatory modifications must occur immediately to sustain extrauterine life.

Question 63

What would be a concerning temperature for a postpartum woman?

Answer 63

Above 100.4 degrees. Temperature up to this may be considered normal for the first 24 hours, partially due to fluid loss/dehydration during labor.

Question 64

A woman in her third trimester comes to the clinic for a prenatal visit. During assessment the woman reports that her breathing has become much easier in the last week but she has noticed increased pelvic pressure, cramping, and lower back pain. The nurse determines that which event has most likely occurred? A. lightening B. Braxton-Hicks contractions C. cervical dilation D. bloody show

Answer 64

Lightening occurs when the fetal presenting part begins to descend into the maternal pelvis. The uterus lowers and moves into the maternal pelvis. The shape of the abdomen changes as a result of the change in the uterus. The woman usually notes that her breathing is much easier. However, she may complain of increased pelvic pressure, cramping, and lower back pain. Although cervical dilation also may be occurring, it does not account for the woman's complaints. Bloody show refers to passage of the mucous plug that fills the cervical canal during pregnancy. It occurs with the onset of labor. Braxton-Hicks contractions increase in strength and frequency and aid in moving the cervix from a posterior position to an anterior position. They also help in ripening and softening the cervix.

Question 65

The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism?

Answer 65

Using a warmed cloth diaper or blanket to cover any cold surface, such as a scale, that touches a newborn directly helps to prevent heat loss through conduction. Drying a newborn and promptly changing wet linens, clothes, or diapers help reduce heat loss via evaporation. Keeping the newborn out of a direct cool draft, working inside an isolette as much as possible, and minimizing the opening of portholes help prevent heat loss via convection. Keeping cribs and isolettes away from outside walls, cold windows, and air conditioners and using radiant warmers while transporting newborns and performing procedures will help reduce heat loss via radiation.

Question 66

What hormone causes afterpains and which group of women will likely have stronger afterpains?

Answer 66

Oxytocin. All women experience afterpains, but they are more acute in multiparous women secondary to repeated stretching of the uterine muscles.

Question 67

How often would you take vital signs on a postpartum woman?

Answer 67

q15x4, q30x2, q4 for 24 hours

Question 68

What is the medication Pitocin? What might it be used for?

Answer 68

Exogenous oxytocin. Frequently used to induce labor. Dosages: For Postpartum hemorrhage: - IV 10 units, 20-40 milliunits/min - IM 10 units after delivery of placenta For induction: - IV 0.5-1 milliunits/min, increased by 1-2 q30-60

Question 69

The nurse is developing a teaching plan for the mother of a 4-year-old girl with cold and fever. What would the nurse include in this teaching plan? A. Keeping the child covered and warm B. Ensuring fluid intake to prevent dehydration C. Calling the doctor if the child's fever lasts more than 36 hours D. Observing for changes in alertness resulting from brain damage

Answer 69

Teaching the mother to ensure fluid intake is important because fever can cause dehydration. The child should be dressed lightly. There is no need to call the doctor unless the child's fever lasts more than 3 to 5 days or the fever is greater than 105ºF. A rapid rise to a high fever can cause a febrile convulsion, but it does not lead to brain damage.

Question 70

A nurse is preparing a class for a group of women at a family planning clinic about contraceptives. When describing the health benefits of oral contraceptives, which benefits would the nurse most likely include? Select all that apply. A. reduced risk for endometrial cancer B. protection against pelvic inflammatory disease C. improvement in acne D. reduced risk for migraine headaches E. decreased risk for depression

Answer 70

The health benefits of oral contraceptives include protection against pelvic inflammatory disease, a reduced risk for endometrial cancer, and improvement in acne. Oral contraceptives are associated with an increased risk for depression and migraine headaches.

Question 71

What additional nutritional needs does the breastfeeding mother need?

Answer 71

Increase diet by 500 calories

Question 72

Which foods are highest in iron? A. Black beans, Quinoa B. Strawberries, green beans C. Red meat, oysters D. Red yeast

Answer 72

C

Question 73

What are 1st, 2nd, 3rd, and 4th degree lacerations?

Answer 73

A first-degree laceration involves only the skin and superficial structures above the muscle. A second-degree laceration extends through the perineal muscles. A third-degree laceration extends through the anal sphincter muscle. A fourth-degree laceration continues through the anterior rectal wall.

Question 74

The nurse is caring for a 4-year-old girl who has been hospitalized for over a week with severe burns. Which would be a priority intervention to help satisfy this preschool child's basic needs? A. Explain necessary procedures in simple language that she will understand. B. Suggest that a family member be present with her 24 hours a day. C. Allow her to make choices about her meals and activities as much as permitted. D. Encourage friends to visit as often as possible.

Answer 74

Preschoolers fear mutilation and are afraid of intrusive procedures since they do not understand the body's integrity. They interpret words literally and have an active imagination; therefore, procedures should be demonstrated and/or explained in simple terms. Adolescents typically do not experience separation anxiety from being away from their parents; instead, their anxiety comes from being separated from friends, and therefore encouraging friends to visit is a priority intervention. Toddlers are especially susceptible to separation anxiety and would benefit from a family member being present as much as possible. School-age children are accustomed to controlling self-care and typically are highly social; they would benefit from being involved in choices about meals and activities.

Question 75

After teaching a group of parents about ear infections in children, which statement indicates that the teaching was successful? A. Adenoids shrink as the child grows, allowing more bacteria to enter. B. The shorter and wider eustachian tubes of an infant increase the risk. C. Infants with congenital deformities have an increased risk for ear infections. D. Ear infections typically increase as the child gets older.

Answer 75

The infant has relatively short, wide, horizontally placed eustachian tubes, allowing bacteria and viruses to gain access to the middle ear and resulting in an increased number of infections as compared to adults. Congenital deformities of the ear are associated with other body system anomalies, but not necessarily an increase in ear infections. As the child matures, the eustachian tubes assume a more slanted position, so older children and adults have fewer infections. A child's adenoids are often enlarged, leading to obstruction of the eustachian tubes and infection.

Question 76

Which of the following nutritional guidelines should a nurse provide to a client who is entering the second trimester of her pregnancy? A. "The more food energy you consume, the greater the chances that you will have a healthy pregnancy." B. "You'll need to eat more calories and to make sure you eat a balanced diet high in nutrients." C. "Maintain your regular calorie intake, but take some supplements and emphasize organic foods." D. "Try to eat your normal number of calories, but aim to eat a diet that's higher in fruits and vegetables."

Answer 76

Nutrient needs during pregnancy increase to support growth and maintain maternal homeostasis, particularly during the second and third trimesters. During the last two trimesters, women of normal weight need approximately 300 extra calories per day. Key nutrient needs include protein, calories, iron, folic acid, calcium, and iodine. It would be inaccurate to encourage the client to maximize calorie intake.

Question 77

The nurse encourages a female client with human papillomavirus (HPV) to receive continued follow-up care because she is at risk for: A. infertility. B. cervical cancer. C. dysmenorrhea. D. dyspareunia.

Answer 77

Clinical studies have confirmed that HPV is the cause of essentially all cases of cervical cancer. Therefore, the client needs continued follow-up for Pap smears. HPV is not associated with an increased risk for infertility, dyspareunia, or dysmenorrhea.

Question 78

When is the infant ready for solid foods? SELECT ALL A. Moro reflex remains B. Tongue extrusion reflex decreases C. Infant will not sleep through the night D. Able to sit upright and turn head away E. Infant appears interested in food F. Birth weight has doubled

Answer 78

A, C, D and F are correct. Not sleeping through the night, does not indicate the baby needs solid food. The Moro reflex disappears around 3-4 months, but is not related to solid food introduction.

Question 79

A woman calls the health care facility stating that she is in labor. The nurse would urge the client to come to the facility if the client reports which symptom? A. pink-tinged vaginal secretions and irregular contractions lasting about 30 seconds B. contractions noted in the front of abdomen that stop when she walks C. increased energy level with alternating strong and weak contractions D. moderately strong contractions every 4 minutes, lasting about 1 minute

Answer 79

Moderately strong regular contractions 60 seconds in duration indicate that the client is probably in the active phase of the first stage of labor. Alternating strong and weak contractions, contractions in the front of the abdomen that change with activity, and pink-tinged secretions with irregular contractions suggest false labor.

Question 80

Which of the following is true regarding regarding emergency preparedness: A. Hospitals can be monetarily fined if they do not have a disaster plan in place. B. The chief medical officer has the authority to mandate a quarantine. C. The County Public Health commissioner has the regulatory power to mandate a quarantine. D. Nurses can be mandated to report to duty when an emergency is declared.

Answer 80

Which of the following is true regarding emergency preparedness:

Question 81

After teaching a group of pregnant women about breastfeeding, the nurse determines that the teaching was successful when the group identifies which hormone as important for the production of breast milk after birth? A. placental estrogen B. gonadotropin-releasing hormone C. prolactin D. progesterone

Answer 81

After birth and expulsion of the placenta, prolactin stimulates the production of milk. Placental estrogen and progesterone stimulate the development of the mammary glands during pregnancy. Gonadotropin-releasing hormone induces the release of follicle-stimulating hormone and luteinizing hormone to assist with ovulation.

Question 82

After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position? A. side-lying B. sitting C. knee–chest D. supine

Answer 82

Pressure on the cord needs to be relieved. Therefore, the nurse would position the woman in a modified Sims, Trendelenburg, or knee–chest position. Supine, side-lying, or sitting would not provide relief of cord compression.

Question 83

A client with genital herpes simplex infection asks the nurse, “Will I ever be cured of this infection?” Which response by the nurse would be most appropriate? A. “Once you have the infection, you develop an immunity to it.” B. “There is a new vaccine available that prevents the infection from returning.” C. “There is no cure, but drug therapy helps to reduce symptoms and recurrences.” D. “All you need is a dose of penicillin and the infection will be gone.”

