Table of Contents PART I: INTRODUCTION TO MATERNAL-NEWBORN NURSING 1. Contemporary Maternal-Newborn Nursing 2. Families, Cultures, and Complementary Therapies PART II: WOMEN’S HEALTH ACROSS THE LIFESPAN 3. Health Promotion 4. Family Planning 5. Commonly Occurring Infections 6. Women’s Health Problems 7. Social Issues 8. Violence Against Women PART III: HUMAN REPRODUCTION 9. Reproductive Physiology, Conception, and Fetal Development 10. Reproductive Genetics PART IV: PREGNANCY 11. Physical and Psychologic Changes of Pregnancy 12. Antepartum Nursing Assessment 13. The Expectant Family: Needs and Care 14. Maternal Nutrition 15. Pregnancy in Selected Populations 16. Assessment of Fetal Well-Being 17. Pregnancy at Risk: Pregestational Problems 18. Pregnancy at Risk: Gestational Onset PART V: LABOR AND BIRTH 19. Processes and Stages of Labor and Birth 20. Intrapartum Nursing Assessment 21. The Family in Childbirth: Needs and Care 22. Pharmacologic Pain Management 23. Childbirth at Risk: Prelabor Onset Complications 24. Childbirth at Risk: Labor-Related Complications 25. Birth-Related Procedures PART VI: THE NEWBORN 26. Physiologic Responses of the Newborn to Birth 27. Nursing Assessment of the Newborn 28. The Normal Newborn: Needs and Care 29. Newborn Nutrition 30. The Newborn at Risk: Conditions Present at Birth 31. The Newborn at Risk: Birth-Related Stressors PART VII: POSTPARTUM 32. Postpartum Adaptation and Nursing Assessment 33. The Postpartum Family: Needs and Care 34. Home Care of the Postpartum Family 35. The Postpartum Family at Risk 36. Grief and Loss in the Childbearing Family
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 1 Contemporary Maternal-Newborn Nursing 1) The nurse is speaking to students about changes in maternal-newborn care. One change is that self-care has gained wide acceptance with clients and the healthcarecommunity due to research findings that suggest that it has which effect? A) Shortens newborn length of stay B) Decreases use of home health agencies C) Decreases healthcare costs D) Decreases the number of emergency department visits Answer: C Explanation: A) Length of stay is often determined by third-party payer (insurance company) policies as well as the physiologic stability of the mother and newborn. Home healthcare agencies often are involved in client care to decrease hospital staytime. B) Home healthcare agencies often are involved in client care to decrease hospitalstay time. C) Research indicates that self-care significantly decreases healthcare costs. D) Acute emergencies are addressed by emergency departments, and are notdelayed by those practicing self-care. Page Ref: 3 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Self-Care Standards: QSEN Competencies: Ⅰ.A.2. Describe strategies to empower patients orfamilies in all aspects of the healthcare process. | AACN Essentials Competencies: Ⅸ .7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Health careeconomic policy; reimbursement structures; accreditation standards; staffing models and productivity; supply chain models | Nursing/Integrated Concepts: Nursing Process:Planning. Learning Outcome: 1 Discuss the impact of the self-care movement on contemporary childbirth. MNL LO: Recognize contemporary issues related to care of the childbearing family.
2) Care delivered by nurse-midwives can be safe and effective and can represent a positive response to the healthcare provider shortage. Nurse-midwives tend to useless technology, which often results in which of the following? A) There is less trauma to the mother. B) More childbirth education classes are available. C) They are instrumental in providing change in the birth environment at work. D) They advocate for more home healthcare agencies. Answer: A Explanation: A) Nurse-midwife models of care can be one way to ensure that mothers receive excellent prenatal and intrapartum care. B) It is appropriate for nurse-midwives, in conjunction with doctors and hospitals, to provide childbirth classes for expectant families. C) By working with other staff members and doctors, the nurse-midwife is able to implement changes as needed within the birthing unit. D) Clients are increasingly going home sooner, so there needs to be more follow-upin the home. Page Ref: 3 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/DiseasePrevention Standards: QSEN Competencies: Ⅲ.A.6. Describe how the strength and relevance of available evidence influences the choice of interventions in provision of patient-centeredcare. | AACN Essentials Competencies: Ⅸ. 5. Deliver compassionate, patient-centered,evidence-based care that respects patient and family preferences. | NLN Competencies: Context and Environment: Read and interpret data; apply health promotion/disease prevention strategies; apply health policy; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Compare the nursing roles available to the maternal-newbornnurse. MNL LO: Recognize contemporary issues related to care of the childbearing family.
3) The nurse is telling a new client how advanced technology has permitted the physician to do which of the following? A) Treat the fetus and monitor fetal development. B) Deliver at home with a nurse-midwife and doula. C) Have the father act as the coach and cut the umbilical cord. D) Breastfeed a new baby on the delivery table. Answer: A Explanation: A) The fetus is increasingly viewed as a patient separate from the mother, although treatment of the fetus necessarily involves the mother. B) A nurse-midwife and a doula are not examples of technological care. C) Fathers being present during labor and coaching their partners represents nontechnological care during childbirth. D) Breastfeeding is not an example of technology impacting care. Page Ref: 2—3 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅰ.B.10. Engage patients or designated surrogatesin active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Teamwork: Scope of practice, roles, and responsibilities of health careteam members, including overlaps. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Evaluate the potential impact of some of the special situations in contemporary maternity care. MNL LO: Recognize contemporary issues related to care of the childbearing family.
4) A nurse is examining different nursing roles. Which example best illustrates an advanced practice nursing role? A) A registered nurse who is the manager of a large obstetrical unit B) A registered nurse who is the circulating nurse during surgical deliveries (cesarean sections) C) A clinical nurse specialist working as a staff nurse on a mother-baby unit D) A clinical nurse specialist with whom other nurses consult for her expertise incaring for high-risk infants Answer: D Explanation: A) A registered nurse who is the manager of a large obstetrical unit is a professionalnurse who has graduated from an accredited program in nursing and completed the licensure examination. B) A registered nurse who is a circulating nurse at surgical deliveries (cesarean sections) is a professional nurse who has graduated from an accredited programin nursing and completed the licensure examination. C) A clinical nurse specialist working as a staff nurse on a mother-baby unit might have the qualifications for an advanced practice nursing staff member but is notworking in that capacity. D) A clinical nurse specialist with whom other nurses consult for expertise in caringfor high-risk infants is working in an advanced practice nursing role. This nurse has specialized knowledge and competence in a specific clinical area, and is master’s prepared. Page Ref: 5 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅱ.A.2. Describe scopes of practice and roles of healthcare team members. | AACN Essentials Competencies: Ⅵ. 6. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on thehealthcare team (i.e. scope of discipline, education, and licensure requirements). | NLN Competencies: Teamwork: Scope of practice, roles, and responsibilities of health care team members, including overlaps. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Compare the nursing roles available to the maternal-newbornnurse. MNL LO: Recognize contemporary issues related to care of the childbearing family.
5) A nursing student investigating potential career goals is strongly considering becoming a nurse practitioner (NP). The major focus of the NP is on which of thefollowing? A) Leadership B) Physical and psychosocial clinical assessment C) Independent care of the high-risk pregnant client D) Tertiary prevention Answer: B Explanation: A) Leadership might be a quality of the NP, but it is not the major focus. B) Physical and psychosocial clinical assessment is the major focus of the NP. C) NPs cannot provide independent care of the high-risk pregnant client, but mustwork under a physician’s supervision. D) The NP cannot do tertiary prevention as a major focus. Page Ref: 5 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅱ.A.2. Describe scopes of practice and roles of healthcare team members. | AACN Essentials Competencies: Ⅵ. 2. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on thehealthcare team (i.e. scope of discipline, education, and licensure requirements). | NLN Competencies: Teamwork: Scope of practice, roles, and responsibilities of health care team members, including overlaps. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Compare the nursing roles available to the maternal-newbornnurse. MNL LO: Recognize contemporary issues related to care of the childbearing family.
6) The nurse manager is consulting with a certified nurse-midwife about a client. Whatis the role of the CNM? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Be prepared to manage independently the care of women at low risk for complications during pregnancy and birth. B) Give primary care for high-risk clients who are in hospital settings. C) Give primary care for healthy newborns. D) Obtain a physician consultation for any technical procedures at delivery. E) Be educated in two disciplines of nursing. Answer: A, C, E Explanation: A) A CNM is prepared to manage independently the care of women at low risk for complications during pregnancy and birth and the care of healthy newborns. B) CNMs cannot give primary care for high-risk clients who are in hospital settings.The physician provides the primary care. C) A CNM is prepared to manage independently the care of women at low risk for complications during pregnancy and birth and the care of healthy newborns. D) The CNM does not need to obtain a physician consultation for any technical procedures at delivery. E) The CNM is educated in the disciplines of nursing and midwifery. Page Ref: 5 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅱ.A.2. Describe scopes of practice and roles of healthcare team members. | AACN Essentials Competencies: Ⅵ. 1. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on thehealthcare team (i.e. scope of discipline, education, and licensure requirements). | NLN Competencies: Teamwork: Scope of practice, roles, and responsibilities of health care team members, including overlaps. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Compare the nursing roles available to the maternal-newbornnurse. MNL LO: Recognize contemporary issues related to care of the childbearing family.
7) The registered nurse who has completed a master’s degree program and passed a national certification exam has clinic appointments with clients who are pregnant or seeking wellwoman care. What is the role of this nurse considered to be? A) Professional nurse B) Certified registered nurse (RNC) C) Clinical nurse specialist D) Nurse practitioner Answer: D Explanation: A) A professional nurse is one who has completed an accredited basic educationalprogram and has passed the NCLEX-RN® exam. B) A certified registered nurse (RNC) has shown expertise in the field and has takena national certification exam. C) A clinical nurse specialist has completed a master’s degree program, has specialized knowledge and competence in a specific clinical area, and often isemployed in hospitals on specialized units. D) A nurse practitioner has completed either a master’s or doctoral degree in nursing and passed a certification exam, and functions as an advanced practicenurse. Ambulatory care settings and the community are common sites for nursepractitioners to provide client care. Page Ref: 5 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/DiseasePrevention Standards: QSEN Competencies: Ⅱ.A.2. Describe scopes of practice and roles of healthcare team members. | AACN Essentials Competencies: Ⅵ. 6. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on thehealthcare team (i.e. scope of discipline, education, and licensure requirements). | NLN Competencies: Teamwork: Scope of practice, roles, and responsibilities of health care team members, including overlaps. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Compare the nursing roles available to the maternal-newbornnurse. MNL LO: Recognize contemporary issues related to care of the childbearing family.
8) While a child is being admitting to the hospital, the parent receives information aboutthe pediatric unit’s goals, including the statement that the unit practices family- centered care. The parent asks why that is important. The nurse responds that whatcommunication dynamic is characteristic of the family-centered care paradigm? A) The mother is the principal caregiver in each family. B) The child’s physician is the key person in ensuring that the health of a child is maintained. C) The family serves as the constant influence and continuing support in the child’slife. D) The father is the leader in each home; thus, all communications should includehim. Answer: C Explanation: A) Culturally competent care recognizes that both matriarchal and patriarchal households exist. B) The physician is not present during the day-to-day routines in a child’s life. C) Family-centered care is characterized by an emphasis on the family and family involvement throughout the pregnancy, birth, and postpartum period. D) Culturally competent care recognizes that both matriarchal and patriarchal households exist. Page Ref: 2 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Developmental Stages andTransitions Standards: QSEN Competencies: Ⅰ.B.3. Provide patient-centered care with sensitivityand respect for the diversity of human experience. | AACN Essentials Competencies: Ⅸ . 6. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in allhealthcare settings. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient’s emotions; accept and respond to distress in the patient and self; facilitate hope, trust and faith. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Identify specific factors that contribute to a family’s value system. MNL LO: Recognize contemporary issues related to care of the childbearing family.
9) The current emphasis on federal healthcare reform has yielded what unexpectedbenefit? A) Assessment of the details of the family’s income and expenditures B) Case management to limit costly, unnecessary duplication of services C) Many healthcare providers and consumers are becoming more aware of the vitally important role nurses play in providing excellent care to clients and families D) Education of the family about the need for keeping regular well-child visit appointments Answer: C Explanation: A) Financial assessment is more commonly the function of a social worker. The social worker is part of the interdisciplinary team working with clients, and this professional’s expertise is helping clients get into the appropriate programs. B) The case management activity mentioned will not provide a source of funding. C) Nurses must clearly articulate their role in the changing environment to define and differentiate practice roles and the educational preparation required for theirnew roles. D) The education of the family will not provide a source of funding. Page Ref: 4 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/DiseasePrevention Standards: QSEN Competencies: Ⅰ.A.4. Examine how the safety, quality and cost effectiveness of health care can be improved through the active involvement of patientsand families. | AACN Essentials Competencies: Ⅵ. 1. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e. scope of discipline, education, and licensure requirements). | NLN Competencies: Context and Environment: Read and interpret data; apply health promotion/disease prevention strategies; apply health policy; conduct population-basedtranscultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Compare the nursing roles available to the maternal-newbornnurse. MNL LO: Recognize contemporary issues related to care of the childbearing family.
10) For prenatal care, the client is attending a clinic held in a church basement. The client’s care is provided by registered nurses and a certified nurse-midwife. What isthis type of prenatal care? A) Secondary care B) Tertiary care C) Community care D) Unnecessarily costly care Answer: C Explanation: A) Secondary care is specialized care; an example is checking the hemoglobin A1Cof a diabetic client at an endocrine clinic. B) Tertiary care is very specialized, and includes trauma units and neonatal intensive care units. C) Prenatal care is primary care. Community care is often provided at clinics in neighborhoods to facilitate clients’ access to primary care, including prenatal careand prevention of illness. D) Community care decreases costs while improving client outcomes, and is not unnecessarily expensive. Page Ref: 3 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ.A.1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅵ. 1. Compare/contrast the roles and perspectives of the nursing profession with other careprofessionals on the healthcare team (i.e. scope of discipline, education, and licensurerequirements). | NLN Competencies: Context and Environment: Environmental health;health promotion/disease prevention (e.g. transmission of disease, disease patterns, epidemiological principles); chronic disease management; health care systems; transcultural approaches to health; family dynamics. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Describe the use of community-based nursing care in meetingthe needs of childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.
11) The nurse at an elementary school is performing TB screenings on all of the students. Permission slips were returned for all but the children of one family. Whenthe nurse phones to obtain permission, the parent states in clearly understandable English that permission cannot be given because the grandmother is out of town for2 more weeks. Which cultural element is contributing to the dilemma that faces the nurse? A) Permissible physical contact with strangers B) Beliefs about the concepts of health and illness C) Religion and social beliefs D) Presence and influence of the extended family Answer: D Explanation: A) The situation the nurse faces is not being caused by permissible contact with strangers. B) The situation the nurse faces is not caused by beliefs about the concepts ofhealth and illness. C) The situation the nurse faces is not caused by religion and social beliefs. D) The presence and influence of the extended family is contributing to the situationthe nurse faces. In many cultures, a family elder is the primary decision maker when it comes to health care. In this case, the parent cannot grant permission tothe nurse until the parent consults the grandmother. Page Ref: 4 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: Ⅰ.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: Ⅸ. 5. Deliver compassionate, patient-centered, evidence- based care that respects patient and family preferences. | NLN Competencies: Context and Environment: Analyze ethical challenges presented by ambiguous and uncertain clinical situations; self-assess one’s own tolerance for ambiguity and uncertainty; acceptthe possibility of multiple "right" answers (rather than one right answer thinking) in patient care and other professional situations. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Identify specific factors that contribute to a family’s value system. MNL LO: Recognize contemporary issues related to care of the childbearing family.
