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40 Cards in this Set

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A client that is 6 months' pregnant comes to the clinic for a routine visit. She asks what she can do to relieve constipation. The nurse should teach the client that the most appropriate measures to alleviate this problem include which of the following recommendations?

1. Take a mild laxative and use a Fleet enema as needed.
2. Drink 8-10 cups of water and take a daily walk.
3. Add more protein and fat to the daily diet.
4. Drink hot coffee or tea each morning at breakfast.
2. Drink 8-10 cups of water and take a daily walk.

RATIONALE
1. Laxatives and enemas stimulate the intestinal tract, but also can initiate uterine contractions.
2. Intestinal motility is slowed in pregnancy due to the influence of progesterone. Increasing fluid intake and exercise stimulates peristalsis.
3. High-fat and high-protein foods contribute to constipation.
4. Caffeine can cause tachycardia in the fetus and its use during pregnancy is discouraged.
A client at 26 weeks of gestation asks why she is having trouble with constipation during her pregnancy. Which of the following explanations by the nurse would be most accurate?
1. The muscle movement of the intestines slows down, which causes dry, hard stools.
2. the muscl emovmeentn of the intestines speeds up, which ccauses dry, hard stools.
3. The intestines are compressed during pregnancy, which causes stool stasis.
4. The intestines are expanded during pregnancy, which causes stool stasis.
1. The muscle movement of the intestines slows down, which causes dry, hard stools.

RATIONALE
1. Progesterone causes peristalsis to slow so more nutrients can be absorbed.
2. An increase in intestinal motility causes diarrhea.
3. Compression of the intestines during pregnancy does not contribute to constipation.
4. The intestines do not increase in diameter due to pregnancy.
A client was admitted to the obstetric unit on 9/10/02 with c/o labor. The nurse palpated regular uterine contractions every 5 minutes with moderate intensity. A sterile vaginal exam revealed a soft cervix that was 85% effaced and dilated to 2 cm. Which of the following admission information is most important in planning nursing care?
1. The client's blood type and Rh were A+.
2. The client's hemoglobin was 11 g/dL.
3. The client's LMP was 2/15/02.
4. The client's blood pressure was 100/64 mm Hg.
3. The client's LMP was 2/15/02.

RATIONALE
1. Blood type A with Rh+ does not present any problems in patient care. Maternal blood type O and/or Rh- blood types can cause severe jaundice in the newborn due to maternal antibodies that destroy fetal RBCs.
2. RBCs are diluted by the increase in plasma volume in pregnancy. A hemoglobin of 11 g/dL is phyiological anemia, as opposed to true anemia.
3. Using Nagle's rule, and LMP of 2/15/02 would give an EDD of 11/29/02. This client is in preterm labor at 28 5/7 weeks' gestation.
4. During the first two trimesters of pregnancy, meternal blood pressure normally decreases by 5-10 mmHg in both systolic and diastolic pressures. This decrease is due to peripheral vasodilation caused by pregnancy hormones.
A 22-year-old client at 7 weeks' gestation attended the first trimester class on nutrition. Which of the following statements indicatea a need for further teaching?
1. "I should gain around 30 pounds by my due date."
2. "Planning meals around the food pyramid guide is best."
3. "Frozen foods are more nutritious than canned foods."
4. "My craving are probably caused by iron deficiency."
4. "My craving are probably caused by iron deficiency."

RATIONALE
1. Appropriate weight gain for pregnancy is between 25 and 35 lbs.
2. Intrauterinie growth retardation can be caused by poor maternal diets. The U.S.F.D.A. recommends following the food pyramid recommendations for improving dietary intake.
3. Canned foods lose some nutrients in processing. Foods that are frozen are processed less and more nutritious.
4. Pica is more related to cultural values and beliefs than to dietary deficiencies. Pica is more likely to cause iron deficiency than to be caused by it.
A client admitted to the obstetric unit with contractions every 8-10 minutes, with cervical effacement of 100%, and dilation of 3 cm, reported that she and her support person planned to use prepared childbirth techniques. The nurse would expect the couple to utilize which of the following pain relief methods during this phase of labor?
1. Slow, deep breathing
2. Rapid, shallow breathing
3. Local anesthesia
4. Narcotic analgesia
1. Slow, deep breathing

RATIONALE
1. This client is in the early phase of labor; slow, deep breathing and relaxation techniques are usually effective in relieving contraction pain during this phase.
2. Rapid, shallow breathing, or hyperventilation, is inappropriate for any phase of labor.
3. Local anesthesia is used for numbing of the perineum immediately before performance of an episiotomy and delivery of the fetus during the last phase of the first stage of labor.
4. Narcotic analgesia is not appropriate for use during early phases of labor. It can slow or stop labor if given before 5 cm dilation. In addition, minimizing use of narcotics is preferred when prepared childbirth techniques are used.
A 30-year-old gravida 5, para 4 (all female) client at 12 weeks' gestation asks the nurse, "Do you think I'm having a boy? If I don't have a boy this time, my husband will probably divorce me." Which of the following explanations by the nurse would be most accurate?