Answer 83

Genital herpes is a lifelong viral infection. No cure exists, but antiviral drug therapy helps to reduce or suppress symptoms, shedding, and recurrent episodes. A vaccine is available for HPV infection but not genital herpes. Penicillin is used to treat syphilis. No immunity develops after a genital herpes infection.

Question 84

What is engorgement?

Answer 84

Engorgement is the process of swelling of the breast tissue as a result of an increase in blood and lymph supply as a precursor to lactation (Figure 15.4). Breast engorgement usually peaks in 3 to 5 days postpartum and usually subsides within the next 24 to 36 hours (Chapman, 2011). Engorgement can occur from infrequent feeding or ineffective emptying of the breasts and typically lasts about 24 hours. Breasts increase in vascularity and swell in response to prolactin 2 to 4 days after birth. If engorged, the breasts will be hard and tender to touch. Involution refers to the process of the uterus returning to its prepregnant state. Mastitis refers to an infection of the breasts. Engrossment refers to the bond that develops between the father and the newborn.

Question 85

A nurse is providing care to a woman during the third stage of labor. Which finding would alert the nurse that the placenta is separating? A. sudden gush of dark blood from the vagina B. shortening of the umbilical cord C. uterus becoming discoid shaped D. boggy, soft uterus

Answer 85

Signs that the placenta is separating including a firmly contracting uterus, a change in uterine shape from discoid to globular ovoid, a sudden gush of dark blood from the vaginal opening, and lengthening of the umbilical cord protruding from the vagina.

Question 86

Which of the following populations, based on their development stage, would benefit from strategies to prevent falls? Select all that apply. A. Adolescents B. Older Adults C. Adults D. Toddlers E. Newborns

Answer 86

Educate parents never to leave newborns alone on a changing table, and also teach parents of toddlers to childproof the home. Parents of preschoolers should make sure their children wear proper safety equipment when riding bicycles or scooters. Adolescents and adults are not at high risk for falls. Older adults, however, are at risk for falls due to the effects of aging on the body systems.

Question 87

What is the leading cause of death in postpartum women?

Answer 87

PPH - Postpartum hemmorhage Defined as \>500 mL of blood loss

Question 88

A woman is diagnosed with a vaginal infection. After teaching the client about measures to reduce her risk, the nurse determines that the client needs additional teaching when she states which factor as increasing her risk? A. antibiotic therapy B. douching C. use of feminine hygiene sprays D. menstruation

Answer 88

The vagina has an acidic environment, which protects it against ascending infections. Antibiotic therapy, douching, perineal hygiene sprays, and deodorants upset the acid balance within the vaginal environment and can predispose women to infections. Menstruation is not considered a risk factor.

Question 89

Which of the following is not one of the six general types of risk factors in regard to increasing an individual 's chances for illness and injury? A. Age B. Lifestyle C. Gender D. Environment

Answer 89

The six general types of risk factors are age, genetics, physiologic factors, health habits, lifestyle, and environment. Gender is not a risk factor per se, but certain conditions, such as pregnancy, can contribute to risk.

Question 90

An adolescent has recently had a ring inserted into her navel. Which of the following is the greatest risk facing the adolescent as a result of this activity? A. A scar over the navel B. A greater acceptance by peers C. A local and/or systemic infection D. A strained relationship with parents

Answer 90

Body piercing is a quick procedure that does not require anesthesia, but the risk for infection is great. This risk includes local infection, hepatitis B virus, and HIV.

Question 91

What information do anthropometric measurements provide in adults?

Answer 91

Indirect measure of protein and fat stores. Anthropometric measurements are used to determine body dimensions. In children, they are used to assess growth rate; in adults, they give indirect measurements of body protein and fat stores.

Question 92

The nurse conducting a community emergency preparedness education class includes which of the following as an example of a natural disaster? A. Earthquake B. War C. Terrorist event D. Toxic spill

Answer 92

A disaster is broadly defined as a tragic event of great magnitude that requires the response of people outside the involved community. Disasters can be categorized as natural (e.g., massive flooding following a hurricane or an earthquake) or man-made (e.g., a toxic spill, war, or a terrorist event).

Question 93

A woman telephones her health care provider and reports that her water just broke. Which suggestion by the nurse would be most appropriate? A. “Drink 3 to 4 glasses of water and lie down.” B. “Come in as soon as you feel the urge to push.” C. “Call us back when you start having contractions.” D. “Come to the clinic or emergency department for an evaluation.”

Answer 93

When the amniotic sac ruptures, the barrier to infection is gone and there is the danger of cord prolapse if engagement has not occurred. Therefore, the nurse should suggest that the woman come in for an evaluation. Calling back when contractions start, drinking water, and lying down are inappropriate because of the increased risk for infection and cord prolapse. Telling the client to wait until she feels the urge to push is inappropriate because this occurs during the second stage of labor.

Question 94

The nurse has been working with a client for several days during the client's recovery from a femoral head fracture. How should a nurse best evaluate whether client education regarding the prevention of falls in the home has been effective? A. "What changes will you make around your house to reduce the chance of future falls?" B. "In light of what we've talked about, why is it important that you remove the throw rugs in your house?" C. "Do you have any questions about the fall prevention measures that we've talked about?" D. "Do you think that the safety measures I taught you are clear and realistic?"

Answer 94

An open-ended question that requires the client to apply the information that has been taught is often the most accurate way to evaluate the effectiveness of client education. Yes/no questions are much less effective ("Do you have any questions?"; "Do you think that the safety measures I taught you are clear and realistic?"). Asking the client about the importance of preventing falls does not directly assess what the client will actually do to prevent falls.

Question 95

Which measure would the nurse include in the teaching plan for a woman to reduce the risk of osteoporosis after menopause? A. taking vitamin supplements B. eating high-fiber, high-calorie foods C. participating in regular daily exercise D. restricting fluid to 1,000 mL daily

Answer 95

Measures to reduce osteoporosis after menopause include daily weight-bearing exercise, increasing calcium and vitamin D intake, and avoiding smoking and excessive alcohol intake. General vitamin supplements may be helpful overall, but they are not specific to reducing the risk of osteoporosis. A diet high in calcium and vitamin D, not fiber and calories, would be appropriate. Restricting fluids would have no effect on preventing osteoporosis.

Question 96

An adolescent is diagnosed with gonorrhea. When developing the plan of care for this adolescent, the nurse would expect that she would also receive treatment for what? A. Genital herpes B. Syphilis C. Chlamydia D. Trichomoniasis

Answer 96

Clients with gonorrhea usually receive treatment for chlamydia as well because they often are coinfected. Coinfection with syphilis, genital herpes, or trichomoniasis is uncommon.

Question 97

After teaching a group of students about the different methods for contraception, the instructor determines that the teaching was successful when the students identify which contraceptive methods as mechanical barrier methods? Select all that apply. A. diaphragm B. condom C. vaginal ring D. cervical sponge E. cervical cap

Answer 97

Barrier methods include the condom, cervical cap, cervical sponge and diaphragm. The vaginal ring is considered a hormonal method of contraception.

Question 98

What is the *most important* sign that the baby is feeding well?

Answer 98

Wet diapers. Should have 2-3 wet diapers in 48 hours, and at least 6/day after 5 days.

Question 99

An older adult male client is admitted to the cardiac ICU after suffering a heart attack. Upon taking a history after the client is stable, the nurse charts that he weighs over 275 pounds, has a history of heart disease in his family, suffers frequent stress at work, drinks alcohol daily, and smokes two packs of cigarettes daily. What are some modifiable risks factors for this client that has attributed to his heart attack? Select all that apply. A. Alcohol intake B. Sex C. Family history D. Smoking E. Stress F. Age

Answer 99

The modifiable risk factors related to this client's heart attack include stress, alcohol intake, and smoking. These are things that a person can change. The others are nonmodifiable, as the client cannot change his age, family history, or sex.

Question 100

A father of a newborn tells the nurse, “I may not know everything about being a dad, but I'm going to do the best I can for my son.” The nurse interprets this as indicating the father is in which stage of adaptation?

Answer 100

The father's statement reflects **transition to mastery** because he is making a conscious decision to take control and be at the center of the newborn's life regardless of his preparedness. The expectations stage involves preconceptions about how life will be with a newborn. Reality occurs when fathers realize their expectations are not realistic. Taking-in is a phase of *maternal* adaptation.

Question 101

What are some things a nurse should include in teaching a couple who just had a baby?

Answer 101

Discharge teaching typically would focus on several techniques to comfort a crying newborn. The nurse needs to emphasize the importance of responding to the newborn's cues, not allowing the infant to cry for an hour before being comforted. Information about solid foods is inappropriate for a newborn because solid foods are not introduced at this time. The mother and newborn need rest periods. Information about newborn sleep–wake cycles and measures for sensory enrichment and stimulation would also be appropriate.

Question 102

A pregnant woman diagnosed with syphilis comes to the clinic for a visit. The nurse discusses the risk of transmitting the infection to her newborn, explaining that this infection is transmitted to the newborn through the: A. birth canal. B. amniotic fluid. C. breast milk. D. placenta.

Answer 102

The syphilis spirochete can cross the placenta at any time during pregnancy. It is not transmitted via amniotic fluid, passage through the birth canal, or breast milk.

Question 103

Which is a nongovernmental agency involved in promoting quality in health care institutions by promoting safety goals? A. Occupational and Safety Health Administration (OSHA) B. Board of Safety in Medicine (BSM) C. Center for Disease Control (CDC) D. Joint Commission for the Accreditation of Health Care Organizations (JCAHO)

Answer 103

D

Question 104

Assessment of a newborn reveals uneven gluteal (buttocks) skin creases and a “clunk” when Ortolani maneuver is performed. What would the nurse suspect?

