OB final Flashcards
(194 cards)
1
Q
A perinatal nurse is interviewing a group of women in the Community about heath care services. Assessment of these services reveals that many of them are being underutilized. Which statement from the women would assist the nurse in identifying potential reasons For this underutilization? Select 4 answers that apply.
A. “The services are hard to get to by public transportation.”
B. “The clinic is only open during the morning hours.”
C. “The staff seems to look down on us when we do come in.”
D. “There are staff there that can speak our language.”
E. “You need insurance to go to the clinic.”
A
A. “The services are hard to get to by public transportation.”
B. “The clinic is only open during the morning hours.”
C. “The staff seems to look down on us when we do come in.”
E. “You need insurance to go to the clinic.”
2
Q
The school public health nurse is teaching a high school class on Sexually transmitted infections
(STIs). The nurse would include what information in the presentation? Select all that apply.
A
1) Fifteen to twenty-four year olds represent almost half of all cases of new STI’s.
2) Two in five sexually active teen girls have an STI.
3) Teens who are sexually active experience high rates of STI’s.
4) Adolescent males make up more than four-fifths of HIV diagnoses.
3
Q
A client with a 28- day cycle reports that she ovulated on May 10th. When would the nurse expect to see the client’s next menses to begin?
A
May 24. Period begins 14 days after ovulation.
4
Q
A nursing group is examining their hospitals maternal outcomes for the previous 5 years. Which identified factors have contributed to the decline in the maternal mortality rate?
Select 4 answers that apply.
A
1) Closer monitoring for complications associated with hypertension of pregnancy.
2) Increased participation of women in prenatal care.
3) Use of ultrasound to detect disorders
4) Better management of hemorrhage and infection.
5
Q
What is the most important consideration for the nurse when communicating with an adolescent about sexually transmitted infections (STIs)?
A
Use communication techniques that are directed and nonjudgemental.
6
Q
The nurse is providing care to a pregnant woman who speaks a different language from that of the nurse. When communicating with this client, the nurse demonstrates best practice by which action?
A
Arranging for an interpreter to be present during any communication.
7
Q
After discussing various methods of contraception with a client and her partner, the nurse determines that the teaching was successful when then identify which contraceptive method as providing protection against sexually transmitted infections?
A
Condoms
8
Q
The nurse would recommend the use of which supplement as a primary prevention strategy to prevent neural tube defects in the future offspring of pregnant women?
A
Folic acid
9
Q
When integrating the principles of family centered care into the birthing process, the nurse wound base care upon which belief?
A
Birth results in changes in relationships.
10
Q
A woman using the cervical mucus ovulation method of fertility awareness reports that her cervical mucus looks like egg whites. The nurse interprets this as which Kind of mucus?
A
Spinnbarkeit mucus
11
Q
When developing a teaching plan for a communiy group about HIV infection, which group would the nurse identify being most vulnerable for HIV infection?
A
Heterosexual women.
12
Q
A nurse is conducting an orientation program for a group of newly hired nurses. As part of the program, the nurse is reviewing the issue of informed consent. The nurse determines that the teaching was effective when the group identifies which situation as a violation of informed consent?
A
Performing a procedure on a 15 year old without parental consent.
13
Q
Assessment of a female client reveals a thick, white vaginal discharge. The client also reports intense itching and dyspareunia. Based on these findings, the nurse would suspect that the client has :
A
Candidiasis.
14
Q
When obtaining the health history from an adolescent client, which factor would lead the nurse to suspect that the client has an increased risk for sexually transmitted infections (STI’s)?
A
Five different sexual partners.
15
Q
A nurse is preparing a class for a group of young adult women about emergency contraceptives
(EC’s) . What Information would the nurse need to stress to the group? Select all that apply.
A
1) EC’s provide little protection for future pregnancies.
2) EC’s are birth control pills in higher, more frequent doses.
3) EC’s are not to be used in place of regular birth control.
16
Q
The nurse is assessing a 13-year-old girl. Which event would the nurse expect to have occurred first?
A
Development of breast buds
17
Q
Which statement made by a nursing student would best indicate that her education on family-centered care was fully understood?
A
“Childbirth affects the entire family and relationships will change.”
18
Q
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?
A. Pulmonary vascular resistance (PVR) is decreased as lungs begin to function.
B. Breath sounds will have rhonchi for at least the first day of life as fluid is absorbed.
C. Heart rate remains elevated after the first few moments of birth.
D. The cardiac murmur heard at birth disappears by 48 hours of age.
A
A. Pulmonary vascular resistance (PVR) is decreased as lungs begin to function.
19
Q
The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism?
A. convection
B. radiation
C. conduction
D. evaporation
A
C. conduction
20
Q
A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for a postpartum infection based on which information? Select all that apply.
A. History of diabetes
B. labor of 12 hours
C. placenta requiring manual extraction
D. rupture of membranes for 16 hours
E. hemoglobin level 10 mg/dL
A
A. history of diabetes
C. placenta requiring manual extraction
E. hemoglobin 10 mg/dL
21
Q
A postpartum client is experiencing subinvolution. When reviewing the woman’s labor and birth history, which factor would the nurse identify as being a significant contributor to this condition?
A. short duration of labor
B. use of anesthetics
C. breastfeeding
D. early ambulation
A
B. use of anesthetics
22
Q
When caring for a mother who has had a cesarean birth, the nurse would expect the client’s lochia to be:
A. about the same as after a vaginal birth.
B. saturated with clots and mucus.
C. less than after a vaginal birth
D. greater than after a vaginal birth.
A
C. less than after a vaginal birth
23
Q
A nurse is developing a teaching plan about sexuality and contraception for a postpartum woman who is breastfeeding. Which information would the nurse most likely include? Select all that apply.
A. resumption of sexual intercourse about two
weeks after birth
B. possible experience of fluctuations in sexual interest
C. possibility of increased beast sensitivity during sexual activity
D. use of water-based lubricant to ease vaginal discomfort
E. use of combined hormonal contraceptives for the first three weeks
A
B. possible experience of fluctuations in sexual interest
C. possibility of increased breast sensitivity during sexual activity
D. use of water-based lubricant to ease vaginal discomfort
24
Q
The nurse administers vitamin K intramuscularly to the newborn based on which rationale?
A. Enhance bilirubin breakdown.
B. promote blood clotting
C. Increase erythropoiesis.
D. Stop Rh sensitization.
A
B. promote blood clotting
25
A nurse is preparing a couple and their newborn for discharge. Which instructions would be most appropriate for the nurse to include in discharge teaching?
