QUESTION: "A primigravida client in active labor whose cervix is dilated to 5 cm and completely effaced is using the Lamaze method of prepared childbirth during labor. The client has been using slow-paced breathing and tells the nurse that this does not appear to be helping her during a contraction. The nurse should suggest to the client that she use which of the following?"
CHOICES
( X ) a.) Deep abdominal breathing.
( X ) b.) Pant-and-blow breathing.
( O ) c.) Open-glottis breathing.
( X ) d.) Modified-pace breathing.
RATIONALE: Open-glottis breathing is useful for the second stage of labor and the delivery process. Deep abdominal breathing is primarily useful in early labor. Pant-and-blow breathing typically is useful during the transition stage. With time, habituation may occur, making slow-paced breathing less effective. The nurse should suggest to the client that she switch to modified-pace breathing, which is performed as an upper chest breath either through nose or mouth. A frequently taught method is three breaths, then a soft blow. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 203 _ about (MC)
QUESTION: "A multigravid client visits the clinic because she suspects that she is pregnant but is unable to tell the nurse when her last menstrual period began. The client has a history of preterm delivery. The nurse instructs the client that the gestational age of the fetus can be estimated by which of the following? "
CHOICES
( X ) a.) Amniocentesis.
( X ) b.) Percutaneous umbilical blood sampling.
( X ) c.) Alpha-fetoprotein level.
( O ) d.) Ultrasonography.
RATIONALE: An ultrasound can provide a fairly accurate estimate of the fetal gestational age through various measurements of fetal landmarks. Amniocentesis is appropriate for determining genetic deviations and fetal lung maturity (lecithin-to-sphingomyelin ratio). Percutaneous umbilical blood sampling is used to detect genetically transmitted (inherited) blood disorders, acidosis, or infection. Alpha-fetoprotein levels are performed between the 15th and 20th weeks of gestation to determine if neural tube defects are present. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 204 _ about (MC)
QUESTION: "A 25-year-old client tells the nurse that she would like to become pregnant, but she has been diagnosed with blocked fallopian tubes due to pelvic inflammatory disease. When helping the client explore infertility treatment options, which of the following would the nurse suggest as most appropriate?"
CHOICES
( X ) a.) Gamete intrafallopian transfer (GIFT).
( X ) b.) Zygote intrafallopian transfer (ZIFT).
( X ) c.) Menotropin (Pergonal) therapy.
( O ) d.) In vitro fertilization (IVF).
RATIONALE: Because this client's tubes are blocked, IVF would be the most appropriate. After ova are removed surgically from the client and fertilized outside the uterus, the fertilized ova are introduced vaginally through a special tube through the cervix to the uterus for implantation, completely bypassing the fallopian tubes. Gamete intrafallopian transfer, the transfer of ova into a patent fallopian tube for fertilization, would be inappropriate for client with blocked fallopian tubes. Zygote intrafallopian transfer involves oocyte retrieval then fertilization. After fertilization, the fertilized eggs are transferred into the client's fallopian tubes. This is not an option for a client who has blocked tubes. Menotropins therapy would be appropriate if the client was experiencing ovarian dysfunction. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 208 _ about (MC)
QUESTION: "During a home visit 4 days after delivery, the breast-feeding primiparous client tells the nurse that her breasts are hard and tender. The nurse suspects breast engorgement and instructs the client to do which of the following?"
CHOICES
( X ) a.) Discontinue breast-feeding immediately and replace it with bottle-feeding during the night.
( X ) b.) Apply ice packs to the breasts for 20 minutes just before breast-feeding the newborn.
( X ) c.) Take a moderately strong analgesic after the infant breast-feeds on both sides.
( O ) d.) Use her hand or a pump to express a small amount of breast milk before breast-feeding.
RATIONALE: The client should be instructed to express milk from the nipples either by hand or with a breast pump to stimulate milk flow and relieve the engorgement. As soon as the areola is soft, the client should begin to breast-feed. Frequent feedings with complete emptying of the breasts should alleviate engorgement. There is no reason why the client needs to discontinue breast-feeding. Rather, more frequent breast-feeding is indicated. Ice packs can be used to relieve edema and pain but should be used between feedings not immediately before a feeding. Warm compresses may be used to help stimulate milk flow. Although the client's breasts are tender, this tenderness is a result of the engorgement. A strong analgesic will not alleviate breast engorgement. Expressing the milk and feeding the neonate are most effective in relieving the problem. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 213 _ about (MC)
QUESTION: "A cerclage procedure is performed on a client at 20 weeks' gestation who is diagnosed with cervical incompetence. When preparing the discharge teaching plan, the nurse would expect to instruct the client to monitor herself for which of the following?"
CHOICES
( X ) a.) Braxton Hicks contractions.
( X ) b.) Nausea and vomiting.
( O ) c.) Symptoms of infection.
( X ) d.) Transient hypotension.
RATIONALE: Placement of a cerclage or purse string suture may be used to maintain cervical closure for women with cervical incompetence. Because of the risk of maternal infection, the client should be taught to contact the health care provider if she experiences pain, fever, or changes in the vaginal discharge. Braxton Hicks contractions are normal during pregnancy and nonthreatening to the fetus. Nausea and vomiting usually are not associated with cerclage. Transient hypotension usually is not associated with cerclage. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 224 _ about (MC)
QUESTION: "During a home birth, when a low-risk multigravid client in active labor has begun pushing and the fetal head is beginning to crown, which of the following would be most appropriate to prevent perineal lacerations during the delivery?"
CHOICES
( O ) a.) Stretching the perineal tissues with sterile gloved fingers.
( X ) b.) Holding the fetal head back with a sterile gloved hand.
( X ) c.) Telling her to stop pushing during the next two contractions.
( X ) d.) Asking her to hold her breath while pushing during the entire contraction.
RATIONALE: Sterile gloves should always be worn by birth attendants to prevent infection to the laboring client and the fetus. Stretching the perineal muscles can decrease the incidence of tearing or lacerations. Holding the fetal head back, even with a sterile gloved hand, is inappropriate because it can cause injury to the fetus. The fetus is ready to be delivered. Telling the client not to push for two contractions is inappropriate because the fetus is ready to be delivered. Asking her to hold her breath is inappropriate because doing so while pushing may result in a Valsalva maneuver, leading to possible fetal compromise and maternal increased intracranial pressure. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 230 _ about (MC)
QUESTION: "Two hours ago, examination of a multigravid client in labor without anesthesia revealed the following: cervical dilation at 5 cm with complete effacement, presenting part at 0 station, and membranes intact. The nurse caring for the client now observes that the client is irritable and has had some nausea with one episode of vomiting. Which of the following would the nurse suspect that the client is most likely experiencing?"
CHOICES
( X ) a.) A precipitous labor pattern.
( X ) b.) Fear and anxiety related to the labor outcome.
( X ) c.) Spontaneous rupture of the membranes.
( O ) d.) Transition phase of labor.
RATIONALE: Irritability, nausea, vomiting, and often the urge to push are all signs that the client is beginning the transition phase of labor that occurs when the client is 7 to 10 cm dilated. A multigravid client generally progresses more rapidly than a primigravid client does. Therefore, it would not be unusual for a client's cervix to dilate from 5 cm to 7 or cm or more within a 2-hour period. No evidence is presented that the client is experiencing a precipitous labor pattern, which would be evidenced by rapid cervical dilation. No evidence is presented that the client is experiencing fear and anxiety related to the labor outcome. Spontaneous rupture of the membranes, evidenced by a sudden gush of fluid, may occur at any time in the labor process. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 239 _ about (MC)
QUESTION: "When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse would expect to do which of the following?"
CHOICES
( X ) a.) Turn the neonate every 6 hours.
( X ) b.) Encourage the mother to discontinue breast-feeding.