Answer 104

A “clunk” indicates the femoral head hitting the acetabulum as the head reenters the area. This, along with uneven gluteal creases, suggests developmental hip dysplasia. These findings are not a normal variation and are not associated with slipping of the periosteal joint or overriding of the pelvic bone.

Question 105

A male client age 61 years has been admitted to a medical unit with a diagnosis of pancreatitis secondary to alcohol use. Which of the client's following statements suggests that nurses' education has resulted in affective learning? A. "I can see how things could have been much worse if I hadn't gotten to the hospital when I did." B. "I understand why they're not letting me eat anything for the time being." C. "I'm starting to see how my lifestyle has caused me to end up here." D. "My intravenous drip will keep me from getting dehydrated right now."

Answer 105

The client's understanding of his contribution to his problem demonstrates a shift in attitude and feelings that is characteristic of affective learning. Understanding the treatment, course, and prognosis of his illness are aspects of cognitive learning.

Question 106

After teaching the parents of a child with varicella zoster, the nurse determines that the parents have understood the teaching when they state that their child can return to school at which time? A. After day 5 of the rash B. After the lesions have crusted C. Once the rash appears D. When the rash is completely healed

Answer 106

Children with chickenpox (varicella zoster) can return to school once the lesions have crusted.

Question 107

A woman comes to the clinic for an evaluation. During the visit, the woman tells the nurse that her menstrual cycles have become irregular. "I've also been waking up at night feeling really hot and sweating. The nurse interprets these findings as: A. perimenopause. B. menarche. C. climacteric. D. menopause.

Answer 107

Perimenopause is the time period occurring 2 to 8 years prior to menopause during which women may experience physical changes associated with decreasing estrogen levels, which may include vasomotor symptoms of hot flashes, irregular menstrual cycles, sleep disruptions, forgetfulness, irritability, mood disturbances, decreased vaginal lubrication, night sweats, fatigue, vaginal atrophy, and depression. Vasomotor symptoms (hot flushes and night sweats) are the most common complaints for which women seek treatment. Menopause or climacteric is defined as 1 year without a menstrual period. Menarche refers to the onset of the first menses.

Question 108

A nurse is assessing a client diagnosed with pelvic inflammatory disease (PID). Which findings would the nurse most likely assess? Select all that apply. A. oral temperature of 102 degrees F (39 degrees C) B. painful urination C. right upper quadrant pain D. clear vaginal discharge E. tenderness with cervical motion F. negative pregnancy history

Answer 108

History and physical examination findings of PID include dysmenorrhea, dysuria, lower abdominal tenderness, cervical or vaginal mucopurulent discharge, and cervical motion tenderness. Typically the client has a fever above 101 degrees F (38 degrees C) and is nulliparous.

Question 109

The parents of a 5-year-old have just found out that their child has head lice. Which statement by the parents would support the nursing diagnosis of deficient knowledge? A. “I can't believe it. We're not unclean, poor people.” B. “Everybody in the house will need to be checked.” C. “That explains his complaints of itching on his neck.” D. “We'll have to get that special shampoo.”

Answer 109

Head lice is not an indication of poor hygiene or poverty. It occurs in all socioeconomic groups. Thus, the parents' statement about being unclean and poor reflects a lack of knowledge about the infection. A pediculicide is used to wash the hair to treat the infestation. Household contacts need to be examined and treated if affected. Extreme pruritus is the most common symptom, with nits or lice especially behind the ears or at the nape of the neck.

Question 110

How often would a nurse recommend a client eat or drink a source of vitamin C?

Answer 110

Vitamin C, a water-soluble vitamin, is usually not stored in the body. Deficiency symptoms are apt to develop quickly when intake is inadequate; a *daily intake* is recommended.

Question 111

The nurse is providing developmentally appropriate care for a toddler hospitalized for observation following a fall down the steps. Which measures might the nurse consider when caring for this child? Select all that apply. A. Use the en face position when holding the toddler. B. Allow the child to select meals and activities. C. Explain activities in concrete, simple terms. D. Avoid leaving small objects that can be swallowed in the bed. E. Encourage parents to stay to prevent separation anxiety. F. Use a bed for toddlers who have an adult present.

Answer 111

For a toddler, the nurse would avoid leaving small objects that can be swallowed in the bed and encourage parents to stay to prevent separation anxiety. The nurse would use the en face position when holding an infant and use a bed only for the older toddler who has an adult present in the room at all times. The nurse would explain activities in concrete, simple terms for a preschooler and allow a school-age child to select meals and activities.

Question 112

The nurse is reviewing the monitoring strip of a woman in labor who is experiencing a contraction. The nurse notes the time the contraction takes from its onset to reach its highest intensity. The nurse interprets this time as which phase? A. decrement B. increment C. peak D. acme

Answer 112

Each contraction has three phases: increment or the buildup of the contraction; acme or the peak or highest intensity; and the decrement or relaxation of the uterine muscle fibers. The time from the onset to the highest intensity corresponds to the increment.

Question 113

What common occurence causes afterpains to be stronger?

Answer 113

*Breastfeeding* stimulates release of oxytocin, increasing uterine contractions.

Question 114

What is the taking-in phase?

Answer 114

During the taking-in phase, new mothers when interacting with their newborns spend time claiming the newborn and touching him or her, commonly identifying specific features in the newborn such as “he has my nose” or “his fingers are long like his father's.” Independence in self-care and interest in caring for the newborn are typical of the taking-hold phase. Confidence in caring for the newborn is demonstrated during the letting-go phase.

Question 115

A mother brings her 12-year-old daughter to the clinic for a visit. The daughter has just started menstruating. As part of the visit, the nurse explains the menstrual cycle and ovulation, including the events that led up to ovulation. Which hormone would the nurse identify as being primarily responsible for ovulation? A. follicle-stimulating hormone B. estrogen C. luteinizing hormone D. progesterone

Answer 115

At ovulation, a mature follicle ruptures in response to a surge of luteinizing hormone. Estrogen is predominant at the end of the follicular phase, directly preceding ovulation. Progesterone peaks 5 to 7 days after ovulation. Follicle-stimulating hormone is highest during the first week of the follicular phase of the cycle.

Question 116

The nurse is caring for a 10-year-old girl who is in an isolation room. Which intervention would be a priority intervention for this child? A. Provide age-appropriate toys and games. B. Discourage visits from family members. C. Reduce noise as much as possible. D. Put on mask prior to entering the room.

Answer 116

Children in this setting may experience sensory deprivation due to the limited contact with others and the use of personal protective equipment such as gloves, masks, and gowns. The nurse should stimulate the child by playing with her with age-appropriate toys/games. Reducing noise would be appropriate for sensory overload. The nurse should encourage the family to visit often, introduce himself or herself before entering the room, and allow the child to view his or her face before applying a mask.

Question 117

A nurse is assessing a postpartum woman. Which finding would lead the nurse to suspect that a postpartum woman is having a problem? A. pulse rate of 110 beats/minute B. slightly increased hematocrit C. increased levels of clotting factors D. elevated white blood cell count

Answer 117

Tachycardia (heart rate above 100 bpm) in the postpartum woman warrants further investigation. It may indicate hypovolemia, dehydration, or hemorrhage. Despite a decrease in blood volume after birth, hematocrit levels remain relatively stable and may even increase. An acute decrease is not an expected finding. The WBC count remains elevated for the first 4 to 6 days and clotting factors remain elevated for 2 to 3 weeks.

Question 118

What are risk factors for postpartum hemorrhage?

Answer 118

Risk factors for postpartum hemorrhage include a precipitous labor less than three hours, uterine atony, placenta previa or abruption, labor induction or augmentation, operative procedures such as vacuum extraction, forceps, or cesarean birth, retained placental fragments, prolonged third stage of labor greater than 30 minutes, multiparity, and uterine overdistention such as from a large infant, twins, or hydramnios.

Question 119

What blood pressure should you expect to find in the postpartum woman?

Answer 119

BP should remain the same as during labor, and deviations should be reported. BP should be between 85/60 and 140/90.

Question 120

A nurse is reviewing the laboratory test results of a newborn. Which result would the nurse identify as a cause for concern? A. platelets 75,000/uL B. hematocrit 52% C. white blood cells 20,000/mm3 D. hemoglobin 19 g/dL

Answer 120

Normal newborn platelets range from 150,000 to 350,000/uL. Normal hemoglobin ranges from 17 to 23g/dL, and normal hematocrit ranges from 46% to 68%. Normal white blood cell count ranges from 10,000 to 30,000/mm3.

Question 121

A camp nurse is teaching a group of adolescent girls about the importance of monthly breast self-examination. What level of preventive care does this activity represent? A. Primary B. Secondary C. Restorative D. Tertiary

Answer 121

Primary preventive care activities are directed toward promoting health and preventing the development of disease. Teaching breast self-examination is an example of a primary preventive care activity.

Question 122

The nurse encourages the mother of a healthy newborn to put the newborn to the breast immediately after birth for which reason?

Answer 122

Breast-feeding can be initiated immediately after birth. This immediate mother–newborn contact takes advantage of the newborn's natural alertness and fosters bonding. This contact also reduces maternal bleeding and stabilizes the newborn's temperature, blood glucose level, and respiratory rate.

Question 123

While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning bluish. What would the nurse do first?

Answer 123

The nurse's first action would be to suction the oral and nasal pharynx with a bulb syringe to maintain airway patency.

Question 124

The nurse is preparing a care plan for an African American man age 68 years who was recently diagnosed with hypertension. Age, race, gender, and genetic inheritance are examples of what human dimension? A. Environmental B. Physical C. Sociocultural D. Emotional

Answer 124

The physical dimension includes genetic inheritance, age, developmental level, race, and gender. These components strongly influence a person's health status and health practices. The emotional dimension focuses on how the mind affects body function and responds to body conditions. The environmental dimension includes influences such as housing, sanitation, climate, and pollution of food, air, and water. Sociocultural dimensions are health practices and beliefs strongly influenced by economic status, lifestyle, family, and culture.