1. "Girls probably run in your family, there's nothing you can do about it."
2. "The heartbeat of the baby is fast, that means it's a boy."
3. "The father's sperm determines if the baby is male or female."
4. "Don't worry, you are carrying this baby low, that means it's a boy."
3. "The father's sperm determines if the baby is male or female."

RATIONALE

1. The sex chromosome of males is XY; the sex chromosome for females is XX. The mother contributes one X chromosome to the fetus, the father contributes either an X or a Y chromosome.
2. The heart rate of the fetus is neither faster nor slower according to fetal gender. The range for the fetal heart rate is 110-160 bpm regardless of gender.
3. Meiosis results in the X and Y chromosomes of the male splitting so that each sperm carries either an X or a Y chromosome, thus determining the gender of the fetus.
4. How a fetus is carried is related to meternal uterine and abdominal muscle tone. The gender of the fetus does not determine how high or low it is carried.
A client at term states, "I would like to breastfeed, but my mother-in-law told me my breasts are too small and I won't have enough milk for my baby." The best response by the nurse would be which of the following?

1. "Your breasts are small, but if you don't produce enough milk, you can give the baby some formula."
2. "The size of the breasts doesn't matter. All women have about the same amount of milk-producing tissue."
3. "You will produce more milk if you use a breast pump and then give it to your baby in a bottle."
4. "Milk production is increased by the hormone estrogen. You can ask your doctor for a prescription to take."
2. "The size of the breasts doesn't matter. All women have about the same amount of milk-producing tissue."

RATIONALE

1. The volume of breast milk produced is related to how often the breasts are emptied of milk. Formula supplementation decreases breast milk production since the infant nurses less often.
2. The amount of milk producing glandular tissue in all women is approximately the same. The size of large breasts is due to increased fatty tissue.
3. An infant is more efficient at emptying a breast than a breast pump. In addition, oral stimulation of the nipples by the infant stimulates the release of oxytocin, which triggers the let-down reflex.
4. Estrogen does not stimulate milk production. Oxytocin and prolactin are the hormones responsible for breast milk production and breastfeeding success.
A 32-hour-old baby has yellowish skin undertones and a serum bilirubin level of 14 mg/100 mL. The blood type of the baby is B+. The mother's blood type os O+. The infant is being breast-fed. The nurse would include which of the following measures in her plan of care?

1. No special measures are necessary, newborns normally get a little jaundiced.
2. Tell the mother to stop breast-feeding and give the baby formula instead.
3. Place the infant under the bililights and prepare for an exchange transfusion.
4. Encourage the mother to increase the frequency of breastfeeding sessions.
4. Encourage the mother to increase the frequency of breastfeeding sessions.

RATIONALE

1. Bilirubin levels in excess of 12 mg/100 mL may indicate the presence of a pathological process. This jaundice is most likely due to an ABO incompatibility.
2. Breastfeeding jaundice occurs around the third day of age. Encouraging early and frequent feedings at the breast lowers neonatal bilirubin levels.
3. Light therapy requires an order from the physician. Exchange transfusions for ABO incompatibilities are seldom necessary.
4. Early and frequent breastfeeding tends to lower serum bilirubin levels.
A primiparous client at 18 weeks' gestation had an ultrasound examination done which showed the fetus in a breech position. The client asked the nurse, "Does this mean I will have to have a C-section?" Which of the following responses by the nurse would be most accurate?

1. "If a first baby is breech, it must always be delivered by cesarean section."
2. "The baby will have more room to turn as your delivery date nears."
3. "You can probably deliver normally, most babies are born breech."
4. "Many babies are breech at this stage of pregnancy, most turn by term."
4. "Many babies are breech at this stage of pregnancy, most turn by term."

RATIONALE

1. If the fetus remains in a breech position, external version may be attempted at approximately 37 weeks' gestation to change position of the fetus. If version is unsuccessful in the nulliparous woman with a fetus in a breech position, cesarean delivery is almost always certain.
2. The uterus becomes more crowded, not less, as pregnancy progresses.
3. Few fetuses (3%-4%) are in a breech position by delivery; even fewer breech positions are delivered vaginally.
4. Approximately 96% of fetuses in a breech position will turn to a cephalic position by term.
A laboring client has been dilated 9-10 cm for 2 hours. The fetal head has remained at zero station for 45 minutes despite adequate pushing efforts by the client. A sterile vaginal exam reveals a position of occiput posterior. Which of the following actions by the nurse would be most appropriate?