( X ) c.) Notify the physician if the skin becomes bronze in color.
( O ) d.) Check the vital signs every 2 to 4 hours.
RATIONALE: While caring for an infant receiving phototherapy for treatment of jaundice, vital signs are checked every 2 to 4 hours because hyperthermia can occur due to the phototherapy lights. The infant should be turned every 2 to 4 hours to expose all body surfaces to the lights, thus promoting the breakdown of bilirubin. Breast-feeding generally does not need to be discontinued. However, the infant needs adequate fluid intake to maintain hydration because the heated phototherapy lights may increase fluid losses. Offering water to the neonate after breast-feeding would be appropriate. The skin of the neonate may become bronze as a result of phototherapy. This benign condition has no adverse effects and disappears when therapy is discontinued. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 242 _ about (MC)
QUESTION: "After being in labor for 12 hours, a primigravida client is now 10 cm dilated and the presenting part is at 0 station. The nurse should inform the client and family members that which of the following is occurring?"
CHOICES
( X ) a.) First stage of labor is beginning.
( X ) b.) Client is now in transition phase.
( X ) c.) Delivery will occur in the next few minutes.
( O ) d.) Second stage of labor is now beginning.
RATIONALE: A client whose cervix is 10 cm dilated has completed the first stage of labor, which lasts from the beginning of cervical dilation to complete dilation (10 cm), and is starting the second stage of labor. Usually the second stage of labor (pushing) for a primigravida client lasts about 1 to 2 hours. The first stage of labor lasts from the beginning of cervical dilation to complete dilation. The transition phase of the first stage of labor occurs when the client is 7 to 10 cm dilated. If the client is a primigravida and the presenting part is at 0 station, delivery is not imminent. A primigravida client needs to push for 1 hour or more before delivery. A +3 station is evidence of crowning and imminent delivery. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 414 _ about (MC)
QUESTION: "Which of the following would the nurse expect to find in a premature female neonate born at 30 weeks' gestation who is small for gestational age?"
CHOICES
( X ) a.) Firm cartilage to the edge of the ear pinna.
( X ) b.) Elbows brought to chest midline with resistance past the midline.
( O ) c.) Fine, downy hair over the upper arms and back.
( X ) d.) Prominent creases on the soles and heels.
RATIONALE: Lanugo (fine, downy hair) covers the entire body until about 20 weeks of gestation, when it begins to disappear from the face, trunk, and extremities, in that order. Lanugo is a consistent finding in preterm neonates. Firm cartilage to the edge of the ear pinna is a physical characteristic found in neonates born at term. The ability to bring elbows to the midline of the chest with resistance past midline, also known as the scarf sign, is a physical characteristic found in neonates born at term. At 30 weeks' gestation, there is no resistance and the elbow can be moved easily past midline. Creases on the soles and heels are physical characteristics found in neonates born at term. A preterm neonate would exhibit few sole creases. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 415 _ about (MC)
QUESTION: "Which of the following would the nurse expect to assess during the physical examination of a preterm male neonate delivered at 28 weeks' gestation?"
CHOICES
( X ) a.) Abundance of scalp hair.
( O ) b.) Thin, wasted appearance.
( X ) c.) Descended testicles.
( X ) d.) Numerous scrotal rugae.
RATIONALE: The premature neonate characteristically exhibits a thin, wasted appearance. The premature neonate commonly exhibits a scarcity of scalp hair. In the premature male neonate, testicles are typically high in the inguinal canal. In the premature male neonate, an absence of rugae on the scrotum is typical. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 416 _ about (MC)
QUESTION: "For which of the following would the nurse be alert in a preterm neonate suffering from cold stress?"
CHOICES
( X ) a.) Yellowish undercast to the skin color.
( X ) b.) Increased abdominal girth.
( O ) c.) Hyperactivity and twitching.
( X ) d.) Slowed respirations.
RATIONALE: A neonate with cold stress must produce heat through increased metabolism, causing oxygen use to increase and glycogen stores to be quickly depleted leading to hypoglycemia. Hyperactivity and twitching are signs of hypoglycemia. Yellowish undercast to the skin color suggest jaundice related to excessive bilirubin levels, not cold stress. Increased abdominal girth suggests abdominal distention, possibly indicating necrotizing enterocolitis. It is unrelated to cold stress or possible hypoglycemia. Increased, not slowed, respirations are associated with neonatal cold stress and hypoglycemia. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 419 _ about (MC)
QUESTION: "A neonate weighing 1870 g with a respiratory rate of 46 breaths/minute, a pulse rate of 175 bpm, and a serum pH of 7.11 is to receive sodium bicarbonate intravenously. The nurse anticipates administration of this drug to alleviate which of the following?"
CHOICES
( X ) a.) Edema.
( X ) b.) Dehydration.
( O ) c.) Metabolic acidosis.
( X ) d.) Respiratory alkalosis.
RATIONALE: Metabolic acidosis results from the metabolic changes associated with cold stress. End products of metabolism increase the acidity of the blood, evidenced by a pH of 7.11. Therefore, sodium bicarbonate, which is a buffer base, is often used. Diuretics, not sodium bicarbonate, would be used to combat edema. Intravenous fluids would be used to treat dehydration. Respiratory alkalosis results from excessive carbon dioxide loss, a condition that would be unusual in this neonate. Additionally, because sodium bicarbonate is a base, administering it to client with alkalosis would only further exacerbate the alkalotic condition. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 421 _ about (MC)
QUESTION: "The nurse carefully documents the premature neonate's response to oxygen therapy, delivering only as much oxygen as is necessary to prevent the development of which of the following?"
CHOICES
( X ) a.) Cataracts.
( X ) b.) Glaucoma.
( X ) c.) Ophthalmia neonatorum.
( O ) d.) Retinopathy of prematurity.
RATIONALE: High levels of oxygen delivered to a preterm neonate can result in retinopathy of prematurity. The immature blood vessels in the eye constrict then overgrow, resulting in edema and hemorrhage that produce scarring, retinal detachment, and eventual blindness. Cataracts are congenital abnormalities in the neonate unrelated to oxygen therapy. Glaucoma is a congenital abnormality in the neonate unrelated to oxygen therapy. Ophthalmia neonatorum is a gonorrheal infection of the eyes that is likely to occur if a mother has the gonorrheal organism in her birth canal. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 615 _ about (MC)
QUESTION: "While making a home visit to a multigravida 2 weeks after delivery of viable twins at 38 weeks' gestation, the nurse observes that the client looks pale, has dark circles around her eyes, and is breast-feeding one of the twins. The client's apartment is clean and nothing appears out of place. The client tells the nurse that she completed three loads of laundry this morning. A priority nursing diagnosis for this client is:"
CHOICES
( X ) a.) Anxiety related to inability to cope with twins who are breast-feeding.
( X ) b.) Risk for Imbalanced Nutrition: Less Than Body Requirements related to twin delivery.
( X ) c.) Possible Anemia related to large volume of blood loss and twin delivery.
( O ) d.) Fatigue related to home maintenance and caring for twins.
RATIONALE: Most postpartum clients complain of excessive fatigue after delivery. This multigravida has dark circles around the eyes and is pale, which can indicate anemia or excessive sleep deprivation. The client maintains a spotless environment, has completed three loads of laundry, and is trying to breast-feed twins. There is no evidence of Anxiety. There is no evidence of Imbalanced Nutrition. Anemia is not a nursing diagnosis. NURSING PROCESS STEP: Analysis, nursing diagnosis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 618 _ about (MC)
QUESTION: "A multipara asks the nurse during a home visit about breast-feeding. She tells the nurse that with her last newborn, her nipples became cracked and sore. The nurse should instruct the client that:"
CHOICES
( O ) a.) The newborn's mouth should cover the areola during the feeding.