12) A maternity client is in need of surgery. Which healthcare member is legally responsible for obtaining informed consent for an invasive procedure? A) The nurse B) The physician C) The unit secretary D) The social worker Answer: B Explanation: A) It is not the nurse’s legal responsibility to obtain informed consent. B) Informed consent is a legal concept designed to allow clients to make intelligent decisions regarding their own health care. Informed consent means that a client,or a legally designated decision maker, has granted permission for a specific treatment or procedure based on full information about that specific treatment orprocedure as it relates to that client under the specific circumstances of the permission. The individual who is ultimately responsible for the treatment or procedure should provide the information necessary to obtain informed consent.In most instances, this is a physician. C) Unit secretaries are not responsible for obtaining informed consent. D) It is not within a social worker’s scope of practice to obtain informed consent. Page Ref: 7—8 Cognitive Level: Remembering Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.12. Facilitate informed patient consent for care. | AACN Essentials Competencies: Ⅷ. 1. Demonstrate the professional standards of moral, ethical, and legal conduct. | NLN Competencies: Context and Environment: Codeof ethics (e.g. American Nurses Association 2005; International Council of Nurses, 2006); regulatory and professional standards (ANA Social Policy Statement [ANA, 2003]; HIPAA [Health Insurance Portability and Accountability Act]); ethical decision making modes; scope of practice considerations; principles of informed consent, confidentiality, patient self-determination. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Delineate significant legal and ethical issues that influence thepractice of nursing for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.
13) A nurse who tells family members the sex of a newborn baby without first consultingthe parents would have committed which of the following? A) A breach of privacy B) Negligence C) Malpractice D) A breach of ethics Answer: A Explanation: A) A breach of privacy would have been committed in this situation, because informing other family members of the child’s sex without the parents’ consent violates the parents’ right to privacy. The right to privacy is the right of a person tokeep his person and property free from public scrutiny (or even from other family members). B) Negligence is a punishable legal offense, and is more serious. C) Malpractice is a punishable legal offense, and is more serious. D) No breach of ethics has been committed in this situation. Page Ref: 8 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Ethical Practice Standards: QSEN Competencies: Ⅰ.B.13. Assess own level of communication skill in encounters with patient and families. | AACN Essentials Competencies: Ⅳ. 8. Uphold ethical standards related to data security, regulatory requirements, confidentiality and clients’ right to privacy. | NLN Competencies: Context and Environment: Code of ethics (e.g. American Nurses Association 2005; International Council of Nurses, 2006); regulatory and professional standards (ANA Social Policy Statement [ANA, 2003]; HIPAA [Health Insurance Portability and Accountability Act]); ethical decision making modes;scope of practice considerations; principles of informed consent, confidentiality, patient self-determination. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Delineate significant legal and ethical issues that influence thepractice of nursing for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.
14) The nursing instructor explains to the class that according to the 1973 SupremeCourt decision in Roe v. Wade, abortion is legal if induced: A) Before the 30th week of pregnancy. B) Before the period of viability. C) To provide tissue for therapeutic research. D) Can be done any time if mother, doctor, and hospital all agree. Answer: B Explanation: A) This statement is not true, because the fetus is viable many weeks before the30th week. B) Abortion can be performed legally until the period of viability. C) Abortion cannot be used for the sole purpose of providing tissue for therapeutic research. D) This is not true. Legal abortion can be done only up until the time of viability. Page Ref: 9 Cognitive Level: Remembering Client Need/Sub: Safe and Effective Care Environment: Ethical Practice Standards: QSEN Competencies: Ⅰ.B.3. Provide patient-centered care with sensitivityand respect for the diversity of human experience. | AACN Essentials Competencies: Ⅳ . 8. Uphold ethical standards related to data security, regulatory requirements,confidentiality and client’s right to privacy. | NLN Competencies: Context and Environment: Code of ethics (e.g. American Nurses Association 2005; International Council of Nurses, 2006); regulatory and professional standards (ANA Social Policy Statement [ANA, 2003]; HIPAA [Health Insurance Portability and Accountability Act]); ethical decision making modes; scope of practice considerations; principles of informedconsent, confidentiality, patient self-determination. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Delineate significant legal and ethical issues that influence thepractice of nursing for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.
15) The nurse reviewing charts for quality improvement notes that a client experienced a complication during labor. The nurse is uncertain whether the labor nurse took the appropriate action during the situation. What is the best way for the nurse to determine what the appropriate action should have been? A) Call the nurse manager of the labor and delivery unit and ask what the nurseshould have done. B) Ask the departmental chair of the obstetrical physicians what the best nursingaction would have been. C) Examine other charts to find cases of the same complication, and determine howit was handled in those situations. D) Look in the policy and procedure book, and examine the practice guidelines published by a professional nursing organization. Answer: D Explanation: A) The nurse should find the standards, and not rely on another person to determine appropriateness of care. B) Physician care and nursing care are very different; physicians might not be up todate on nursing standards of care or nursing policies and procedures. C) What nursing action was undertaken in a different situation might not be basedon the policies and procedures or other standards of care. The quality improvement nurse will obtain the most accurate information by examining thepolicies, procedures, and standards of care. D) Agency policies, procedures, and protocols contain guidelines for nursing actionin specific situations. Professional organizations such as the Association of Women’s Health, Obstetrical, and Neonatal Nurses (AWHONN) also publish standards of practice that should guide nursing care. Page Ref: 7 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅳ.A.4. Explain the importance of variation and measurement in assessing quality of care. | AACN Essentials Competencies: Ⅴ. 1. Demonstrate basic knowledge of healthcare policy, finance, and regulatory environments; including local, state, national, and global healthcare trends. | NLN Competencies: Knowledge and Science: Retrieve research findings and other sources of information; critique research to judge its value and usefulness; evaluate the strengthof evidence for application of research findings to clinical practice. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 5 Delineate significant legal and ethical issues that influence thepractice of nursing for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.
16) The nurse is reviewing care of clients on a mother-baby unit. Which situation shouldbe reported to the supervisor? A) A 2-day-old infant has breastfed every 2-3 hours and voided four times. B) An infant was placed in the wrong crib after examination by the physician. C) The client who delivered by cesarean birth yesterday received oral narcotics. D) A primiparous client who delivered today is requesting discharge within 24 hours. Answer: B Explanation: A) Breastfeeding every 2 hours and voiding four times is within normal limits for a 2-dayold infant. There is no negligence in this situation. B) Placing an infant in the wrong crib is malpractice. Malpractice is negligent actionby a professional person. C) Receiving oral narcotics at this point in the client’s stay is within normal limits.There is no negligence in this situation. D) If the client is feeling well and able to care for her infant, it is normal to be discharged at this time. The mother and baby both must be within normal limits tobe discharged. Page Ref: 7 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅴ.B.1. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: Ⅷ. 1. Demonstrate the professional standards of moral, ethical, and legal conduct. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals(team members, other care providers, patients, families, etc.) so as to minimize risksassociated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 5 Delineate significant legal and ethical issues that influence thepractice of nursing for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.
17) The nurse manager is planning a presentation on ethical issues in caring for childbearing families. Which example should the nurse manager include to illustratematernal-fetal conflict? A) A client chooses an abortion after her fetus is diagnosed with a genetic anomaly. B) A 39-year-old nulliparous client undergoes therapeutic insemination. C) A family of a child with leukemia requests cord-blood banking at a sibling’s birth. D) A cesarean delivery of a breech fetus is court ordered after the client refuses. Answer: D Explanation: A) Abortion is a different type of ethical situation. B) Achieving pregnancy through the use of therapeutic insemination is a form of reproductive assistance, and is not considered a maternal-fetal conflict. C) Cord-blood banking is a different type of ethical situation. D) Maternal-fetal conflict is a special ethical situation where the rights of the fetus and the rights of the mother are considered separately. Forced cesarean birth, coercion of mothers who practice high-risk behaviors, and, perhaps most controversial, mandating experimental in utero therapy or surgery in an attemptto correct a specific birth defect are interventions that infringe on the mother’s autonomy. Page Ref: 9 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.9. Assess level of patient’s decisional conflict andprovide access to resources. | AACN Essentials Competencies: Ⅷ. 1. Demonstrate the professional standards of moral, ethical, and legal conduct. | NLN Competencies: Context and Environment: Show respect for others’ values; appreciate diversity; be civilduring relationships and work; value community empowerment and social justice; work to improve social conditions affecting health; adopt inclusive language. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Delineate significant legal and ethical issues that influence thepractice of nursing for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.
18) Client safety goals, which are evaluated and updated regularly, are requirements forwhat? A) Clinical practice guidelines B) Scope of practice C) Accreditation D) Standards of care Answer: C Explanation: A) Clinical practice guidelines are adopted within a healthcare setting to reduce variation in care management, to limit costs of care, and to evaluate the effectiveness of care. B) State nurse practice acts protect the public by broadly defining the legal scope ofpractice within which every nurse must function and by excluding untrained or unlicensed individuals from practicing nursing. C) The Joint Commission has identified client safety as an important responsibility of healthcare providers. D) Standards of care establish minimum criteria for competent, proficient delivery of nursing care. Page Ref: 7 Cognitive Level: Remembering Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅴ.A.7. Discuss potential and actual impact of national patient safety resources, initiatives, and regulations. | AACN Essentials Competencies: Ⅸ. 12. Create a safe environment that results in high quality patientoutcomes. | NLN Competencies: Quality and Safety: Value and encourage nurses’ involvement in the design, selection, implementation, and evaluation of informationtechnologies to support patient care (e.g. as recommended by QSEN ). | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Delineate significant legal and ethical issues that influence thepractice of nursing for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.
19) A fetus has been diagnosed with myelomeningocele. Which of the following surgeries would be performed to correct this condition? A) Tubal ligation B) Intrauterine fetal surgery C) Cesarean section D) Sterilization Answer: B Explanation: A) Tubal ligation is not an intrauterine fetal surgery. B) Intrauterine fetal surgery, which is generally considered experimental, is a therapy for anatomic lesions that can be corrected surgically and are incompatible with life if not treated. Examples include surgery for myelomeningocele and some congenital cardiac defects. C) A cesarean birth is not considered an intrauterine fetal surgery. D) Sterilization surgery does not involve the fetus. Page Ref: 9 Cognitive Level: Remembering Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅱ.B.8. Integrate the contributions of others who playa role in helping the patient/family achieve health goals. | AACN Essentials Competencies: Ⅵ. 1. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e. scope of discipline,education, and licensure requirements). | NLN Competencies: Teamwork: Function competently within one’s own scope of practice as leader or member of the health care team and manage delegation effectively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Delineate significant legal and ethical issues that influence thepractice of nursing for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.
20) A nurse is providing guidance to a group of parents of children in the infant-to- preschool age group. After reviewing statistics on the most common cause of deathin this age group, the nurse includes information about prevention of which of the following? A) Cancer by reducing the use of pesticides in the home B) Accidental injury by reducing the risk of pool and traffic accidents C) Heart disease by incorporating heart-healthy foods into the child’s diet D) Pneumonia by providing a diet high in vitamin C from fruits and vegetables Answer: B Explanation: A) Cancer due to pesticide use is not a large cause of death in this age group. B) Unintentional injuries cause death in infants more often than cancer, heartdisease, and pneumonia. C) Heart disease is not a large cause of death in this age group. D) Pneumonia does not cause a large number of deaths. Page Ref: 13 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅴ.A.1. Examine human factors and other basic safety design principles as well as commonly used unsafe practices (such as work- arounds and dangerous abbreviations) | AACN Essentials Competencies: Ⅱ. 7. Promote factors that create a culture of safety and caring. | NLN Competencies: Qualityand Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Contrast descriptive and inferential statistics. MNL LO: Recognize contemporary issues related to care of the childbearing family.
21) The nurse is preparing a report on the number of births by three service providers at the facility (certified nurse-midwives, family practitioners, and obstetricians). What is this an example of? A) Inferential statistics B) Descriptive statistics C) Evidence-based practice D) Secondary use of data Answer: B Explanation: A) Inferential statistics allow the investigator to draw conclusions from data to either support or refute causation. B) Descriptive statistics concisely describe phenomena such as births by providers. C) Evidence-based practice is the use of research conclusions to improve nursingcare. D) Secondary use of data is analyzing data in a different way than was originally undertaken, or looking at different variables from a data set. Page Ref: 11 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅲ.A.2. Describe EBP to include the components of research evidence, clinical expertise and patient/family values. | AACN Essentials Competencies: Ⅲ. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice. | NLN Competencies: Knowledge and Science: Retrieve research findings and other sources of information; critique research to judge its value and usefulness; evaluate the strengthof evidence for application of research findings to clinical practice. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Contrast descriptive and inferential statistics. MNL LO: Recognize contemporary issues related to care of the childbearing family.
22) The nurse is explaining the difference between descriptive statistics and inferential statistics to a group of student nurses. To illustrate descriptive statistics, what wouldthe nurse use as an example? A) A positive correlation between breastfeeding and infant weight gain B) The infant mortality rate in the state of Oklahoma C) A causal relationship between the number of sexual partners and sexually transmitted infections D) The total number of spontaneous abortions in drug-abusing women as comparedwith non-drug-abusing women Answer: B Explanation: A) A positive correlation between two or more variables is an inferential statistic. B) The infant mortality rate in the state of Oklahoma is a descriptive statistic, because it describes or summarizes a set of data. C) A causal relationship between the number of sexual partners and sexually transmitted infections is an inferential statistic. D) The total number of spontaneous abortions in drug-abusing women is an inferential statistic. Page Ref: 11 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/DiseasePrevention Standards: QSEN Competencies: Ⅲ.A.2. Describe EBP to include the components of research evidence, clinical expertise, and patient/family values. | AACN Essentials Competencies: Ⅲ. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice. | NLN Competencies: Knowledge and Science: Retrieve research findings and other sources of information; critique research to judge its value and usefulness; evaluate the strengthof evidence for application of research findings to clinical practice. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 7 Contrast descriptive and inferential statistics. MNL LO: Recognize contemporary issues related to care of the childbearing family.
23) The nurse manager is examining the descriptive statistics of increasing teen pregnancy rates in the community. Which inferential statistical research question would the nurse manager find most useful in investigating the reasons for increasedfrequency of teen pregnancy? A) What providers do pregnant teens see for prenatal care? B) What are the ages of the parents of pregnant teens in the community? C) Do pregnant teens drink caffeinated beverages? D) What do pregnant teens do for recreation? Answer: A Explanation: A) Understanding which providers pregnant teens are most likely to seek out for prenatal care can lead to further investigation on why prenatal care with that provider is more acceptable to teens, which in turn can lead to greater understanding of the issue of teen pregnancy. B) A question about the age of parents of pregnant teens might prove useful inseeking causes of teen pregnancy, but it is not the most useful question in understanding the increased frequency of teen pregnancy. C) Whether pregnant teens drink caffeinated beverages gives no further insight intothe issues of teen pregnancy. D) Understanding the recreational activities of pregnant teens would not lead to an understanding of the issues surrounding increasing teen pregnancy rates. Page Ref: 11 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Health Promotion/DiseasePrevention Standards: QSEN Competencies: Ⅲ.A.2. Describe EBP to include the components of research evidence, clinical expertise, and patient/family values. | AACN Essentials Competencies: Ⅲ. 2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice. | NLN Competencies: Knowledge and Science: Retrieve research findings and other sources of information; critique research to judge its value and usefulness; evaluate the strengthof evidence for application of research findings to clinical practice. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 7 Contrast descriptive and inferential statistics. MNL LO: Recognize contemporary issues related to care of the childbearing family.
24) The Quality and Safety Education for Nurses (QSEN) project focused on competencies in which areas? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Client-centered care B) Teamwork and collaboration C) Evidence-based practice D) Family planning E) Injury and violence prevention Answer: A, B, C Explanation: A) The Quality and Safety Education for Nurses (QSEN ) project is designed "to meet the challenge of preparing future nurses who will have the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work," which includes client-centered care. B) The Quality and Safety Education for Nurses (QSEN ) project, is designed "tomeet the challenge of preparing future nurses who will have the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality andsafety of the healthcare systems within which they work," which includes teamwork and collaboration. C) The Quality and Safety Education for Nurses (QSEN ) project, is designed "tomeet the challenge of preparing future nurses who will have the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality andsafety of the healthcare systems within which they work," which includes evidence-based practice. D) Healthy People 2020 focuses on family planning. E) Healthy People 2020 focuses on injury and violence prevention. Page Ref: 7 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: V.B.8. Use national patient safety resources for ownprofessional development and to focus attention on safety in care settings. | AACN Essentials Competencies: Ⅷ. 12. Act to prevent unsafe, illegal, or unethical care practices. | NLN Competencies: Quality and Safety: Value and encourage nurses’ involvement in the design, selection, implementation, and evaluation of information
technologies to support patient care (e.g., as recommended by QSEN ). |Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Delineate significant legal and ethical issues that influence thepractice of nursing for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.