1. Assist the client to a hands and knees position.
2. Assist the client to a supine position.
3. Prepare the client for a forceps rotation.
4. Prepare the client for a cesarean delivery.
1. Assist the client to a hands and knees position.

RATIONALE

1. Maternal position changes such as sitting, kneeling, lateral, or hands and knees, can assist fetal head rotation to an occiput anterior position.
2. The gravid uterus compresses the pelvic blood vessels and compromises uteroplacental blood flow. This position not only has no effect on rotation of the fetal head, but can cause fetal compromise.
3. Use of forceps at zero station is considered to be a high forceps classification and is not acceptable practice according to the American College of Obstetricians and Gynecologists.
4. Cesarean delivery should be considered only if adequate pushing efforts of 2 or more hours do not result in descent of the fetal head.
A client with preterm contractions at 34 weeks' gestation has had an amniocentesis for fetal lung maturity. Which of the following lab tests should the nurse monitor?

1. Human chorionic gonadotropin (hCG)
2. Phosphatidylgycerol (PG)
3. a-Fetoprotein (AFP)
4. Partial thromboplastin time (PTT)
2. Phosphatidylgycerol (PG)

RATIONALE

1. hCG is a hormone produced by the placenta that stimulates the corpus luteum to persist and secrete estrogen and progesterone, which maintains the pregnancy for the first 20 weeks of gestation. It is found in maternal blood and urine.
2. PG is a major phospholipid of surfactant. The presence of PG in amniotic fluid indicates fetal lung maturity.
3. AFP is a plasma protein that is produced by the fetus. Abnormally high or low levels can indicate fetal anomalies. AFP levels are drawn from maternal blood.
4. PTT levels are drawn to determine if sodium warfarin levels are at a therapeutic level in women with thromboembolic disease.
A client at 12 weeks' gestation has just been told that she is carrying dizygotic twins. She asks the nurse what the difference is between monozygotic and dizygotic twins. Which of the following explanations by the nurse would be most accurate?

1. "Monozygotic twins come from two different eggs and sperm."
2. "Dizygotic twins come from one fertilized egg that split."
3. "Monozygotic twins come from one egg and two sperm."
4. "Dizygotic twins come from two different eggs and sperm."
4. "Dizygotic twins come from two different eggs and sperm."

RATIONALE

1. Monozygotic twins (identical) develop from one fertilized egg that splits into identical halves early in embryonic development.
2. Dizygotic twins develop from two different ova fertilized by two different sperm.
3. Once an egg has been penetrated by a single sperm, chemical changes take place that prevent multiple sperm fertilization.
4. See rationale 2.
A 20-year-old client has come to the obstetric clinic because her menstrual period is 7 days late. She tells the nurse, "I'm sure I'm pregnant because my period is late and my breasts are tender." Which of the following responses by the nurse would be most accurate?

1. "Missed menses and breast tenderness are positive signs of pregnancy."
2. "Missed menses and breast tenderness are presumptive signs of pregnancy."
3. "Missed menses and breast tenderness are probable signs of pregnancy."
4. "Missed menses and breast tenderness are negative signs of pregnancy."
2. "Missed menses and breast tenderness are presumptive signs of pregnancy."

RATIONALE

1. The only positive signs of pregnancy are auscultation of fetal heart tones, visualization of the fetus by ultrasound, and fetal movement felt by the health-care provider.
2. Presumptive signs of pregnancy are amenorrhea, fatigue, breast tenderness and enlargement, morning sickness, and quickening.
3. Probable signs of pregnancy are Hegar's sign, ballottement, poristive pregnancy test, and Goodell's sign.
4. Amenorrhea and breast tenderness are presumptive signs of pregnancy.
A client is seen in the emergency room at 16 weeks' gestation with pelvic cramping and bright red vaginal bleeding. Which of the following signs and symptoms should the nurse observe the client for?

1. Increased temperature
2. Increased pulse pressure
3. Increasing heart rate
4. Increased blood pressure
3. Increasing heart rate

RATIONALE

1. Increased temperature may be a sign of infection; however, the risk of infection is greatest during the first 72 hours after spontaneous abortion or operative procedures.
2. The client is at risk for excess blood loss. The pulse pressure decreases with hemorrhage.
3. An increased pulse in the prescence of visible bleeding indicates excessive blood loss.
4. Increased blood pressure at this stage of pregnancy would be a symptom of a hydatidiform mole.
The anesthetist has just placed an epidural catheter dosed with bupivacaine hydrochloride (Marcaine) in a client at term in active labor. The nurse should observe the client for which of the following side effects?

