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2. The nurse teaches a pregnant woman about the characteristics of true labor contractions. The nurse evaluates the womans understanding of the instructions when she states, True labor contractions will:

a. Subside when I walk around.
b. Cause discomfort over the top of my uterus.
c. Continue and get stronger even if I relax and take a shower.
d. Remain irregular but become stronger.


True labor contractions occur regularly, becoming stronger, lasting longer, and occurring closer together. They may become intense during walking and continue despite comfort measures. Typically true labor contractions are felt in the lower back, radiating to the lower portion of the abdomen. During false labor, contractions tend to be irregular and felt in the abdomen above the navel. Typically the contractions often stop with walking or a change of position.


A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurses best response is:

a. Dont worry about it. Youll do fine.
b. Its normal to be anxious about labor. Lets discuss what makes you afraid.
c. Labor is scary to think about, but the actual experience isnt.
d. You can have an epidural. You wont feel anything.


Its normal to be anxious about labor. Lets discuss what makes you afraid allows the woman to share her concerns with the nurse and is a therapeutic communication tool. Dont worry about it. Youll do fine negates the womans fears and is not therapeutic. Labor is scary to think about, but the actual experience isnt negates the womans fears and offers a false sense of security. It is not true that every woman may have an epidural. A number of criteria must be met for use of an epidural. Furthermore, many women still experience the feeling of pressure with an epidural.


11. The nurse knows that the second stage of labor, the descent phase, has begun when:

a. The amniotic membranes rupture.
b. The cervix cannot be felt during a vaginal examination.
c. The woman experiences a strong urge to bear down.
d. The presenting part is below the ischial spines.


During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Rupture of membranes has no significance in determining the stage of labor. The second stage of labor begins with full cervical dilation. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5-cm dilation.


The nurse instructs a client on the steps needed to obtain a peak expiratory flow rate. In which order should these steps occur?
1. Take as deep a breath as possible.
2. Stand up (unless you have a physical disability).
3. Place the meter in your mouth, and close your lips around the mouthpiece.
4. Make sure the device reads zero or is at base level.
5. Blow out as hard and as fast as possible for 1 to 2 seconds.
6. Write down the value obtained.
7. Repeat the process two additional times, and record the highest number in your chart.
a. 4, 2, 1, 3, 5, 6, 7
b. 3, 4, 1, 2, 5, 7, 6
c. 2, 1, 3, 4, 5, 6, 7
d. 1, 3, 2, 5, 6, 7, 4

The proper order for obtaining a peak expiratory flow rate is as follows. Make sure the device reads zero or is at base level. The client should stand up (unless he or she has a physical disability). The client should take as deep a breath as possible, place the meter in the mouth, and close the lips around the mouthpiece. The client should blow out as hard and as fast as possible for 1 to 2 seconds. The value obtained should be written down. The process should be repeated two more times, and the highest of the three numbers should be recorded in the clients chart.


A nurse is conducting discharge teaching to parents about the care of their infant after cardiac surgery. The nurse instructs the parents to notify the physician if what conditions occur (Select all that apply)?

a. Respiratory rate of 36 at rest
b. Appetite slowly increasing
c. Temperature above 37.7 C (100 F)
d. New, frequent coughing
e. Turning blue or bluer than normal

ANS: C, D, E

The parents should be instructed to notify the physician after their infants cardiac surgery for a temperature above 37.7 C (100 F); new, frequent coughing; and any episodes of the infant turning blue or bluer than normal. A respiratory rate of 36 at rest for an infant is within normal expectations, and it is expected that the appetite will increase slowly.


1. A new mother asks the nurse when the soft spot on her sons head will go away. The nurses answer is based on the knowledge that the anterior fontanel closes after birth by _____ months.

a. 2
b. 8
c. 12
d. 18


The larger of the two fontanels, the anterior fontanel, closes by 18 months after birth.


The nurse provides teaching for a postpartal woman who will take bisacodyl tablets to help with constipation. What information will the nurse include when teaching this patient about this medication?
a. Crush the tablet if it is difficult to swallow.
b. Store this medication in a cool, dry place.
c. Take the tablet with a carbonated beverage.
d. Take with milk if gastrointestinal upset occurs.

Bisacodyl tablets should be stored in a cool, dry place. They should not be crushed. It is not necessary to give with a carbonated beverage. Bisacodyl tablets should not be taken within 1 to 2 hours of milk or antacid.


. A child with cystic fibrosis (CF) receives aerosolized bronchodilator medication. When should this medication be administered?

a. Before chest physiotherapy (CPT)
b. After CPT
c. Before receiving 100% oxygen
d. After receiving 100% oxygen


Bronchodilators should be given before CPT to open bronchi and make expectoration easier. Aerosolized bronchodilator medications are not helpful when used after CPT. Oxygen administration is necessary only in acute episodes with caution because of chronic carbon dioxide retention.