A. demonstrating comfort measures to a crying infant
B. allowing the infant to cry for at least an hour before picking him or her up
C. encouraging daily outings to the shopping mall with the newborn
D. introducing solid foods immediately to increase sleep cycle
A. demonstrating comfort measures to a quiet crying infant
26
A postpartum woman who has experienced diastasis recti asks the nurse about what to expect related to this condition.
Which response by the nurse would be most appropriate?
A. "Exercise will help to improve the muscles."
B. "You'll notice that your shoe size will increase."
C. "Expect the color to lighten somewhat."
D. "You'll notice that this will fade to silvery lines."
A. "Exercise will help to improve the muscles."
27
A nurse is reviewing information about maternal and paternal adaptations to the birth of a newborn. The nurse observes the parents interacting with their newborn physically and emotionally. The nurse documents this as:
A. lactation
B. engrossment
C. attachment.
D. puerperium.
C. Attatchment
28
A client who is breastfeeding her newborn tells the nurse, " I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate?
A. "Let me check your vaginal discharge just to make sure everything is fine."
B. "The baby's sucking releases a hormone that causes the uterus to contract."
C. "Your body is responding to the events of labor, just like after a tough workout."
D. "Your uterus is still shrinking in size; that's why you're feeling this pain."
B. "The baby's sucking releases a hormone that causes the uterus to contract."
29
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?
A. 2 to 4 ounces
B. 6 to 8 ounces
C. 4 to 6 ounces
D. 1 to 2 ounces
A. 2 to 4 ounces
30
During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as:
A. stork bites.
B. birth trauma.
C. Mongolian spots
D. milia.
C. Mongolian spots
31
When reviewing the medical record of a postpartum client, the nurse notes that the client has experienced a third-degree laceration. The nurse understands that the laceration extends to which area?
A. through the perineal muscles
B. through the anterior rectal wall
C. through the anal sphincter muscle
D. superficial structures above the muscle
C. through the anal sphincter muscle
32
A postpartum client has a fourth-degree perineal laceration. The nurse would expect which medication to be prescribed?
A. methylergonovine
B. bromocriptine
C. docusate
D. ferrous sulfate
C. docusate
33
A postpartum client comes to the clinic for her 6-week postpartum checkup. When assessing the client's cervix, the nurse would expect the external cervical os to appear:
A. circular.
B. slit-like
C. triangular.
D. shapeless.
B. slit-like
34
Which factor in a client's history would alert the nurse to an increased risk for postpartum hemorrhage?
A. size of placenta, small baby, operative birth
B. prematurity, infection, length of labor
C. uterine atony, placenta previa, operative procedures
D multiparity, age of mother, operative birth
C. uterine atony, placenta previa, operative procedures
35
Assessment of a postpartum client reveals a firm uterus with bright-red bleeding and a localized bluish bulging area just under the skin at the perineum. The women also reports significant pelvic pain and is experiencing problems with voiding. The nurse suspects what condition?
A. bladder distention
B. uterine atony
C. laceration
D. hematoma
D. hematoma
36
A nurse is making a home visit to a postpartum woman who gave birth to a healthy newborn 4 days ago. The woman's breasts are swollen, hard, and tender to the touch. The nurse documents this finding as:
A. engorgement
B. engrossment.
C. mastitis.
D. involution.
A. Engorgement
37
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?
A. increase in stool passage
B. overproduction of bilirubin
C. shift of water from extracellular space to intracellular space
D. insufficient calorie intake
D. insuficient calorie intake
38
A postpartum client who is bottle feeding her newborn asks,
"When should my period return?" Which response by the nurse would be most appropriate?
A. "It varies, but you can estimate it returning in about 7 to 9 weeks."
B. "You don't have to worry about that now. It'll be quite a while."
C. "You won't have to worry about it returning for at least 3 months.
D. "It's difficult to say, but it will probably return in about 2 to 3 weeks."
A. "It varies but you can estimate it returning in about 7 to 9 weeks."
39
A nurse is massaging a postpartum client's fundus and places the nondominant hand on the area above the symphysis pubis based on the understanding that this action:
A. aids in expressing accumulated clots.
B. prevents uterine muscle fatigue.
C. helps support the lower uterine segment
D. determines that the procedure is effective.
C. helps support the lower uterine segment
40
The nurse is assessing a postpartum client's lochia and finds that there is about a 4-inch stain on the perineal pad. The nurse documents this finding as which description?
A. light
b. large
C. moderate
D. scant
A. light
41
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?
A. "I'II take a sample and check it for possible bleeding."
B. "This is unusual, and I need to report this to your pediatrician. "
C. "This is meconium stool and is normal for a newborn."
D. "You probably took iron during your pregnancy and that is what causes this type of stool.
C. "This is meconium stool and is normal for a newborn."
42
A woman who gave birth 24 hours ago tells the nurse, "I've been urinating so much over the past several hours." Which response by the nurse would be most appropriate?
A. "Your body is undergoing many changes that cause your bladder to fill quickly."
B. "The anesthesia that you received is wearing off and your bladder is working again."
C. "Your uterus is not contracting as quickly as it should."
D. "You must have an infection, so let me get a urine specimen."
A. "Your body is undergoing many changes that cause your bladder to fill quickly."
43
When teaching new parents about the sensory capabilities of their newborn, which sense would the nurse identify as being the least mature?
A. taste
B. vision
C. touch
D. hearing
B. vision
44
A nurse is observing the interaction between a new father and his newborn. The nurse determines that engrossment has yet to occur based on which behavior?
A. identifies imperfections in the newborn's appearance
B. shows feelings of pride with the birth of the
newborn
C. is able to distinguish his newborn from others in the nursery
D. demonstrates pleasure when touching or holding the newborn
A. identifies imperfections in the newborn's appearance
45
The nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they.
A. have an abundant amount of subcutaneous fat all over.
B. are unable to shiver effectively to increase heat production.
C. lose more body heat when they sweat than adults.
D. have a smaller body surface compared to body mass.
B. are unable to shiver effectively to increase heat production.
46
A client who just gave birth to a healthy newborn required an episiotomy. Which action would the nurse implement immediately after birth to decrease the client's pain from the procedure?
A. encourage the women to void
B. offer a warm sitz bath
C. apply an ice pack to the site
D. offer warm blankets
C. apply an ice pack to the site
47
A nurse teaches a postpartum woman about her risk for thromboembolism. The nurse determines that additional teaching is required when the woman identifies which as a factor that increases her risk?