25) The nurse is serving on a panel to evaluate the hospital staff’s reliance on evidence- based practice in their decision-making processes. Which practices characterize the basic competencies related to evidence-based practice? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Recognizing which clinical practices are supported by good evidence B) Recognizing and including clinical practice supported by intuitive evidence C) Using data in clinical work to evaluate outcomes of care D) Including quality-improvement measures in clinical practice E) Appraising and integrating scientific bases into practice Answer: A, C, E Explanation: A) Recognizing which clinical practices are supported by sound evidence is a basic competency related to evidence-based practice. B) Including clinical practice supported by intuitive evidence is not a basic competency related to evidence-based practice. C) Using data in clinical work to evaluate outcomes of care is one of the basic competencies related to evidence-based practice. D) Including quality-improvement measures is a form of evidence that can be usefulin making clinical practice decisions, but it is not a basic competency related to evidencebased practice. E) Appraising and integrating scientific bases into practice is one of the characteristics of the basic competencies related to evidence-based practice. Page Ref: 7 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅲ.A.2. Describe EBP to include the components of research evidence, clinical expertise and patient/family values. | AACN Essentials Competencies: Ⅱ. 5. Participate in quality and patient safety initiatives, recognizing thatthese are complex system issues, which involve individuals, families, groups, communities, populations and other members of the healthcare team. | NLN Competencies: Knowledge and Science: Translate research into practice in order to promote quality and improve practices. | Nursing/Integrated Concepts: Nursing Process:Assessment. Learning Outcome: 8 Identify the impact of evidence-based practice in improving thequality of nursing care for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.
26) Nursing research is vital to do which of the following? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Expand the science of nursing. B) Foster evidence-based practice. C) Improve client care. D) Visually depict nursing management. E) Plan and organize care. Answer: A, B, C Explanation: A) Research is vital to expanding the science of nursing. B) Research is vital to fostering evidence-based practice. C) Research is vital to improving client care. D) The nursing process is research-based, but is not a part of the clinical pathway. Visually depicting nursing management is part of concept mapping, not nursingresearch. E) Organizing patient care is an aspect of the nursing process. Planning and organizing care is part of nursing care plans, not nursing research. Page Ref: 11 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅲ.A.7. Discriminate between valid and invalid reasons for modifying evidence-based clinical practice based on clinical expertise or patient/family preferences. | AACN Essentials Competencies: Ⅲ. 5. Participate in the process of retrieval, appraisal and synthesis of evidence in collaboration with other members of the healthcare team to improve patient outcomes. | NLN Competencies: Knowledge and Science: Retrieve research findings and other sources of information; critique research to judge its value and usefulness; evaluate the strength of evidence forapplication of research findings to clinical practice. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 8 Identify the impact of evidence-based practice in improving thequality of nursing care for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.
27) A group of nurses are meeting as identified in the image below. Which behavior arethe nurses demonstrating during this meeting?
A) Privacy B) Advocacy C) Collaboration D) Informed consent Answer: C Explanation: C) Collaborative practice is a comprehensive model of health care that uses a multidisciplinary team of health professionals to provide cost-effective, high- quality care. In a successful team, each individual has autonomy but functions within a clearly defined scope of practice. In such a collaborative approach, no single profession "owns the patient." The right to privacy is the right of a person to keep his or her person and property free from public scrutiny. Advocacy is ensuring a patient receives necessary and required support. Informed consent isa legal concept designed to allow patients to make intelligent decisions regardingtheir own health care. Page Ref: 7 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅱ.B.9.9. Communicate with team members, adapting own style of communicating to needs of the team and situation. | AACN Essentials Competencies: Ⅵ.5. 5. Demonstrate appropriate teambuilding and collaborative strategies when working with interprofessional teams. | NLN Competencies: Relationship Centered Care; Practice; Share responsibility responsibly;collaborate and work cooperatively with others. | Nursing/Integrated Concepts: Assessment; Communication and Documentation. Learning Outcome: 3 Describe the use of community-based nursing care in meetingthe needs of childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.
28) The nurse is reviewing the Quality and Safety Education for Nurses (QSEN) competencies while preparing an in-service program to address safety in the neonatal intensive care unit. In which order should the nurse present these competencies? 1. Safety 2. Informatics 3. Patient-centered care 4. Quality improvement 5. Evidence-based practice 6. Teamwork and collaboration Answer: 3, 6, 5, 4, 1, 2 Explanation: The Quality and Safety Education for Nurses (QSEN) project is designed "to meet the challenge of preparing future nurses who will have the knowledge, skills and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work. The project focuses on competencies in six areas: 1. Patient-centered care, 2. Teamwork and collaboration; 3. Evidence-based practice; 4.Quality improvement; 5. Safety; and 6. Informatics. Page Ref: 7 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ.A.1.1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: Ⅱ. 7. Promotefactors that create a culture of safety and caring. | NLN Competencies: Quality and Safety; Ethical Comportment; Commit to a generative safety culture. | Nursing/Integrated Concepts: Implementation; Teaching/Learning. Learning Outcome: 5 Delineate significant legal and ethical issues that influence thepractice of nursing for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.
29) The nurse is ensuring that a patient has provided informed consent before agreeing to an amniocentesis. In which order should the nurse validate that informed consent was provided by the patient? 1. Information provides risk and benefits 2. Information provided clearly and concisely 3. Information included treatment alternatives 4. Information explaining the right to refuse treatment 5. Information reviews consequences if no treatment provided Answer: 2, 1, 3, 5, 4 Explanation: Several elements must be addressed to ensure that the patient has given informed consent. The information must be clearly and concisely presented in a manner understandable to the patient and must include risks and benefits, the probability of success, and significant treatment alternatives. The patient also needs to be told the consequences of receiving no treatment or procedure. Finally, the patient must be toldof the right to refuse a specific treatment or procedure. Each patient should be told thatrefusing the specified treatment or procedure does not result in the withdrawal of all support or care. Page Ref: 7 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅰ.B.12. Facilitate informed patient consent for care. | AACN Essentials Competencies: Ⅱ. 7. Promote factors that create a culture of safetyand caring. | NLN Competencies: Context and Environment; Knowledge; principles of informed consent, confidentiality, patient self-determination. | Nursing/Integrated Concepts: Evaluation; Nursing Process. Learning Outcome: 5 Delineate significant legal and ethical issues that influence thepractice of nursing for childbearing families. MNL LO: Recognize contemporary issues related to care of the childbearing family.
30) The nurse is preparing a presentation for new labor and delivery nurses. Which cultural group should the nurse identify as having the lowest birth rate for the 20 to24 age range? Table 1-2 Birth Rate by Age and Race of Mother, 2011 American Indianor Alaska Age All Races White Black Native 10-14 0.4 0.3 0.9 0.5 15-19 31.3 29.1 47.3 36.1 15-17 15.4 14.1 24.7 18.2 18-19 54.1 50.8 78.8 61.6 20-24 85.3 83 111.9 86.6 25-29 107.2 110 101.7 75.4 30-34 96.5 100.1 74.1 47.3 35-39 47.2 47.6 38.0 23.1 40-44 10.3 10.1 9.4 5.5 45-49 0.7 0.6 0.7 0.2
Asian or Pacific Islander 0.1 10.2 4.6 18.1 41.9 93.7 114.9 64.1 15.2 1.2
Source: Martin, J.A., Hamilton, B.E., Ventura, S.J., Osterman, M.J.K., & Matthews, T.J.(2013). Births: Final data 2011. National Vital Statistics Reports, 62(1), 1-70. A) Asian B) White C) Black D) American Indian Answer: A Explanation: A) For the 20 to 24 age group, the lowest birth rate is within the Asian or Pacific Islander cultural group. The birth rate for Whites for this age range is the nextlowest. The birth rate for American Indians within this age group is the third highest and the highest birth rate for this age group is within the Black culturalgroup. Page Ref: 11-12 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅰ.A.1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: Ⅴ. 6. Explore the impact of socio-cultural, economic, legal and political factors influencing healthcaredelivery and practice. | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person’s development. | Nursing/Integrated Concepts: Implementation; Teaching/Learning. Learning Outcome: 6 Evaluate the potential impact of some of the special situations in contemporary maternity care. MNL LO: Recognize contemporary issues related to care of the childbearing family.
31) The manager of a maternal-child care area is preparing information to share withnursing staff regarding the leading causes of infant death in the United States. Inwhich order, from most to least frequent, should the manager provide this information? 1. SIDS 2. Low birth weight 3. Unintentional injuries 4. Maternal complications 5. Congenital malformation Answer: 5, 2, 1, 4, 3 Explanation: The five leading causes of deaths of infants in the United States, from highest to lowestin frequency, are congenital malformations, low birth weight, SIDS, maternal complications, and unintentional injuries. Page Ref: 13 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅰ.A.1. Integrate understanding of multiple dimensions of patient centered care. | AACN Essentials Competencies: Ⅴ. 6. Explore the impact of socio-cultural, economic, legal and political factors influencing healthcaredelivery and practice. | NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person’s development. | Nursing/Integrated Concepts: Implementation; Teaching/Learning. Learning Outcome: 6 Evaluate the potential impact of some of the special situations in contemporary maternity care. MNL LO: Recognize contemporary issues related to care of the childbearing family.
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 2 Family, Culture, and Complementary Therapies 1) A couple who came to the United States two years ago with their two children are seeing the nurse in the community clinic. The nurse knows their family is acculturating when the mother makes which statement? 1. “The children are much less well-behaved than they used to be.” 2. “Our diet now includes hamburgers and French fries.” 3. “We celebrate the same holidays that we used to at home.” 4. “When the children leave the house, I worry about them.” Answer: 2. Inclusion of fast food in the diet is an indication of acculturation, because it shows a belief in the nutritional value of these foods and an acceptance of purchasing fast food as equivalent in value to home-cooked meals. 2) Which of the following best describes a nuclear family? 1. A family is composed of an unmarried woman who chooses to conceive or adopt without a life partner. 2. Children live in a household with both biologic parents and no other relatives or persons. 3. A couple shares household and childrearing responsibilities with parents, siblings, or other relatives. 4. The head of the household is widowed, divorced, abandoned, or separated or most often the mother remains unmarried. Answer: 2. In the nuclear family, children live in a household with both biologic parents and no other relatives or persons. 3) What is the term for when children alternate between two homes, spending varying amounts of time with each parent in a situation called co-parenting and usually involving joint custody? 1. Blended or reconstituted nuclear family 2. Extended kin network family 3. Binuclear family 4. Extended family Answer: 3. A binuclear family is a postdivorce family in which the biologic children are members of two nuclear households, with parenting by both the father and the mother. 4) Duvall’s eight stages in the family life cycle of a traditional nuclear family have been used as the foundation for contemporary models that describe the developmental processes and role expectations for different family types. Which of the following is an example of Stage IV of this family life cycle? 1. Families launching young adults (all children leave home) 2. Families with preschool-age children (oldest child is between 2.5 and 6 years of age) 3. Middle-aged parents (empty nest through retirement) 4. Families with schoolchildren (oldest child is between 6 and 13 years of age) Answer 4. Stage IV is families with schoolchildren (oldest child is between 6 and 13 years of age).
5) A 7-year-old client tells the nurse that “Grandpa, Mommy, Daddy, and my brother live at my house.” The nurse identifies this as what type of family? 1. Binuclear 2. Extended 3. Gay or lesbian 4. Traditional Answer: 2. An extended family consists of a couple who share the house with their parents, siblings, or other relatives. 6) A nurse is performing an assessment on a family with a father and mother who both work. What type of family does she record this family as being? 1. A traditional nuclear family 2. A dual-career/dual-earner family 3. An extended family 4. An extended kin family Answer: 2. A dual-career/dual-earner family is characterized by both parents working, by choice or necessity. 7) Why is it important for the nurse to understand the type of family that a client comes from? Select all that apply. 1. Family structure can influence finances. 2. Some families choose to conceive or adopt without a life partner. 3. The nurse can anticipate which problems a client will experience based on the type of family the client has. 4. Understanding if the client’s family is nuclear or blended will help the nurse teach the client the appropriate information. 5. The values of the family will be predictable if the nurse knows what type of family the client is a part of. Answer: 1, 2 1. Single-parent families often face difficulties because the sole parent may lack social and emotional support, need assistance with childrearing issues, and face financial strain. 2. In the single mother by choice family, the mother is typically older, college-educated, and financially stable and has contemplated pregnancy significantly prior to conceiving. 8) The public health nurse is working with a student nurse. The student nurse asks which of the six groups of people they have seen today are considered to be families. How should the nurse respond?Select all that apply. 1. “The married heterosexual couple without children” 2. “The gay couple with two adopted children” 3. “The unmarried heterosexual couple with two biological children” 4. “The lesbian couple not living together that have no children” 5. “The married heterosexual couple with three children, living with grandparents” Answer: 1, 2, 3, 5
1. Families take many forms in today’s society. The basis for people to be considered a family is a commitment to one another and the sharing of responsibilities, chores, and expenses. A couple without children is still a family. 2. Families take many forms in today’s society. The basis for people to be considered a family is a commitment to one another and the sharing of responsibilities, chores, and expenses. Gay and lesbian families are those in which two or more people who share a same-sex orientation live together, or in which a gay or lesbian single parent rears a child. 3. Families take many forms in today’s society. The basis for people to be considered a family is a commitment to one another and the sharing of responsibilities, chores, and expenses. A family may be formed without a legal marriage. 5. Families take many forms in today’s society. The basis for people to be considered a family is a commitment to one another and the sharing of responsibilities, chores, and expenses. Extended family members, including parents or grandparents, will often live with their adult children or grandchildren, creating intergenerational families. 9) In assessing a new family coming to the clinic, the nurse determines they are an extended kin family because the family exhibits what as characteristics of an extended kin network family? Select all that apply. 1. A sharing of a social support network 2. Each family establishes their own sources of goods and services 3. Elderly parents share housing 4. Children are members of two nuclear families 5. A sharing of goods and services Answer: 1, 5 Explanation: 1. Extended kin family networks share a social support network. 5. Extended kin family networks share goods and services. 10) The transcultural nursing theory was developed in 1961 by Dr. Madeleine Leininger. Its foundation is in which of the following? 1. The framework categorizes a family’s progression over time 2. The family life cycle of a traditional nuclear family 3. Anthropology and nursing 4. Holistic health beliefs Answer: 3. Transcultural nursing theory is rooted in the caring that embraces the beliefs and practices of individuals or groups of similar or different cultures. 11) The nurse is preparing a community presentation on family development. Which statement should the nurse include? 1. The youngest child determines the family’s current stage. 2. A family does not experience overlapping of stages. 3. Family development ends when the youngest child leaves home. 4. The stages describe the family’s progression over time. Answer: 4. Family development stages describe the changes and adaptations that a family goes through over time as children are added to the family.
12) In learning about Duvall’s life-cycle stages ascribed to traditional families, the nursing student recognizes that developmental tasks of each stage include which of the following? Select all that apply. 1. Adjusting to new roles as mother and father 2. Working out authority and socialization roles with the school 3. Becoming a single parent with custodial responsibilities 4. Becoming a couple and dating 5. Adjusting to the loss of a spouse Answer: 1, 2, 5 1. Adjusting to new roles as mother and father occurs in Stage II, which describes childbearing families with infants. 2. Working out authority and socialization roles with schools occurs in Stage IV, which describes families with school-age children. 5. Stage VIII includes adjusting to the loss of a spouse. 13) The nurse is planning a community education program on the role of complementary and alternative therapies during pregnancy. Which statement about alternative and complementary therapies should the nurse include? 1. “They bring about cures for illnesses and diseases.” 2. “They are invasive but effective for achieving health.” 3. “They emphasize prevention and wellness.” 4. “They prevent pregnancy complications.” Answer: 3. Complementary and alternative therapies have many benefits during pregnancy. They emphasize prevention and wellness, aiming for holistic health rather than cure or treatment. 14) The nurse is preparing to assess the development of a family new to the clinic. The nurse understands that which of the following is the primary use of a family assessment tool? 1. Obtain a comprehensive medical history of family members. 2. Determine to which clinic the client should be referred. 3. Predict how a family will likely change with the addition of children. 4. Understand the physical, emotional, and spiritual needs of members. Answer: 4. Understanding the physical, emotional, and spiritual needs of members is the main reason for using a family assessment tool. 15) The nurse in the community should use a family assessment tool to obtain what type of information? 1. How long the family has lived at its current address 2. What other health insurance the family has had in the past 3. How the family meets its nutritional needs and obtains food 4. What eye color the family desires in its unborn child Answer: 3. A family assessment is a collection of data about the family’s type and structure, current level of functioning, support system, sociocultural background, environment, and needs.