( X ) b.) Breast-feeding every 4 to 5 hours should decrease nipple soreness.
( X ) c.) Nipples should be washed with a mild soap and rinsed thoroughly.
( X ) d.) Using plastic nipple shields that fit over the nipples should alleviate the problem.
RATIONALE: Cracked and sore nipples usually result from the newborn failing to take in the areola or from the nipple being improperly removed from the newborn's mouth. Most babies breast-feed on demand. Increasing the length of time between feedings does not affect nipple soreness or cracking. When one nipple is more sore than the other, the mother should be instructed to begin each feeding with the least sore side first. Nipples should be cleansed only with water because soap makes the nipples drier and more susceptible to cracking. Applying colostrum or breast milk to the nipples after the feeding aids healing. A mild analgesic can be taken before the feeding to ease nipple soreness. Plastic nipple shields should not be used because they prevent air circulation. Air drying the nipples after feedings can help reduce irritation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 621 _ about (MC)
QUESTION: "While caring for a multigravida in active labor with no anesthesia, the nurse midwife determines that the client's cervix is completely dilated. The nurse midwife should instruct the client to deliver the fetal head by pushing:"
CHOICES
( X ) a.) As soon as a contraction begins.
( O ) b.) When she has an urge to push.
( X ) c.) Near the end of a contraction.
( X ) d.) Between contractions.
RATIONALE: The best approach is to allow the client to push when she feels the urge to push with a contraction. When the contraction begins, the client may have an immediate urge to push, or it may take time for fetal descent to stimulate stretch receptors. The client may not feel the urge to push at the beginning of the contraction. Urging the client to push before she feels the urge may needlessly tire her. Pushing at the end of a contraction is not as effective as pushing when the client feels the urge. Pushing between contractions is not as effective as pushing when the client feels the urge. Additionally, clients should rest between contractions. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 625 _ about (MC)
QUESTION: "The nurse is caring for a primipara after a cesarean section delivery 12 hours ago. The nurse observes that the client's fundus is at the umbilicus and firm. The nurse should:"
CHOICES
( X ) a.) Ask the client if she feels the urge to void.
( O ) b.) Document this as a normal finding.
( X ) c.) Contact the physician for an order for an oxytocic.
( X ) d.) Encourage the client to remain on bed rest.
RATIONALE: Clients who deliver by cesarean section are often given oxytocic medications to prevent uterine atony. The client's fundus located at the umbilicus 12 hours after delivery is a normal sign. There is no evidence of a full bladder which would cause displacement of the fundus. The client does not need an oxytocic agent if the fundus is firm. Early ambulation is preferred to prolonged bed rest. Clients frequently have an order to be up in a chair soon after cesarean section delivery. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 634 _ about (MC)
QUESTION: "The nurse is caring for a primigravida in active labor when the client's membranes rupture spontaneously. The nurse should assess the client for:"
CHOICES
( X ) a.) Increased intensity of contractions.
( X ) b.) Fetal head engagement.
( O ) c.) Prolapsed cord.
( X ) d.) A need for an analgesic medication.
RATIONALE: Whenever the membranes rupture, it is important for the nurse to assess for a prolapsed cord. Prolapse of the umbilical cord is a serious intrapartum complication occurring in about 1 of 200 pregnancies. The spontaneous rupture of the membranes produces a gush of fluid, and the force can cause the cord to enter the vagina. This is an emergency situation because the compression of the fetal presenting part on the cord can occlude the perfusion of blood to the fetus. After spontaneous rupture of the membranes, the contractions may become more frequent and may increase in intensity. This, though, is not a priority at this time. There is no evidence that rupture of the membranes shortens labor. Checking if the fetal head is engaged is not indicated. Once the membranes have ruptured, the client is at risk for chorioamnionitis; therefore, vaginal examinations should be kept to a minimum. There is no pain associated with spontaneous rupture of the membranes, so an analgesic is not necessary. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 636 _ about (MC)
QUESTION: "A primipara on the postpartum unit 2 hours after a vaginal delivery tells the nurse that she was in labor for 16 hours and pushed for 2 hours before delivery of a viable female neonate. She tells the nurse that she is "thirsty and very happy it is over." A priority nursing diagnosis for this client is:"
CHOICES
( O ) a.) Deficient Fluid Volume related to decreased fluid intake during labor.
( X ) b.) Risk for Impaired Parenting related to lack of experience as a mother.
( X ) c.) Risk for Urinary Retention related to lengthy labor process.
( X ) d.) Anxiety related to inexperience in the new role of parenting.
RATIONALE: The most appropriate priority diagnosis for this client is Deficient Fluid Volume. The average length of the second stage of labor is about 1 hour. Analgesia and anesthesia can result in a prolonged second stage of labor. Thirst is a common phenomenon after delivery because clients may be kept NPO during the labor process and may be dehydrated. There is no evidence that the client's inexperience as a mother will affect the bonding process. Although the nurse should monitor the client's intake and output after delivery, there is no evidence of a full bladder due to a lengthy labor process, so Urinary Retention is not a priority diagnosis at this time. The client has not expressed any evidence of Anxiety at this point. NURSING PROCESS STEP: Analysis, nursing diagnosis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 644 _ about (MC)
QUESTION: "A 1-day postpartum client asks the nurse about resuming sexual activity after delivery of a viable male infant. After giving instructions, the nurse determines that the client understands the instructions when she says:"
CHOICES
( X ) a.) "I should refrain from intercourse until I no longer have any vaginal discharge."
( X ) b.) "Kegel exercises shouldn't be started until 4 weeks postpartum."
( O ) c.) "Sexual intercourse may be resumed about 3 to 4 weeks postpartum."
( X ) d.) "Sitz baths once a week can help to heal the episiotomy."
RATIONALE: Sexual intercourse may be resumed about 3 to 4 weeks postpartum. The general rule is that intercourse may be resumed when the episiotomy (if present) is healed and all bleeding has stopped. Usually these two conditions are met by 3 weeks postpartum. Sexual intercourse can be resumed as soon as lochia serosa has stopped. The client may continue to have slight lochia alba up to 6 weeks postpartum. Kegel exercises to tighten the muscles can begin immediately after birth. Sitz baths should be used three times daily to help heal the episiotomy. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 645 _ about (MC)
QUESTION: "The nurse is caring for a primipara who delivered a viable neonate 12 hours ago. The client says, "Look at all of the beautiful things my family brought for the new baby." The nurse should become concerned if the client has:"
CHOICES
( X ) a.) Four neonatal receiving blankets.
( X ) b.) Breast-pumping equipment.
( O ) c.) A soft pillow for the neonate's crib.
( X ) d.) A clean, but used, infant car seat.
RATIONALE: Newborn infants should not sleep with a pillow in the crib because this could lead to suffocation. The client should be instructed to avoid using a pillow in the infant's crib.
Receiving blankets are appropriate.
A breast pump is an appropriate item to have.
A car seat is an appropriate item for a neonate.
NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 650 _ about (MC)
QUESTION: "The nurse observes a neonate 2 hours after birth and determines that the neonate has acrocyanosis. The nurse should explain to the neonate's parents that this symptom is due to:"
CHOICES
( X ) a.) Cardiac anomalies.
( O ) b.) Sluggish peripheral circulation.
( X ) c.) Vasomotor instability.
( X ) d.) Decreased red blood cell production.
RATIONALE: Acrocyanosis, or localized cyanosis of the hands and feet, is common in the neonate and is due to sluggish peripheral circulation. Persistent circumoral cyanosis that persists with feeding or crying may be indicative of cardiac anomalies. Mottling is a result of vasomotor instability. Newborns normally have a high erythrocyte count. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 651 _ about (MC)
QUESTION: "The nurse has assisted a multigravida with a precipitous delivery of a viable neonate in a local grocery store. Because a precipitous delivery can lead to decreased uterine tone, what nursing action would help to prevent this complication?"