1. Hypotension
2. Hypertension
3. Hyperventilation
4. Hypoventilation
1. Hypotension

RATIONALE

1. Hypotension is common with epidural anesthesia because the sympathetic nerves are also blocked by the medication, which results in vasodilation.
2. Hypertension is not a side effect of epidural anesthesia.
3. Hyperventilation is not a side effect of epidural anesthesia. A client is more likely to hyperventilate during painful contractions. Epidural anesthesia relieves contraction pain.
4. Hypoventilation is possible if epidural narcotics are used. An epidural narcotic (such as fentanyl) was not used in this case.
A client at 12 weeks' gestation has a history of thromboembolitic disease. The client is placed on daily heparin therapy. The nurse should monitor the results of which of the following laboratory tests?

1. Prothrombin time
2. Partial thromboplastin time
3. Bleeding time
4. Clotting time
2. Partial thromboplastin time

RATIONALE

1. The PT is assessed to maintain correct dosages of warfarin (Coumadin). Coumadin crosses the placental barrier and is contraindicated in pregnancy.
2. The PTT is evaluated to determine the effectiveness of heparin therapy.
3. A bleeding time is obtained preoperatively to determine how quickly blood clots to maintain homeostasis. It is not routinely performed on pregnant women, and is unnecessary for a pregnant woman on heparin therapy.
4. A clotting time is a ficitonal test.
A postpartum client complains of sharp pain in the calf of her right leg when walking. The nurse notes that the leg has a circumscribed area of redness, warmth, and tenderness. Which of the following nursing actions is most appropriate in this client's nursing care?

1. Instructing the client to massage the affected area to relieve the tenderness
2. Applying cold packs to the affected area to decrease inflammation
3. Encourage the client to ambulate to increase circulation.
4. Elevating the affected extremity to promote venous blood flow.
4. Elevating the affected extremity to promote venous blood flow.

RATIONALE

1. These are symptoms of thrombophlebitis; massage of the area can break the thrombus from the venous wall and cause an embolus.
2. Local application of heat is one of the treatments for superficial thrombosis.
3. The client with symptoms of thrombophlebitis should be placed on bed rest.
4. Administration of analgesics, local application of heat, bed rest for 5-7 days, and elevation of the affected extremity are often all that is needed to treat superficial thrombophlebitis.
A client has just started the third stage of labor. Which of the following nursing actions have priority at this time?

1. Encouraging the client to push
2. Administration of an oxytocic medication
3. Physical assessment of the infant
4. Promotion of the bonding process
3. Physical assessment of the infant

RATIONALE

1. The third stage of labor is the stage of delivery of the placenta. The placenta will spontaneously separate from the uterine wall and be expelled by uterine contractions. Maternal pushing is unnecessary.
2. Oxytocin should not be administered until after the placenta is delivered, which usually occurs 5-7 minutes after delivery of the infant.
3. The infant's physical condition is a priority at on eand five minutes after delivery. The physical assessment done at this time is known as Apgar scoring.
4. Initiation of the bonding process as soon as possible after birth is important, bu the physical stability of the newborn is most important at this time.
A client who delivered 45 minutes ago comes into the transitional nursery to see her infant. She askss the nurse, "My baby's head is shpaed like a cone? Will it stay like that?" Which of the following responses by the nurse is most accurate?

1. "That is called a caput. It usually lasts for 3 or 4 days."
2. "That is called molding. It usually lasts for a few days."
3. "That is called a cephalhematoma. It usually lasts for a few weeks."
4. "That is called a nevi. It usually lasts several months."
2. "That is called molding. It usually lasts for a few days."

RATIONALE

1. Caput succedaneum is an area of generalized edema of the scalp that was present at birth.
2. Molding is an overlapping of the skull bones at the occiput of the skull. The infant skull has a cone shaped appearance.
3. A cephalhematoma is a collection of blood between the skull bone and its periosteum. It is one-sided(does not cross suture lines), and appears within the first 2 days after delivery.
4. Nevi (also known as 'stork bites')are pink areas on the upper eyelids, nose, upper lip, lower occiput, and the nape of the neck.
A 20-year-old primiparous client, who is breastfeeding, is preparing to be discharged home with her newborn son. The nusre has completed discharge instructions on newborn care. Which of the following statements by the client would indicate a need for further teaching?

1. "I should clean the cord stump with alcohol or peroxide every day until it falls off."
2. "If my baby has at least two wet diapers and one bowel movement a day, he is getting enough to eat."
3. "I should dress my baby in clothing I would be comfortable in, plus a light blanket."
4. "I should nurse my baby whenever he acts hungry and for as long as he wants to nurse."
2. "If my baby has at least two wet diapers and one bowel movement a day, he is getting enough to eat."