16) In assessing a family, the community nurse uses a family assessment tool, which provides an organized framework to collect data concerning which of the following?Select all that apply. 1. Access to laundry and grocery facilities 2. Access to health care 3. Sharing of religious beliefs and values 4. Acculturation to traditional lifestyles 5. Ability to include a new spouse into the family unit Answer: 1, 2, 3 1. Access to laundry, grocery, and recreational facilities is a means of meeting the physical, emotional, and spiritual needs of members, which is part of the family assessment tool. 2. Access to health care is a means of meeting the physical, emotional, and spiritual needs of members, which is part of the family assessment tool. 3. Sharing of religious beliefs and values is a means of meeting the physical, emotional, and spiritual needs of members, which is part of the family assessment tool. 17) The nurse is assessing a client who reports seeing an acupuncturist on a weekly basis to treat back pain. The nurse understands that acupuncture is an example of what? 1. A risky practice without evidence of efficacy 2. A folk remedy 3. A complementary therapy 4. An alternative therapy Answer: 3 Explanation: 3. Acupuncture is a therapy that is used in conjunction with conventional medical treatment, and therefore is an example of a complementary therapy. 18) In caring for pregnant clients, the nurse realizes that information on conventional, complementary, and alternative medicine is best obtained by which of the following means? 1. Obtained at the medical office if the physician feels it is appropriate 2. Obtained from family and friends who have already experienced a situation 3. Readily obtainable on the Internet 4. Passed on by word of mouth Answer: 3. The dramatic increase in complementary and alternative therapies that began in the final decade of the 20th century is partially due to the advent of the Internet. 19) In working with immigrants in an inner-city setting, the nurse recognizes that acculturation of immigrants often brings with it which of the following benefits?Select all that apply. 1. Improved socioeconomic status 2. Use of preventive care services 3. Better nutrition 4. Increase in substance abuse over time 5. More physician visits due to language barriers Answer: 1, 2, 3 1. Improvement of socioeconomic status is a benefit of acculturation in the United States.
2. Acculturation of immigrants increases the likelihood that the family members will use preventive health services. 3. Improved socioeconomic status leads to better nutrition and access to health care. 20) The nurse is caring for a postpartal client of Hmong descent who immigrated to the United States 5 years ago. The client asks for the regular hospital menu because American food tastes best. The nurse assesses this response to be related to which of the following cultural concepts? 1. Acculturation 2. Ethnocentrism 3. Enculturation 4. Stereotyping Answer: 1. Acculturation (assimilation) is the correct assessment because the client adapted to a new cultural norm in terms of food choices. 21) The nurse is teaching a community education class on complementary and alternative therapies. To assess learning, the nurse asks, “In traditional Chinese medicine, what is the invisible flow of energy in the body that maintains health and ensures physiologic functioning?” Which answer indicates that teaching was successful? 1. Meridians 2. Chi 3. Yin 4. Yang Answer: 2. Chi is the energy that flows through the body along meridians, or pathways, to maintain health. 22) The nurse is admitting a client in labor who states that she is a naturopath. The nurse understands that this client believes which of the following? 1. An initial worsening of symptoms after treatment means the correct remedy has been used. 2. There are five elements that take form in the body. 3. Her pregnancy is a kapha condition. 4. Naturopathy is a form of medicine that utilizes the healing forces of nature. Answer: 4. This is the correct answer. Naturopathy is more precisely defined as a healing system that combines safe and effective traditional means of preventing and treating human disease with the most current advances in modern medicine. 23) The nurse is counseling a pregnant woman who intends to see a naturopathic physician. The nurse tells the woman that she can expect education on which of the following? Select all that apply. 1. Clinical nutrition 2. Botanical medicine 3. Lifestyle modification 4. Use of “like to cure like” 5. The role of yin and yang Answer: 1, 2, 3
1. Naturopathic physicians teach their clients about clinical nutrition. 2. The use of botanical medicine is a part of naturopathy. 3. Lifestyle modification is a part of naturopathy. 24) During the assessment phase of a family, the community nurse recognizes that culture influences childrearing and childbearing in which of the following ways?Select all that apply. 1. Beliefs about the importance of children 2. Beliefs and attitudes about pregnancy 3. Norms regarding infant feeding 4. Acculturation is important in rearing children 5. Time orientation to the future is very important Answer: 1, 2, 3 1. Culture influences beliefs about the importance of children. 2. Culture influences attitudes about pregnancy and the right vs. the obligation of women to bear children. 3. Culture influences infant feeding norms and practices. 25) The nurse is teaching a class to the community on mind-based therapies. A class participant gives an example of a friend with leukemia who was taught by her complementary therapist to concentrate on making antibodies that will fight and kill the cancer cells in the bloodstream. How would the nurse identify this technique? 1. Guided imagery 2. Qigong 3. Biofeedback 4. Homeopathy Answer: 1. Guided imagery is a state of intense, focused concentration used to create compelling mental images and is useful in imagining a desired effect. 26) The nurse in a rural clinic is talking with some clients about biofeedback. The nurse explains to the clients that biofeedback is which of the following? 1. An alternative therapy 2. A state of great mental and physical relaxation in which one is susceptible to suggestion 3. A method used to help individuals learn to control their physiologic responses based on the concept that the mind controls the body 4. A complementary therapy in which one goes into a relaxed state and focuses on positive scenes Answer: 3. Biofeedback is a method to learn control of physiological responses based on the concept that the mind controls the body. 27) The nurse is admitting a Mexican woman scheduled for a cholecystectomy. The nurse uses a cultural assessment tool during the admission. Which question would be most important for the nurse to ask? 1. “What other treatments have you used for your abdominal pain?” 2. “In what country were you were born?”
3. “When you talk to family members, how close do you stand?” 4. “How would you describe your role within your family?” Answer: 1. Knowing what other treatments the client has used for pain is most important because some traditional or folk remedies include the use of herbs, which can have medication interactions. 28) The nurse works in a facility that cares for clients from a broad range of racial, ethnic, cultural, and religious backgrounds. Which statement should the nurse include in a presentation to recently hired nurses on the client population of the facility? 1. “Our clients come from a broad range of backgrounds, but we have a good interpreter service.” 2. “Many of our clients come from backgrounds different from your own, but it doesn’t cause problems for the nurses.” 3. “Because most of the doctors are bilingual, we don’t have to deal with the differences in cultural backgrounds of our clients.” 4. “Understanding the common values and health practices of our diverse clients will facilitate better care and health outcomes.” Answer: 4. Because of the implications for care based on cultural background, it is important for nurses to understand the backgrounds of the client population that accesses the facility. Without cultural awareness, caregivers tend to project their own cultural responses onto foreign-born clients; clients from different socioeconomic, religious, or educational groups; or clients from different regions of the country. 29) The nurse manager in a hospital with a large immigrant population is planning an in-service. Aware of how ethnocentrism affects nursing care, the nurse manager asks, “The belief that one’s own values and beliefs are the only or the best values has which of the following results?” 1. It implies newcomers to the United States should adopt the norms and values of the country. 2. It can create barriers to communication through misunderstanding. 3. It leads to an expectation that all clients will exhibit pain the same way. 4. It improves the quality of care provided to culturally diverse client bases. Answer: 2. When the nurse assumes that a client has the same values and beliefs as the nurse, misunderstanding will frequently occur, which in turn can negatively impact nurse-client communication. Ethnocentrism is the conviction that the values and beliefs of one’s own cultural group are the best or only acceptable ones. 30) The client reports using an alternative therapy that involves the manipulation of soft tissues. This therapy has reduced the client’s stress, diminished pain, and increased circulation. Which therapy has this client most likely received? 1. Guided imagery 2. Homeopathy 3. Massage therapy 4. Reflexolog yAnswer: 3 Explanation: 3. Massage therapy involves the manipulation of soft tissues.
31) The client in the first trimester of pregnancy tells the nurse she regularly sees a massage therapist to help with pain in her shoulders and neck. The nurse tells her that massage has which of the following added advantages?Select all that apply. 1. Increasing circulation 2. Reducing anxiety 3. Promoting a sense of well-being 4. Eliminating energy blockages 5. Allowing coordination of breathing and moving Answer: 1, 2, 3 1. Massage therapy has been shown to increase circulation. 2. Massage therapy has been shown to reduce anxiety. 3. Massage therapy has been shown to promote a sense of well-being. 32) A nurse is working in a clinic where clients from several cultures are seen. As a first step toward the goal of personal cultural competence, the nurse will do which of the following? 1. Enhance cultural skills. 2. Gain cultural awareness. 3. Seek cultural encounters. 4. Acquire cultural knowledge. Answer: 2. One begins to gain cultural competence by gaining cultural awareness or by gaining an effective and cognitive self-awareness of personal worldview biases, beliefs, etc. 33) When teaching a culturally diverse group of childbearing families about hospital birthing options, the culturally competent nurse does which of the following? 1. Understands that the families have the same values as the nurse 2. Teaches the families how childbearing takes place in the United States 3. Insists that the clients answer questions instead of their husbands 4. Incorporates the specific beliefs of the cultural groups that are attending the class Answer: 4. Providing culturally competent care involves recognizing the importance of the childbearing family’s value system, acknowledging that differences occur among people, and respecting and responding to ethnic diversity in a way that leads to mutually desirable outcomes. 34) Which questions are appropriate for the nurse to ask during a cultural assessment of a client who is new to the clinic? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. What genetic and other biological differences affect caregiving? 2. Which family member must be consulted for decisions about care? 3. What type of health provider is the most appropriate? 4. Does the client have beliefs or traditions that might impact the care plan? 5. Are communications patterns established? Answer: 2, 3, 4
2. It is important the nurse recognize cultural differences in regard to which family member must be consulted for decisions about care. 3. Some cultures do not allow a person of the opposite gender to touch the client. Cultural sensitivity will recognize and allow for this. 4. The nurse must be aware of traditions and beliefs that might impact the care plan. 35) The nurse is working with a client whose religious beliefs differ from those of the general population. What is the best nursing intervention to use to meet the specific spiritual needs of this family? 1. Ask how important the client’s religious and spiritual beliefs are when making decisions about health care. 2. Show respect while allowing time and privacy for religious rituals. 3. Ask for the client’s opinion on what caused the illness. 4. Identify healthcare practices forbidden by religious or spiritual beliefs. Answer: 2. Providing spiritually sensitive care involves determining the current spiritual and religious beliefs and practices that will affect the mother and baby, accommodating these practices where possible, and examining one’s own spiritual or religious beliefs to be more aware and able to provide nonjudgmental care. 36) The labor and delivery nurse is caring for a laboring client who has asked for a priest to visit her during labor. The client’s mother died during childbirth, and although there are no complications during her pregnancy, the client is fearful of her own death during labor. What is the best response by the nurse? 1. “Nothing is going to happen to you. We’ll take very good care of you during your birth.” 2. “Would you like to have an epidural so that you won’t feel the pain of the contractions?” 3. “The priest won’t be able to prevent complications, and might get in the way of your providers.” 4. “Would you like me to contact your parish or our hospital chaplain to come see you?” Answer: 4. Providing spiritually sensitive care involves determining the current spiritual and religious beliefs and practices that will affect the mother and baby and accommodating these practices where possible. 37) The client reports relief from headaches when she rubs the temples on each side of the head. The nurse understands that this is a form of which of the following? 1. Acupressure 2. Acupuncture 3. Reflexology 4. Hydrotherapy Answer: 1. Acupressure uses pressure from the fingers and thumbs to stimulate pressure points to relieve symptoms.
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 3. Health Promotion 1) The clinic nurse is returning phone calls. Which call should the nurse return first? 1. The call from a 22-year-old reporting that she has menstrual cramps and vomiting every month 2. The call from a 17-year-old asking whether there is a problem with using one tampon for a whole day 3. The call from a 46-year-old mother of a teen wondering if her daughter should be on birth control 4. The call from a 34-year-old requesting information on douching after intercourse Answer: 2 Explanation: 2. Using a single tampon for an entire day can lead to toxic shock syndrome, a potentially life-threatening condition. This client needs education on the danger of using one tampon longer than 3-6 hours. Page Ref: 39 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts Nursing Process: Implementation Learning Outcome: 2 Summarize information that women may need in order to implement appropriate self-care measures for dealing with menstruation. 2) The nurse who is taking a sexual history from a client should do which of the following? 1. Ask questions that the client can answer with "yes" or "no." 2. Ask mostly open-ended questions. 3. Have the client fill out a comprehensive questionnaire and review it after the client leaves. 4. Try not to make much direct eye contact. Answer: 2 Explanation: 2. Open-ended questions are often useful in eliciting information. Page Ref: 37 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: RelationshipCentered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1 Discuss the key points a nurse should consider when taking a sexual history.
3) The nurse is taking a history on a new client in the clinic. She determines from talking with the client that she is recently divorced, is dating, and has had sex with various men. The nurse would be concerned about and would provide some education on what issues? 1. The ethics of dating and having sex with more than one man 2. The client having some kind of permanent birth control done, so she does not become pregnant 3. Education about sexual activity and sexually transmitted infections 4. Referral to a psychologist or counselor for follow-up on the multiple dating Answer: 3 Explanation: 3. Education about sexual activity and sexually transmitted infections is correct, since it has been determined that the client is having sex with multiple partners. Page Ref: 37 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. C. 4. Seek learning opportunities with patients who represent all aspects of human diversity. | AACN Essentials Competencies: VII. 6. Use information and communication technologies in preventive care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1 Discuss the key points a nurse should consider when taking a sexual history. MNL LO: 6.2.1 Recognize client behaviors associated with the acquisition of sexually transmitted infections. 4) The nurse is taking a history of a new client in the clinic. Histories tend to be lengthy, and the sexual part can be difficult for the client. The nurse should use what technique to make it easier for the client? 1. Let the client fill out a paper copy, so she does not have to talk about intimate matters. 2. Skip the sexual part until the next time the client comes into the clinic. 3. Start with the easier medical and surgical questions, and develop a feeling of trust with the client. 4. Leave the sexual part of the history for the doctor to ask about. Answer: 3 Explanation: 3. Starting with easy-to-answer questions and then going to the sexual ones helps, as client might be at ease by then. Page Ref: 37 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Read and interpret data; apply health promotion/disease prevention strategies; apply health policy; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1 Discuss the key points a nurse should consider when taking a sexual history.
5) The nurse working in a women's clinic is training a recent graduate of nursing school who has been hired. The experienced nurse explains that nurses caring for women of all ages must be which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Aware of their own feelings 2. Judgmental when discussing sexuality 3. Aware of personal values and attitudes 4. Minimally knowledgeable about reproduction 5. Willing to discuss sexuality only one-on-one Answer: 1, 3 Explanation: 1. Nurses must be aware of their own feelings. 3. Nurses must develop an awareness of their own values and attitudes about sexuality so that they can be more sensitive and objective when they encounter the values and beliefs of others. Page Ref: 37 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: II. B. 5. Assume role of team member or leader based on the situation. | AACN Essentials Competencies: VI. 2. Use inter-and intraprofessional communication and collaborative skills to deliver evidence-based, patient-centered care. | NLN Competencies: Teamwork: Function competently within one's own scope of practice as leader or member of the health care team and manage delegation effectively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1 Discuss the key points a nurse should consider when taking a sexual history. 6) A client asks her nurse, "Is it okay for me to take a tub bath during the heavy part of my menstruation?" What is the nurse's correct response? 1. "Tub baths are contraindicated during menstruation." 2. "You should shower and douche daily instead." 3. "Either a bath or a shower is fine at that time." 4. "You should bathe and use a feminine deodorant spray during menstruation." Answer: 3 Explanation: 3. Bathing, whether it is a tub bath or a shower, is as important (if not more so) during menses as at any other time. Page Ref: 39 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 6. Use information and communication technologies in preventive care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2 Summarize information that women may need in order to implement appropriate self-care measures for dealing with menstruation.