A. vessel damage
B. increase in red blood cell production
C. immobility
D. increase in clotting factors
B. increase in red blood cell production
48
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. 54 breaths per minute
B. 68 breaths per minute
C. 46 breaths per minute
D. 38 breaths per minute
B. 68 breaths per minute
49
When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes?
A. respiratory and cardiovascular
B. neurological and integumentary
C. urinary and hematologic
D. gastrointestinal and hepatic
A. respiratory and cardiovascular
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?
A. promotes uterine involution
B. alleviates perineal pain
C. improves pelvic floor tone
D. reduces lochia
C. improves pelvic floor tone
51
A pregnant woman is receiving misoprostol to ripen her cervix and induce labor. The nurse assesses the woman closely for which effect?
A. headache
B. uterine hyperstimulation
C. blurred vision
D. hypotension
B. uterine stimulation
52
The fetus of a nulliparous woman is in a shoulder presentation. The nurse would prepare the client for which type of birth?
A. forceps-assisted
B. vaginal
C. ceasarean
D. vacuum extraction
C. ceasarean
53
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 pattern?
A. early decelerations
B. late decelerations
C. prolonged decelerations
D. Variable decelerations
D. variable decelerations
54
When applying the ultrasound transducer for continuous external electronic fetal monitoring, the nurse would place the transducer at which location on the client's body to record the FHR?
A. between the umbilicus and the symphysis pubis
B. over the uterine funds where contractions are most intense
C. between the xiphoid process and umbilicus
D. above the umbilicus toward the right side of the diaphragm
A. between the umbilicus and the symphysis pubis
55
The nurse is providing care to several pregnant women who may be scheduled for labor induction. The nurse identifies the woman with which Bishop score as having the best chance for a successful induction and vaginal birth?
A. 7
B. 11
C. 5
D. 3
B. 11
56
A nurse is reading a journal article about cesarean births and the indications for them. Place the indications for cesarean birth below in the proper sequence from most frequent to least frequent. All options must be used:
-multiple gestation
-labor distocia
-abnormal fetal heart rate tracing
-suspected macrosomia
-fetal malpresentation
1). Labor distocia
2). Abnormal fetal heart rate tracing
3). fetal malpresentation
4). multiple gestation
5). suspected macrosomia
57
A nurse is performing Leopold maneuvers on a pregnant woman. The nurse determines which information with the first maneuver?
A. fetal presentation
B. Fetal attitude
C. Fetal position
D. Fetal flexion
A. fetal presentation
58
When assessing cervical effacement of a client in labor, the nurse assesses which characteristic?
A. degree of thinning
B. passage of the mucous plug
C. extent of opening to its widest diameter
D. fetal presenting part
A. degree of thinning
59
A woman is in the first stage of labor. The nurse would encourage her to assume which position to facilitate the progress of labor?
A. upright
B. knee-chest
C. supine
D. lithotomy
A. upright
60
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. 0
B. -2
C. +1
D. -1
A. 0
61
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 3 that apply.
A. pelvic outlet
B. pelvic floor muscles
C. cervix
D. mid pelvis
E. vagina
F. pelvic inlet
A. pelvic outlet
D. mid pelvis
F. pelvic inlet
62
A client has not received any medication during her labor. She is having frequent contractions about 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. perineal phase of the first stage of labor.
B. early phase of the third stage of labor.
C. late active phase of the first stage of labor.
D. latent phase of the first stage of labor.
c. late active phase of the first stage of labor
63
A nurse is providing care to a pregnant client in labor. Assessment of a fetus identifies the buttocks as the presenting part, with the legs extended upward. The nurse identifies this as which type of breech presentation?
A. footling
B. complete
C. full
D. frank
D. frank
64
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:
A. molding.
B. caput succedaneum.
C. cephalhematoma
D. microcephaly.
B. caput succeadaneum
65
A nurse is teaching a new mother about breastfeeding. The nurse determines that the teaching was successful when the woman identifies which hormone as responsible for milk let-down?
A. prolactin
B. oxytocin
C. progesterone
D. estrogen
B. oxytocin
66
A nurse is conducting an in-service presentation to a group of perinatal nurses about sexually transmitted infections and their effect on pregnancy. The nurse determines that the teaching was successful when the group identifies which infection as being responsible for ophthalmia neonatorum?
A. HPV
B. chlamydia
C. gonorrhea
D. syphilis
C. gonorrhea
67
A postpartum woman who developed deep vein thrombosis is being discharged on anticoagulant therapy. After teaching the woman about this treatment, the nurse determines that additional teaching is needed when the woman makes which statement?
A. "I need to avoid drinking any alcohol."
B. "I can take ibuprofen if I have any pain."
C. "I will call my health care provider if my stools are black and tarry."
D. "I will use a soft toothbrush to brush my teeth."
B. "I can take ibuprofen if I have any pain."
68
A pregnant woman comes to the clinic for her first evaluation. The woman is screened for hepatitis B (HBV) and tests positive. The nurse would anticipate administering which agent?
A. acylcovir
B. HBV vaccine
C. HBV immune globulin
D. valacyclovir
C. HBV immune globulin
69
Which assessment finding will alert the nurse to be on the lookout for possible placental abruption during labor?
A. gestational hypertension
B. low parity
C. gestational diabetes
D. macrosomia
A. gestational hypertension
70
A client comes to the clinic for an evaluation. The client is at 22 weeks' gestation. After reviewing a client's history, which factor would the nurse identify as placing her at risk for preeclampsia?
A. Her sister-in-law had gestational hypertension.
B. Client has a twin sister.
C. Her mother had preeclampsia during pregnancy.
D. This is the client's second pregnancy.
C. Her mother had preeclampsia during pregnancy
71
A nurse is assessing a pregnant woman with gestational hypertension. Which finding would lead the nurse to suspect that the client has developed severe preeclampsia?
A. mild facial edema
B. urine protein 300 mg/24 hours
C. blood pressure 150/96 mm Hg
D. hyperreflexia
D. hyperreflexia
72
After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position?
A. sitting
B. supine
C. knee-chest
D. side-lying
c. knee-chest
73
Assessment of a pregnant woman and her fetus reveals tachycardia and hypertension. There is also evidence suggesting vasoconstriction. The nurse would question the woman about use of which substance?
A. heroin
B. marijuana
c. alcohol
D. cocaine
D. cocaine
74
A nurse suspects that a pregnant client may be experiencing a placental abruption based on assessment of which finding? Select 3 that apply.
A. insidious onset
B. dark red vaginal bleeding
C. rigid uterus
D. absence of pain
E. absent fetal heart tones
B. dark red bleeding
C. rigid uterus
E. absent fetal heart tones
75
A woman who is 2 weeks postpartum calls the clinic and says, "My left breast hurts. After further assessment on the phone, the nurse suspects the woman has mastitis. In addition to pain, the nurse would question the woman about which symptom?