Question 125

What is diastasis recti?

Answer 125

Separation of the rectus abdominis muscles, called diastasis recti, is more common in women who have poor abdominal muscle tone before pregnancy. After birth, muscle tone is diminished and the abdominal muscles are soft and flabby. Specific exercises are necessary to help the woman regain muscle tone. Fortunately, diastasis responds well to exercise, and abdominal muscle tone can be improved. Stretch marks (striae gravidarum) fade to silvery lines. The darkened pigmentation of the abdomen (linea nigra), face (melasma), and nipples gradually fades. Parous women will note a permanent increase in shoe size.

Question 126

What are some things a new mother can do to prevent sore/cracked nipples and mastitis?

Answer 126

Colostrum/lanolin application, frequent feedings, nipple shields, clean breasts, no soap, supportive bra, frequent assessment

Question 127

A nurse is caring for a client with excessive abdominal fat. Which of the following is a risk associated with excessive abdominal fat about which the nurse should inform the client? A. Cachexia B. Emaciation C. Anorexia D. Cardiovascular disease

Answer 127

Excess abdominal fat may lead to cardiovascular disease, hypertension, and diabetes. Anorexia is the loss of appetite. Emaciation is characterized by excessive leanness. Cachexia is the general wasting away of body tissue.

Question 128

A client who gave birth 12 hours ago is experiencing scant, frequent voidings. What do you suspect?

Answer 128

Infrequent or insufficient voiding may be a sign of infection and is not a normal finding on the second postpartum day. Note: Lochia serosa, a firm fundus below the umbilicus, and milk filling the breasts are expected findings.

Question 129

A woman gives birth to a healthy newborn. As part of the newborn's care, the nurse instills erythromycin ophthalmic ointment as a preventive measure related to which STI? A. genital herpes B. gonorrhea C. syphilis D. hepatitis B

Answer 129

To prevent gonococcal ophthalmia neonatorum, erythromycin or tetracycline ophthalmic ointment is instilled into the eyes of all newborns. This action is required by law in most states. The ointment is not used to prevent conditions related to genital herpes, hepatitis B, or syphilis.

Question 130

What changes would you expect in BP post-delivery?

Answer 130

In most instances of postpartum hemorrhage, blood pressure and cardiac output remain increased because of the compensatory increase in heart rate. Thus, a decrease in blood pressure and cardiac output are not expected changes during the postpartum period. Early identification is essential to ensure prompt intervention. Deep red, fleshy-smelling lochia is a normal finding 6 hours postpartum. Voiding in small amounts such as less than 150 cc would indicate a problem, but 350 cc would be appropriate. Profuse sweating also is normal during the postpartum period.

Question 131

What would a blood pressure of less than 85/45 indicate in a postpartum woman? What is the primary cause of this?

Answer 131

We would worry about hemmoraging due to the placenta tearing away from the uterus.

Question 132

What is a *hematoma*? What are the s/s?

Answer 132

Bleeding into a *closed* area. The patient will complain of *sudden, severe* pain.

Question 133

Assessment of a pregnant woman reveals that the presenting part of the fetus is at the level of the maternal ischial spines. The nurse documents this as which station? A. -1 B. +1 C. 0 D. -2

Answer 133

Station refers to the relationship of the presenting part to the level of the maternal pelvic ischial spines. Fetal station is measured in centimeters and is referred to as a minus or plus, depending on its location above or below the ischial spines. Zero (0) station is designated when the presenting part is at the level of the maternal ischial spines. When the presenting part is above the ischial spines, the distance is recorded as minus stations. When the presenting part is below the ischial spines, the distance is recorded as plus stations.

Question 134

The nurse is performing Leopold's maneuvers to determine fetal presentation, position, and lie. Which action would the nurse do first? A. Feel for the fetal buttocks or head while palpating the abdomen. B. Determine flexion by pressing downward toward the symphysis pubis. C. Feel for the fetal back and limbs as the hands move laterally on the abdomen. D. Palpate for the presenting part in the area just above the symphysis pubis.

Answer 134

The first maneuver involves feeling for the buttocks and head. Next the nurse palpates on which side the fetal back is located. The third maneuver determines presentation and involves palpating the area just above the symphysis pubis. The final maneuver determines attitude and involves applying downward pressure in the direction of the symphysis pubis.

Question 135

A baby is born with Down syndrome, which influences his health–illness status. This is an example of which of the following human dimensions? A. Sociocultural B. Emotional C. Environmental D. Physical

Answer 135

The physical dimension includes genetic inheritance, age, developmental level, race, and gender. These components strongly influence the person's health status and health practices.

Question 136

A woman in her 40th week of pregnancy calls the nurse at the clinic and says she's not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor? A. “I'm feeling contractions mostly in my back.” B. “The contractions slow down when I walk around.” C. “My contractions are about 6 minutes apart and regular.” D. “If I try to talk to my partner during a contraction, I can't.”

Answer 136

False labor is characterized by contractions that are irregular and weak, often slowing down with walking or a position change. True labor contractions begin in the back and radiate around toward the front of the abdomen. They are regular and become stronger over time; the woman may find it extremely difficult if not impossible to have a conversation during a contraction.

Question 137

A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information would the nurse integrate into the explanation to support this description?

Answer 137

Although all the body systems of the newborn undergo changes, respiratory gas exchange along with circulatory modifications must occur immediately to sustain extrauterine life. With the first breath, PVR decreases, and the heart rate initially increases but then decreases to 120 to 130 bpm after a few minutes. The ductal murmur will go away in 80+%of infants by 48 hours. Rhonchi caused by retained amniotic fluid is an abnormal findings and would not be expected.

Question 138

A nurse is preparing a class for pregnant women about labor and birth. When describing the typical movements that the fetus goes through as it travels through the passageway, which movement would the nurse most likely include? Select all that apply. A. pronation B. flexion C. internal rotation D. abduction E. descent

Answer 138

The positional changes that occur as the fetus moves through the passageway are called the cardinal movements of labor and include engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion. The fetus does not undergo abduction or pronation.

Question 139

What is subinvolution?

Answer 139

A *slow* return of the uterus to its normal size

Question 140

Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as: A. the period of decreased responsiveness preceding sleep. B. evidence that the newborn is becoming chilled. C. a sign that the infant is being overstimulated. D. a good time to initiate breast-feeding.

Answer 140

The newborn is demonstrating behaviors indicating the first period of reactivity, which usually begins at birth and lasts for the first 30 minutes. This is a good time to initiate breast-feeding. Decreased responsiveness occurs from 30 to 120 minutes of age and is characterized by muscle relaxation and diminished responsiveness to outside stimuli. None of the behaviors indicate overstimulation. Chilling would be evidenced by tachypnea, decreased activity, and hypotonia.

Question 141

The nurse is examining a 3-year-old boy with acute otitis media who has a mild earache and a temperature of 38.5ºC. Which action will be taken? A. Obtain a culture of the middle ear fluid. B. Instruct the parents to watch for worsening symptoms. C. Administer antibiotics. D. Administer antivirals.

Answer 141

In this case, the child will be continually observed. If the symptoms persist or become worse, antibiotics will be prescribed. This clinical practice guideline was developed by the American Academy of Pediatrics and the American Academy of Family Physicians in order to avoid overusing antibiotics or obtaining a middle ear fluid culture with every occurrence of acute otitis media. Administering antiviral agents would not be appropriate for this child.

Question 142

What does the acronym REEDA stand for? When is it used?

Answer 142

Redness, edema, ecchymosis (bruising), discharge, approximation. It is used for perineal assessment.

Question 143

The nurse knows that a health care facility should determine its disaster-preparedness plan for delivering care in the event of an emergency or disaster? A. As soon as the disaster is announced publicly B. When officially informed that a disaster has occurred C. In advance of a possible emergency or disaster D. After the first disaster has been experienced

Answer 143

Each health care facility should determine in advance how to deliver care, if an emergency or disaster occurs. This involves collaboration with internal committees and external agencies.

Question 144

A client states, "I must be in poor health because I am a senior citizen. That's what my neighbor says and she is older than I am." This statement is based on which of the following factors? A. Illness factors B. Gender C. Peer influence D. Age

Answer 144

Peer influence, personality characteristics, ethnicity, and socioeconomic factors may affect a person's response to illness.

Question 145

When can a postpartum woman safely resume use of hormonal contraceptives?

Answer 145

The Centers for Disease Control and Prevention recommend that postpartum women not use combined hormonal contraceptives during the first 21 days after childbirth because of the high risk for venous thromboembolism (VTE) during this period.

Question 146

A nurse is assessing a newborn who is about 4 1/ 2 hours old. The nurse would expect this newborn to exhibit which behavior? Select all that apply. A. passage of meconium B. spontaneous Moro reflexes C. interest in environmental stimuli D. difficulty arousing the newborn E. sleeping

Answer 146

A and C The newborn is in the second period of reactivity, which begins as the newborn awakens and shows an interest in environmental stimuli. This period lasts 2 to 8 hours in the normal newborn. Heart and respiratory rates increase. Peristalsis also increases. Thus, it is not uncommon for the newborn to pass meconium or void during this period. In addition, motor activity and muscle tone increase in conjunction with an increase in muscular coordination. Spontaneous Moro reflexes are noted during the first period of reactivity. Sleeping and difficulty arousing the newborn reflect the period of decreased responsiveness.

Question 147

Which of the following is an essential component of the definition of learning? A. Cannot be measured B. Decreases stress C. Increases self-esteem D. Can be measured

Answer 147

Learning is the process by which a person acquires or increases knowledge, or changes behavior in a measurable way, as a result of an experience.