CHOICES
( X ) a.) Place the neonate on the client's fundus.
( O ) b.) Encourage the mother to breast-feed the infant.
( X ) c.) Massage the client's fundus continuously.
( X ) d.) Place the mother in a supine position.
RATIONALE: The nurse should encourage the mother to breast-feed the infant. Neonatal sucking will induce the release of natural oxytocin which will help contract the uterus and control uterine bleeding. Placing the neonate on the client's fundus will help keep the neonate warm but will not help to control excessive uterine bleeding. Gentle massage will help contract the fundus. Continuous massage can actually decrease uterine tone and lead to increased bleeding. Placing the mother in a supine position has no effect on uterine tone. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 652 _ about (MC)
QUESTION: "The nurse is caring for a primigravida who delivered a viable neonate 2 hours ago under epidural anesthesia. The new mother has a midline episiotomy. Which of the following findings by the nurse would warrant further assessment?"
CHOICES
( X ) a.) Distended vaginal tissue.
( X ) b.) Edema around the episiotomy site.
( O ) c.) Two perineal pads soaked with blood within 30 minutes.
( X ) d.) Tenderness around the episiotomy site.
RATIONALE: Two perineal pads soaked within 30 minutes may be indicative of early postpartum hemorrhage and warrants further investigation. The most frequent cause of early postpartum hemorrhage is uterine atony or a "boggy fundus." The nurse should gently massage the fundus and call for assistance if heavy bleeding continues. Distended vaginal tissue is a normal finding. Edema around the episiotomy is a normal finding. Tenderness and soreness around the episiotomy site are normal once the anesthesia has worn off. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 654 _ about (MC)
QUESTION: "The nurse has discussed sexuality issues during the prenatal period with a primigravida client who is at 32 weeks' gestation. She has had one episode of preterm labor. The nurse determines that the client understands the instructions when she says:"
CHOICES
( X ) a.) "I can resume sexual intercourse when the bleeding stops."
( O ) b.) "I should not get sexually aroused or have any nipple stimulation."
( X ) c.) "I can resume sexual intercourse in 1 to 2 weeks."
( X ) d.) "I should not have sexual intercourse until my next prenatal visit."
RATIONALE: This client has already had one episode of preterm labor at 32 weeks' gestation. Sexual intercourse, arousal, and nipple stimulation may result in the release of oxytocin which can contribute to continued preterm labor and early delivery. The client should be advised to refrain from these activities until closer to term, which is 6 to 8 weeks later. Telling the client that intercourse is acceptable after the bleeding stops is incorrect and may lead to early delivery of a preterm neonate. The client should not have intercourse for at least 6 weeks because of the danger of inducing labor. There is no indication when the client's next prenatal visit is scheduled. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 661 _ about (MC)
QUESTION: "A pregnant client at 12 weeks' gestation visits the clinic for a routine visit. The nurse plans to discuss neonatal nutrition with the client. The nurse should plan to instruct the client that:"
CHOICES
( X ) a.) Formula feeding provides greater calories to the neonate than breast-feeding.
( X ) b.) Breast-feeding can be successful even if the mother does not want to breast-feed.
( X ) c.) No additional daily calories are needed for the breast-feeding mother.
( O ) d.) Breast milk is sufficient to provide nutrition for the first 4 months of the neonate's life.
RATIONALE: Breast milk is sufficient to provide the neonate's nutrition for the first 4 months of life. Specific nutrient supplements include vitamin K, vitamin D, fluoride, and iron. Breast milk also may provide protection against infections and allergies and may enhance the maternal:infant bonding process. Formula feeding does not provide more calories than breast-feeding. Breast-feeding will not be successful if the mother does not want to breast-feed. Breast-feeding mothers require an additional 500 calories per day. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 662 _ about (MC)
QUESTION: "A primigravida at 36 weeks' gestation complains of discomfort during a pelvic examination. To help the client relax during the examination, the nurse should instruct the client to:"
CHOICES
( X ) a.) Hold on tightly to the nurse with both hands.
( X ) b.) Visualize the examination being completed.
( X ) c.) Hold her breath until the speculum is inserted.
( O ) d.) Breathe in and out with slow deep breaths.
RATIONALE: The nurse should assist the client to relax by instructing her to breathe in and out slowly. This relaxes the muscles and allows for easier insertion of the moistened speculum. Telling the client to hold the nurse tightly with both hands increases muscular tension. Visualization requires training and usually involves visualizing a pleasant scene. Holding her breath until the speculum is inserted is not appropriate. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
******************************
--> QUESTION NUMBER _ 665 _ about (MC)
QUESTION: "The nurse caring for a multigravida client in active labor observes a variable fetal heart rate deceleration pattern. The nurse should first:
"
CHOICES
( X ) a.) Administer oxygen by mask at 4 liters.
( O ) b.) Change the client's position.
( X ) c.) Contact the client's physician.
( X ) d.) Document the tracing in the client's record.
RATIONALE: A variable deceleration pattern of the fetal heart rate is usually due to cord compression. This may be a result of the cord around the presenting part, a short cord, or the maternal position. Treatment involves changing the maternal position. If this does not resolve the variable heart rate pattern, the physician or nurse midwife should be notified. Oxygen may be needed at a rate of 8 to 12 liters. If changing the position does not resolve the problem, the physician should be notified. Documenting the problem does not resolve the problem of cord compression. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 671 _ about (MC)
QUESTION: "The nurse is caring for a primipara during the first hour after a vaginal delivery of a viable neonate under lumbar epidural anesthesia and intravenous fluids. While assessing the client, the nurse observes that the client has a pulse rate of 65 bpm, temperature of 99.9%F (37.7%C), fundus firm at one finger breath above the midline, and a slow trickle of dark red vaginal bleeding on the perineal pad. The client's legs are still somewhat numb. The nurse should:"
CHOICES
( X ) a.) Notify the anesthesiologist who performed the lumbar epidural anesthesia.
( O ) b.) Massage the fundus and contact the client's physician immediately.
( X ) c.) Continue to monitor the client's temperature on an hourly basis.
( X ) d.) Discontinue the client's intravenous fluids if the client is drinking fluids.
RATIONALE: A slow, dark-red trickle of blood after a delivery is a symptom of postpartum hemorrhage; it should be reported and treated immediately. If the cause is due to uterine atony, the nurse should gently massage the fundus, call for assistance, and prepare to administer oxytocic drugs. If the cause is due to massive blood clots in the uterus, the client may need to have the clots manually extracted. It is not unusual for the client's legs to still be numb; therefore, it is not necessary to call the anesthesiologist. The client's temperature is normal for this stage of the postpartum period. If the client has an intravenous line, this should not be discontinued until the bleeding is under control because the client may need intravenous fluids or blood replacement therapy to prevent shock. Hemorrhage is one of the three leading causes of maternal mortality. The other two causes are infection and pregnancy-induced hypertension. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 679 _ about (MC)
QUESTION: "A 30-year-old multigravida with prolonged rupture of membranes is diagnosed with endometritis 36 hours after delivery of a viable neonate. While assessing the client after intravenous antibiotic therapy is initiated, the nurse notes that the client's temperature is 100%F (37.8%C), pulse rate is 124 bpm, and respirations are 24 breaths/minute. The nurse should:"
CHOICES
( X ) a.) Administer an analgesic as ordered.
( X ) b.) Provide the client with clear liquids.
( X ) c.) Monitor the vital signs every 4 hours.
( O ) d.) Contact the physician immediately.