A. an ecchymotic area on the affected breast
B. an inverted nipple on the affected breast
C. no breast milk in the affected breast
D. hardening of an area in the affected breast
d. hardening of an area in the affected breast
76
It is determined that a client's blood Rh is negative and her partner's is Rh positive. To help prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time?
A. at 32 weeks' gestation and immediately before discharge
B. 24 hours before birth and 24 hours after birth
C. at 28 weeks' gestation and again within 72 hours after birth
D. in the first trimester and within 2 hours of birth
C. at 28 weeks' gestation and again within 72 hours after birth
77
A client with severe preeclampsia is receiving magnesium sulfate as part of the treatment plan. To ensure the client's safety, which compound would the nurse have readily available?
A. calcium carbonate
B. potassium chloride
C. calcium gluconate
D. ferrous sulfate
C. calcium gluconate
78
A pregnant woman is admitted with premature rupture of the membranes. The nurse is assessing the woman closely for possible infection. Which findings would lead the nurse to suspect that the woman is developing an infection? Select 3 that apply.
A. fetal bradycardia
B. decreased C-reactive protein levels
C. elevated maternal pulse rate
D. abdominal tenderness
E. cloudy malodorous fluid
C. elevated maternal pulse rate
D. abdominal tenderness
E. cloudy malodorous
79
A client with hyperemesis gravidarum is admitted to the facility after being cared for at home without success. What would the nurse expect to include in the client's plan of care?
A. clear liquid diet
B. nothing by mouth
C. administration of labetalol
D. total parenteral nutrition
B. nothing by mouth
80
A pregnant client with iron-deficiency anemia is prescribed an iron supplement. After teaching the woman about using the supplement, the nurse determines that more teaching is needed based on which client statement?
A. "I will need to avoid coffee and tea when I take this supplement."
B. "If I happen to miss a dose, I will take it as soon as I remember."
C. "Taking the iron supplement with food will help with the side effects."
D. "I will take the iron with milk instead of orange or grapefruit juice."
D. "I will take the iron with milk instead of orange or grapefruit juice."
81
A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority?
A. jaundice
B. infection
C. hemorrhage
D. edema
C. hemorrhage
82
A pregnant client at 24 weeks' gestation comes to the clinic for an evaluation. The client called the clinic earlier in the day stating that she had not felt the fetus moving since yesterday evening. Further assessment reveals absent fetal heart tones. Intrauterine fetal demise is suspected. The nurse would expect to prepare the client for which testing to confirm the suspicion?
A. Human chorionic gonadotropin (hCG) level
B. Triple marker screening
C. Amniocentesis
D. Ultrasound
D. Ultrasound
83
A nurse is reviewing a client's history and physical examination findings. Which information would the nurse identify as contributing to the client's risk for an ectopic pregnancy?
A. ovarian cyst 2 years ago
B. heavy, irregular menses
C. recurrent pelvic infections
D. use of oral contraceptives for 5 years
C. recurrent pelvic infections
84
A nurse is preparing a presentation for a group of young adult pregnant women about common infections and their effect on pregnancy. When describing the infections, which infection would the nurse include as the most common congenital and perinatal viral infection in the world?
A. cytomegalovirus
B. parvovirus B19
C. rubella
D. hepatitis B
A. cytomegalovirus
85
A client comes to the emergency department with moderate vaginal bleeding. She says, "I have had to change my pad about every 2 hours and it looks like I may have passed some tissue and clots." The woman reports that she is 9 weeks' pregnant. Further assessment reveals the following:
* Cervical dilation
* Strong abdominal cramping
* Low human chorionic gonadotropin (hCG) levels
* Ultrasound positive for products of conception
The nurse suspects that the woman is experiencing which type of spontaneous abortion?
A. Complete
B. Inevitable
C. Incomplete
D. Threatened
B. Inevitable
86
A multipara client develops thrombophlebitis after birth. Which assessment findings would lead the nurse to intervene immediately?
A. weakness, anorexia, change in level of consciousness, and coma
B. dyspnea, bradycardia, hypertension, and confusion
C. dyspnea, diaphoresis, hypotension, and chest pain
D. pallor, tachycardia, seizures, and jaundice
C. dyspnea, diaphoresis, hypotension, and chest pain
87
A client experienced prolonged labor with prolonged premature rupture of membranes. The nurse would be alert for which condition in the mother and the newborn?
A. hemorrhage
B. infection
C. hypovolemia
D. trauma
B. infection
88
After teaching a pregnant woman with iron deficiency anemia about nutrition, the nurse determines that the teaching was successful when the woman identifies which foods as being good sources of iron in her diet? Select 3 that apply.
A. white bread
B. meats
C. dried fruits
D. peanut butter
E. milk
B. meats
C. dried fruits
D. peanut butter
89
A nurse is taking a history on a woman who is at 20 weeks' gestation. The woman reports that she feels some heaviness in her thighs since yesterday. The nurse suspects that the woman may be experiencing preterm labor based on which additional assessment findings? Select all that apply.
A. constipation
B. dull low backache
C. occasional cramping
D. viscous vaginal discharge
E. dysuria
B. dull low backache
D. viscous vaginal discharge
E. dysuria
90
A neonate born to a mother who was abusing heroin is exhibiting signs and symptoms of withdrawal. Which signs would the nurse assess? Select all that apply.
A. low whimpering cry
B. tremors
C. lethargy
D. excessive sneezing
E. hypertonicity
F. overly vigorous sucking
B. tremors
D. excessive sneezing
E. hypertonicity
91
A nurse is conducting a review course on tocolytic therapy for perinatal nurses. After teaching the group, the nurse determines that the teaching was successful when they identify which drugs as being used for tocolysis? Select 3 that apply.
A. dinoprostone
B. magnesium sulfate
C. misoprostol
D. indomethacin
E. nifedipine
B. magnesium sulfate
D. indomethacin
E. nifedipine
92
A postpartum client is prescribed medication therapy as part of the treatment plan for postpartum hemorrhage. Which medication would the nurse expect to administer in this situation?
A. nifedipine
B. Magnesium sulfate
C. methylergonovine
D. Indomethacin
C. methylergonovine
93
A nurse is assessing a postpartum client who is at home. Which statement by the client would lead the nurse to suspect that the client may be developing postpartum depression?