Question 148

While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as:

Answer 148

Caput succedaneum is localized edema on the scalp, a poorly demarcated soft tissue swelling that crosses the suture lines. Note: Molding refers to the elongated shape of the fetal head as it accommodates to the passage through the birth canal. Microcephaly refers to a head circumference that is 2 standard deviations below average or less than 10% of normal parameters for gestational age. Cephalhematoma is a localized effusion of blood beneath the periosteum of the skull.

Question 149

What is *preeclampsia*

Answer 149

High blood pressure *during pregnancy*

Question 150

A nurse is conducting a refresher in-service program for a group of neonatal nurses. After teaching the group about hepatic system adaptations after birth, the nurse determines that the teaching was successful when the group identifies which process as reflective of the change of bilirubin from a fat-soluble product to a water-soluble product? A. jaundice B. hyperbilirubinemia C. conjugation D. hemolysis

Answer 150

The process in which bilirubin is changed from a fat-soluble product to a water-soluble product is called conjugation. Hemolysis involves the breakdown of blood cells. In the newborn, hemolysis of the red blood cells is the principal source of bilirubin. Jaundice is the manifestation of increased bilirubin in the bloodstream. Hyperbilirubinemia refers to the increased level of bilirubin in the blood.

Question 151

A woman has just entered the second stage of labor. The nurse would focus care on which intervention? A. palpating the woman's fundus for position and firmness B. completing the identification process of the newborn with the mother C. alleviating perineal discomfort with the application of ice packs D. encouraging the woman to push when she has a strong desire to do so

Answer 151

During the second stage of labor, nursing interventions focus on motivating the woman, encouraging her to put all her efforts toward pushing. Alleviating perineal discomfort with ice packs and palpating the woman's fundus would be appropriate during the fourth stage of labor. Completing the newborn identification process would be appropriate during the third stage of labor.

Question 152

A grade school nurse is addressing parents at a PTA meeting regarding car safety. Which of the following is a recommended safety guideline for this age group? A. All school-age children need to be secured in safety seats. B. Children under 8 years old should ride in the back seat. C. Booster seats should be used for children until they are 4 feet 9 inches tall or at least 8 years of age. D. All school-age children need to be secured in lap seat belts.

Answer 152

All school-age children need to be secured in safety seats, belt-positioning booster seats, or shoulder lap belts for their size. The National Highway Traffic Safety Administration recommends booster seats for children until they are 4 feet 9 inches tall or at least 8 years of age, and all children 12 and under should ride in the back seat to eliminate the risk of injury from airbag deployment (National Highway Traffic Safety Administration [NHTSA], 2008).

Question 153

A group of nursing students are reviewing information about childhood infectious diseases. The students demonstrate understanding of this information when they identify which disease as a common childhood exanthema? A. Mumps B. Rubella C. West Nile virus D. Rabies

Answer 153

Rubella is a common childhood exanthema. Mumps is a viral infection. Rabies is a zoonotic infection. West Nile virus is a vector-borne disease.

Question 154

The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal?

Answer 154

Decrease the serum bilirubin level. Jaundice reflects elevated serum bilirubin levels; phototherapy helps to break down the bilirubin for excretion.

Question 155

A nurse is caring for a young adult female client who has a folic acid defiency. When teaching the client about this condition, the nurse would include a discussion about the client's increased risk for which of the following? A. Impaired neuromuscular functioning B. Neural tube deficits in the fetus C. Inadequate absorption of calcium and phosphorus D. Hemolysis of red blood cells

Answer 155

B ## Footnote Folic acid deficiency in pregnant women can lead to neural tube deficits like spina bifida in the fetus. Because fetal neural development begins so early in pregnancy, women in their childbearing years must have adequate folic acid intake. Deficiency in vitamin D intake leads to inadequate absorption of calcium and phosphorus, and a deficiency of mineralization in bones and teeth. Increased hemolysis of red blood cells, poor reflexes, impaired neuromuscular functioning, and anemias are signs of vitamin E deficiency, not folic acid deficiency.

Question 156

A nurse is providing care to a woman in labor. After assessment of the fetus, the nurse documents the fetal lie. Which term would the nurse most likely use? A. cephalic B. flexion C. extension D. longitudinal

Answer 156

Fetal lie refers to the relationships of the long axis (spine) of the fetus to the long axis (spine) of the mother. There are two primary lies: longitudinal and transverse. Flexion and extension are terms used to describe fetal attitude. Cephalic is a term used to describe fetal presentation.

Question 157

The nurse determines that it is necessary to implement airborne precautions for children with which infection? A. Rubella B. Measles C. Scarlet fever D. Streptococcus group A

Answer 157

Airborne precautions are designed to reduce the risk of infectious agents transmitted by airborne droplet nuclei or dust particles such as for children with measles, varicella, or tuberculosis. Droplet precautions would be used for children with streptococcal group A infections, rubella, and scarlet fever.

Question 158

What is the visible line which travels from the navel to the pubis in postpartum women? Does it go away?

Answer 158

Linea nigra - it typically goes away

Question 159

A girl age 4 years has been admitted to the emergency department after accidently ingesting a cleaning product. Which of the following treatments is most likely appropriate in the immediate treatment of the girl's poisoning? A. Administration of activated charcoal B. Inducing vomiting C. Gastric lavage D. Intravenous rehydration

Answer 159

Activated charcoal is the most common treatment for many poisonings and is more effective and safe than induced vomiting or gastric lavage. Rehydration is likely necessary, but this does not actively treat the girl's poisoning.

Question 160

What are some ways to wake up a sleeping baby?

Answer 160

- Loosen clothing (makes them cold/uncomfortable) - Tickle their feet - Talk loudly - Holy baby upright - Dim lights (bright lights keep their eyes closed)

Question 161

The mother of a 4-year-old boy has contacted the physician's office. She reports her son was exposed to someone with chickenpox. She has inquired about when her son may show if he has gotten the disease. What information should be provided? A. Younger children will have longer periods of incubation. B. The incubation period for the disease is between 10 and 21 days. C. Symptoms of the disease should show up within 24 to 48 hours of exposure. D. The illness should be seen in a week if he has been exposed.

Answer 161

Chickenpox is the common name for varicella. This condition has an incubation period of 10 to 21 days.

Question 162

What hormones are related to breastfeeding? Explain what each of them does.

Answer 162

Oxytocin: Milk ejection reflex (milk let down) Prolactin: Responsible for milk production *Note: Oxytocin is also responsible for uterine contractions, which help the uterus return to its original size (involution). It also plays a role in mother-child bonding.*

Question 163

What is Methergine?

Answer 163

Methylergonovine maleate - used to control postpartum hemmorhaging that doesn't respond to convention therapies Dosage: Oral: 200-400 mcg q6-12 for 2-7 days IM/IV: 200 mcg q2-4 up to 5 doses

Question 164

The nurse observes the stool of a newborn who is being bottle-fed. The newborn is 2 days old. What would the nurse expect to find?

Answer 164

The milk stools of the formula-fed newborn vary depending on the type of formula ingested. They may be yellow, yellow-green, or greenish and loose, pasty, or formed in consistency, and they have an unpleasant odor. After breast-feedings are initiated, a transitional stool develops, which is greenish brown to yellowish brown, thinner in consistency, and seedy in appearance. Meconium stool is greenish black and tarry. The last development in the stool pattern is the milk stool. Milk stools of the breast-fed newborn are yellow-gold, loose, and stringy to pasty in consistency, and typically sour-smelling.

Question 165

What's the *first* thing a nurse should typically assess on a postpartum woman? Explain normal findings.

Answer 165

Lochia Rubra - red, bloody, 1-3 days (*measure*) Serosa - pink, brown, d3-10 Alba - clear, white, d10-21

Question 166

A client is in the third stage of labor. Which finding would alert the nurse that the placenta is separating? A. uterus becomes globular B. umbilical cord shortens C. mucous plug is expelled D. fetal head at vaginal opening

Answer 166

Placental separation is indicated by the uterus changing shape to globular and upward rising of the uterus. Additional signs include a sudden trickle of blood from the vaginal opening, and lengthening (not shortening) of the umbilical cord. The fetal head at the vaginal opening is termed crowning and occurs before birth of the head. Expulsion of the mucous plug is a premonitory sign of labor.

Question 167

A new mother asks the nurse, "Why has my baby lost weight since he was born?" The nurse integrates knowledge of which cause when responding to the new mother?

Answer 167

Normally, term newborns lose 5% to 10% of their birth weight as a result of insufficient caloric intake within the first week after birth, shifting of intracellular water to extracellular space, and insensible water loss. ## Footnote *Stool passage and bilirubin have no effect on weight loss.*

Question 168

The nurse is assessing the respirations of several newborns. The nurse would notify the health care provider for the newborn with which respiratory rate at rest? A. 68 breaths per minute B. 46 breaths per minute C. 54 breaths per minute D. 38 breaths per minute

Answer 168

After respirations are established in the newborn, they are shallow and irregular, ranging from 30 to 60 breaths per minute, with short periods of apnea (less than 15 seconds). Thus a newborn with a respiratory rate below 30 or above 60 breaths per minute would require further evaluation.

Question 169

A nutritionist helps to plan a diet for a client with diabetes. Which of the following foods is a carbohydrate that should be included to help improve glucose tolerance? A. Oatmeal B. Nuts C. Milk D. Eggs

Answer 169

Oatmeal is a water-soluble carbohydrate that helps improve glucose tolerance in diabetics. Milk, eggs, and nuts are proteins.

Question 170

A woman comes to the clinic because she has been unable to conceive. When reviewing the woman's history, the nurse would least likely identify which factor as a possible risk? A. age of 25 years B. diabetes since age 15 years C. weight below standard for height and age D. history of smoking

Answer 170

Female risk factors for infertility include age older than 27 years, smoking and alcohol consumption, history of chronic illness such as diabetes, and overweight or underweight, which can disrupt hormonal function.