RATIONALE: The nurse should contact the physician immediately because the client is demonstrating danger signals of septic shock. Tachycardia, or a pulse rate greater than 120 bpm, and tachypnea, or respirations of 24 breaths/minute or higher, are both danger signs of septic shock. Hypotension, changes in the level of consciousness, and decreased urine output are later signs. Analgesics can assist the client's comfort but are not critical at this time. Providing the client with clear liquids does not address the life-threatening problem of septic shock. The vital signs should be monitored more frequently than every 4 hours if the client is developing septic shock. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
******************************
--> QUESTION NUMBER _ 681 _ about (MC)
QUESTION: "The nurse is caring for a primigravida at 28 weeks' gestation who is admitted with a diagnosis of preterm labor. The client's contractions are occurring every 15 to 20 minutes, lasting 25 seconds. The membranes are intact. The nurse should plan to:"
CHOICES
( X ) a.) Obtain equipment for an amniotomy.
( X ) b.) Prepare terbutaline in an intravenous solution of normal saline.
( X ) c.) Request assistance from the neonatal resuscitation team.
( O ) d.) Place the client on bed rest on her left side.
RATIONALE: This client is experiencing early signs of preterm labor. The nurse should plan to place the client on bed rest on her left side, which promotes uterine placental perfusion and increased oxygen supply to the fetus. Amniotomy, or rupture of the membranes, will not be performed unless delivery is necessary due to an infection or fetal compromise. Terbutaline should be given in an intravenous solution of 5% dextrose and water, not normal saline, to prevent edema and possible cardiac overload. The neonatal resuscitation team should be alerted to the client's admission and potential delivery, but their assistance is not needed at this time. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 684 _ about (MC)
QUESTION: "A primigravida client at 26 weeks' gestation visits the clinic and tells the nurse that her lower back aches when she arrives home from work. The nurse should suggest that the client perform:"
CHOICES
( O ) a.) Tailor sitting.
( X ) b.) Leg lifting.
( X ) c.) Shoulder circling.
( X ) d.) Squatting exercises.
RATIONALE: Tailor sitting is an excellent exercise that helps to strengthen the client's back muscles and also prepares the client for the process of labor. The client should be encouraged to rest periodically during the day and avoid standing or sitting in one position for a long time. Leg lifts are helpful for leg aches. Shoulder circling exercises are helpful for neck and upper backaches. Squatting is not helpful for alleviating lower backaches. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
******************************
--> QUESTION NUMBER _ 686 _ about (MC)
QUESTION: "The nurse is caring for a primipara who delivered a viable neonate vaginally 12 hours ago. The client is diagnosed with class II heart disease. The nurse should instruct the client to:"
CHOICES
( X ) a.) Remain on bed rest continuously.
( O ) b.) Allow the nursing staff to assist her in baby care.
( X ) c.) Avoid breast-feeding because this may cause exertion on the heart.
( X ) d.) Keep fluid intake to a minimum to avoid fluid overload.
RATIONALE: The client diagnosed with class II heart disease may become easily fatigued with exertion. The client should be encouraged to rest frequently and ask for assistance with care of the neonate. The client does not need to remain on continuous bed rest. Breast-feeding is not contraindicated. The client should be encouraged to remain well-hydrated by drinking plenty of fluids. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 690 _ about (MC)
QUESTION: "The nurse is caring for a multigravida in active labor with continuous electronic fetal heart rate monitoring. As the client begins to push, the nurse observes that the fetal heart rate shows a deceleration pattern that mirrors the contractions. The nurse should:"
CHOICES
( X ) a.) Turn the client to her left side.
( X ) b.) Ask the client to push in the squatting position.
( O ) c.) Continue to monitor the client and fetus.
( X ) d.) Administer oxygen by mask at 8 liters.
RATIONALE: Early decelerations are decelerations that mirror the contraction pattern. They are caused by pressure on the fetal skull and are not considered an ominous sign. The nurse should continue to monitor the client and fetus. Early decelerations are common during the second stage of labor. Turning the client to the left side is not warranted. Pushing in the squatting position should not alter the early deceleration pattern. Administering oxygen is not warranted. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 694 _ about (MC)
QUESTION: "While caring for a neonate 2 days after birth, the nurse observes a swelling on the neonate's head that appears to have blood between the bone and the periosteum and does not cross the cranial suture line. The nurse should explain to the parents that this will:"
CHOICES
( X ) a.) Require several surgeries to repair.
( X ) b.) Remain swollen for at least 6 months before receding.
( O ) c.) Resolve without treatment by 6 weeks of age.
( X ) d.) Be a normal symptom of a skull fracture that occurred during the delivery.
RATIONALE: The neonate has a cephalohematoma, which usually resolves without treatment by 6 weeks of age. It is usually not present at birth and begins about 24 hours after delivery. It is caused by pressure on the fetal skull during the birth process. Because of the breakdown of red blood cells within the hematoma, the neonate is at greater risk for hyperbilirubinemia. The neonate does not need repeated surgeries. The condition will resolve in 6 weeks, not 6 months. About 10% to 25% of neonates may have a skull fracture, but the skull fracture is not the cause of the hematoma. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 697 _ about (MC)
QUESTION: "A client with class II cardiac disease in active labor is planning on epidural anesthesia for labor and delivery. After the anesthesiologist has explained the procedure and potential complications, the nurse determines that the client needs further instructions when she says:"
CHOICES
( X ) a.) "Sometimes the labor process is slower after the epidural anesthesia is administered."
( X ) b.) "If my bladder gets full, I may need to be catheterized."
( X ) c.) "I may not feel the urge to push with this type of anesthesia."
( O ) d.) "I may need to lie flat for 6 hours and drink plenty of fluids after I deliver."
RATIONALE: Headache is not a common side effect of epidural anesthesia because the dura mater is not entered. Anesthesia and analgesia can slow the process of labor. Epidural anesthesia is associated with a decreased urge to void; therefore, catheterization of a full bladder may be necessary. Because the client is anesthetized, the client may not feel the urge to push so bearing-down efforts during the second stage of labor may be less effective. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 702 _ about (MC)
QUESTION: "A multigravida is admitted to the labor area for induction with intravenous oxytocin because she is 42 weeks pregnant. The nurse should instruct the client that during the process of labor:"
CHOICES
( O ) a.) Continuous fetal heart rate monitoring will be implemented.
( X ) b.) Frequent ultrasound examinations will be performed.
( X ) c.) At least 5 to 10 fetal scalp pH tests will be performed.
( X ) d.) Oligohydramnios will be carefully evaluated.
RATIONALE: Uteroplacental insufficiency is associated with a post-term fetus; therefore, it is recommended that the fetal heart rate and contraction pattern be monitored throughout the labor and delivery process. In addition, intravenous oxytocin, which is frequently used for induction of labor, may result in hyperstimulation of the uterus. Therefore, monitoring the client is critical. One ultrasound may be performed to assess position and confirm gestational age. A scalp pH may be performed if there is evidence of fetal bradycardia, particularly late decelerations, but 5 to 10 scalp pH measurements would be highly unusual. These clients generally do not have a decreased amount of amniotic fluid (oligohydramnios). NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 706 _ about (MC)
QUESTION: "The nurse is caring for a primigravida at about 9 weeks' gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she says:"
CHOICES
( O ) a.) "Nausea and vomiting can be decreased if I eat a few crackers before arising."
( X ) b.) "If I start to leak colostrum, I should cleanse my nipples with soap and water."
( X ) c.) "If I have a vaginal discharge, I should wear nylon underwear."
( X ) d.) "Leg cramps can be alleviated if I put an ice pack on the area."