A. "I just feel so overwhelmed and tired."
B. "It's strange, one minute I'm happy, the next I'm sad."
C. "I'm feeling so guilty and worthless lately."
D. "I keep hearing voices telling me to take my baby to the river."
D. "I keep hearing voices telling me to take my baby to the river."
94
A pregnant women is to undergo an invasive procedure to evaluate the status of her fetus. To ensure informed consent, which action would be priority responsibility of the nurse providing care to this women?
Asking relevant questions to determine the clients understanding
95
Which factors are causes of the high infant mortality rate? SATA
1) Low birth weight
2) sudden infant death syndrome
3) necrotizing enterocolitis
96
A nurse is preparing for a health promotion presentation for new mothers. Which topics would be appropriate for the nurse to include in the presentation? SATA
1) breast feeding encouragement
2) proper infant sleeping position
3) infants in smoke-free environments
97
A client asks the nurse about her potential risk factors for breast cancer. Which risk factors would be important for the nurse to include in the response? SATA
1) oral contraceptive use
2) irregularities in menstruation
3) obesity
98
A public heath nurse is preparing presentation for a parenting class with focus on childhood discipline. Which principles of childhood discipline would the nurse expect to emphasize? SATA
1) Discipline methods should ensure the preservation of the child’s self esteem
2) Positive reinforcement will increase desirable behaviors
3) Maintain a positive, supportive, nurturing parent-child relationship
99
After teaching a group of adolescent girls about female reproductive development, the nurse determines that teaching was successful when the girls state that menarche is defined as a woman’s first:
Menstrual period
100
A school nurse who is teaching a health course at the local high school is presenting information on human development and sexuality. When talking about the role of hormones in sexual development, which hormone does the nurse teach the class is the most important for developing and maintaining the female reproductive organs?
Estrogen
101
After teaching a group of pregnant women about breastfeeding, the nurse determines that the teaching was successful when the group identifies which hormone as being inhibited during pregnancy but is important for the production of breast milk after birth?
Prolactin
102
A nurse is preparing a presentation for a group of young adults about the sexual response cycle. Place the events in the sequence that they would occur. All options must be used.
- Excitement, Orgasm, Desire, Resolution, Plateau
1) Desire
2) Excitement
3) Plateau
4) Orgasm
5) Resolution
103
The nurse discusses various contraceptive methods with a client and her partner. Which method would the nurse explain as being available only by prescription?
Diaphragm
104
When developing a teaching plan for a couple who are considering contraception options, the nurse would include which statement?
The best contraceptive is one that you will use correctly and consistently
105
A nurse manager in a family planning clinic is conducting an in-service presentation for the nursing staff on contraception. After teaching the group about the different methods for contraception, the manager determines that the teaching was successful when the group identifies which contraceptive methods as mechanical barrier methods? SATA
-condom
-cervical cap
-cervical sponge
-diaphragm
106
Which finding would the nurse expect in a client with bacterial vaginosis?
Fish-like odor of discharge
107
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?
"There is no cure, but drug therapy helps to reduce symptoms and recurrences."
108
While obtaining a health history from a male adolescent during a well checkup, the nurse assesses his sexual behavior and risk for sexually transmitted infections. Based on the information, the nurse plans to teach the adolescent about using a condom. What statement would the nurse include in the teaching plan?
"Put the condom on before engaging in any genital contact."
109
A woman is diagnosed with gonorrhea. The client asks why she needs to take two medications. How should the nurse respond? SATA
1) The medicines are needed to kill the bacteria causing the infection
2) The medications help prevent the spread of the bacteria to your female organs
3) The medications will stop the bacteria before it can cause complications
110
To assist the woman in regaining control of the urinary sphincter after bladder surgery, the nurse should teach the client to perform which action?
Perform Kegel exercises daily
111
The nurse is presenting a class at a local community health center on violence during pregnancy. Which possible complications would the nurse include?
Chorioamnionitis
112
When describing an episode of intimate partner violence, the victim reports attempting to calm the partner down to keep things from escalating. The nurse interprets this behavior as reflecting which phase of the cycle of violence?
Tension-building phase
113
A nurse is listening to a client who is a victim of intimate partner violence. The client is describing how events would unfold with the partner. The nurse interprets the client’s statements and identifies which action as characteristic of second phase of the cycle of violence?
The physical battery is abrupt and unpredictable
114
A pregnant woman undergoes a triple screening at 16 to 18 weeks’ gestation. What would the nurse suspect if the woman’s estriol and alpha-fetoprotein levels are decreased with high hCG levels?
Down-syndrome
115
During a prenatal visit, a pregnant woman says, “I know that amniotic fluid is important, but can you tell me more about it?” When describing amniotic fluid to a pregnant woman, which description would the nurse most likely include?
"This fluid acts as a cushion to protect your baby from injury."
116
Assessment of a pregnant woman reveals oligohydramnios. The nurse would be alert for the development of which condition?
Placental insufficiency
117
Which mother is in the fetal stage of development?
A pregnant mother who is at thirty weeks gestation
118
Which characteristics about amniotic fluid would alert the prenatal nurse to further investigate? SATA
1) oligohydramnios is noted on assessment
2) polyhydramnios is noted on assessment
3) The client has approximately 2 L of amniotic fluid
119
A client’s recent prenatal ultrasound assessment reveals a normal placenta. Which outcomes would the nurse expect? SATA
1) The hormones made by the placenta support fetal growth
2) The placenta protects the fetus from immune attack created by the mother
3) The placenta produced hormones that ready the fetus for extrauterine life
120
In order for conception to take place, it is most common for a woman to get pregnant:
Two weeks after her normal menstrual period
121
The nurse is assessing a 12-hour-old newborn and hears a heart murmur. What initial action should the nurse take?
Document the finding as normal for this age
122
A woman visits the prenatal clinic and is noted to have oligohydramnios. The client asks, “Why is this fluid important anyway?” Which statement would be included in the nurse’s response? SATA
1) "Amniotic fluid helps maintain your baby’s body temperature.”
2) "Too little amniotic fluid is linked with placental problems.”
3) "It acts like a cushion protecting your baby from trauma that may occur.”
123
During a vaginal exam, the nurse notes that the lower uterine segment is softened. The nurse documents this finding as:
Hegar sign
124
In a client’s seventh month of pregnancy, she reports feeling “dizzy, like I’m going to pass out, when I like down flat on my back.” The nurse explains that this is due to:
Pressure of the gravid uterus on the vena cava
125
When teaching a pregnant client about the physiological changes of pregnancy, the nurse reviews the effect of pregnancy on glucose metabolism. Which underlying reason for the effect would the nurse include?