RATIONALE

1. The cord stump should be cleaned with the solution ordered by the health-care provider daily until it falls off. Cord care helps the cord to dry and prevents infection.
2. A breastfeeding infant should have at least six wet diapers daily. Adequate urinary output is a reliable indicator of adequate intake of breast milk.
3. The infant should be dressed as parents would dress themselves. Overdressing can cause prickly heat rash. Wrapping the infant in a light blanket maintains body temperature and makes the infant feel secure.
4. Breast milk is more completely and quickly digested than formula. Breast-fed infants should be fed on deman. It is important for the infant to completely empty the breast, so infant sucking time at the breast should also not be limited.
The nurse is planning care for a client who had a spontaneous vaginal delivery with epidural anesthesia over an intact perineum. She is currently in the fourth stage of labor. Which of the following nursing goals would be most appropriate for this client?

1. The client will ambulate in the room without assistance.
2. The client will turn, coudh, and deep breathe 10 times an hour.
3. The client's epsiotomy will remain clean, dry, and intact.
4. The client will maintain physiological homeostasis.
4. The client will maintain physiological homeostasis.

RATIONALE

1. The fourth stage of labor is the immediate (approx. 1 hour) postpartum period. Epidural anesthesia takes approximately an hour to wear off. The client will be unable to ambulate during this time. In addition, all postpartum clients should be assisted with ambulation the first few times out of bed.
2. Pulmonary hygiene is important in clients with a respiratory condition, or those who have undergone an operative procedure. The client doesn't have an episiotomy.
3. The most common complication of the fourth stage of labor is uterine atony and hemorrhage.
A client delivered a term infant 6 hours ago. Which of the following assessment findings indicate normal postpartum progression?

1. Firm fundus at the umbilicus and midline with moderate lochia rubra
2. Firm fundus 1-2 bingerfbreadths above the umbilicus and midline with moderate lochia rubra
3. Firm fundus 1-2 fingerbreadths above the umbilicus and deviated to the right side with moderate lochia rubra
4. Firm fundus 3-4 fingerbreadths below the umbilicus and midline with moderate lochia rubra
2. Firm fundus 1-2 bingerfbreadths above the umbilicus and midline with moderate lochia rubra

RATIONALE

1. The fundal height is approximately 2 fingerbreadths below the umbilicus immediately after delivery. The fundal height increases to 1 fingerbreadth above the umbilicus within 12 hours. The fundal height will decrease approximately 1-2 fingerbreadths a day afterward. Lochia rubra will be present for 3-4 days after delivery.
2. Fundal height increases to 1 fingerbreadth above the umbilicus within 12 hours after delivery.
3. Fundal deviation to one side or the other indicates a full bladder and risk for hemorrhage.
4. The fundal height is 3-4 fingerbreadths below the umbilicus by the fourth to fifth postpartum day.
A client is pregnant at 12 weeks' gestation. Which of the following lab tests would the nurse need to interpret that would indicate a need for change in the client's plan of care?

1. White blood count = 14 mm3
2. Hematocrit = 32%
3. Hemoglobin = 10 g/dL
4. Serum glucose = 105 g/dL
3. Hemoglobin = 10 g/dL

RATIONALE

1. WBC counts indicate the presence or absence of infection. The normal range for WBCs in pregnancy is 9-15 mm3. There is no evidence of infection.
2. The normal hematocrit in pregnancy ranges from 32%-45%.
3. The normal hemoglobin in pregnancy ranges from 11-12 g/dL. This client is slightly anemic.
4. The normal serum glucose in pregnancy ranges from 65-110 g/dL.
A laboring client received epidural anesthesia with bupivacaine hydrochloride (Marcaine) for contraction pain 1 hour ago. Considering the effects of epidural anesthesia, which of the following nursing measures are important her care?

1. Assessing the client hourly for respiratory depression
2. Assessing the client hourly for bladder distention
3. Assessing the client hourly for uterine atony
4. Assessing the client hourly for hypertension
2. Assessing the client hourly for bladder distention

RATIONALE

1. Respiratory depression is associated with epidural narcotics. Marcaine is an anesthetic agent.
2. The woman may not sense the urge to void because of decreased sensation to the area. Pain caused by bladder distention can last for long periods of time.
3. Uterine atony is associated with administration of oxytoxic drugs. It is not an effect of epidural anesthesia.
4. Maternal hypertension is not an effect of epidural anesthesia.
A client arrived on the OB unit at term with mild irregular contractions. Findings from a sterile vaginal exam were as follow: cervical dilation of 3 cm, membranes were intact, and the presenting part at -1 station. An external fetal monitor was placed and the fetal heart tracing revealed a baseline of 130 with accelerations to the 150s during contractions. Which of the following nursing acitons would be most appropriate considering the client's situation?