RATIONALE: Eating dry crackers before arising can assist in decreasing the common discomfort of nausea and vomiting. Avoiding strong food odors and eating a high-protein snack before bedtime can also help. Nipples should not be cleansed with soap. Cotton, not nylon, underwear should be worn if there is a vaginal discharge. The client should contact her health care provider for evaluation of the discharge. Leg cramps should be treated with heat, not ice. Adequate dairy products can also decrease the incidence of leg cramps. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 707 _ about (MC)
QUESTION: "The nurse is preparing to administer promethazine (Phenergan) intramuscularly to a client in active labor. The nurse should explain to the client that one effect of this medication is:"
CHOICES
( O ) a.) Decreased nausea and vomiting.
( X ) b.) Increased fetal heart rate.
( X ) c.) Increased neonatal sucking reflex.
( X ) d.) Increased blood pressure in the client.
RATIONALE: Promethazine is a tranquilizer that also serves as an antinauseant. It is a muscle relaxant that potentiates narcotics and barbiturates. The fetal heart rate and beat-to-beat variability usually decrease after analgesia is administered. Tranquilizers used in labor may have a central nervous system depressant effect on the neonate; reduced sucking may occur. Tranquilizers used in labor can decrease the client's blood pressure. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 710 _ about (MC)
QUESTION: "A primigravida client visits the clinic at 12 weeks' gestation and tells the nurse that she has a cold and her nose is stuffy. The nurse should instruct the client to treat the nasal stuffiness by using:"
CHOICES
( X ) a.) Oral antihistamines.
( X ) b.) Oral decongestants.
( X ) c.) Ice packs to the nasal area.
( O ) d.) Saline nose drops.
RATIONALE: Saline nose drops are a natural remedy and can alleviate the discomfort. Clients who are pregnant should not take any medications without consulting the health care provider; therefore, oral antihistamines should be avoided. Clients who are pregnant should not take any medications without consulting the health care provider; therefore, oral decongestants should be avoided. Ice packs are not helpful in alleviating congestion. Warm moist towels might be helpful. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 720 _ about (MC)
QUESTION: "The nurse makes a home visit to a primigravida on the fourth postpartum day after delivery of a viable neonate. When the nurse enters the house, the nurse finds the client sitting in a chair, crying inconsolably, while the neonate is crying in another room. The client tells the nurse that she hasn't been sleeping well and has been hearing voices. The nurse determines that the client is most likely experiencing:"
CHOICES
( X ) a.) Normal reactions to being a new mother.
( O ) b.) Postpartum psychosis.
( X ) c.) The "baby blues."
( X ) d.) Postpartum depression.
RATIONALE: The client's symptoms of insomnia, crying inconsolably, and hearing voices (hallucinations) are all symptoms of postpartum psychosis. The client needs immediate treatment to prevent injury to herself and the neonate. Postpartum psychosis occurs in about 1 in 1000 pregnancies; thus, it is relatively rare but serious. Hospitalization, social support, and psychotherapy are used to treat postpartum psychosis. Prognosis for recovery is good, but the condition may recur with subsequent pregnancies. Although crying at times may be expected, ignoring a crying newborn and hearing voices are not normal reactions. "Baby blues" is a transient condition; mothers experiencing this do not hear voices. Postpartum depression continues for several weeks or months after delivery. Crying, sadness, and lack of appetite may be present but the client does not hear voices. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 721 _ about (MC)
QUESTION: "The nurse admits a multigravida client in active labor to the birthing center. The client has had no prenatal care with this pregnancy. The nurse determines that the client's cervix is 9 cm dilated, completely effaced, and 0 station with a face presentation. After explaining to the client about face presentations, the nurse determines that the client understands the issues associated with face presentation when she says:"
CHOICES
( X ) a.) "Face presentation is associated with abruptio placentae."
( X ) b.) "Babies who are past their due date may have a face presentation."
( X ) c.) "If the baby's chin is facing my back, a vaginal delivery is likely."
( O ) d.) "Face presentation is associated with a small maternal pelvis."
RATIONALE: Face presentations are associated with a small or contracted maternal pelvis. It may occur with the relaxed uterus of a multigravida, prematurity, hydramnios, or placenta previa. Face presentations are associated with placenta previa, not abruptio placentae. Face presentations are associated with prematurity, not prolonged gestation. If the fetal chin is posterior, a cesarean section is warranted because uterine dysfunction or transverse arrest may occur. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 725 _ about (MC)
QUESTION: "The nurse is caring for a multigravida in active labor with a fetus in a frank breech presentation. The nurse should notify the physician if the nurse observes:"
CHOICES
( O ) a.) Fetal bradycardia at any time during the labor process.
( X ) b.) Intense uterine contractions during the transition phase of labor.
( X ) c.) Maternal tachycardia during a contraction.
( X ) d.) Meconium-stained amniotic fluid during the second stage of labor.
RATIONALE: The client with a breech presentation needs to be carefully monitored for fetal distress or fetal bradycardia, which is often associated with umbilical cord compression. It is not unusual to see an increased intensity and frequency of contractions during the transition stage of labor. Maternal tachycardia between contractions is indicative of an infection, not breech presentation. It is normal for the heart rate to increase during contractions; the healthy woman will adjust to these changes. Meconium-stained amniotic fluid is not unusual with a breech presentation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 728 _ about (MC)
QUESTION: "The nurse assessing a multigravida at 36 weeks' gestation plans to assess the client for symptoms of pregnancy-induced hypertension. The nurse should plan to first assess the client's:"
CHOICES
( O ) a.) Face.
( X ) b.) Reflexes.
( X ) c.) Pulse.
( X ) d.) Ankles.
RATIONALE: The most consistent signs of pregnancy-induced hypertension are sudden, excessive weight gain and facial and finger edema. Checking the reflexes will not provide the nurse with data related to pregnancy-induced hypertension. Checking the client's pulse will not give information relevant to pregnancy-induced hypertension. Ankle and leg edema are common in pregnant women due to the fluid volume shifts associated with pregnancy. Therefore, it is not a reliable indicator of pregnancy-induced hypertension. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 738 _ about (MC)
QUESTION: "A 37-year-old Hispanic client visits the clinic for the first time. She is about 12 weeks pregnant, and this is her first pregnancy. The nurse instructs the client that one test that will most likely be ordered is a:"
CHOICES
( O ) a.) Glucose tolerance test.
( X ) b.) Chorionic villi sampling.
( X ) c.) Urine culture and sensitivity.
( X ) d.) Hepatitis D test.
RATIONALE: There is a greater incidence of both gestational diabetes and preexisting diabetes among women older than 35 years. In addition, clients of Native American and Hispanic descent have a greater incidence of gestational diabetes than the general population. The client does not present symptoms that would warrant testing of chorionic villi. The client does not present symptoms that would warrant a urine culture and sensitivity test. The client does not present symptoms that would warrant testing for hepatitis D. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 743 _ about (MC)
QUESTION: "The nurse is caring for a 38-year-old primigravida in the third trimester of pregnancy. The nurse plans to assess the client for symptoms of:"
CHOICES
( X ) a.) Pelvic inflammatory disease.
( X ) b.) Ruptured membranes.
( X ) c.) Cardiac overload.
( O ) d.) Pregnancy-induced hypertension.
RATIONALE: There is a strong association between advanced maternal age and pregnancy-induced hypertension as well as chronic hypertension. The incidence of pregnancy-induced hypertension is greatest among primigravidas. Pregnancy-induced hypertension is much more common than pelvic inflammatory disease. The client in the third trimester rarely exhibits symptoms of pelvic inflammatory disease. Although the older client is at risk for preterm labor and birth, this client does not present any symptoms of preterm labor. Cardiac overload may occur with clients who have been diagnosed with cardiac disease. Cardiac adjustment in healthy women occurs during pregnancy, labor, and delivery. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 747 _ about (MC)
QUESTION: "While assessing a primipara during the immediate postpartum period, the nurse plans to use both hands to assess the client's fundus to:"
CHOICES
( O ) a.) Prevent uterine inversion.
( X ) b.) Promote uterine involution.