Glucose moves through the placenta to assist the fetus
126
A nurse strongly encourages a pregnant client to avoid eating swordfish and tilefish because these fish contain which component?
Mercury, which can harm the developing fetus is eaten in large amounts
127
Which change in the musculoskeletal system would the nurse mention when teaching a group of pregnant women about the physiological changes of pregnancy?
Increased lordosis (swayback)
128
Assessment of a pregnant woman reveals a pigmented line down the middle of her abdomen. The nurse documents this as which finding?
Linea nigra
129
A nurse is assessing a pregnant woman on a routine checkup. When assessing the woman’s gastrointestinal tract, what would the nurse expect to find? SATA
1) Hyperemic gums
2) Reports of bloating
3) Heartburn
4) Nausea
130
A woman suspecting she is pregnant asks the nurse about which signs would confirm her pregnancy. The nurse would explain that which sign would confirm the pregnancy?
Palpable fetal movement
131
A woman in her second trimester comes for a follow-up visit and says to the nurse, “I feel like I’m on an emotional roller-coaster.” Which response by the nurse would be most appropriate?
"Mood swings are completely normal during pregnancy."
132
A nurse is assessing a client who may be pregnant. The nurse reviews the client’s history for presumptive signs. Which sign would the nurse most likely note? SATA
1) Amenorrhea- missed period
2) Nausea
133
A woman is at 20 weeks’ gestation. The nurse would expect to find the fundus at which area?
At the level of the umbilicus
134
The nurse is assessing a pregnant woman who is at 12 weeks’ gestation. The woman’s BMI was 18 prior to becoming pregnant. Her pre-pregnancy weight was 98 lb. Which measurement would the nurse determine as appropriate weight gain for the woman during the first trimester?
104 lbs. (47 kg)
135
A woman in the 34th week of pregnancy says to the nurse, “I still feel like having intercourse with my husband.” The woman’s pregnancy has been uneventful. The nurse responds based on the understanding that:
It is safe to have intercourse at this time.
136
On the first prenatal visit, examination of the woman’s internal genitalia reveals a bluish coloration of the cervix and vaginal mucosa. The nurse documents this finding as:
Chadwick sign
137
When assessing a woman at follow-up prenatal visits, the nurse would anticipate which procedure to be performed?
Fundal height measurement
138
During a routine prenatal visit, a client, 36 weeks pregnant, states she has difficulty breathing and feels like her pulse rate is really fast. The nurse finds her pulse to be 100 beats per minute (increased from baseline readings of 70 to 74 beats per minutes) and irregular, with bilateral crackles in the lower lung bases. Which nursing diagnosis would be the priority for this client?
Impaired gas exchange related to pulmonary congestion
139
When preparing a woman for an amniocentesis, the nurse would instruct her to
perform which action?
Emptying the bladder
140
A pregnant woman needs an update in her immunization. Which vaccination would the nurse ensure that the woman receives?
Hep B
141
A nurse is teaching a pregnant client in her first trimester about discomforts that she may experience, The nurse determines that the teaching was successful when the woman identifies which discomforts as common during the first trimester?
A. leg cramps
B. backache
C. breast tenderness
D. urinary frequency
E. cravings
1) urinary frequency
2) Breast tenderness
3) Cravings
142
A pregnant woman has a rubella titer drawn on her first prenatal visit. The nurse explains that this test measures:
A) Platelet level
B) Rh status
C) Immunity to German measles
D) Red blood cell count
Immunity to german measles
143
A 24-year-old client who is planning to become pregnant comes to the clinic for an evaluation. When assessing the client, which finding would alert the nurse to implement measures to reduce the client’s risk for problems during pregnancy? SATA
A. has a BMI of 22
B. drinks wine 3 to 4 times/week
C. quit smoking 4 years ago
D. uses ibuprofen daily
E. follows a vegetarian diet
- Drinks wine 3 to 4 times a week
- Uses ibuprofen daily
144
A client comes to the prenatal clinic for her first visit. When determining the client’s estimated due date, the nurse understands what which method is the most accurate?
a. Nagele's rule
b. gestational wheel
c. birth calculator
d. ultrasound
Nagele's rule
145
A woman in her 40th week of pregnancy calls the nurse at the clinic and says she is 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) Im feeling contractions mostly in my back.
B) My contractions are about 6 minutes apart and regular.
C) The contractions slow down when I walk around.
D) If I try to talk to my partner during a contraction, I cant.
" The contractions slow down when I walk around.”
146
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 use?
A) Flexion
B) Extension
C) Longitudinal
D) Cephalic
Longitudinal
147
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) Sutures
B) Fontanelles
C) Frontal bones.
D) Biparietal diameter.
A. Sutures
148
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) Perform a vaginal exam.
C) Notify the physician immediately.
D) Change the linen saver pad.
A. check the fetal heart rate
149
When palpating the fundus during a contraction, the nurse notes that it feels like a chin. The nurse interprets this finding as indicating which type of contraction?
A) Intense
B) Strong
C) Moderate
D) Mild
C. moderate
150
A woman’s amniotic fluid is noted to be cloudy. The nurse interprets this finding as:
A) Normal
B) Possible infection
C) Meconium passage
D) Transient fetal hypoxia
B. possible infection
151
Which positions would be most appropriate for the nurse to suggest as a comfort measure to a woman who is in the first stage of labor? SATA
A. straddling with forward leaning over a chair
B. rocking back and forth with foot on chair
C. walking with partner support
D. supine with legs raised at a 90-degree angle
E. closed knee-chest position
A. straddling with forward leaning over a chair
B. rocking back and forth with foot on chair
C. walking with partner support
152
A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpates the client’s fundus. Which finding would the nurse identify as expected?
-At the level of the umbilicus
153
A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client’s fundus and documents which finding as normal?
A) two fingerbreadths above the umbilicus
B) at the level of the umbilicus
C) two fingerbreadths below the umbilicus
D) four fingerbreadths below the umbilicus
C. two fingerbreadths below the umbilicus
154
The nurse administers Rho(D) immune globulin to an Rh-negative client after birth of an
Rh-positive newborn based on the understanding that thus drug will prevent her from:
A. becoming Rh positive.
B. developing Rh sensitivity.
C. developing AB antigens in her blood.
D. becoming pregnant with an Rh-positive fetus.
B. developing Rh sensitivity
155
When teaching parents about their newborn, the nurse describes the development of a close emotional attraction to a newborn by the parents during the first 30 to 60 minutes after birth. The nurse refers to this process by which term?