1. Prepare the client for an immediate operative delivery.
2. Turn the client to her left side and adminster oxygen.
3. Notify the registered nurse to start an intravenous infusion stat.
4. Send the client home and encourage her to ambulate.
4. Send the client home and encourage her to ambulate.

RATIONALE

1. This is a reassuring fetal heart pattern; no immediate nursin gactions othe rthan comfort measures are necessary.
2. There ais no fetal distresss.
3. The client is in no need for fluid volume expansion; neither she nor the fetus is in distress.
4. This client is in very early labor. The fetal heart pattern is reassuring. Ambulation at home would stimulate labor and descent of the presenting part and decrease hospitalization time.
A 6-week postpartum client, who is breastfeeding, asks for information on birth control methods that do not affect breast milk production. Which of the following statements would indicate the client needs further instruction?

1. "Using condoms would be a good choice for me."
2. "I can use Dep-Provera and breastfeed without problems."
3. "Breastfeeding itself is effective at preventing pregnancy."
4. "I can use contraceptive foam for birth control."
3. "Breastfeeding itself is effective at preventing pregnancy."

RATIONALE

1. Condoms are a mechanical barrier method of contraception with an effectiveness rate of 88%. Condom usage does not interfere with breast feeding.
2. Depo-Provera is an injectable form of progestin with an effectiveness rate of 99.7%. Pregnancy is prevented for 3 months. It is safe for use during lactation once the milk supply is established.
3. High prolactin levels with exclusive breastfeeding can delay ovulation for up to 6 months. However, it is an unpredictable method of birth control.
4. The effectiveness of the contraceptive foams range from 72%-82%. It has no hormones to affect lactation, and is safe for use during the postpartum period.
An antepartum client at 16 weeks' gestation has tested positive for gonorrhea. All tests for other sexually transmitted infections were negative. Which fo the following information is most important in planning her nursing care?

1. Client drug allergies
2. Fishy-smelling discharge
3. The presence of a chancre
4. The presence of vesicles
1. Client drug allergies

RATIONALE

1. Gonorrhea is usually treated with penicillin. Drug allergies to penicillin are ocmmon and can result in an anaphylactic reaction.
2. A malodorous vaginal discharge is cause by Gardnerella vaginalis.
3. A chancre is seen with syphilis.
4. Vesicles are seen with herpes.
A non-insulin-dependent diabetic has just found out she is pregnant. She asks th eclinic nurse what she shoudl do about her diabetes. The most appropriate response by the nurse would be which of the following?

1. "You can control your blood sugar with oral hypoglycemic agents."
2. "You can control your blood sugar with insulin injectons."
3. "You can control your blood sugar with dietary changes."
4. "You can control your blood sugar by exercising more."
2. "You can control your blood sugar with insulin injectons."

RATIONALE

1. Oral hypoglycemic agents cross the placenta and cna cause fetal anomalies.
2. Insulin does not cross the placenta and is safe for use in pregnancy.
3. Only gestational diabetes can be treated with diet during pregnancy.
4. Only gestation diabetes can be treated with exercise during pregnancy.
An insulin-dependent diabetic at 18 weeks' gestation has arrived for a-fetoprotein testing. She asks the nurse why this test is being performed. Which of the following explanations by the nurse would be most accurate?

1. "This test is to determine the sex of your baby."
2. "This test is for fetal lung maturity."
3. "This test is for neural tube defects."
4. "This test is to determine glycemic control."
3. "This test is for neural tube defects."

RATIONALE

1. Analysis of amniotic fluid from amniocentesis allows determination of fetal gender.
2. The presence of phosphatidylglycerol and the L/S ratio determine fetal lung maturity. It is obtained from amniotic fluid.
3. AFP is a mternal blood test that can detect neural tube defects (The most common anomaly) in fetuses of diabetic women. It can also indicate the presence of Down's syndrome.
4. Glycemic control is determined by hemoglobin A1c, A meternal blood test.
A postpartum client had a spontaneous vaginal delivery 30 minutes ago. During the postpartum assessment, the nurse notes that there is constant tricling of bright red vaginal bleeding in the presence of a contracted uterus at midline. Which action by the nurse would be most appropriate in this situation?