( X ) c.) Hasten the puerperium period.
( X ) d.) Determine the size of the fundus.
RATIONALE: Using both hands to assess the fundus is useful for the prevention of uterine inversion. Using both hands does not hasten or promote uterine involution, which lasts about 6 weeks from the time of delivery. Using both hands to assess the fundus will not hasten the puerperium period. Determining the size of the fundus may be important if the client is experiencing excessive lochia because an enlarged fundus may be an indicator of retained blood clots or placenta fragments. The nurse, though, does not need to use both hands to determine this. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 748 _ about (MC)
QUESTION: "Which of the following would indicate effective therapy in a neonate born at 38 weeks gestation and given oxygen as a treatment for cold stress?"
CHOICES
( X ) a.) Heart rate is 200 bpm at rest.
( X ) b.) Respiratory rate is 48 breaths/minute at rest.
( O ) c.) Axillary temperature is 98%F (36.3%C).
( X ) d.) Blood pressure is 56/30 mm Hg.
RATIONALE: Oxygen is given to a neonate experiencing cold stress to support an increase in the metabolic rate through a complex process of increasing metabolism. Axillary temperature readings are used because the initial response to cold stress is vasoconstriction, resulting in a decreased skin temperature. A heart rate of 200 bpm is above the normal range for a neonate at rest, possibly reflecting the need for more oxygen at the cellular level. A respiratory rate of 48 breaths per minute is above the normal range for a neonate at rest, possibly reflecting the need for more oxygen at the cellular level. A blood pressure reading of 56/30 mm Hg is normal for a neonate at 38 weeks' gestation. Thus, it is not a reliable indicator of effective therapy. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 749 _ about (MC)
QUESTION: "Which of the following methods for checking placement of a gavage feeding catheter would be most appropriate after introducing the catheter into the neonate's stomach?"
CHOICES
( O ) a.) Aspirating stomach contents through the catheter with a syringe.
( X ) b.) Auscultating clear breath sounds after instilling a small amount of air into the catheter.
( X ) c.) Aspirating water back into a syringe after introducing it into the catheter.
( X ) d.) Flushing the catheter with a small amount of water.
RATIONALE: The method most often recommended to determine whether or not the gavage catheter is in the stomach is to aspirate stomach contents with a syringe. The presence of stomach contents indicates that the catheter is in the stomach. Any stomach contents obtained should be reintroduced into the stomach to prevent loss of electrolytes. Water introduced into the catheter before placement is confirmed may end up in the lungs. Air introduced into the catheter can be auscultated as a "whoosh" in the stomach area, not as clear breath sounds. No water should be used to confirm placement because water introduced into the catheter before placement is confirmed may end up in the lungs. No water should be used to confirm placement because water introduced into the catheter before placement is confirmed may end up in the lungs. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 750 _ about (MC)
QUESTION: "When preparing to give a neonate the first feeding by nipple, for which of the following reasons would the nurse anticipate using a 5 mL feeding of sterile water first?"
CHOICES
( O ) a.) Ascertain the patency of the neonate's esophagus.
( X ) b.) Determine if the neonate can retain the feeding.
( X ) c.) Ensure that the neonate has the energy to take oral feedings.
( X ) d.) Ensure that the mother will be able to feed the neonate.
RATIONALE: Small amounts of sterile water are given to a neonate first to ascertain if the esophagus is patent and to prevent the aspiration of formula if it is not. Assessment of the neonate's ability to retain feedings requires additional time and collection of additional information. Determining if the neonate has the energy to take oral feedings requires additional assessment time and data. More information about the mother is needed. For example, the nurse should watch the mother actually feeding the neonate to determine her ability. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 751 _ about (MC)
QUESTION: "The parents express concern about the condition of their premature neonate. To meet the short-term goals of decreasing the parents' fears and fostering bonding, which of the following would the nurse include in the plan of care?"
CHOICES
( O ) a.) Allowing the parents to see and touch their neonate.
( X ) b.) Arranging for a visit with another couple who have an ill preterm neonate.
( X ) c.) Encouraging the parents to participate in the neonate's care.
( X ) d.) Telling the parents not to worry because the neonate is doing well.
RATIONALE: Permitting the parents to see and touch the neonate allows for visual searching and information gathering, one of the first steps in the bonding process. Fingertip touching also helps promote the bonding process. Seeing and touching the neonate can often help the parents feel less concerned and more comfortable. The nurse should be present to help the parents understand therapeutic measures being used for the neonate. Although support from others is important, arranging for a visit and meeting with parents of another ill neonate may only increase the parents' concerns. Although parents are generally encouraged to care for their ill children, a high-risk neonate's care involves special skills that the parents may lack. A long-term nursing goal would be to instruct the parents in such care. Telling the parents not to worry ignores their feelings and tends to cut off communication. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 752 _ about (MC)
QUESTION: "A nurse working in a neonatal intensive care unit is developing infection control policies. Which of the following policies would the nurse expect to include as the single most effective means of preventing the spread of infection?"
CHOICES
( O ) a.) Having everyone coming in contact with neonates perform frequent hand and arm washing.
( X ) b.) Keeping each neonate in an isolation incubator that is opened as infrequently as possible.
( X ) c.) Maintaining a ventilation system in the unit that provides for continuous clean-air exchange.
( X ) d.) Requiring everyone who comes in contact with neonates to wear gowns and masks.
RATIONALE: Authorities agree that the single most effective way to control the spread of infection is to have personnel perform frequent arm and hand washings. Although using isolation incubators may be beneficial, it is not the most effective means of infection control. Although ventilation systems with clean-air exchanges may be beneficial, they are not the most effective means of infection control. Wearing gowns and masks is helpful but not the most effective means of infection control. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control
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--> QUESTION NUMBER _ 753 _ about (MC)
QUESTION: "A 10-day-old neonate brought to the clinic by the parents is lethargic and tachypneic with a heart rate of 200 bpm. Which of the following would be the nurse's primary focus initially?"
CHOICES
( X ) a.) Temperature pattern over the last few days.
( O ) b.) Number of wet diapers in the past 24 hours.
( X ) c.) Pupillary response now and 30 minutes later.
( X ) d.) Sleep patterns over the past week.
RATIONALE: The neonate is exhibiting signs and symptoms of a possible infection that place her or him at risk for sepsis due to an immature immunologic response. In addition, a neonate's kidneys are immature so they cannot conserve water as necessary, making dehydration a rapid process in an ill neonate. Thus, the nurse's primary focus is to determine the neonate's hydration status by assessing the number of wet diapers in the past 24 hours. Sepsis can result in shock. Other important assessment data would include skin turgor, mucous membrane status, and status of the fontanel. (A sunken fontanel indicates dehydration.) A neonate with sepsis would exhibit a normal or lower than normal temperature. A neonate has an immature immune system and does not manifest signs and symptoms of illness as an older infant would. Pupillary response would be assessed if meningitis or another neurologic infection were suspected. When a neonate develops sepsis, sleep patterns change. Typically, the neonate sleeps more than usual and is commonly irritable when awake. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 754 _ about (MC)
QUESTION: "Which of the following would lead the nurse to suspect that a neonate with an infection is developing septic shock?"
CHOICES
( X ) a.) Axillary temperature is 99.8%F (37.7%C).
( X ) b.) Blood pressure is 45/25 mm Hg.
( O ) c.) Heart rate during sleep is 205 bpm.
( X ) d.) Respiratory rate while awake is 32 breaths/minute.
RATIONALE: A sleeping heart rate of 205 bpm is above the normal 200 bpm for this age. Increased heart rate is an early indication of ensuing septic shock. Although the temperature is slightly elevated, it is not an indication of shock. A low axillary temperature may indicate the peripheral blood supply shutdown that occurs early in shock. A blood pressure of 45/25 mm Hg is normal for a neonate. The neonate's respiratory rate is within normal limits for age. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 755 _ about (MC)
QUESTION: "Which of the following laboratory values would the nurse interpret as associated with cold stress in a 1-day-old preterm neonate?"