A) Reciprocity
B) Engrossment
C) Bonding
D) Attachment
C. bonding
156
When developing the plan of care for the parents of a newborn, the nurse identifies interventions to promote bonding and attachment based on the rationale that bonding and attachment are most supported by which measure?
A) Early parent-infant contact following birth
B) Expert medical care for the labor and birth
C) Good nutrition and prenatal care during pregnancy
D) Grandparent involvement in infant care after birth
A. Early parent-infant contact following birth
157
After teaching a postpartum woman about breastfeeding, the nurse determines that the teaching was successful when the woman makes which statement?
A) "I should notice a decrease in abdominal cramping during breast-feeding."
B) "I should wash my hands before starting to breast-feed."
C) "The baby can be awake or sleepy when I start to feed him."
D) "The baby's mouth will open up once I put him to my breast."
B. "I should wash my hands before starting to breast-feed."
158
A woman gave birth to a healthy term neonate today at 1330. It is now 1430 and the nurse has completed the client’s assessment. At which time would the nurse next assess the client?
1500
159
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) A good time to initiate breast-feeding
B) The period of decreased responsiveness preceding sleep
C) The need to be alert for gagging and vomiting
D) Evidence that the newborn is becoming chilled
A. a good time to initiate breast-feeding
160
After the birth of a newborn, which action would the nurse do first to assist in thermoregulation?
A) Dry the newborn thoroughly.
B) Put a hat on the newborn's head.
C) Check the newborn's temperature.
D) Wrap the newborn in a blanket.
A. Dry the newborn thoroughly
161
A nurse is assessing a newborn. Which finding would alert the nurse to the possibility of respiratory distress in a newborn?
A) Symmetrical chest movements
B) Periodic breathing
C) Respirations of 40 breaths/minute
D) Sternal retractions
D. sternal retractions
162
The nurse observes the stool of a newborn who has begun to breastfeed. Which finding would the nurse expect?
A. greenish black, tarry stool
B. yellowish-brown, seedy stool
C. yellow-gold, stringy stool
D. yellowish-green, pasty stool
B. yellowish-brown, seedy stool
163
The nurse dries the neonate thoroughly and promptly changes the wet linens. The nurse does so to minimize heat loss via which mechanism?
A. evaporation
B. conduction
C. convection
D. radiation
A. evaporation
164
Prior to discharging a 24-hour-old newborn, the nurse assesses the newborn’s respiratory status. What would the nurse expect to assess?
A) Respiratory rate 45, irregular
B) Costal breathing pattern
C) Nasal flaring, rate 65
D) Crackles on auscultation
A. Respiratory rate 45, irregular
165
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 for which reason?
A) the newborn should not be sleeping on his back.
B) soft bedding material should not be in areas where infants sleep.
C) the bulb syringe should not be kept in the bassinet.
D) this newborn should be sleeping in a crib.
B) soft bedding material should not be in areas where infants sleep.
166
The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal?
A) Prevent cold stress
B) Increase surfactant levels in the lungs
C) Promote respiratory stability
D) Decrease the serum bilirubin level
D) Decrease the serum bilirubin level
167
A nurse is assessing a newborn’s reflexes. The nurse strokes the lateral sole of the newborn’s foot from the heel to the ball of the foot to elicit which reflex?
A) Babinski
B) tonic neck
C) stepping
D) plantar grasp
A) Babinski
168
Assessment of a newborn’s head circumference reveals that it is 34 cm. The nurse would suspect that this newborn’s chest circumference would be:
A) 30 cm
B) 32 cm
C) 34 cm
D) 36 cm
B. 32 cm
169
A nurse is providing teaching to a new mother about her newborn’s nutritional needs. Which suggestions would the nurse include in the teaching? SATA
A) Supplement with iron if the woman is breast-feeding.
B) Provide supplemental water intake with feedings.
C) Feed the newborn every 2 to 4 hours during the day.
D) Burp the newborn frequently throughout each feeding.
E) Use feeding time for promoting closeness.
C) Feed the newborn every 2 to 4 hours during the day.
D) Burp the newborn frequently throughout each feeding.
E) Use feeding time for promoting closeness.
170
A new parent is talking with the nurse about feeding the newborn. The parent has chosen to use formula. The parent asks, “How can I make sure that my baby is getting what is needed?” Which response by the nurse would be appropriate? SATA
A. "Make sure to use an iron-fortified formula until your baby is 1 year old."
B. "Start giving your baby fluoride supplements now so your baby develops strong teeth."
C. "Since you are not breastfeeding, your baby needs a baby multivitamin each day."
D. "Your baby gets enough fluid with formula, so you do not need to give extra water."
E. "It is important to give your baby vitamin D each day."
A. "Make sure to use an iron-fortified formula until your baby is 1 year old."
D. "Your baby gets enough fluid with formula, so you do not need to give extra water."
E. "It is important to give your baby vitamin D each day."
171
A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. The nurse determines that the medication is at a therapeutic level based on which finding?
A. respiratory rate of 10 breaths/minute
B. difficulty in arousing
C. urinary output of 20 mL per hour
D. deep tendons reflexes 2+
D. deep tendons reflexes 2+
172
Upon entering the room of a client who has had a spontaneous abortion, the nurse observes the client crying. Which response by the nurse would be most appropriate?
A) "Why are you crying?"
B) "Will a pill help your pain?"
C) "I'm sorry you lost your baby."
D) "A baby still wasn't formed in your uterus."
C) "I'm sorry you lost your baby."
173
A nurse is conducting an assessment of a woman who has experienced PROM. Which amniotic fluid finding would lead the nurse to suspect infection as the cause of a client’s PROM?
A. yellow-green fluid
B. blue color on Nitrazine testing
C. ferning
D. foul odor
D. foul odor
174
A nurse is conducting an in-service presentation to a group of perinatal nurses about sexually transmitted infections and their effect on pregnancy. The nurse determines that the teaching was successful when the group identifies which infection as being responsible for ophthalmia neonatorum?
A. HPV
B. gonorrhea
C. chlamydia
D. syphilis
B. gonorrhea
175
A nurse is providing care to several pregnant women at different weeks of gestation. The nurse would expect to screen for group B streptococcus infection in the client who is at:
A) 16 weeks' gestation
B) 28 week' gestation
C) 32 weeks' gestation
D) 36 weeks' gestation
D) 36 weeks' gestation
176
A pregnant client undergoing labor induction is receiving an oxytocin infusion. Which would require immediate intervention?