1. Massage the fundus
2. Call the health-care provider
3. Have the client empty her bladder
4. Increase the oxytocin (Pitocin) infusion
2. Call the health-care provider

RATIONALE

1. Uteirne atony would reveal a constant trickle of bright red blood in the prexence of a boggy uterus.
2. Excessive lochia in the presence of a contracted uterus suggests lacerations of the birth canal. The HCP must be notified so the laceration can be repaired.
3. Excessive bleeding caused by a full bladder would reveal a uterus that was high and deviated to one side.
4. Increasing the rate of an infusion of oxytocin would not correct the problem of a lacerated birth canal.
The nurse enters the room of a breastfeeding client who delivered 3 hours ago and who is in tears. "I just don't know what I'm doing wrong!" she sobs. "I can't get my baby to take the nipple!" Which of the following nursing diagnoses would be most appropriate in this case?

1. Altered parenting related to difficulty in breastfeeding
2. Altered comfort related to sore nipples
3. Altered bonding process related to maternal frustration
4. Knowledge deficit related to breastfeeding techniques
4. Knowledge deficit related to breastfeeding techniques

RATIONALE

1. One session of breastfeeding problems does not result in altered parenting.
2. The difficulty is in infant latch-on, not sore nipples.
3. Success in breastfeeding has little to do with bonding/attachment.
4. Instruction and assistance from the nurse would most likely result in successful latch-on and breastfeeding.
A client delivered her first infant 1 day ago at term. Which of the following actions by the nurse would most likely promote the attachment process?

1. Take pictures of the baby for the mother to see.
2. Tell the mother what her baby looks like.
3. Take the mother to the nursery window to see her baby.
4. Give the baby to his mother and point out his features.
4. Give the baby to his mother and point out his features.

RATIONALE

1. Giving the mother pictures of her baby is appropriate only when an infant is too ill for physical contact.
2. Descriptions of the infant do not replace physical contact between mother an dbaby.
3. Direct physical contact between mother and baby is most likely to promote attachment.
4. The combination of direct physical contact between mother and baby and discussion of the child's physical and personality attributes assists the mother in recognizing her infant as a distinct individual who is yet a part of her. This process is the beginnings of attachment.
A 20-year-old multipara at 18 weeks gestation reports symptoms of thick white vaginal dishcarge and intense itching. A wet mount specimen reveals budding yeast cells with a diagnosis of Candida albicans. The client asks how to prevent future infections. Which of the following responses by the nurse is most accurate?

1. "Eat a serving of live culture yogurt daily."
2. "Douche after intercourse with vinegar and water."
3. "Douche with live culture yogurt daily."
4. "Take antibiotics as ordered until all are gone."
1. "Eat a serving of live culture yogurt daily."

RATIONALE

1. Evidence indicates that ingestion of live-culture yogurt decreases the incidence of vaginal yeast infections.
2. Vinegar and water douches decrease vaginal pH and inhibit the growth of yeast cells. However, douching is not recommended in pregnancy.
3. Douching with live-culture yogurt decreases vaginal pH. However douching is not recommended in pregnancy.
4. All antimicrobials cross the placenta; many can cause fetal organ damage. In addition, antibiotic therapy can increase the incidence of vaginal yeast infections.
A 24-year-old primipara at 32 weeks' gestation comes into the clinic with complaints of nasal stuffiness, nosebleeds, and bilateral hearing loss. She asks why she is having these symptoms. Which of the following explanations by the nurse is most accurate?

1. "This sounds like a bad cold, you need to take a decongestant."
2. "These symptoms are common in pregnancy because pregnancy hormones cause increased blood flow, which causes head congestion."
3. "These are symptoms of a major problem. You need to be referred to a specialist."
4. "This sounds like a sinus infection. It is caused by exposure to allergens, such as cat dander or plant pollen. You need to take antibiotics and antihistamines."
2. "These symptoms are common in pregnancy because pregnancy hormones cause increased blood flow, which causes head congestion."

RATIONALE

1. Increased estrogen levels cause congestion, swelling, an dhyperemia of the capillaries in the upper respiratory tract. These symptoms will not be relieved by antihistamines.
2. The elevated levels of estrogen during pregnancy cause increased blood blow in the upper respiratory tract. Nasal stuffiness, ear aches, hearing loss, and nose bleeds are common.
3. Referral to a specialist is not necessary because these are normal pregnancy symptoms.
4. These are normal pregnancy symptoms. Many antibiotics cross the placenta and are contraindicated in pregnancy. Antihistamines are also generallly not recommended in pregnancy.
A client in the second trimester of pregnancy has blood drawn for routine 12-week lab work. Which of the following results would be considered normal for this stage of pregnancy?

1. Hemoglobin of 11 g/mL
2. Hemoglobin of 18 g/mL
3. Serum glucose of 80
4. RBC count of 4
1. Hemoglobin of 11 g/mL

RATIONALE

1. Blood volume increases by 30%-50% in pregnancy. This causes hemodilution of RBCs and physiological anemia. Normal hemoglobin levels in pregnancy range from 11-12 g/dL.
2. Plethora is not a normal finding in pregnancy.
3. Normal serum glucose in pregnancy is 65.
4. This is a normal RBC count for nonpregnant individuals. Normal RBCs in pregnancy range from 11-12.
A nurse educator teaching a prenatal class asked for feedback from the class on the topic "Breast Changes During Pregnancy." Which of the following statements from on eo fthe attendees would indicate further instruction is needed?