Question 171

A client is interested in losing 15 pounds, and she informs the nurse she is counting her calorie intake each day. The client has a goal of losing one pound a week until she reaches her goal. The client asks the nurse how many calories she should decrease daily to lose a pound a week. What is the nurse's best response?

Answer 171

To lose 1 pound (0.45 kg) in a week, daily calorie intake should be decreased by 500 calories a day. One pound of body fat equals about 3,500 calories; 3,500 calories divided by 7 days = 500 calories/day.

Question 172

What vital sign would be measure in postpartum women related to the blood loss they have experienced?

Answer 172

Blood pressure checks for orthostatic hypotension

Question 173

What are some relief measures for a non-breastfeeding mother?

Answer 173

* Wearing a tight supportive bra 24 hours daily * Applying ice to her breasts for approximately 15 to 20 minutes every other hour * Not stimulating her breasts by squeezing or manually expressing milk. Note: * Warm showers enhance the let-down reflex and would be appropriate if the woman *was* breast-feeding * Limiting fluid intake is inappropriate * Fluid intake is important for all postpartum women, regardless of the feeding method chosen.

Question 174

The nurse is auscultating a newborn's heart and places the stethoscope at the point of maximal impulse at which location?

Answer 174

The point of maximal impulse (PMI) in a newborn is a lateral to midclavicular line located at the fourth intercostal space.

Question 175

The nurse is caring for an infant with candidal diaper rash. Which topical agent would the nurse expect the physician to order? A. Antifungals B. Antibiotics C. Retinoids D. Corticosteroids

Answer 175

Candidal diaper rash would require a fungicide. The nurse would expect to administer topical antifungals as ordered. Corticosteroids are not typically recommended for young infants and are used for atopic dermatitis and certain types of contact dermatitis. Antibiotics would be ineffective against fungal infections. Retinoids are indicated for moderate to severe acne.

Question 176

When assessing several women for possible VBAC, which woman would the nurse identify as being the best candidate? A. one who has a vertical incision from a previous cesarean birth B. one who has undergone a previous myomectomy C. one who had a previous cesarean birth via a low transverse incision D. one who has a history of a contracted pelvis

Answer 176

VBAC is an appropriate choice for women who have had a previous cesarean birth with a lower abdominal transverse incision. It is contraindicated in women who have a prior classic uterine incision (vertical), prior transfundal surgery, such as myomectomy, or a contracted pelvis.

Question 177

An alcoholic is most likely to be defienct in: A. Biotin B. Folic Acid C. Thiamin D. Pyridoxine

Answer 177

C

Question 178

What would you expect to find on your breast assessment?

Answer 178

d2-3 full and soft d3 firm and lumpy (as milk comes in)

Question 179

A postpartum client who is bottle feeding her newborn asks, “When should my period return?” What response by the nurse would be most appropriate?

Answer 179

“It varies, but you can estimate it returning in about 7 to 9 weeks.”

Question 180

What are risk factors for postpartum infection?

Answer 180

Risk factors for postpartum infection include history of diabetes, labor over 24 hours, hemoglobin less than 10.5 mg/dL, prolonged rupture of membranes (more than 24 hours), and manual extraction of the placenta.

Question 181

The nurse is caring for a 7-year-old girl hospitalized in isolation. The nurse notices that she has begun sucking her thumb and changing her speech patterns to those of a toddler. What condition is the girl manifesting? A. Repression B. Suppression C. Regression D. Denial

Answer 181

Sucking the thumb and changing of speech pattern (such as to baby talk) are signs of regression, a defense mechanism used by children to deal with unpleasant experiences by returning to a previous stage that may be more comfortable to the child. Suppression is a conscious inhibition of an idea or desire. Repression is an unconscious inhibition of an idea or desire. Denial would be exhibited by expressions of resignation instead of true contentment, not thumb sucking or baby talk.

Question 182

A nurse is assessing a male client recently diagnosed with genital herpes. Which finding would most likely correlate with this diagnosis? A. wart-like flesh-colored lesions on the scrotal area B. painful urination with a penile discharge present C. a chancre on the penis D. reports of itching, tingling and pain in genital area

Answer 182

Initial symptoms for a male with genital herpes would include itching, tingling, and pain in genital area followed by small pustules and blister-like genital lesions. Gonorrhea presents with a penile discharge (pus). Wart-like lesions that are soft, moist, or flesh-colored and appear on the scrotum with HPV. Syphilis in both male and female presents with a chancre.

Question 183

What is *involution*?

Answer 183

Return of reproductive organs to their pre-pregnancy state.

Question 184

Prior to inserting a nasogastric tube, the nurse correctly verifies the client's identity through which of the following methods? A. Call the client by his or her first name. B. Check the client's identification bracelet. C. Ask the client: "Is your name\_\_\_?" D. Verify the client's room number.

Answer 184

The Joint Commission's National Patient Safety Goals include improving the accuracy of client identification. The nurse should check the client's identification bracelet to verify the client's identity.

Question 185

A nurse is describing the risks associated with prolonged pregnancies as part of an inservice presentation. Which factor would the nurse be least likely to incorporate in the discussion as an underlying reason for problems in the fetus? A. aging of the placenta B. cord compression C. meconium aspiration D. increased amniotic fluid volume

Answer 185

Fetal risks associated with a prolonged pregnancy include macrosomia, shoulder dystocia, brachial plexus injuries, low Apgar scores, postmaturity syndrome (loss of subcutaneous fat and muscle and meconium staining), and cephalopelvic disproportion. All of these conditions predispose this fetus to birth trauma or a surgical birth. Uteroplacental insufficiency, meconium aspiration, and intrauterine infection contribute to the increased rate of perinatal deaths. As the placenta ages, its perfusion decreases and it becomes less efficient at delivering oxygen and nutrients to the fetus. Amniotic fluid volume also begins to decline by 40 weeks of gestation, possibly leading to oligohydramnios, subsequently resulting in fetal hypoxia and an increased risk of cord compression because the cushioning effect offered by adequate fluid is no longer present. Hypoxia and oligohydramnios predispose the fetus to aspiration of meconium, which is released by the fetus in response to a hypoxic insult.

Question 186

A middle-aged woman is 40 pounds over her ideal weight. Which of the following statements best illustrates the effect of her self-concept on health and illness? A. "My husband loves me this way." B. "Why should I lose weight? I'll still be fat." C. "I am just too busy with my kids to bother about a diet." D. "My sister is thin, but I don't think she looks that good."

Answer 186

Self-concept is an important variable affecting health and illness. People who are overweight may believe that nothing can change the way they look and refuse to follow a diet and exercise program.

Question 187

The nurse is inspecting the external genitalia of a male newborn. Which finding would alert the nurse to a possible problem? A. palpable testes in scrotal sac B. absence of engorgement C. large scrotum D. limited rugae

Answer 187

The scrotum usually appears relatively large and should be pink in white neonates and dark brown in neonates of color. Rugae should be well formed and should cover the scrotal sac. There should not be bulging, edema, or discoloration. Testes should be palpable in the scrotal sac and feel firm and smooth and be of equal size on both sides of the scrotal sac.

Question 188

A nurse calculates the BMI of a client during a general survey as 26. Under which of the following categories would this client fall? A. Underweight B. Obesity Class I C. Normal D. Overweight

Answer 188

BMI values are: Underweight \<18.5; normal 18.5 to 24.9; overweight 25.0 to 29.9; obesity class I 30.0 to 34.9; obesity class II 35.0 to 39.9; and extreme obesity 40.0+.

Question 189

What safety device for children is mandated by law in all 50 states? A. Parental controls for Internet access B. Bumper pads in baby cribs C. Infant car seats and carriers D. Automatic hot water heater controls

Answer 189

All 50 states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle.

Question 190

Most nutritionists recommend increasing fiber in the diet. In addition to other benefits, how does fiber affect cholesterol?

Answer 190

Increases fecal excretion of cholesterol To help lower serum cholesterol levels, researchers recommend limiting cholesterol intake, eating less total fat, eating more unsaturated fat, and increasing fiber intake. Fiber increases fecal excretion of cholesterol.

Question 191

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do next? A. Check the fetal heart rate. B. Notify the primary care provider immediately. C. Perform a vaginal exam. D. Change the linen saver pad.

Answer 191

When membranes rupture, the priority focus is on assessing fetal heart rate first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. A vaginal exam may be done later to evaluate for continued progression of labor. The primary care provider should be notified, but this is not a priority at this time. Changing the linen saver pad would be appropriate once the fetal status is determined and the primary care provider has been notified.

Question 192

The nurse is preparing a plan of care for a 5-year-old boy with chickenpox. Which nursing intervention should be questioned? A. Keep the child's fingernails short. B. Provide alcohol baths as needed. C. Monitor fluid intake and output. D. Administer antipyretics as ordered.

Answer 192

Treatments such as sponging the child with alcohol or cold water are not appropriate interventions for fever management. Rather, the nurse would use tepid sponge baths and cool compresses. Administering antipyretics, keeping the child's fingernails short, and monitoring intake and output are appropriate.

Question 193

What is the acronym for postpartum assessment?

Answer 193

BUBBLE-EE Breasts, uterus, bladder, bowels, lochia, episiotomy/perineum/epidural site, extremities, and emotional status *Note: Lochia should be checked first*

Question 194

A client with polycystic ovarian syndrome (PCOS) is receiving oral contraceptives as part of her treatment plan. When discussing this treatment with the client, the nurse would discuss which rationale for this therapy? A. induce ovulation B. improve insulin uptake C. restore menstrual regularity D. alleviate hirsutism

Answer 194

Oral contraceptives are used as treatment for PCOS to restore menstrual irregularities and treat acne. Ovulation induction agents such as clomiphene are used to induce ovulation. Metformin is used to improve insulin uptake. Mechanical hair removal methods are used to treat hirsutism.