A. urine output of 20 mL/hour
B. uterine resting tone of 14 mm Hg
C. fetal heart rate of 150 beats/minute
D. contractions every 2 minutes, lasting 45 seconds
A. urine output of 20 mL/hour
177
A woman who is 2 weeks postpartum calls the clinic and says, “my left breast hurts.” After further assessment on the phone, the nurse suspects the woman has mastitis. In addition to pain, the nurse would question the woman about which symptom.
A) An inverted nipple on the affected breast
B) No breast milk in the affected breast
C) An ecchymotic area on the affected breast
D) Hardening of an area in the affected breast
D) Hardening of an area in the affected breast
178
A nurse is reviewing a journal article on the causes of postpartum hemorrhage. Which condition would the nurse most likely find as the most common cause?
A. uterine inversion
B. uterine atony
C. cervical or vaginal lacerations
D. labor augmentation
B. uterine atony
179
Assessment of a postpartum woman experiencing postpartum hemorrhage reveals mild shock. Which finding would the nurse expect to assess? SATA
A) diaphoresis
B) tachycardia
C) oliguria
D) cool extremities
E) confusion
A. Diaphoresis
D. Cool extremities
180
A nurse is assessing a postpartum client who is at home. Which statement by the client would lead the nurse to suspect that the client may be developing postpartum depression?
"I’m feeling so guilty and worthless lately.”
181
A nurse is teaching a woman with mild preeclampsia about important areas that she needs to monitor. The nurse determines that the teaching was successful based on which statement by the woman? Select all that apply.
A. I'll call my health care provider if I have burning when I urinate
B. I should check my blood pressure twice a day
C. I will weight myself once a week
D. I will check my urine for proteins four times a day
E. I should complete a fetal kick count each day
A. I'll call my health care provider if I have burning when I urinate
B. I should check my blood pressure twice a day
E. I should complete a fetal kick count each day
182
A pregnant woman is admitted with premature rupture of the membranes. The nurse is assessing the woman closely for possible infection. Which finding would lead the nurse to suspect that the woman is developing an infection? Select all that apply.
A. Cloudy malodorous fluid
B. Fetal bradycardia
C. Decreased C-reactive protein levels
D. Abdominal tenderness
E. Elevated maternal pulse rate
A. Cloudy malodorous fluid
D. Abdominal tenderness
E. Elevated maternal pulse rate
183
A nurse is taking a history on a woman who is at 20 weeks’ gestation. The woman reports that she feels heaviness in her thighs since yesterday. The nurse suspects that the woman may be experiencing preterm labor on which additional assessment? SATA
A. dysuria
B. four to five contractions in 1 hour
C. malodorous vaginal discharge
D. dull low backache
E. constipation
A. dysuria
C. malodorous vaginal discharge
D. dull low backache
184
A nurse suspects that a pregnant client may be experiencing abruptio placenta based on assessment of which finding? Select all that apply.
A. Insidious onset
B. Absent fetal heart tones
C. Dark red vaginal bleeding
D. Rigid uterus
E. Absence of pain
B. Absent fetal heart tones
C. Dark red vaginal bleeding
D. Rigid uterus
185
A nurse is observing a new mother interacting with her newborn. Which statement would alert the nurse to the potential for impaired bonding between mother and newborn?
A) "You have your daddy's eyes."
B) "He looks like a frog to me."
C) "Where did you get all that hair?"
D) "He seems to sleep a lot."
B. He looks like a frog to me
186
Which action is a priority when caring for a woman during the fourth stage of labor?
A) Assessing the uterine fundus
B) Offering fluids as indicated
C) Encouraging the woman to void
D) Assisting with perineal care
A) Assessing the uterine fundus
187
A nurse is describing the risks associated with post-term pregnancies as part of an inservice presentation. The nurse determines that more teaching is needed when the group identifies which factor as an underlying reason for problems in the fetus?
A. cord compression
B. meconium aspiration
C. increased amniotic fluid volume
D. aging of the placenta
C. increased amniotic fluid volume
188
A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage?
Cervical dilation
189
A nurse is teaching a pregnant woman with preterm premature rupture of membranes who is about to be discharged home about caring for herself. Which statement by the woman indicates a need for additional teaching?
A) "I need to keep a close eye on how active my baby is each day."
B) "I need to call my doctor if my temperature increases."
C) "It's okay for my husband and me to have sexual intercourse."
D) "I can shower but I shouldn't take a tub bath."
C) "It's okay for my husband and me to have sexual intercourse."
190
A pregnant client at 30 weeks' gestation calls the clinic because she thinks that she
may be in labor. To determine if the client is experiencing labor, which question(s) would be
appropriate for the nurse to ask? SATA
- . "Are you feeling any pressure or heaviness in your pelvis?"
- "Are you having contractions that come and go, off and on?"
- "Have you noticed any fluid leaking from your vagina?"
- "Have you been having any nausea or vomiting?"
*All but heartburn*
191
A nurse is assessing a client who gave birth vaginally about 4 hours ago. The client tells the Nurse that she changed her perineal pad about an hour ago. On inspection, the nurse notes that the pad is now saturated. The uterus is firm and approximately at the level of the umbilicus. Further inspection of the perineum reveals an area, bluish in color and bulging just under t
the skin surface. Which action would the nurse do next?
Notify the HCP
192
Client in her first trimester comes to the clinic for an evaluation. Assessment reveals
reports of fatigue, anorexia, and frequent upper respiratory infections. The client's skin is pale and the client is slightly tachycardic. The client also reports drinking about 6 cups of coffee on average each day. A diagnosis of iron-deficiency anemia is suspected. The client is scheduled for laboratory testing and the results are as follows:
Hemoglobin 11.5 g/dL (115 g/L)
Hematocrit 35% (0.35)
Serum iron 32 µg/dL (5.73 µmol/L)
Serum ferritin 90 ng/dL (90 µg/L)
Which laboratory finding would the nurse correlate with the suspected diagnosis?
Serum ferritin level
193
The nurse is developing a teaching plan for a client who has decided to bottle feed her newborn. Which of the following would the nurse include in the teaching plan to facilitate suppression of lactation?
A) Encouraging the woman to manually express milk
B) Suggesting that she take frequent warm showers to soothe her breasts
C) Telling her to limit the amount of fluids that she drinks
D) Instructing her to apply ice packs to both breasts every other hour
D) Instructing her to apply ice packs to both breasts every other hour
194
A postpartum woman is having difficulty voiding for the first time after giving birth. Which action would be least effective in helping to stimulate voiding?
A) Pouring warm water over her perineal area
B) Having her hear the sound of water running nearby
C) Placing her hand in a basin of cool water
D) Standing her in the shower with the warm water on
C) Placing her hand in a basin of cool water