A school-age child is admitted in vaso-occlusive sickle cell crisis. The childs care should include:

a. Correction of acidosis.
b. Adequate hydration and pain management.
c. Pain management and administration of heparin.
d. Adequate oxygenation and replacement of factor VIII.


The management of crises includes adequate hydration, minimizing energy expenditures, pain management, electrolyte replacement, and blood component therapy if indicated. The acidosis will be corrected as the crisis is treated. Heparin and factor VIII are not indicated in the treatment of vaso-occlusive sickle cell crisis. Oxygen may prevent further sickling, but it is not effective in reversing sickling because it cannot reach the clogged blood vessels.


A common, serious complication of rheumatic fever is:

a. Seizures.
b. Cardiac arrhythmias
c. Pulmonary hypertension.
d. Cardiac valve damage


Cardiac valve damage is the most significant complication of rheumatic fever. Seizures, cardiac arrhythmias, and pulmonary hypertension are not common complications of rheumatic fever.


A school-age child with leukemia experienced severe nausea and vomiting when receiving chemotherapy for the first time. The most appropriate nursing action to prevent or minimize these reactions with subsequent treatments is to:

a. Encourage drinking large amounts of favorite fluids.
b. Encourage child to take nothing by mouth (remain NPO) until nausea and vomiting subside.
c. Administer an antiemetic before chemotherapy begins.
d. Administer an antiemetic as soon as child has nausea.


The most beneficial regimen to minimize nausea and vomiting associated with chemotherapy is to administer the antiemetic before the chemotherapy is begun. The goal is to prevent anticipatory symptoms. Drinking fluids will add to the discomfort of the nausea and vomiting. Encouraging the child to remain NPO will help with this episode, but the child will have the discomfort and be at risk for dehydration. Administering an antiemetic after the child has nausea does not avoid anticipatory nausea.


A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. Which action should the nurse take next?
a. Collect the nasal drainage on a piece of filter paper.
b. Encourage the client to blow his or her nose.
c. Perform a test focused on a neurologic examination.
d. Palpate the nose, face, and neck.

The client with nasal drainage after facial trauma could have a skull fracture that has resulted in leakage of cerebrospinal fluid (CSF). CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper. The other actions would be appropriate but are not as high a priority as assessing for CSF. A CSF leak would increase the clients risk for infection.


A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60pack-year smoking history. Which action is most important for the nurse to take when interviewing this client?
a. Tell the client that he needs to quit smoking to stop further cancer development.
b. Encourage the client to be completely honest about both tobacco and marijuana use.
c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.
d. Avoid giving the client false hope regarding cancer treatment and prognosis.

Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and other controlled substances. Because the client may have guilt or denial about this habit, assume a nonjudgmental attitude during the interview. This will encourage the client to be honest about the exposure. Ask the client whether any of these substances are used now or were used in the past. Assess whether the client has passive exposure to smoke in the home or workplace. If the client smokes, ask for how long, how many packs per day, and whether he or she has quit smoking (and how long ago). Document the smoking history in pack-years (number of packs smoked daily multiplied by the number of years the client has smoked). Quitting smoking may not stop further cancer development. This statement would be giving the client false hope, which should be avoided, but is not as important as maintaining a nonjudgmental attitude.


A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next?
a. Administer an albuterol treatment.
b. Notify the Rapid Response Team.
c. Assess the clients peripheral pulses.
d. Obtain blood and sputum cultures.

Cyanosis unresponsive to oxygen therapy is a manifestation of methemoglobinemia, which is an adverse effect of benzocaine spray. Death can occur if the level of methemoglobin rises and cyanosis occurs. The nurse should notify the Rapid Response Team to provide advanced nursing care. An albuterol treatment would not address the clients oxygenation problem. Assessment of pulses and cultures will not provide data necessary to treat this client.


23. The primary difference between the labor of a nullipara and that of a multipara is the:

a. Amount of cervical dilation.
b. Total duration of labor
c. Level of pain experienced.
d. Sequence of labor mechanisms.


In a first-time pregnancy, descent is usually slow but steady; in subsequent pregnancies, descent is more rapid, resulting in a shorter duration of labor. Cervical dilation is the same for all labors. Level of pain is individual to the woman, not to the number of labors she has experienced. The sequence of labor mechanisms is the same with all labors.


15. When assessing a multiparous woman who has just given birth to an 8-pound boy, the nurse notes that the womans fundus is firm and has become globular in shape. A gush of dark red blood comes from her vagina. The nurse concludes that:

a. The placenta has separated.
b. A cervical tear occurred during the birth.
c. The woman is beginning to hemorrhage.
d. Clots have formed in the upper uterine segment.