Question 195

After discussing various methods of contraception with a client and her partner, the nurse determines that the teaching was successful when they identify which contraceptive method as providing protection against sexually transmitted infections (STIs)? A. tubal ligation B. condoms C. intrauterine system D. oral contraceptives

Answer 195

Condoms are a barrier method of contraception. In addition to providing a physical barrier for sperm, they also protect against STIs. Oral contraceptives, tubal ligation, and intrauterine systems provide no protection against STIs.

Question 196

When developing a teaching plan for a couple who are considering contraception options, the nurse would include which statement? A. “The best contraceptive is one that you will use correctly and consistently.” B. “You should select one that is considered to be 100% effective.” C. “A good contraceptive doesn't require a primary care provider's prescription.” D. “The best one is the one that is the least expensive and most convenient.”

Answer 196

For a contraceptive to be most effective, the client must be able to use it correctly and consistently. Even if a method is considered 100% effective, it is not the best choice if the couple does not use it correctly or consistently. Cost is a consideration, but the least expensive method is not necessarily the best choice. The need for a prescription is not relevant to the couple's choice.

Question 197

Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in: A. active phase of the first stage. B. latent phase of the first stage. C. transition phase of the first stage. D. perineal phase of the second stage.

Answer 197

The latent phase of the first stage of labor involves cervical dilation of 0 to 3 cm, cervical effacement of 0% to 40%, and contractions every 5 to 10 minutes lasting 30 to 45 seconds. The active phase is characterized by cervical dilation of 4 to 7 cm, effacement of 40% to 80%, and contractions occurring every 2 to 5 minutes lasting 45 to 60 seconds. The transition phase is characterized by cervical dilation of 8 to 10 cm, effacement of 80% to 100%, and contractions occurring every 1 to 2 minutes lasting 60 to 90 seconds. The perineal phase of the second stage occurs with complete cervical dilation and effacement, contractions occurring every 2 to 3 minutes and lasting 60 to 90 seconds, and a tremendous urge to push by the mother.

Question 198

A client arrives at the emergency department with nausea, hematemesis, fever, abdominal pain, and severe diarrhea. There is a suspicion the client has been exposed to the anthrax bacillus. What category of medications will be administered? A. Antihistamines B. Narcotics C. Antacids D. Antimicrobials

Answer 198

Anthrax is a potentially fatal bacterial infection. The recommended treatment for exposure to, as well as symptoms of, an anthrax infection is with rapid administration of antimicrobial therapy. Narcotics are administered to manage pain. Antihistamines are prescribed to manage allergy conditions. Antacids are prescribed to manage gastrointestinal disorders.

Question 199

A nurse is preparing a teaching program for a parenting group about preventing foreign body aspiration. What information would the nurse include? A. Keep pennies and dimes out of the child's reach; quarters do not pose a problem. B. Withhold peanuts from children until they are at least 5 years of age. C. Avoid giving popcorn to children younger than the age of 2 years. D. If an object fits through a standard toilet paper roll, the child can aspirate it.

Answer 199

Items smaller than 1.25 inches (3.2 cm) can be aspirated easily. A simple way for parents to estimate the safe size of a small item or toy piece is to gauge its size against a standard toilet paper roll, which is generally about 1.5 inches in diameter. If it fits through the roll, it can be aspirated. Popcorn and peanuts should not be given to children until they are at least 3 years old. All coins should be kept out of the reach of children.

Question 200

When describing the neurologic development of a newborn to his parents, the nurse would explain that it occurs in which fashion?

Answer 200

Neurologic development follows a cephalocaudal (head-to-toe) and proximal-distal (center to outside) pattern.

Question 201

When discussing contraceptive options, the nurse would recommend which option as being the most reliable? A. intrauterine system B. lactational amenorrheal method (LAM) C. coitus interruptus D. natural family planning

Answer 201

An intrauterine system is the most reliable method because users have to consciously discontinue using them to become pregnant rather than making a proactive decision to avoid conception. Coitus interruptus, LAM, and natural family planning are behavioral methods of contraception and require active participation of the couple to prevent pregnancy. These behavioral methods must be followed exactly as prescribed; otherwise, they are associated with a 27% failure rate.

Question 202

A client is admitted to the labor and birthing suite in early labor. On review of her prenatal history, the nurse determines that the client's pelvic shape as identified in the antepartal progress notes is the most favorable one for a vaginal delivery. Which pelvic shape would the nurse have noted? A. android B. gynecoid C. platypelloid D. anthropoid

Answer 202

The most favorable pelvic shape for vaginal delivery is the gynecoid shape. The anthropoid pelvis is favorable for vaginal birth, but it is not the most favorable shape. The android pelvis is not considered favorable for a vaginal birth because descent of the fetal head is slow and failure of the fetus to rotate is common. Women with a platypelloid pelvis usually require cesarean birth.

Question 203

Assessment of a newborn reveals a heart rate of 180 beats/minute. To determine whether this finding is a common variation rather than a sign of distress, what else does the nurse need to know?

Answer 203

Time of birth. The typical heart rate of a newborn ranges from 110 to 160 beats per minute with wide fluctuation during activity and sleep. Typically heart rate is assessed every 30 minutes until stable for 2 hours after birth.

Question 204

A nurse is giving a talk to a local community group on the importance of proper diet and regular exercise. This is an example of which type of health promotion? A. Primary health promotion B. Tertiary health promotion C. Chronic health promotion D. Secondary health promotion

Answer 204

Primary health promotion is aimed at promoting health and preventing the development of a disease. Examples of primary promotion are immunizations, family planning, the teaching of healthy diet, regular exercise, safety, and safe sex. Secondary health promotion is aimed at early detection of the disease and treatment. Tertiary promotion begins after the disease is diagnosed and treated, with the goal of reducing disability and helping in rehab. The term chronic is not related to health promotion.

Question 205

The nurse is teaching a health education class on male reproductive anatomy and asks the students to identify the site of sperm production. Which structure, if identified by the group, would indicate to the nurse that the teaching was successful? A. prostate gland B. scrotum C. seminal vesicles D. testes

Answer 205

The testes are responsible for sperm production. The seminal vesicles produce nutrient seminal fluid. The scrotum surrounds and protects the testes. The prostate gland and the seminal vesicles produce fluid to nourish the sperm.

Question 206

A nurse in the sexual health clinic assesses a female client and notes wart-like lesions on the genital area and rectum. Which diagnosis best correlates with these findings? A. trichomoniasis infection B. syphilis C. human papillomavirus D. genital herpes

Answer 206

HPV presents itself with wart-like lesions that are soft, moist, or flesh colored and appear on the vulva and cervix, and inside and surrounding the vagina and anus. The other diagnoses do not present with wart-like lesions.

Question 207

Which of the following activities related to respiratory health is an example of tertiary health promotion and illness prevention? A. Assisting with lung function testing of a client to help determine a diagnosis B. Administering a nebulized bronchodilator to a client who is short of breath C. Advocating politically for more explicit warning labels on cigarette packages D. Teaching a client that "light" cigarettes do not prevent lung disease

Answer 207

The use of medications is characteristic of tertiary health promotion and illness prevention. Testing and screening are examples of secondary health promotion and illness prevention, while client education and political advocacy are associated with primary prevention.

Question 209

A client with a 28-day cycle reports that she ovulated on May 10. When would the nurse expect the client's next menses to begin? A. June 1 B. May 30 C. May 26 D. May 24

Answer 209

For a woman with a 28-day cycle, ovulation typically occurs on day 14. Therefore, her next menses would begin 14 days later, on May 24.

Question 210

A nurse is teaching new parents about bathing their newborn. The nurse determines that the teaching was successful when the parents make which statement? A. "We should avoid using any kind of baby powder." B. "We can put a tiny bit of lotion on his skin, and then rub it in gently." C. "We should clean his eyes after washing his face and hair." D. "We need to bathe him at least four to five times a week."

Answer 210

Powders should not be used because they can be inhaled, causing respiratory distress. If the parents want to use oils and lotions, have them apply a small amount onto their hand first, away from the newborn; this warms the lotion. Then the parents should apply the lotion or oil sparingly. Parents need to be instructed that a bath two or three times weekly is sufficient for the first year because too frequent bathing may dry the skin. The eyes are cleaned first and only with plain water; then the rest of the face is cleaned with plain water.

Question 211

What would be some assessment findings in a postpartum woman that would compel you to call the physician?

Answer 211

Signs of infection, uterine subinvolution, baby not gaining weight or voiding, urine retention in mother, mastitis

Question 212

A client who has come to the clinic is diagnosed with endometriosis. What would the nurse expect the primary care provider to prescribe as a first-line treatment? A. progestins B. NSAIDs C. antiestrogens D. gonadotropin-releasing hormone analogues

Answer 212

Although progestins, antiestrogens, and gonadotrophin-releasing analogues are used as treatment options for endometriosis, NSAIDS are considered the first-line treatment to reduce pain.

Question 213

A client is to receive an implantable contraceptive. The nurse describes this contraceptive as containing: A. synthetic progestin. B. concentrated spermicide. C. concentrated estrogen. D. combined estrogen and progestin.

Answer 213

Implantable contraceptives deliver synthetic progestin that act by inhibiting ovulation and thickening cervical mucus so sperm cannot penetrate. Implantable contraceptives do not contain combined estrogen and progestin, concentrated spermicide, or concentrated estrogen.

Question 214

A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which effect? A. urinary retention B. respiratory depression C. hyperreflexia D. abdominal distention

Answer 214

Opioids given close to the time of birth can cause central nervous system depression, including respiratory depression, in the newborn, necessitating the administration of naloxone. Urinary retention may occur in the woman who received neuraxial opioids. Abdominal distention is not associated with opioid administration. Hyporeflexia would be more commonly associated with central nervous system depression due to opioids.