7) Which client would the nurse document as exhibiting signs and symptoms of primary dysmenorrhea? 1. 17-year-old, has never had a menstrual cycle 2. 16-year-old, had regular menses for 4 years, but has had no menses in 4 months 3. 19-year-old, regular menses for 5 years that have suddenly become painful 4. 14-year-old, irregular menses for 1 year, experiences cramping every cycle Answer: 4 Explanation: 4. Dysmenorrhea, or painful menstruation, occurs at, or a day before, the onset of menstruation and disappears by the end of menses. Primary dysmenorrhea is defined as cramps without underlying disease. Page Ref: 40 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 4 Contrast dysmenorrhea and premenstrual syndrome. 8) The nurse is conducting health screening at a community clinic. The client has asked whether there are any risks with body piercing and tattooing, or whether these activities would impact sexual activity. How should the nurse respond? 1. "You should avoid piercing your genitalia and your nipples." 2. "There are no problems that occur with either body piercing or tattooing." 3. "Both piercing and tattooing carry risks of infection, including hepatitis." 4. "The benefit of body art outweighs any risk of infection of a tattoo or piercing." Answer: 3 Explanation: 3. For tattooing and body piercing, risks include infections such as HIV and hepatitis B and C because of the use of inadequately sterilized equipment, as well as allergic reactions, local swelling and burns, granulomas, and keloid formation. Page Ref: 44 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. C. 4. Seek learning opportunities with patients who represent all aspects of human diversity. | AACN Essentials Competencies: VII. 5. Use evidencebased practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1 Discuss the key points a nurse should consider when taking a sexual history. MNL LO: 6.2.1 Recognize client behaviors associated with the acquisition of sexually transmitted infections.
9) The nurse is teaching a class on menstruation to young girls. What information would be important for 10-12-year-olds to know? 1. The age they will start having their periods 2. Variations in the age menstruation begins, length of the cycle, and duration of the menses 3. The number of days they will be ill when they have their menses 4. The number of days they will not be able to take part in physical education at school during their menses Answer: 2 Explanation: 2. These are the issues young girls like to know, as they always question whether they are different from their peers. Page Ref: 44 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Developmental Stages and Transitions Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2 Summarize information that women may need in order to implement appropriate self-care measures for dealing with menstruation. 10) The nurse is interviewing a 16-year-old client who has been using deodorant tampons during her menses. She comes into the gynecology office complaining of a rash and open sores on her labia and tenderness in the vagina. After obtaining her history, what will the nurse determine is the most likely cause of this client's problem? 1. She had forceful intercourse, which caused the trauma. 2. She is reacting to the deodorant in the tampon. 3. She might be allergic to the underwear she is wearing. 4. She is having a normal reaction to her menses. Answer: 2 Explanation: 2. This is the correct answer, as women often will react to the deodorant used on pads and tampons. Page Ref: 38 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2 Summarize information that women may need in order to implement appropriate self-care measures for dealing with menstruation.
11) The nurse educator is teaching a group of teens and 20-year-olds reproductive health care. When several of the women bring up douching, what is the best response the nurse could make? 1. "One should always douche after having intercourse." 2. "When douching, use force putting them in and get the solution up high." 3. "It is a good idea to douche before intercourse so the area is clean for the sperm." 4. "Douching is unnecessary because the lining of the vagina has numerous glands that provide natural cleansing." Answer: 4 Explanation: 4. This is a true statement. The vagina has a natural cleansing system. Page Ref: 39 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2 Summarize information that women may need in order to implement appropriate self-care measures for dealing with menstruation.
12) The nurse is instructing a young client on avoiding toxic shock syndrome. Education was successful when the client makes which statements? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. "I will wash my hands before inserting a tampon." 2. "I will change my tampon every 3-6 hours." 3. "I will not touch the part of the tampon I insert." 4. "I will just put the used tampon in the trash." 5. "I will take prophylactic antibiotics if needed." Answer: 1, 2, 3 Explanation: 1. Washing hands before inserting or removing a tampon is correct. 2. Changing the tampon every 3-6 hours will help prevent toxic shock syndrome from developing. 3. After the tampon is unwrapped, the client should avoid touching the portion of the tampon to be inserted into the vagina. Page Ref: 39 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2 Summarize information that women may need in order to implement appropriate self-care measures for dealing with menstruation.
13) The nurse is interviewing an adolescent client. The client reports a weight loss of 50 pounds over the last 4 months, and reports running at least 5 miles per day. The client asserts that her menarche was 5 years ago. Her menses are usually every 28 days, but her last menstrual period was 4 months ago. The client denies any sexual activity. Which is the best statement for the nurse to make? 1. "Your lack of menses might be related to your rapid weight loss." 2. "It is common and normal for runners to stop having any menses." 3. "Increase your intake of iron-rich foods to reestablish menses." 4. "Adolescents rarely have regular menses, even if they used to be regular." Answer: 1 Explanation: 1. Secondary amenorrhea can be caused by rapid weight loss, including the development of the eating disorders anorexia and bulimia. Runners with low body fat might have irregular menses, but amenorrhea is not a normal condition. Page Ref: 39 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3 Identify causes of amenorrhea. 14) A 19-year-old woman comes to the gynecologist's office. When the nurse asks the reason for this visit, the client explains that she has never had a menstrual period, and that she is concerned there might be something wrong. What is the diagnosis that the physician is most likely to make based on this information? 1. Primary dysmenorrhea 2. Secondary infertility 3. Primary amenorrhea 4. Secondary amenorrhea Answer: 3 Explanation: 3. Primary amenorrhea is the term for the condition when menses have never occurred. Page Ref: 39 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 3 Identify causes of amenorrhea.
15) The nurse educator is talking with the students in the clinical area about amenorrhea. She has discussed both primary and secondary amenorrhea and their possible causes and knows that her teaching has been successful when, upon being questioned, a student explains that amenorrhea can be caused by which of the following? 1. Malfunctioning of the pancreas and insulin usage 2. Lack of testosterone after the time for menses to start 3. Lack of vitamin D and calcium in the system 4. Dysfunction of the hypothalamus Answer: 4 Explanation: 4. Causes for amenorrhea include dysfunction of the hypothalamus, pituitary, and/or anovulation. Page Ref: 39, 40 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 3 Identify causes of amenorrhea. 16) A client comes to the clinic complaining of severe menstrual cramps. She has never been pregnant, has been diagnosed with ovarian cysts, and has had an intrauterine device (IUD) for 2 years. What is the most likely cause for the client's complaint? 1. Primary dysmenorrhea 2. Secondary dysmenorrhea 3. Menorrhagia 4. Hypermenorrhea Answer: 2 Explanation: 2. Secondary dysmenorrhea is associated with pathology of the reproductive tract, and usually appears after menstruation has been established. Conditions that most frequently cause secondary dysmenorrhea include ovarian cysts and the presence of an intrauterine device. Page Ref: 40 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 4 Contrast dysmenorrhea and premenstrual syndrome. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications of contraception methods.
17) The nurse teaches a group of young women that self-care measures for dysmenorrhea include which of the following actions? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Taking vitamins B and E 2. Decreasing salt intake 3. Using cold packs as needed 4. Using intermittent exercise 5. Taking FSH replacement Answer: 1, 2 Explanation: 1. Some nutritionists suggest that vitamins B and E help relieve the discomforts associated with menstruation. 2. Self-care measures such as regular exercise, rest, application of heat, and good nutrition— including reducing salt—will help dysmenorrhea symptoms. Page Ref: 40 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4 Contrast dysmenorrhea and premenstrual syndrome.
18) The nurse at a women's clinic is planning a class on premenstrual dysphoric disorder (PMDD). The nurse includes in the education information about what medications that are shown to be effective for PMDD? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Fluoxetine hydrochloride (Prozac) 2. Sertraline hydrochloride (Zoloft) 3. Paroxeline CR (Paxil CR) 4. Hyoscyamine (Anaspaz) 5. Promethazine (Phenergan) Answer: 1, 2, 3 Explanation: 1. Selective serotonin inhibitors such as fluoxetine hydrocholoride (Prozac) have been found to be effective in controlling PMDD. 2. Setraline hydrochloride (Zoloft) is a selective serotonin inhibitor and has been found to be effective in controlling PMDD. 3. Paroxeline CR (Paxil CR) is a selective serotonin inhibitor and has been found to be effective in controlling PMDD. Page Ref: 41 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2 Summarize information that women may need in order to implement appropriate self-care measures for dealing with menstruation.
19) The nurse is teaching a group of women about menopause at a community clinic. The nurse tells them that the best indicator of menopause is which of the following symptoms? 1. No menses for 8 consecutive months 2. Hot flashes and night sweats 3. FSH levels rise and ovarian follicles cease to produce estrogen 4. Diagnosed with osteoporosis 4 months ago Answer: 3 Explanation: 3. Examining FSH and estrogen levels is a very accurate indication of menopause. Page Ref: 45 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5 Delineate the physical and psychologic aspects of menopause. MNL LO: 6.1.1 Explain hormonal changes that occur in menopause and methods to manage the associated symptoms. 20) A client who is in perimenopause is having a number of severe symptoms. The nurse assesses this client and knows the doctor will likely prescribe what to assist in relieving the distress? 1. Calcium and vitamin D 2. A form of hormonal contraception 3. Prescriptive pain medication 4. Antibiotics Answer: 2 Explanation: 2. Hormonal contraception is the correct answer, as pregnancy can still be a concern, plus the estrogen will relieve other symptoms, such as hot flashes and vaginal dryness. Page Ref: 45 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients and designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5 Delineate the physical and psychologic aspects of menopause. MNL LO: 6.1.1 Explain hormonal changes that occur in menopause and methods to manage the associated symptoms.
21) The nurse is teaching a group of menopausal women about the signs and symptoms of menopause and how they can get relief. One of the main concerns of the group is vaginal dryness and difficult intercourse. What is the reason the nurse will give for this? 1. The loss of cervical gland function leads to dryness of the mucous membranes of the vagina. 2. The vaginal pH increases, and the number of Doderlein's bacilli decreases. 3. The uterine lining thins and the muscle layer atrophies. 4. The labia shrink and lose their pigmentation. Answer: 1 Explanation: 1. The loss of cervical gland function leads to dryness of the mucous membranes of the vagina. Page Ref: 45 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships in health and safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5 Delineate the physical and psychologic aspects of menopause. MNL LO: 6.1.1 Explain hormonal changes that occur in menopause and methods to manage the associated symptoms. 22) A client is asking the nurse what she can do about the "falling down of her reproductive organs and urinary tract wall." The nurse will tell the client to try what exercise? 1. Lifting weights to strengthen those muscles 2. Running two miles a day 3. Running up and down stairs a few times every day 4. Performing Kegel exercises and having regular sexual activity Answer: 4 Explanation: 4. This is the correct answer. Kegel exercises are done by tightening and relaxing the perineal muscles, and this activity as well as sexual activity will help the client's problem. Page Ref: 45 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5 Delineate the physical and psychologic aspects of menopause. MNL LO: 6.1.1 Explain hormonal changes that occur in menopause and methods to manage the associated symptoms. 23) The nurse educator is talking with a group of students doing their gynecological rotation. The
nurse describes a number of symptoms that include anovulation, reduced fertility, either decreased or increased menstrual flow, and menstrual cycle irregularities. The nurse is describing what condition? 1. Intermenstrual bleeding 2. Hypermenorrhea 3. Menopause 4. Primary amenorrhea Answer: 3 Explanation: 3. This is the correct answer. Anovulation, reduced fertility, either decreased or increased menstrual flow, and menstrual cycle irregularities are some of the symptoms of menopause. Page Ref: 45 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5 Delineate the physical and psychologic aspects of menopause. MNL LO: 6.1.1 Explain hormonal changes that occur in menopause and methods to manage the associated symptoms.
24) When caring for the menopausal woman, nurses need to be empathetic in approaching which of the following areas? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Administering medications 2. Health teaching 3. Providing physical care 4. Counseling 5. Encouraging hormone therapy Answer: 2, 3, 4 Explanation: 2. The nurse needs to use an empathetic approach in counseling, health teaching, and providing physical care. 3. The nurse needs to use an empathetic approach in counseling, health teaching, and providing physical care. 4. The nurse needs to use an empathetic approach in counseling, health teaching, and providing physical care. Page Ref: 50 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5 Delineate the physical and psychologic aspects of menopause. MNL LO: 6.1.1 Explain hormonal changes that occur in menopause and methods to manage the associated symptoms.
25) The nurse assessing a 47-year-old client who is perimenopausal includes which important topics? Note: credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Vasomotor symptoms 2. A decrease in vaginal lubrication 3. Pregnancy not being an option 4. Mood changes that occur 5. An increase in the libido Answer: 1, 2, 4 Explanation: 1. Women need to know that vasomotor symptoms occur. It might be important to investigate other possible causes of the vasomotor symptoms. 2. Women need to know that a decrease in vaginal lubrication occurs, and that water-soluble lubricants should be used. 4. Mood changes and irritability occur, and the woman might experience more forgetfulness. Page Ref: 44 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients and designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5 Delineate the physical and psychologic aspects of menopause. MNL LO: 6.1.1 Explain hormonal changes that occur in menopause and methods to manage the associated symptoms.
26) In teaching a group of adolescents, the nurse discusses which risk factors for cardiovascular disease (CVD) in women? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Being over 55 and postmenopausal 2. Using cigarettes and tobacco 3. Being overweight 4. Having a low cholesterol level 5. Having an active lifestyle Answer: 1, 2, 3 Explanation: 1. Being over the age of 55 and postmenopausal increases the risk of CVD. 2. The use of cigarettes and tobacco increases the risk of CVD. 3. Being overweight or obese increases the risk of CVD. Page Ref: 46 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5 Delineate the physical and psychologic aspects of menopause. MNL LO: 6.1.1 Explain hormonal changes that occur in menopause and methods to manage the associated symptoms.
27) The nurse in the OB-GYN clinic has been seeing a client through her menopausal stage of life. The nurse assesses psychological concerns if the client makes which statement? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. "I feel so lost with all of the kids away from home." 2. "I wish I were younger, and could have a baby." 3. "Although my parents are aging, they travel a lot." 4. "I don't think I am a good wife anymore." 5. "I really enjoy being able to go out when I want." Answer: 1, 2, 4 Explanation: 1. Adjustment to an "empty nest" is a psychological concern during menopause. 2. Some women express disappointment in approaching this time of their lives, whereas others might see it as a positive transition that offers freedom from menses or concern about contraception. 4. Numerous personal factors influence a woman's ability to transition and cope with these changes, such as self-concept. Page Ref: 45 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5 Delineate the physical and psychologic aspects of menopause. MNL LO: 6.1.1 Explain hormonal changes that occur in menopause and methods to manage the associated symptoms.
28) The nurse is answering the perimenopausal client's questions about hormone replacement therapy. Which client statement indicates a need for further teaching? 1. "Estrogen therapy will decrease my chances of developing osteoporosis." 2. "If I am taking estrogen therapy, I will not have to worry about my cholesterol being checked." 3. "Osteoporosis is a decrease in bone strength due to bone density and quality." 4. "Bone mass tends to decrease after menopause." Answer: 2 Explanation: 2. Cholesterol levels should be checked regularly even when normal, so this statement indicates the need for more teaching. Page Ref: 43 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5 Delineate the physical and psychologic aspects of menopause. MNL LO: 6.1.1 Explain hormonal changes that occur in menopause and methods to manage the associated symptoms.