1. "My areolas will get smaller and lighter in color."
2. "My breasts will be tender and swollen."
3. "The nipples will get darker and more erect."
4. "My breasts will enlarge and may feel lumpy."
1. "My areolas will get smaller and lighter in color."

RATIONALE

1. Pregnancy causes the areolas to darken and enlarge.
2. Breast tenderness and swelling ar almost universal findings in pregnancy.
3. Pregnancy causes darkening of the pigment in the nipples and causes them to become more erectile.
4. Breast enlargement is caused by the influence of progesterone and estrogen. Nodularity is caused by an increase in the size of the mammary glands during the second trimester.
A 36-year-old professional woman who is pregnant for the first time at 10 weeks' gestation tells the nurse that her pregnancy was planned, bu that "I'm feeling like maybe this wasn't such a good idea." Which of the following responses by the nurse would be most appropriate?

1. "These are unnatural feelings. You should be happy to be pregnant."
2. "Maybe you should consider abortion since you feel this way."
3. "Don't worry, you'll feel differently once the baby is born."
4. "Many women have mixed emotions when they are first pregnant."
4. "Many women have mixed emotions when they are first pregnant."

RATIONALE

1. Ambivalent feelings about pregnancy are common in all women. In addition, this response is a block to therapeutic communication. The nurse is telling the client how she "should" feel.
2. Even women with a desired pregnancy have ambivalent feelings. Such feelings do not necessarily mean the woman desires an abortion.
3. "Mother love" does not necessarily appear right after birth, especially in a first pregnancy. It may take time for such feelings to grow.
4. Ambivalence is a normal response experienced by any individual preparing for a new role.
A 20-year-old client came in fo rher first prenatal appointment at 10 weeks' gestation. Blood is drawn for routine prenatal screening. Which of the following lab results would indicate a risk to the fetus for erythroblastosis fetalis?

1. Low a-fetoprotein
2. B-, antibody+
3. L:S ratio of 2:1
4. O+, antibody-
2. B-, antibody+

RATIONALE

1. AFP is drawn in the second trimester around 18 weeks' gestation. Low AFP may indicate Down's syndrome.
2. Antibodies formed by a mother because of an ABO or Rh incompatibility cause erythroblastosis fetalis. Blood and Rh typing an dantibody screening can alert the HCP to the possible development of this condition.
3. The L/S ratio is obtained from amniotic fluid analysis and indicates fetal lung maturity..
4. There is a possibility of ABO incompatibility that could result in erythroblastosis fetalis; however the antibody screen is negative.
A client is in active labor at term with cervical findings of 5 cm dilated, effacement of 90% station -1. The FHR baseline is in the 120s with long-term variability. Three late decelerations were noted within the last hour with a quick return to the 150s and then baseline. Which of the following nursing actions would be most appropriate?

1. Position the client on her back so the monitor strip is more accurate.
2. Prepare for a stat cesarean section.
3. Turn the client to her left side.
4. Encourage the client to ambulate.
3. Turn the client to her left side.

RATIONALE

1. Compression of the major vessels of the pelvis occurs with a supine position. This will compromise placental perfusion and contribute to fetal distress.
2. Fetal reserves are still present as evidenced by long-term variability, "shoulders," and a return to baseline. An operative delivery is not yet required.
3. Late decelerations are caused by decreased uteroplacental perfusion. Positioning a woman on her left side promotes fetal well-being by increasing placental perfusion and subsequent fetal oxygenation. This position change may stop the late decelerations.
4. Ambulation will stimulate uterine contractions and promote fetal descent. Increased frequency and/or intensity of contractions will impair uterine perfusion.
A client in the 26th week of gestation has been admitted to the OB unit with a diagnosis of PIH. Which of the following symptoms would indicate worsening of the disease?

1. Epigastric discomfort
2. BP of 140/90 mm Hg
3. 2+ deep tendon reflexes
4. 2+ dependent edema
1. Epigastric discomfort

RATIONALE

1. Epigastric pain/discomfort is a sign of impending seizure in the client with severe PIH.
2. A blood pressure reading of 140/90 mm Hg indicates hypertension. Hypertension is considered severe when diastolic blood pressures exceed 110 mm Hg.
3. Normal deep tendon reflexes are 2+.
4. Dependent edema is a normal finding of pregnancy. Edema of the hands or face or pitting edema indicate a worsening of the disease.