CHOICES
( X ) a.) Bilirubin level of 13 mg/dL.
( O ) b.) Glucose level of 15 mg/dL.
( X ) c.) Hematocrit of 65%.
( X ) d.) Hemoglobin level of 23.5 g/dL.
RATIONALE: A common finding in neonates with cold stress is low serum glucose level. The normal range for this infant is 20 to 60 mg/dL. Thus, a level of 15 mg/dL suggests hypoglycemia. Bilirubin levels typically do not exceed 5 mg/dL. At 13 mg/dL, the infant would be jaundiced owing to hyperbilirubinemia. A hematocrit of 65% suggests polycythemia, not cold stress. Normally, hemoglobin is below 22 g/dL. A hemoglobin level of 23.5 mg/dL is associated with polycythemia, not cold stress. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 756 _ about (CM)
QUESTION: "A woman arrives at her obstetrician's office for an antepartum visit. Which of the following assessment findings if reported by the client would the nurse identify as presumptive signs of pregnancy? Select all that apply."
CHOICES
( O ) a.) Breast tenderness
( O ) b.) Fatigue
( O ) c.) Amenorrhea
( X ) d.) Braxton Hicks contractions
( X ) number="5">Fetal heartbeat
RATIONALE: Presumptive signs of pregnancy are those that cannot be verified by the examiner and could possibly indicate a condition other than pregnancy. Presumptive signs include breast tenderness, fatigue, and amenorrhea. Braxton Hicks contractions are considered probable signs of pregnancy. Fetal heartbeat is considered a positive sign of pregnancy. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 757 _ about (CM)
QUESTION: "Assessment of a multiparous woman during the beginning of the second stage of labor reveals contractions with a duration of 1 minute 45 seconds and a 30-second rest period. The nurse anticipates that which of the following will occur if these contractions continue? Select all that apply."
CHOICES
( X ) a.) Increased risk for cord compression
( O ) b.) Reduction of placental blood flow
( O ) c.) Increased risk of a pathological ring
( O ) d.) Increased risk of fetal anoxia
( X ) number="5">Shortening of the second stage of labor
( X ) number="6">Requests for increasing the amount of pain medication needed
RATIONALE: Contractions less than 2 minutes apart or lasting greater than 90 seconds decrease the amount of placental blood flow, which compromises fetal oxygen and increases the risk of anoxia. Decreased resting of uterine muscle increases the risk of uterine rupture from a pathological ring. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 758 _ about (FI)
QUESTION: "A high-risk client with diabetes was given a nutritional plan to promote a healthy pregnancy. To establish an estimate of a more specific weight gain, the dietitian determines the client's body mass index (BMI). The client is 5'5" tall, and weighs 155 pounds. What is the client's BMI?"
.
RATIONALE: To determine BMI = divide weight (kg) by m^2 (height into meters squared). First convert the client's weight to kilograms: 155 pounds 9 2.2 = 70.45 kg Then determine the client's height: 5'5" = 162.5 cm 9 100 = 1.625 m Then square the client's height in meters: 1.625 x 1.625 = 2.64 Lastly, divide the client's weight in kilograms by the height in meters squared: 70.45 9 2.64 = 27.11
The client's BMI = 27 NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 759 _ about (CM)
QUESTION: "A primipara has been in labor for 8 hours. She has been pushing for 30 minutes. The head is crowning. The nurse instructs the client to pant rather than continue pushing to avoid which of the following? Select all that apply."
CHOICES
( O ) a.) Rapid expulsion of the head
( X ) b.) An increase in severity of maternal hemorrhoids
( O ) c.) Risk of perineal tears
( X ) d.) The risk of maternal hyperventilation
( O ) number="5">Rapid changes in pressure to the infant's head
( X ) number="6">An increase in maternal blood pressure
RATIONALE: Rapid expulsion of the fetal head produces increased pressure on the head during the birth process. An increased risk for perineal tears can also occur when the contractions are continued while the head is being delivered. Hemorrhoids, maternal hyperventilation, and increased maternal blood pressure would not be a concern at this point. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 760 _ about (CM)
QUESTION: "Upon her arrival to the birthing room, the client informs the nurse that her previous labors were precipitous. When developing the client's plan of care, the nurse would expect to focus interventions on preventing possible complications associated with precipitous labor including which of the following? Select all that apply."
CHOICES
( O ) a.) Premature separation of placenta
( O ) b.) Fetal subdural hematoma
( X ) c.) Fetal respiratory depression
( O ) d.) Postpartal maternal hemorrhage
( X ) number="5">Increased fetal anoxia
RATIONALE: Labor of less than 3 hours' duration is known as precipitous labor. Contractions are stronger and may occur more frequently in multiparas or during induction with the use of oxytocin. The nurse needs to be alert for possible complications, including an increased risk for fetal subdural hemorrhage, maternal lacerations, and postpartum hemorrhage. Fetal respiratory depression and increased fetal anoxia are not complications associated with precipitous labor. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 761 _ about (CM)
QUESTION: "The nurse initiates a follow-up call with the client 5 days after discharge. Which of the following statements would lead the nurse to suspect that the client is experiencing postpartum depression? Select all that apply. "
CHOICES
( O ) a.) "I can't seem to stop crying with the baby keeping me up all night."
( X ) b.) "I'm trying to be more organized now that my sister has gone back home."
( O ) c.) "I just feel so awful. What a rotten mother I am."
( O ) d.) "Things are just so hard. I don't know what to do."
( X ) number="5">"I don't think that the baby is getting enough milk when I breastfeed."
RATIONALE: It is not uncommon for a mother to feel let down after the birth of the baby. She has had to cope in many ways to adjust to the changes in her body and her life to meet the demands of caring and raising a child. However, depression can begin as early as 1 to 2 days postpartum. Signs and symptoms include crying, difficulty concentrating, and feelings of anxiety. Complaints such as an inability to stop crying, feeling awful, stating she is a rotten mother, and not knowing what to do suggest depression. Although depression usually resolves within 2 weeks, it can lead to more severe psychosis. The statement about trying to be more organized indicates coping with a new situation. The statement about the baby not getting enough milk with breastfeeding indicates a need for additional teaching. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 762 _ about (CM)
QUESTION: "When developing a teaching plan emphasizing maternal and fetal needs for a 13-year-old adolescent who is 12 weeks pregnant, which of the following would the nurse include as being increased for pregnant teenagers? Select all that apply."
CHOICES
( O ) a.) Inadequate nutritional needs
( O ) b.) Pregnancy induced hypertension
( O ) c.) Cephalopelvic disproportion
( O ) d.) Postpartal hemorrhage
( O ) number="5">Preterm labor
( X ) number="6">Abruptio placentae
RATIONALE: A 13-year-old adolescent is still in the developmental stage of establishing relationships and sense of self. Nutrition during the adolescent years is often less than optimal in meeting the daily requirements. This less-than-optimal nutritional status is further compounded by the increased nutritional needs of pregnancy. The adolescent teenager also is at increased risk for pregnancy-induced hypertension, possibly related to poor nutrition and socioeconomic factors. The adolescent's reproductive organs are not mature, which leads to an increased risk of cesarean section for cephalopelvic disproportion. The risk for postpartal hemorrhage is increased due to uterine immaturity, which interferes with the ability of the uterus to contract readily due to overdistention from the growing fetus. Preterm labor may be a result of a lack of education, a poor understanding of the labor process and an inability to recognize signs and symptoms of early labor. The risk for developing abruptio placentae is not increased with adolescent pregnancy. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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