29) The charge nurse is giving an in-service to the orthopedic and gynecology nurses concerning the relationship between estrogen and osteoporosis. Which is a statement the nurse would make concerning this relationship? 1. "Males have a higher incidence of osteoporosis than do females." 2. "Women who experience menopause at a younger age and have less bone mass could have more bone loss." 3. "Estrogen levels affect only bone mass, but they have nothing to with bone strength and bone density." 4. "Osteoporosis puts the client at a decreased risk for fractures of the forearm and vertebrae." Answer: 2 Explanation: 2. This is a true statement, as women who experience menopause at a younger age and have less bone mass lose the benefit of estrogen for more years. Page Ref: 39 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6 Explain the relationship between menopause and osteoporosis. MNL LO: 6.1.1 Explain hormonal changes that occur in menopause and methods to manage the associated symptoms.
30) The nurse is interviewing a new client in the clinic. The client is premenopausal, but is concerned about the bone changes and osteoporosis that can occur, since she is getting close to menopause. The nurse tells the client that prevention is the primary goal. Which of the following would be a primary goal for prevention? 1. Eliminating all alcohol intake 2. Taking 500 mg of calcium each day 3. Use of sunscreen to assist with absorption of vitamin D 4. Regular weight-bearing and muscle-strengthening exercises Answer: 4 Explanation: 4. This is correct. Regular weight bearing of the long bones is a primary goal for the prevention of osteoporosis. Page Ref: 48 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6 Explain the relationship between menopause and osteoporosis. MNL LO: 6.1.1 Explain hormonal changes that occur in menopause and methods to manage the associated symptoms.
31) The nurse is teaching a group of clients about risk factors for osteoporosis. The nurse will include which of the following risk factors in the teaching? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Menopause at an early age increases bone loss 2. A family history of osteoporosis 3. A lifetime of high calcium intake 4. Having an active lifestyle 5. A vitamin D deficiency Answer: 1, 2, 5 Explanation: 1. Abnormal absence of menses and early onset of menopause increase the risk of osteoporosis. 2. Family history of osteoporosis, especially a maternal hip fracture, increases the risk of osteoporosis. 5. Vitamin D deficiency increases the risk of osteoporosis. Page Ref: 46 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships in health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6 Explain the relationship between menopause and osteoporosis. MNL LO: 6.1.1 Explain hormonal changes that occur in menopause and methods to manage the associated symptoms.
32) A menopausal woman tells her nurse that she experiences discomfort from vaginal dryness during sexual intercourse, and asks, "What should I use as a lubricant?" The nurse should recommend which of the following? 1. Petroleum jelly 2. A water-soluble lubricant 3. Body cream or body lotion 4. Less-frequent intercourse Answer: 2 Explanation: 2. A water-soluble jelly should be used. Page Ref: 50 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5 Delineate the physical and psychologic aspects of menopause. MNL LO: 6.1.1 Explain hormonal changes that occur in menopause and methods to manage the associated symptoms.
33) A 49-year-old client comes to the clinic with complaints of severe perimenopausal symptoms including hot flashes, night sweats, urinary urgency, and vaginal dryness. The physician has prescribed a combination hormone replacement therapy of estrogen and progestin. When the client asks the nurse why she must take both hormones, what is the nurse's best reply? 1. "Hot flashes respond better when replacement includes both hormones." 2. "You are having very severe symptoms, so you need more hormones replaced." 3. "There is an increased risk of tissue abnormality inside the uterus if only one is given." 4. "Your blood pressure can become elevated if only one hormone is used." Answer: 3 Explanation: 3. Estrogen alone, in a woman with a uterus (unopposed estrogen), increases the risk of endometrial (the lining of the uterus) cancer by eightfold and, therefore, is never given without progesterone in these women. Page Ref: 47 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4 Contrast dysmenorrhea and premenstrual syndrome. MNL LO: 6.1.1 Explain hormonal changes that occur in menopause and methods to manage the associated symptoms.
34) The nurse assessing a 50-year-old female client at an orthopedic center asks about the use of complementary and alternative therapies. Which of the following are among those women often try during menopause? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Vitamin and mineral supplements 2. Increasing caffeine intake 3. Soy and red clover 4. Selective estrogen receptor modulators 5. Salmon calcitonin Answer: 1, 3 Explanation: 1. Vitamin and mineral supplements, especially calcium and vitamins D, E, and B complex, are used to control the symptoms of menopause. 3. Soy and red clover have shown to be effective for some women in controlling their menopausal symptoms. Page Ref: 49 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7 Identify medical and complementary therapies to alleviate the discomforts of menopause. MNL LO: 6.1.1 Explain hormonal changes that occur in menopause and methods to manage the associated symptoms.
35) The nurse is teaching a group of perimenopausal women about treatment choices for their symptoms. The nurse will include which information? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Importance of continuing contraception 2. Benefits of menstrual regulation with hormones 3. Increase in vaginal dryness with hormones 4. Decrease in acne and hirsutism 5. Increase in endometrial cancer risk Answer: 1, 2, 4 Explanation: 1. Thirty-eight percent of pregnancies for women ages 40 and older are unplanned; some form of contraception is needed. 2. Regulation of menses with effective contraception is a benefit to the perimenopausal woman. 4. Women on hormones might experience less acne and hirsutism. Page Ref: 45 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concept: Nursing Process: Implementation Learning Outcome: 5 Delineate the physical and psychologic aspects of menopause. MNL LO: 6.1.1 Explain hormonal changes that occur in menopause and methods to manage the associated symptoms.
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 4. Family Planning 1. A nurse is teaching contraception to a group of college students during a health
class. What reason will the nurse include as to why couples might choose to use contraception?Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Couples use contraception to avoid pregnancy. 2. Couples use contraception to space future pregnancies. 3. Couples use contraception to gain control over the number of children conceived. 4. Couples use contraception to avoid decisions about the number of children to have. 5. Couples use contraception to avoid contracting sexually transmitted diseases. Answer: 1, 2, 3, 5 Explanation: 1. This is the main reason for the use of contraception. 2. Contraception is used to space children. 3. Contraception is used to control the number of children that a couple desires. 5. Some types of birth control will avoid sexually transmitted diseases—for example, some ofthe barrier methods. Page Ref: 53, 57 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships to promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1 Describe the reasons why women and couples choose to use contraception. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 1) The nurse is planning an educational session about contraception. What will the nurse emphasize as being the most significant factor in determining the effectiveness of a specificmethod of contraception to avoid pregnancy? 1. Reliability 2. Ease of use 3. Consistency of use 4. Cost Answer: 3 Explanation: 3. Consistency of use is the most important factor for determining the effectiveness of a specific type of contraception.
Page Ref: 54 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered
Care: Communicate information effectively; listen openly and cooperatively. |Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1 Describe the reasons why women and couples choose to use contraception. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 2) The culturally sensitive nurse will assess cultural attitudes and beliefs about contraception, which can include which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected.Select all that apply. 1. Gender inequities 2. Religion 3. Deference to authority figures 4. Devaluation of large families 5. Attitudes about bleedingAnswer: 1, 2, 3, 5 Explanation: 1. Gender inequities may prohibit some Arab, Latina, and Eastern Indian women from seeking out or using a contraceptive method unless their husbands do not object. 2. The Roman Catholic Church considers all artificial methods of contraception unacceptable. 3. Deference to authority figures is not uncommon in traditional Chinese, Arab, Latina, andEast Indian women, especially if the nurse is male. 5. Attitudes toward bleeding affect a woman’s duties to her family and partner. Vaginal bleeding may be seen as “unclean” by Muslim and Orthodox Jewish women. Any contraceptive method that involves irregular bleeding might not be acceptable. Among women who feel a monthly period is necessary, any method that ultimately causes amenorrhea would not be acceptable. Page Ref: 67 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Personal and Professional Development: Demonstrate respect for all persons, and for human dignity, equality, and justice. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1 Describe the reasons why women and couples choose to use contraception. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 3) A client in the clinic asks the nurse about available contraceptives. Before responding, thenurse must assess which of the following factors? Note: Credit will be given only if all correct and no incorrect choices are
selected.Select all that apply. 1. When menarche occurred 2. How frequently the client has intercourse 3. Whether the client has a history of thrombophlebitis
4. What the client’s partner prefers 5. Whether the client is in a monogamous
relationship Answer: 2, 3, 5 Explanation: 2. A factor to consider when choosing a method of contraception is how frequently the client has intercourse. 3. A factor to consider when choosing a method of contraception is whether the client has ahistory of thrombophlebitis or any other condition that would contraindicate its use. 5. A factor to consider when choosing a method of contraception is whether the client is in amonogamous relationship. Page Ref: 54 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: VII. 3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health and illness. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1 Describe the reasons why women and couples choose to use contraception. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 4) A client asks the nurse, “Can you explain to us how to use the basal body temperature method to detect ovulation and prevent pregnancy?” What response by the nurse is best? 1. “Take your temperature every evening at the same time and keep a record for a period of several weeks. A noticeable drop in temperature indicates that ovulation has occurred.” 2. “Take your temperature every day at the same time and keep a record of the findings. Anoticeable rise in temperature indicates ovulation.” 3. “Take your temperature each day, immediately upon awakening, and keep a record ofeach finding. A noticeable rise in temperature indicates that ovulation is about to occur.” 4. “This is an unscientific and unproven method of determining ovulation, and is not recognized as a means of birth control.” Answer: 3 Explanation: 3. The basal body temperature method is used to detect ovulation by an increase in the basal temperature during the menstrual cycle. It requires that the woman takeher temperature every morning upon awakening (before any activity) and record the findings on a temperature graph, and is based on the fact that the temperature almost always rises and remains elevated after ovulation because of the production of progesterone, a thermogenic (heat-producing) hormone. Page Ref: 56 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated
surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered
Care: Communicate information effectively; listen openly and cooperatively. |Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2 Discuss types of fertility awareness-based methods such as natural family planning. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 5) During a counseling session on natural family planning techniques, the nurse explains thatcervical mucus at the time of ovulation should be of what consistency? 1. Egg white appearance and stretchable 2. Opaque and acidic 3. High in leukocytes 4. Lacking in quantityAnswer: 1 Explanation: 1. Cervical mucus at the time of ovulation has an “egg white” appearance and is known as fertile mucus; it is friendly to sperm because it assists passage through the cervix and uterus up into the fallopian tubes. Page Ref: 55 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients and designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2 Discuss types of fertility awareness-based methods such as natural family planning. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 6) A woman is asking the nurse about using the calendar method of contraception. She reports that her last six menstrual cycles were 28, 32, 29, 36, 30, and 27 days long, respectively. Based on this information, when should the nurse tell the client to abstain from intercourse? 1. Days 9-25 2. Days 9-15 3. Days 10-214. Days 10-16 Answer: 1 Explanation: 1. To calculate the period of abstinence, the nurse must subtract 18 from the shortest cycle length and 11 from the longest cycle length. Page Ref: 55 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients and designated surrogates in active partnerships that promote health, safety and well-being, and self-care
management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered
Care: Communicate information effectively; listen openly and cooperatively. |Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2 Discuss types of fertility awareness-based methods such as natural family planning. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 7) A nurse is teaching a group of college students at a Catholic university about natural family planning (NFP). Teaching was successful if the students say natural family planning is which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected.Select all that apply. 1. “It is free, safe, and acceptable according to our religion.” 2. “It includes breastfeeding for 1 year.” 3. “It is useful in helping us plan pregnancies.” 4. “It allows us to safely have intercourse during our fertile days.” 5. “It does not involve the use of artificial substances or devices.”Answer: 1, 3, 5 Explanation: 1. NFP is free, safe, and acceptable to many whose religious beliefs prohibit other methods. 3. NFP is useful in helping couples to plan a pregnancy. 5. NFP involves no artificial substances or devices. Page Ref: 55 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2 Discuss types of fertility awareness-based methods such as natural family planning. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 8) The nurse educator is planning a class about contraception, and includes information about the effects of various contraceptive methods on sexually transmitted diseases. Whichstatement will the nurse include concerning spermicides? 1. “Spermicides are effective against gonorrhea and chlamydia, but not against HIV.” 2. “Spermicides are not effective against sexually transmitted diseases, and can increase awoman’s susceptibility to HIV.” 3. “Spermicides are effective against HIV, but are not effective against the other sexually transmitted diseases.” 4. “Whether or not spermicides are effective against sexually transmitted diseases depends on where the woman is in her cycle.” Answer: 2
Explanation: 2. Spermicides are not effective against any sexually transmitted disease. Spermicides have a negative effect on the integrity of vaginal cells, making them more susceptible.
Page Ref: 57 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3 List the spermicide preparations currently available in the UnitedStates. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 9) The OB-GYN nurse is teaching a client at the clinic that use of a spermicide has anincreased effectiveness if used with which other items? Note: Credit will be given only if all correct and no incorrect choices are selected.Select all that apply. 1. A non-water-based lubricant 2. A diaphragm 3. A contraceptive sponge 4. Prophylactic antibiotics 5. A condom Answer: 2, 3, 5 Explanation: 2. Barrier contraceptives such as a diaphragm act by blocking the transport of sperm and are often used in conjunction with a spermicide. 3. Barrier contraceptives such as the contraceptive sponge act by blocking the transport of sperm and are often used in conjunction with a spermicide. 5. Barrier contraceptives such as the condom act by blocking the transport of sperm and areoften used in conjunction with a spermicide. Page Ref: 57 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patient or designated surrogates in activepartnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3 List the spermicide preparations currently available in the UnitedStates. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 10) The nurse in the clinic instructs a client using the natural method of contraception to begin counting the first day of her cycle as which day?
1. The day her menstrual period ceases 2. The first day after her menstrual period ceases 3. The first day of her menstrual period
4. The day of
ovulation Answer: 3 Explanation: 3. The first day of menstruation is the first day of the cycle. Page Ref: 55 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2 Discuss types of fertility awareness-based methods such as natural family planning. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 11) A client in the women’s clinic asks the nurse, “How is the cervical mucus method of contraception different from the rhythm method?” The appropriate response by the nurse is that the cervical mucus method is which of the following? 1. More effective for women with irregular cycles 2. Not acceptable to women of many different religions 3. Harder to work with than is the rhythm method 4. Requires an artificial substance or deviceAnswer: 1 Explanation: 1. The cervical mucus method (Billings Ovulation Method) can be used bywomen with irregular cycles. Page Ref: 55 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2 Discuss types of fertility awareness-based methods such as natural family planning. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 12) A client who wants to use the vaginal sponge method of contraception shows that sheunderstands the appropriate usage when she makes which statement? 1. “I need to use a lubricant prior to insertion.” 2. “I need to add spermicidal cream prior to intercourse.” 3. “I need to moisten it with water prior to use.” 4. “I need to leave it in no longer than 6
hours.”Answer: 3
Explanation: 3. To activate the spermicide in the vaginal sponge, it must be moistened thoroughly with water. Page Ref: 61 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Respect the patient’s dignity, uniqueness, integrity, and self-determination, and his or her own power and self-healing process. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4 Compare the barrier methods of contraception with regard to correct use and advantages and disadvantages. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 13) A female client who is 36 years old, weighs 200 pounds, is monogamous, and does not smoke desires birth control. The nurse understands that which contraceptive method is inappropriate for this client? 1. Intrauterine device 2. Vaginal sponge 3. Combined oral contraceptives 4. Transdermal hormonal contraceptionAnswer: 4 Explanation: 4. Transdermal hormonal contraception is contraindicated because of theclient’s obesity. Page Ref: 64 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families and the health care team. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 6 Compare other hormonal methods of birth control, including Depo-Provera, NuvaRing, Ortho Evra, Nexplanon, and the progestin-only minipill. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 14) When assessing a client asking about birth control, the nurse knows that the client wouldnot be a good candidate for Depo-Provera (DMPA) if which of the following is true? 1. She wishes to get pregnant within 3 months. 2. She is a nursing mother. 3. She has a vaginal prolapse.
4. She weighs 200
pounds. Answer: 1 Explanation: 1. Return of fertility after use may be delayed for an average of 10 months.