Placental separation is indicated by a firmly contracting uterus, a change in the uterus from a discoid to a globular ovoid shape, a sudden gush of dark red blood from the introitus, an apparent lengthening of the umbilical cord, and a finding of vaginal fullness. Cervical tears that do not extend to the vagina result in minimal blood loss. Signs of hemorrhage are a boggy uterus, bright red vaginal bleeding, alterations in vital signs, pallor, lightheadedness, restlessness, decreased urinary output, and alteration in the level of consciousness. If clots have formed in the upper uterine segment, the nurse would expect to find the uterus boggy and displaced to the side.


Which immunization should be given with caution to children infected with human immunodeficiency virus?

a. Influenza
b. Varicella
c. Pneumococcus
d. Inactivated poliovirus


The children should be carefully evaluated before giving live viral vaccines such as varicella, measles, mumps, and rubella. The child must be immunocompetent and not have contact with other severely immunocompromised individuals. Influenza, pneumococcus, and inactivated poliovirus are not live vaccines.


The parents of a child with cancer tell the nurse that a bone marrow transplant (BMT) may be necessary. What should the nurse recognize as important when discussing this with the family?

a. BMT should be done at time of diagnosis.
b. Parents and siblings of child have a 25% chance of being a suitable donor.
c. Finding a suitable donor involves matching antigens from the human leukocyte antigen (HLA) system.
d. If BMT fails, chemotherapy or radiotherapy must be continued.


The most successful BMTs come from suitable HLA-matched donors. The timing of a BMT depends on the disease process involved. It usually follows intensive high-dose chemotherapy and/or radiation therapy. Usually parents only share approximately 50% of the genetic material with their children. A one-in-four chance exists that two siblings will have two identical haplotypes and will be identically matched at the HLA loci. Discussing the continuation of chemotherapy or radiotherapy is not appropriate when planning the BMT. That decision will be made later.


A woman who is 2 months pregnant tells the nurse that she has never received the MMR vaccine and has not had these diseases. She has a 3-year-old and a 5-year-old child who have not been immunized. The nurse will counsel the patient to perform which action?
a. Delay obtaining the vaccines for her children and herself until after her baby is born.
b. Have her children vaccinated now and obtain the vaccine for herself after the baby is born.
c. Obtain the MMR vaccine for her children and herself when she is in her third trimester of pregnancy.
d. Obtain the MMR vaccine for her children and herself within the next few weeks.

Pregnant women should not receive MMR vaccine because it is a live virus and there is risk to the fetus. Her children should be vaccinated so they do not contract rubella and pass it to her.


When caring for the child with Kawasaki disease, the nurse should understand that:

a. The childs fever is usually responsive to antibiotics within 48 hours.
b. The principal area of involvement is the joints.
c. Aspirin is contraindicated.
d. Therapeutic management includes administration of gamma globulin and aspirin.


High-dose intravenous gamma globulin and aspirin therapy are indicated to reduce the incidence of coronary artery abnormalities when given within the first 10 days of the illness. The fever of Kawasaki disease is unresponsive to antibiotics and antipyretics. Involvement of mucous membranes and conjunctiva, changes in the extremities, and cardiac involvement are seen.


A nurse auscultates a clients lung fields. Which pathophysiologic process should the nurse associate with this breath sound?
(Click the media button to hear the audio clip.)
a. Inflammation of the pleura
b. Constriction of the bronchioles
c. Upper airway obstruction
d. Pulmonary vascular edema

A pleural friction rub can be heard when the pleura is inflamed and rubbing against the lung wall. The other pathophysiologic processes would not cause a pleural friction rub. Constriction of the bronchioles may be heard as a wheeze, upper airway obstruction may be heard as stridor, and pulmonary vascular edema may be heard as crackles.


20. In order to care for obstetric patients adequately, the nurse understands that labor contractions facilitate cervical dilation by:

a. Contracting the lower uterine segment.
b. Enlarging the internal size of the uterus.
c. Promoting blood flow to the cervix.
d. Pulling the cervix over the fetus and amniotic sac.


Effective uterine contractions pull the cervix upward at the same time that the fetus and amniotic sac are pushed downward. The contractions are stronger at the fundus. The internal size becomes smaller with the contractions; this helps to push the fetus down. Blood flow decreases to the uterus during a contraction.


The nurse is conducting discharge teaching about signs and symptoms of heart failure to parents of an infant with a repaired tetralogy of Fallot. Which signs and symptoms should the nurse include (Select all that apply)?

a. Warm flushed extremities
b. Weight loss
c. Decreased urinary output
d. Sweating (inappropriate)
e. Fatigue

ANS: C, D, E

The signs and symptoms of heart failure include decreased urinary output, sweating, and fatigue. Other signs include pale, cool extremities, not warm and flushed, and weight gain, not weight loss.