Question 215

Which suggestion by the nurse about pushing would be most appropriate to a woman in the second stage of labor? A. "Let me help you decide when it is time to start pushing." B. "Choose whatever method you feel most comfortable with for pushing." C. "Bear down like you're having a bowel movement with every contraction." D. "Lying flat with your head elevated on two pillows makes pushing easier."

Answer 215

The role of the nurse should be to support the woman in her choice of pushing method and to encourage confidence in her maternal instinct of when and how to push. In the absence of any complications, nurses should not be controlling this stage of labor, but empowering women to achieve a satisfying experience. Common practice in many labor units is still to coach women to use closed glottis pushing with every contraction, starting at 10 cm of dilation, a practice that is not supported by research. Research suggests that directed pushing during the second stage may be accompanied by a significant decline in fetal pH and may cause maternal muscle and nerve damage if done too early. Effective pushing can be achieved by assisting the woman to assume a more upright or squatting position. Supporting spontaneous pushing and encouraging women to choose their own method of pushing should be accepted as best clinical practice.

Question 216

A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as: A. -2 station. B. +2 station. C. 0 station. D. crowning.

Answer 216

The ischial spines serve as landmarks and are designated as zero status. If the presenting part is palpated higher than the maternal ischial spines, a negative number is assigned. Therefore, the nurse would document the finding as -2 station. If the presenting part is below the ischial spines, then the station would be +2. Crowning refers to the appearance of the fetal head at the vaginal opening.

Question 217

The nurse is assessing a 13-year-old girl. Which event would the nurse expect to have occurred first? A. development of breast buds B. growth spurt C. evidence of pubic hair D. onset of menses

Answer 217

Pubertal events preceding the first menses have an orderly progression beginning with the development of breast buds, followed by the appearance of pubic hair, then axillary hair, then a growth spurt. Menses typically occurs about 2 years after the start of breast development.

Question 218

The nurse notes persistent early decelerations on the fetal monitoring strip. Which action would the nurse do next? A. Administer oxygen after turning the client on her left side. B. Continue to monitor the FHR because this pattern is benign. C. Perform a vaginal exam to assess cervical dilation and effacement. D. Stay with the client while reporting the finding to the primary care provider.

Answer 218

Early decelerations are not indicative of fetal distress and do not require intervention. Therefore, the nurse would continue to monitor the fetal heart rate pattern. There is no need to perform a vaginal exam, report the finding to the primary care provider, or administer oxygen.

Question 219

A nurse is educating women on the need for calcium to prevent bone loss. What level of prevention does this represent? A. Secondary prevention B. Tertiary prevention C. Residual prevention D. Primary prevention

Answer 219

Primary prevention or primary health care involves the education of clients in the prevention of disease.

Question 220

What do we look for in the extremities of postpartum women? What would cause this?

Answer 220

Look for s/s of blood clots, because *estrogen* increases blood clotting.

Question 221

A newborn is experiencing cold stress. Which findings would the nurse expect to assess? Select all that apply. A. metabolic alkalosis B. jaundice C. hypoglycemia D. respiratory distress E. decreased oxygen needs

Answer 221

B, C, D ## Footnote Cold stress in the newborn can lead to the following problems if not reversed: depleted brown fat stores, increased oxygen needs, respiratory distress, increased glucose consumption leading to hypoglycemia, metabolic acidosis, jaundice, hypoxia, and decreased surfactant production.

Question 222

Which instructions would the nurse include when teaching a woman with pediculosis pubis? A. “Wash your bed linens in bleach and cold water.” B. “Your partner doesn't need treatment at this time.” C. “Remove the nits with a fine-toothed comb.” D. “Take the antibiotic until you feel better.”

Answer 222

The nurse should instruct the client to remove the nits from the hair using a fine-toothed comb. Permethrin cream and lindane shampoo are used as treatment, not antibiotics. Bedding and clothing should be washed in hot water to decontaminate it. Sexual partners should also be treated, as well as family members who live in close contact with the infected person.

Question 223

A dietitian is providing an in-service for the nurses on a medical-surgical unit. During the in-service, she informs the group that there are six classes of nutrients, and three supply the body with energy. What are the three sources of energy?

Answer 223

Of the six classes of nutrients, three supply energy (carbohydrates, protein, and lipids), and three are needed to regulate body processes (vitamins, minerals, and water).

Question 224

Which of the following is most likely to negatively affect a client's adherence to a health care regimen. A. The client is very busy with sports and actvities. B. The client lives in a senior living complex. C. The client states he is not motivated to change. D. The client's wife is overinvolved.

Answer 224

C

Question 225

Assessment of a child leads the nurse to suspect viral conjunctivitis based on what finding? A. Mild pain B. Photophobia C. Itching D. Watery discharge

Answer 225

Viral conjunctivitis is characterized by lymphadenopathy, photophobia, and tearing. Mild pain is associated with bacterial conjunctivitis. Itching and watery discharge are associated with allergic conjunctivitis.

Question 226

What does *fundus* refer to, and how do we use it in postpartum women

Answer 226

Fundus - Refers to the *top* of something, as in *uteral fundus height*

Question 227

When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be: More or less than a vaginal birth?

Answer 227

Less ## Footnote Response Feedback: Women who have had cesarean births tend to have less flow because the uterine debris is removed manually along with delivery of the placenta.

Question 228

A woman's amniotic fluid is noted to be cloudy. The nurse interprets this finding as: A. transient fetal hypoxia. B. possible infection. C. meconium passage. D. normal.

Answer 228

Amniotic fluid should be clear when the membranes rupture, either spontaneously or artificially through an amniotomy (a disposable plastic hook [Amnihook] is used to perforate the amniotic sac). Cloudy or foul-smelling amniotic fluid indicates infection. Green fluid may indicate that the fetus has passed meconium secondary to transient hypoxia, prolonged pregnancy, cord compression, intrauterine growth restriction, maternal hypertension, diabetes, or chorioamnionitis; however, it is considered a normal occurrence if the fetus is in a breech presentation.

Question 229

When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats/minute, and a respiratory rate of 60 breaths/minute. The nurse would identify which area as the highest priority?

Answer 229

The newborn's heart rate is slightly below the accepted range of 120 to 160 beats/minute; the respiratory rate is at the high end of the accepted range of 30 to 60 breaths per minute. However, the newborn's temperature is significantly below the accepted range of 97.7 to 99.7 degrees F. Therefore, the priority problem area is hypothermia.

Question 230

A nurse is caring for a client who is in the remission state of leukemia. The client expresses anxiety about the recurrence of leukemia. The client feels depressed when thinking about the outcome of leukemia. Which aspect of health is the client talking about? A. Social health B. Physical health C. Emotional health D. Spiritual health

Answer 230

Anxiety and depression are components of emotional health. The client is not feeling emotionally well because of worry about the disease outcomes. Currently the client is in remission and thus is physically healthy. The client does not mention anything about social interactions and spiritual health.

Question 231

The nurse is caring for a hospitalized 13-year-old girl, who is questioning everything the medical staff is doing and is resistant to treatment. How should the nurse respond? A. “Let's work together to plan your day along with your treatments.” B. “Please don't make me call your parents about this.” C. “The sooner you cooperate, the sooner you are going to leave.” D. “If you are more cooperative, perhaps we can arrange a visit from friends.”

Answer 231

Collaborating with the adolescent will provide the teen with increased control. The nurse should work with the teen to provide a mutually agreeable schedule that allows for the teen's preferences while incorporating the required nursing care. Threatening to call the parents will most likely promote further resistance. The nurse should try to immediately engage the girl, rather than making the nurse's cooperation conditional upon the girl's cooperation. Telling the girl that the sooner she cooperates, the sooner she will leave is inappropriate. The nurse is incorrectly implying that her behavior, rather than her medical needs, is going to determine when she will be discharged from the hospital.

Question 232

Which finding would the nurse expect to find in a client with endometriosis? A. hot flashes B. fluid retention C. dyspareunia D. fever

Answer 232

The client with endometriosis is often asymptomatic, but clinical manifestations include pain before and during menstrual periods (dyspareunia), pain during or after sexual intercourse, infertility, depression, fatigue, painful bowel movements, chronic pelvic pain, hypermenorrhea, pelvic adhesions, irregular and more frequent menses, and premenstrual spotting. Hot flashes may be associated with premenstrual syndrome or menopause. Fluid retention is associated with premenstrual syndrome. Fever would suggest an infection.

Question 233

A client has not received any medication during her labor. She is having frequent contractions every 1 to 2 minutes and has become irritable with her coach and no longer will allow the nurse to palpate her fundus during contractions. Her cervix is 8 cm dilated and 90% effaced. The nurse interprets these findings as indicating: A. active phase of the first stage of labor. B. pelvic phase of the second stage of labor. C. transition phase of the first stage of labor. D. latent phase of the first stage of labor.

Answer 233

The transition phase is characterized by cervical dilation of 8 to 10 cm, effacement of 80% to 100%, contractions that are strong, painful, and frequent (every 1 to 2 minutes) and last 60 to 90 seconds, and irritability, apprehension, and feelings of loss of control. The latent phase is characterized by mild contractions every 5 to 10 minutes, cervical dilation of 0 to 3 cm and effacement of 0% to 40%, and excitement and frequent talking by the mother. The active phase is characterized by moderate to strong contractions every 2 to 5 minutes, cervical dilation of 4 to 7 cm and effacement of 40% to 80%, with the mother becoming intense and inwardly focused. The pelvic phase of the second stage of labor is characterized by complete cervical dilation and effacement, with strong contractions every 2 to 3 minutes; the mother focuses on pushing.

Question 234

Which of the following people has the greatest risk for accidental injury? A. An athlete who exercises on a regular basis B. An older adult who walks two miles a day C. An infant just learning to crawl D. A worker who operates industrial machines

Answer 234

Certain occupations, lifestyles, and environments place people in more hazardous situations. A worker who operates industrial machines is at greater risk for accidental injury as well as for hearing loss.