The nurse instructs a client on how to correctly use an inhaler with a spacer. In which order should these steps occur?
1. Press down firmly on the canister to release one dose of medication.
2. Breathe in slowly and deeply.
3. Shake the whole unit vigorously three or four times.
4. Insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer.
5. Place the mouthpiece into your mouth, over the tongue, and seal your lips tightly around the mouthpiece.
6. Remove the mouthpiece from your mouth, keep your lips closed, and hold your breath for at least 10 seconds.
a. 2, 3, 4, 5, 6, 1
b. 3, 4, 5, 1, 6, 2
c. 4, 3, 5, 1, 2, 6
d. 5, 3, 6, 1, 2, 4

The proper order for correctly using an inhaler with a spacer is as follows. Insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer. Shake the whole unit vigorously three or four times. Place the mouthpiece into the mouth, over the tongue, and seal the lips tightly around it. Press down firmly on the canister of the inhaler to release one dose of medication into the spacer. Breathe in slowly and deeply. Remove the mouthpiece from the mouth, and, keeping the lips closed, hold the breath for at least 10 seconds. Then breathe out slowly. Wait at least 1 minute between puffs.


. A patient is brought to the emergency department and reports having taken a lot of acetaminophen extra-strength tablets 16 hours prior. The nurse will expect the provider to order
a. acetylcysteine (Mucomyst).
b. dornase alfa (Pulmozyme).
c. gastric lavage.
d. renal enzyme tests.

Acetylcysteine is used as an antidote for acetaminophen overdose if given within 12 to 24 hours of ingestion. Dornase alfa is used to treat cystic fibrosis. Gastric lavage is no longer used as treatment. Liver enzyme tests are indicated since acetaminophen is hepatotoxic.


10. With regard to factors that affect how the fetus moves through the birth canal, nurses should be aware that:

a. The fetal attitude describes the angle at which the fetus exits the uterus.
b. Of the two primary fetal lies, the horizontal lie is that in which the long axis of the fetus is parallel to the long axis of the mother.
c. The normal attitude of the fetus is called general flexion.
d. The transverse lie is preferred for vaginal birth.


The normal attitude of the fetus is general flexion. The fetal attitude is the relation of fetal body parts to one another. The horizontal lie is perpendicular to the mother; in the longitudinal (or vertical) lie the long axes of the fetus and the mother are parallel. Vaginal birth cannot occur if the fetus stays in a transverse lie.


A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process should the nurse correlate with this clients history and clinical manifestations?
a. Increased pulmonary pressure creating a higher workload on the right side of the heart
b. Exposure to irritants resulting in increased inflammation of the bronchi and bronchioles
c. Increased number and size of mucus glands producing large amounts of thick mucus
d. Left ventricular hypertrophy creating a decrease in cardiac output

Smoking increases pulmonary hypertension, resulting in cor pulmonale, or right-sided heart failure. Increased pressures in the lungs make it more difficult for blood to flow through the lungs. Blood backs up into the right side of the heart and then into the peripheral venous system, creating distended neck veins and dependent edema. Inflammation in bronchi and bronchioles creates an airway obstruction which manifests as wheezes. Thick mucus in the lungs has no impact on distended neck veins and edema. Left ventricular hypertrophy is associated with left heart failure and is not caused by a 40-year smoking history.


5. When planning care for a laboring woman whose membranes have ruptured, the nurse recognizes that the womans risk for _________________________ has increased.

a. Intrauterine infection
b. Hemorrhage
c. Precipitous labor
d. Supine hypotension


When the membranes rupture, microorganisms from the vagina can ascend into the amniotic sac and cause chorioamnionitis and placentitis. Rupture of membranes (ROM) is not associated with fetal or maternal bleeding. Although ROM may increase the intensity of contractions and facilitate active labor, it does not result in precipitous labor. ROM has no correlation with supine hypotension.


A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed?
a. Applying suction while inserting the catheter
b. Preoxygenating the client prior to suctioning
c. Suctioning for a total of three times if needed
d. Suctioning for only 10 to 15 seconds each time

Suction should only be applied while withdrawing the catheter. The other actions are appropriate.


A client is receiving oxygen at 4 liters per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)?
a. Apply water-soluble ointment to nares and lips.
b. Periodically turn the oxygen down or off.
c. Remove the tubing from the clients nose.
d. Turn the client every 2 hours or as needed.

Oxygen can be drying, so the UAP can apply water-soluble lubricant to the clients lips and nares. The UAP should not adjust the oxygen flow rate or remove the tubing. Turning the client is not related to comfort measures for oxygen.