Page Ref: 65 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the health care team. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6 Compare other hormonal methods of birth control, including Depo-Provera, NuvaRing, Ortho Evra, Nexplanon, and the progestin-only minipill. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 15) A couple asks the nurse what is the safest method of sterilization. What should the nursereply? 1. “Laparotomy tubal ligation.” 2. “Laparoscopy tubal ligation.” 3. “Minilaparotomy.” 4. “Vasectomy. ”Answer: 4 Explanation: 4. Vasectomy (male sterilization) is a relatively minor procedure. Page Ref: 66 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9 Contrast the forms of sterilization—tubal ligation, Essure, and vasectomy—with regard to risk, effectiveness, advantages, and disadvantages. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 16) When the nurse is teaching a woman about the use of a diaphragm, it is important to instruct her that the diaphragm should be rechecked for correct size how often? 1. Every five years routinely 2. When weight gain or loss beyond five pounds has occurred 3. After each birth 4. Only after significant weight lossAnswer: 3 Explanation: 3. The diaphragm should be rechecked for correct size after each childbirth andwhenever a woman has gained or lost 10 pounds or more. Page Ref: 58
Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. |AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4 Compare the barrier methods of contraception with regard to correct use and advantages and disadvantages. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 17) What issues should the nurse consider when counseling a client on contraceptivemethods? Note: Credit will be given only if all correct and no incorrect choices are selected.Select all that apply. 1. Cultural perspectives on menstruation and pregnancy 2. Effectiveness of the method 3. Future childbearing plans 4. Whether the client is a vegetarian 5. Age at menarcheAnswer: 1, 2, 3 Explanation: 1. Decisions about contraception should be made voluntarily with full knowledge of advantages, disadvantages, effectiveness, side effects, contraindications, andlong-term effects. Many outside factors influence this choice, including cultural practices, religious beliefs, personality, cost, effectiveness, availability, misinformation, practicality of method, and self-esteem. 2. Decisions about contraception should be made voluntarily with full knowledge of advantages, disadvantages, effectiveness, side effects, contraindications, and long-term effects. Many outside factors influence this choice, including cultural practices, religious beliefs, personality, cost, effectiveness, availability, misinformation, practicality of method,and self-esteem. 3. Decisions about contraception should be made voluntarily with full knowledge of advantages, disadvantages, effectiveness, side effects, contraindications, and long-term effects. Many outside factors influence this choice, including cultural practices, religious beliefs, personality, cost, effectiveness, availability, misinformation, practicality of method,and self-esteem. Page Ref: 54 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: Patient-centered Care: Skills: Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: Clinical Prevention and Population Health: Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated
Concepts: Nursing Process: Assessment Learning Outcome: 1 Describe the reasons why women and couples choose to use contraception.
MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 18) The nurse teaching a group of new mothers and explains that barrier methods ofcontraception are appropriate if which of the following conditions exist? Note: Credit will be given only if all correct and no incorrect choices are selected.Select all that apply. 1. Just started an oral contraceptive 2. Is opposed to systemic medications 3. Is lactating 4. Is unconcerned about using contraception 5. Does not smoke and is perimenopausal Answer: 1, 2, 3, 5 Explanation: 1. A backup method of contraception is needed for a period of time when beginning oral contraceptives. 2. Opposition to taking systemic medications is a reason to use barriers for contraception. 3. Using a barrier method of contraception is appropriate in the early postpartum period orwhen lactating. 5. Being perimenopausal and smoking make barrier contraception an appropriate choice.Page Ref: 57 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care measures. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4 Compare the barrier methods of contraception with regard to correct use and advantages and disadvantages. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 19) The nurse is instructing a client in the use of combined oral contraceptives. The nurse knows that additional teaching is required when the client makes which statement about therisks of taking combined oral contraceptives? 1. “They will lower my risk for breast cancer.” 2. “They will increase my risk for cervical cancer.” 3. “They will lower my risk for ovarian cancer.” 4. “They will increase my risk for uterine cancer.”Answer: 3 Explanation: 3. This is true. There is a reduction in the incidence of ovarian cancer.Page Ref: 63, 64 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to
guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered
Care: Communicate information effectively; listen openly and cooperatively. |Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5 Summarize the key points that women who use combined oral contraceptives should know, including the correct procedure for taking pills, common sideeffects, warning signs, and noncontraceptive benefits. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 20) Extended use combined oral contraceptives (COCs) reduce the side effects of COCs such as which of the following? 1. Cramping 2. Hypertension 3. Breast tenderness 4. Bloatin gAnswer: 2 Explanation: 2. Complications of COCs include: myocardial infarction, stroke, blood clots, and hypertension. Page Ref: 63 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan and in all healthcare settings. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5 Summarize the key points that women who use combined oral contraceptives should know, including the correct procedure for taking pills, common sideeffects, warning signs, and noncontraceptive benefits. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 21) The nurse in the community clinic instructs a client starting on a combined oral contraceptive that she must immediately report which of the following symptoms? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Only four withdrawal bleeds per year 2. Speech problems 3. Unscheduled bleeding 4. Blood pressure of 126/84 5. New lumps in her breast Answer: 2, 5 Explanation: 2. The woman using combined oral contraceptives should contact herhealthcare provider if she develops speech problems. 5. The woman using combined oral contraceptives should contact her healthcare provider ifshe develops a breast lump.
Page Ref: 64 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active relationships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan and in all healthcare settings. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5 Summarize the key points that women who use combined oral contraceptives should know, including the correct procedure for taking pills, common sideeffects, warning signs, and noncontraceptive benefits. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 22) The nurse is discussing the use of contraception with a client who has just becomesexually active. What factors should the nurse include when educating the client on contraceptive methods? Note: Credit will be given only if all correct and no incorrect choices are selected.Select all that apply. 1. Contraindications in the client’s health history 2. Religious or moral beliefs 3. Partner’s belief in the effectiveness of the choice 4. Personal preferences to use method 5. Future childbearing plansAnswer: 1, 2, 4, 5 Explanation: 1. Decisions about contraception should take into consideration anycontraindications the client might have. 2. Religious or moral beliefs often impact which choices are acceptable. 4. Personal preferences need to be considered when deciding on a contraceptive method. 5. Plans for future children should be considered before determining whether sterilization should be performed. Page Ref: 67 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active relationships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1 Describe the reasons why women and couples choose to use contraception. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 23) A nurse is providing contraceptive counseling to a perimenopausal client in a monogamous relationship. What comment by the client indicates that further teaching is necessary?
1. “The calendar method is the most reliable method for me to use.” 2. “If I use the IUC, I will be at minimal risk for pelvic inflammatory disease.”
3. “I should still use birth control, even though I had only three periods last year.” 4. “The contraceptive skin patch contains both estrogen and
progesterone.”Answer: 1 Explanation: 1. The client who believes the calendar method is the most reliable method requires more teaching. The menstrual cycle of perimenopausal women is irregular, and it is difficult to determine safe and unsafe times. Page Ref: 55 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active relationships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1 Describe the reasons why women and couples choose to use contraception. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 24) A client is using the contraceptive sponge as a birth control method. What action is important in order to maintain the sponge’s effectiveness? 1. Insert the sponge at least 1 hour before intercourse. 2. Thoroughly moisten the sponge with water before inserting. 3. Spermicidal jelly must be inserted at the same time the sponge is inserted. 4. A new sponge must be inserted every time a couple has intercourse. Answer: 2 Explanation: 2. The sponge is moistened thoroughly with water before use to activate the spermicide. Page Ref: 61 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the lifespan, and in all healthcare setting. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4 Compare the barrier methods of contraception with regard to correct use and advantages and disadvantages. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 25) The nurse is preparing educational materials at a family planning clinic. The client who is an appropriate candidate for using emergency contraception would be one who
reports which of the following? 1. Forgetting to start her pill pack yesterday 2. Unprotected intercourse during her menses
3. That a condom broke yesterday in the middle of her cycle 4. Increased dysmenorrhea since IUC
insertion Answer: 3 Explanation: 3. Research indicates that oral hormonal EC taken as soon as possible within 72 hours, but up to 5 days, can reduce the risk of pregnancy after a single act of unprotectedintercourse by at least 74%. Page Ref: 65 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. C. 2. Respect and encourage individual expression of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the lifespan, and in all healthcare setting. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7 Identify the appropriate time frame for initiating postcoital emergency contraception (EC). MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 26) A woman comes into the emergency department stating she was raped the day before, and requests emergency contraception. She states that she is in the middle of her cycle. Thenurse knows which of the following about the client? 1. This client has waited too long before coming to the emergency department. 2. The client will have to wait 10 days before she can have emergency contraception. 3. The client can receive emergency contraception up to 72 hours to 5 days after theintercourse. 4. The client will have to wait and see whether she misses a period.Answer: 3 Explanation: 3. This client is within the 72-hour to 5-day timeframe, and is able to receive themedicine. Page Ref: 65 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. C. 2. Respect and encourage individual expression of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the lifespan, and in all healthcare setting. | NLN Competencies: Relationship-Centered Care: Appreciate the person as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7 Identify the appropriate time frame for initiating postcoital emergency contraception (EC). MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods.
27) A client who was raped is in the emergency department. She asks the nurse what
her alternatives are for emergency contraception. The nurse tells her she can receive which ofthe following treatments? Note: Credit will be given only if all correct and no incorrect choices are selected.Select all that apply. 1. Take levonorgestrel and ethinyl estradiol. 2. Have Essure implanted. 3. Have a laparoscopic tubal ligation. 4. Take levonorgestrel alone, but in a high dose. 5. Take high doses of male hormones. Answer: 1, 4 Explanation: 1. Preparations for EC include high doses of levonorgestrel and ethinyl estradiol (Yuzpe regimen). 4. Preparations for EC include high doses of levonorgestrel (Plan B).Page Ref: 65 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the lifespan, and in all healthcare setting. | NLN Competencies: Context and Environment: Read and interpret data; apply health promotion/disease prevention strategies; apply health policy; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7 Identify the appropriate time frame for initiating postcoital emergency contraception (EC). MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 28) The nurse in the clinic is seeing four clients. Which one is the best candidate forreceiving an IUC? 1. An unmarried, 22-year-old college graduate 2. A married 24-year-old who has never been pregnant 3. An unmarried 25-year-old with a history of chlamydia 4. A married 26-year-old who has two children Answer: 4 Explanation: 4. This client is the best candidate, as she is in a stable relationship, and has children. Page Ref: 62 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 3. Implement holistic,
patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the lifespan, and in all healthcare setting. | NLN Competencies: Relationship-Centered Care: Read and interpret data; apply health promotion/disease prevention strategies; apply health policy; conduct population-
based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8 Delineate the advantages and disadvantages of an IUD as a method ofcontraception. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 29) The nurse is providing instructions for a woman who has just had intrauterinecontraception inserted. What is essential for the nurse to teach the client? 1. To palpate her lower abdomen each month to check the patency of the device 2. To remain on bed rest for 24 hours after insertion of the device 3. To report any pain during intercourse to the physician 4. To insert spermicidal jelly within 4 hours of every sexual encounterAnswer: 3 Explanation: 3. The client should report any pain during intercourse to the physician. This can be due to an infection. Page Ref: 62 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active relationships that promote health, safety and well-being, and self-care management. |AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8 Delineate the advantages and disadvantages of an IUD as a method ofcontraception. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 30) The nurse is educating a client on intrauterine contraception (IUC). Which advantages of IUC will the nurse include? Note: Credit will be given only if all correct and no incorrect choices are selected.Select all that apply. 1. It is effective, continuous contraception. 2. It is relatively inexpensive over time. 3. It does not need to be inserted immediately prior to coitus. 4. Small amounts of estrogen are released daily. 5. It slightly increases the risk of ectopic pregnancy. Answer: 1, 2, 3 Explanation: 1. One advantage of IUC is a high rate of effectiveness. 2. One advantage of IUC is that it is inexpensive over time. 3. It is non-coitus-related contraception. Page Ref: 62 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease
Prevention Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation,
referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8 Delineate the advantages and disadvantages of an IUD as a method ofcontraception. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 31) The nurse in the OB-GYN office is explaining the benefits and risks associated with Essure to a client and her husband. What statement made by the client indicates that additional education is needed? 1. “A stainless steel microinsert is placed into the distal section of one fallopian tube.” 2. “The Essure method of permanent sterilization requires no surgical incision.” 3. “The steel microinserts create a benign tissue response that occludes the fallopian tubes.” 4. “Women allergic to nickel should consult their physician before placement.”Answer: 1 Explanation: 1. The stainless steel microinsert is placed in the proximal section of both fallopian tubes. Page Ref: 66 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9 Contrast the forms of sterilization—tubal ligation, Essure, and vasectomy—with regard to risk, effectiveness, advantages, and disadvantages. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 32) A client using oral contraceptives tells the nurse that her family is complete, and she nowdesires permanent contraception. Which statement should the nurse include in teaching this client about sterilization options? 1. “Essure becomes effective 3 months after insertion.” 2. “Vasectomy is effective immediately after the procedure.” 3. “Tubal ligation cannot be performed until the client is age 35.” 4. “Oral contraception should be taken until menopause.”Answer: 1 Explanation: 1. The insertion of Essure creates a tissue response that results in tubal occlusion in about 3 months. Page Ref: 66 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. |AACN Essentials Competencies: VII. 5. Use evidence-based practices to
guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 9 Contrast the forms of sterilization—tubal ligation, Essure, and vasectomy—with regard to risk, effectiveness, advantages, and disadvantages. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 33) The nurse is developing a teaching plan for a client undergoing a tubal ligation. What information should be included in the plan? 1. The surgical procedure is easily reversible. 2. Laparotomy is performed following a vaginal birth. 3. Minilaparotomy is performed in the postpartum period soon after a vaginal birth. 4. Tubal ligation can be done at any time the woman is either pregnant or not pregnant. Answer: 3 Explanation: 3. A tubal ligation minilaparotomy is performed in the postpartum period soon after a vaginal birth. Page Ref: 66 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I. B. 10. Skills: Engage patients and designated surrogatesin active relationships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 9 Contrast the forms of sterilization—tubal ligation, Essure, and vasectomy—with regard to risk, effectiveness, advantages, and disadvantages. MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 34) The client who was raped is extremely upset when a pregnancy test confirms that she is pregnant, and requests information regarding pregnancy termination. Which statement is best for the nurse to include? 1. “Abortion is morally wrong, and should not be undertaken.” 2. “Hypertension is a risk with any abortion.” 3. “Surgical abortion in the first trimester is technically easier and safer than abortion in thesecond trimester.” 4. “The most accurate method to determine gestational age are the results of a pregnancy test.” Answer: 3 Explanation: 3. Secondtrimester abortion (greater than 13 weeks’ gestation up to 24 weeks or as per state law) may be done medically or surgically. Page Ref: 69 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I. C. 11. Respect patient preferences for degree of active engagement in care process. | AACN Essentials Competencies: II. 8. Promote achievement of safe and quality outcomes of care for diverse populations. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. |
Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10 Compare medical and surgical approaches to pregnancy termination.
MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications ofcontraception methods. 35) A client who is currently 12 weeks pregnant is seeking information on pregnancy termination. The nurse is teaching the client about the risks involved if she were to take themedication mifepristone. Which adverse signs would the client need to know and report immediately to a physician? 1. Fatigue, lack of appetite, and inability to concentrate 2. Nausea, diarrhea, vomiting, and stomach pain 3. Increase in heart rate, inability to sit still, and lack of appetite 4. Headache, fatigue, and hungerAnswer: 2 Explanation: 2. Nausea, diarrhea, vomiting, and stomach pain are the symptoms that must be reported immediately to the physician. Page Ref: 69 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the health care team. | AACN Essentials Competencies: II. 8. Promote achievement of safe and quality outcomes of care for diverse populations. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10 Compare medical and surgical approaches to pregnancy termination.MNL LO: 6.1.2 Compare advantages, disadvantages, risk factors, and contraindications of contraception methods.
Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig) Chapter 5 Commonly Occurring Infections 1) A nonpregnant client is diagnosed with bacterial vaginosis (BV). What does thenurse expect to administer? A) Penicillin G 2 million units IM one time B) Zithromax 1 mg PO bid for 2 weeks C) Doxycycline 100 mg PO bid for a week D) Metronidazole 500 mg PO bid for a week Answer: D Explanation: A) Penicillin is not used to treat bacterial vaginosis. B) Zithromax is not used to treat bacterial vaginosis. C) Doxycycline is not used to treat bacterial vaginosis. D) The nonpregnant woman who is diagnosed with bacterial vaginosis (BV) istreated with metronidazole 500 mg orally twice a day for 7 days. Page Ref: 78 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: Ⅰ. B. 3. Provide patient-centered care with sensitivityand respect for the diversity of human experience. | AACN Essentials Competencies: Ⅸ. 3. Implement holistic, patient-centered care that reflects an understanding of humangrowth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in allhealthcare settings. | NLN Competencies: Context and Environment: Apply professionalstandards; show accountability for nursing judgment and actions; develop advocacy skills; apply ethical decision making models. | Nursing/Integrated Concept: Nursing Process: Planning. Learning Outcome: 1 Compare vulvovaginal candidiasis and bacterial vaginosis. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
2) The nurse is providing discharge instructions to a client with a diagnosis of vulvovaginal candidiasis (VVC), and knows the client understands when she makeswhich of the following statements? A) "I need to apply the miconazole for 10 days." B) "I need to douche daily." C) "I need to add yogurt to my diet." D) "I need to wear nylon panties." Answer: C Explanation: A) Applying miconazole for 10 days does not prevent or assist in treating vulvovaginal candidiasis. B) Douching daily does not prevent or assist in treating vulvovaginal candidiasis. C) Yogurt helps reestablish normal vaginal flora. D) Wearing nylon panties does not prevent or assist in treating vulvovaginal candidiasis. Page Ref: 77 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/DiseasePrevention Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅶ. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreakinvestigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concept: Nursing Process: Evaluation. Learning Outcome: 1 Compare vulvovaginal candidiasis and bacterial vaginosis. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
3) The nurse provides a couple with education about the consequences of not treating chlamydia, and knows they understand when they make which statement? A) "She could become pregnant." B) "She could have severe vaginal itching." C) "He could get an infection in the tube that carries the urine out." D) "It could cause us to develop a rash." Answer: C Explanation: A) Chlamydia does not cause a woman to become pregnant. B) Chlamydia does not cause vaginal itching. C) Chlamydia is a major cause of nongonococcal urethritis (NGU) in men. D) Chlamydia does not cause a rash. Page Ref: 77 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/DiseasePrevention Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅶ. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreakinvestigation, referral, and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concept: Nursing Process: Evaluation. Learning Outcome: 2 Summarize modes of transmission, treatments, and descriptionsof the most commonly occurring sexually transmitted infections (STIs). MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
4) The nurse is seeing clients in the women's clinic. Which client should be treated with ceftriaxone IM and doxycycline orally? A) A pregnant client with gonorrhea and a yeast infection B) A nonpregnant client with gonorrhea and chlamydia C) A pregnant client with syphilis D) A nonpregnant client with chlamydia and trichomoniasis Answer: B Explanation: A) A pregnant client would not be treated with doxycycline. B) The combined treatment of ceftriaxone IM and doxycycline orally provides dual treatment for gonorrhea and chlamydia, which frequently occur together. C) The combined treatment of ceftriaxone IM and doxycycline orally is not the correct treatment for syphilis, and a pregnant client would not be treated withdoxycycline. D) The combined treatment of ceftriaxone IM and doxycycline orally is not the correct treatment for trichomoniasis. Page Ref: 77 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: Ⅰ. B. 3. Provide patient-centered care with sensitivityand respect for the diversity of human experience. | AACN Essentials Competencies: Ⅸ. 3. Implement evidence-based nursing interventions as appropriate for managing theacute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Teamwork: Function completely within one's own scope of practice as leader and member of the healthcare team and manage delegation effectively. | Nursing/Integrated Concept: Nursing Process: Implementation. Learning Outcome: 2 Summarize modes of transmission, treatments, and descriptionsof the most commonly occurring sexually transmitted infections (STIs). MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
5) The nurse is providing follow-up education to a client just diagnosed with vaginal herpes. What statement by the client verifies correct knowledge about vaginal herpes? A) "I should douche daily to prevent infection." B) "I could have another breakout during my period." C) "I am more likely to develop cancer of the cervix." D) "I should use sodium bicarbonate on the lesions to relieve discomfort." Answer: B Explanation: A) Douching does not prevent infection. B) Menstruation seems to trigger recurrences of herpes. C) There is no relation between herpes and cancer of the cervix. D) Burow's (aluminum acetate) solution, not sodium bicarbonate, relieves discomfort. Page Ref: 80 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Health Promotion/DiseasePrevention Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concept: Nursing Process: Evaluation. Learning Outcome: 3 Describe the health teaching that a nurse needs to provide to awoman with an STI. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
6) The nurse seeing a client just diagnosed with Chlamydia trachomatis knows thatwhich client is at greatest risk for the infection? A) 16-year-old sexually active girl, using no contraceptive B) 22-year-old mother of two, developed dyspareunia C) 35-year-old woman on oral contraceptives D) 48-year-old woman with hot flashes and night sweats Answer: A Explanation: A) Teens have the highest incidence of sexually transmitted infections, especially chlamydia. A client not using contraceptives is not using condoms, which decrease the risk of contracting a STI. B) Dyspareunia sometimes develops with chlamydia infection, but dyspareunia isnot a symptom specific to chlamydia. C) There is no correlation between oral contraceptive use and an increased rate of chlamydia infection. Additionally, chlamydia is more commonly seen in young women. D) This client is experiencing signs of menopause, not of chlamydia infection. Page Ref: 78 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/DiseasePrevention Standards: QSEN Competencies: Ⅰ. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: Ⅸ. 2. Recognize the relationshipof genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols andterminology. | NLN Competencies: Context and Environment: Read and interpret data;apply health promotion/disease prevention strategies; apply health policy; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concept: Nursing Process: Assessment. Learning Outcome: 2 Summarize modes of transmission, treatments, and descriptionsof the most commonly occurring sexually transmitted infections (STIs). MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
7) A client comes to the clinic complaining of difficulty urinating, flu-like symptoms, genital tingling, and blister-like vesicles on the upper thigh and vagina. She denies having ever had these symptoms before. The medication the physician is most likelyto order would be: A) Oral acyclovir B) Ceftriaxone IM C) Azithromycin PO D) Penicillin G IM Answer: A Explanation: A) Malaise, dysuria, and tingling or painful vesicles are indicative of a primary herpes simplex outbreak. Acyclovir treats herpes. B) Ceftriaxone IM does not treat herpes. C) Azithromycin does not treat herpes. D) Penicillin does not treat herpes. Page Ref: 80 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: Ⅰ. B. 3. Provide patient-centered care with sensitivityand respect for the diversity of human experience. | AACN Essentials Competencies: Ⅸ. 3. Implement holistic, patient-centered care that reflects an understanding of humangrowth and development, pathophysiology, pharmacology, medical management, and nursing management across the lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills; apply ethical decision making models. | Nursing/Integrated Concept: Nursing Process: Implementation. Learning Outcome: 2 Summarize modes of transmission, treatments, and descriptionsof the most commonly occurring sexually transmitted infections (STIs). MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
8) The nurse is caring for a client hospitalized for pelvic inflammatory disease. Which nursing intervention would have priority? A) Encourage oral fluids B) Administer cefotetan Ⅳ C) Enforce bed rest D) Remove IUC, if present Answer: B Explanation: A) Encouraging oral fluids is not a priority. B) Administration of medications to treat the disease is the first priority. C) Bed rest is not a priority. D) Removal of an IUC is not a nursing intervention. Page Ref: 84 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: Ⅰ. B. 3. Provide patient-centered care with sensitivityand respect for the diversity of human experience. | AACN Essentials Competencies: Ⅸ. 11. Provide nursing care based on evidence that contributes to safe and high-qualitypatient outcomes within healthcare microsystems. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills; apply ethical decision making models. | Nursing/Integrated Concept: Nursing Process: Planning. Learning Outcome: 4 Relate the implications of pelvic inflammatory disease (PID) forfuture fertility to its pathologic origin, signs and symptoms, and treatment. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
9) The nurse obtains a health history from four clients. To which client should she givepriority for teaching about cervical cancer prevention? A) Age 30, treated for PID B) Age 25, monogamous C) Age 20, pregnant D) Age 27, uses a diaphragm Answer: A Explanation: A) Exposure to sexually transmitted infections increases the risk of abnormal cell changes and cervical cancer. B) Practicing monogamy does not increase the risk of cervical cancer. C) Pregnancy does not increase the risk of cervical cancer. D) Use of a diaphragm does not increase the risk of cervical cancer. Page Ref: 84 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/DiseasePrevention Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concept: Nursing Process: Planning. Learning Outcome: 3 Describe the health teaching that a nurse needs to provide to awoman with an STI. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
10) The nurse is discharging a client after hospitalization for pelvic inflammatory disease(PID). Which statements indicate that teaching was effective? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) "I might have infertility because of this infection." B) "It is important for me to finish my antibiotics." C) "Tubal pregnancy could occur after PID." D) "My PID was caused by a yeast infection." E) "I am going to have an IUD placed for contraception." Answer: A, B, C Explanation: A) Women sometimes become infertile because of scarring in the fallopian tubes asa result of the inflammation of PI D. B) Antibiotic therapy should always be completed when a client is diagnosed withany infection. C) The tubal scarring that occurs from tubal inflammation during PID can prevent a fertilized ovum from passing through the tube into the uterus, causing an ectopic or tubal pregnancy. D) PID is caused by bacteria, most commonly Chlamydia trachomatis or Neisseria gonorrhoeae. E) An intrauterine device (IUD) in place increases the risk of developing PID; aclient who has a history of PID is not a good candidate for an IUD. Page Ref: 84 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Health Promotion/DiseasePrevention Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concept: Nursing Process: Evaluation. Learning Outcome: 4 Relate the implications of pelvic inflammatory disease (PID) forfuture fertility to its pathologic origin, signs and symptoms, and treatment. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
11) Which of the following diagnostic tests would the nurse question when ordered for aclient diagnosed with pelvic inflammatory disease (PID)? A) CBC (complete blood count) with differential B) Venereal Disease Research Laboratory (VDRL) C) Throat culture for Streptococcus A D) RPR (Rapid Plasma Reagin) Answer: C Explanation: A) CBC with differential will be ordered to give an indication of the severity of the infection. B) The Venereal Disease Research Laboratory (VDRL) test checks for syphilis. C) Streptococcus of the throat is not associated with PID. D) RPR is a test for syphilis, a cause of PID. Page Ref: 84 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅰ. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan and evaluation of care. | AACN Essentials Competencies: Ⅸ. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. |NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills; apply ethical decision making models. | Nursing/Integrated Concept: Nursing Process: Implementation. Learning Outcome: 4 Relate the implications of pelvic inflammatory disease (PID) forfuture fertility to its pathologic origin, signs and symptoms, and treatment. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
12) Women with pyelonephritis during pregnancy are at significantly increased risk forwhich condition? A) Foul-smelling discharge B) Ectopic pregnancy C) Preterm labor D) A colicky large intestine Answer: C Explanation: A) Foul-smelling discharge is not a symptom of pyelonephritis. B) Ectopic pregnancy is not a symptom of pyelonephritis. C) Women with pyelonephritis during pregnancy are at significantly increased risk of preterm labor, preterm birth, development of adult respiratory distress syndrome, and septicemia. D) A colicky large intestine is an incorrect response. Page Ref: 85 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: Ⅰ. B. 3. Provide patient-centered care with sensitivityand respect for the diversity of human experience. | AACN Essentials Competencies: Ⅸ. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in allhealthcare settings. | NLN Competencies: Context and Environment: Apply professionalstandards; show accountability for nursing judgment and actions; develop advocacy skills; apply health promotion/disease prevention strategies; apply health policy; conductpopulation-based transcultural health assessments and interventions. | Nursing/Integrated Concept: Nursing Process: Implementation. Learning Outcome: 5 Contrast cystitis and pyelonephritis. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
13) The nurse is preparing an education session for women on the prevention of urinarytract infections (UTIs). Which statement should be included? A) Lower urinary tract infections rarely occur in women. B) The most common causative organism of cystitis is E. coli. C) Wiping from back to front after a BM will help prevent a UTI. D) Back pain often develops with a lower urinary tract infection. Answer: B Explanation: A) About 60% of women will experience an episode of cystitis during their lifetime. B) E. coli is present in 75% to 90% of women with UTIs. C) Wiping from back to front increases the risk of UTIs because the E. coli of the bowel is being drawn toward the urethra. Women should be instructed always towipe from front to back. D) Low back or flank pain is a sign of pyelonephritis, which is an upper urinary tract infection. Page Ref: 85 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concept: Nursing Process: Planning. Learning Outcome: 5 Contrast cystitis and pyelonephritis. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
14) The nurse in the community clinic is preparing educational materials to be used for teaching patients with sexually transmitted infections. What information should the nurse include regarding the medications metronidazole or tinidazole? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. 1. Take this medication until symptoms disappear 2. Abstain from all alcohol while taking these medications 3. Stop taking oral contraceptives while taking these medications 4. Abstain from all alcohol for 72 hours after completing tinidazole 5. Abstain from all alcohol for 24 hours after completing metronidazole Answer: 2, 4, 5 Explanation: Alcohol should be avoided when taking either metronidazole or tinidazole. When combined with alcohol, both metronidazole and tinidazole can produce effects similar tothat of alcohol and Antabuse–abdominal pain, flushing, and tremors. The CDC (2010b)recommends abstaining from alcohol for 24 hours after completing metronidazole and 72 hours after completing tinidazole. If the woman is taking oral contraceptives, a backup nonhormonal contraceptive method is recommended during treatment with metronidazole. The patient should be encouraged to complete the full course of prescribed medications. Page Ref: 74 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 2 Summarize modes of transmission, treatments, and descriptionsof the most commonly occurring sexually transmitted infections (STIs). MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
15) A patient is concerned about contracting herpes genitalis from a sexual partner andasks the nurse what to expect if the infection is present. In which order should the nurse explain the infection to the patient? 1. Emotional trigger occurs 2. Lesions spontaneously appear 3. Take oral acyclovir as prescribed 4. Virus enters a dormant phase with no lesions 5. Development of single or multiple blister-like vesicles Answer: 5, 3, 4, 1, 2 Explanation: The primary episode (first outbreak) of herpes genitalis is characterized by the development of single or multiple blister-like vesicles. Primary episodes usually last thelongest and are the most severe. The recommended treatment of the first clinical episode of genital herpes is oral acyclovir, valacyclovir, or famciclovir. After the lesionsheal, the virus enters a dormant phase, residing in the nerve ganglia of the affected area. Recurrences are usually less severe than the initial episode and seem to be triggered by emotional stress, menstruation, ovulation, pregnancy, and frequent or vigorous intercourse. Recurrence of the lesions is less severe. Page Ref: 80 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation; Teaching/Learning. Learning Outcome: 2 Summarize modes of transmission, treatments, and descriptionsof the most commonly occurring sexually transmitted infections (STIs). MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
16) A female patient comes into the clinic because of concerns about a sore that was present on her labia but spontaneously healed. During the interview the patient askswhat could occur if the infection is syphilis. In what order should the nurse explain the course of this sexually transmitted infection? 1. Latent period with no lesions 2. Development of a chancre sore 3. Skin eruptions and sore throat occur 4. Tertiary stage with various symptoms 5. Development of a fever, weight loss, and malaise Answer: 2, 5, 3, 1, 4 Explanation: Syphilis is divided into early and late stages. During the early stage (primary), a chancreappears at the site where the T. pallidum organism entered the body. Symptoms include slight fever, loss of weight, and malaise. The chancre persists for about 4 weeks and then disappears. In 6 weeks to 6 months, secondary symptoms appear. Skin eruptions called condylomata lata, which resemble wart-like plaques and are highly infectious, may appear on the vulva. Other secondary symptoms are acute arthritis, enlargement ofthe liver and spleen, nontender enlarged lymph nodes, iritis, and a chronic sore throat with hoarseness. A latent phase with no lesions may be followed by a tertiary stage. Page Ref: 80 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation; Teaching/Learning. Learning Outcome: 2 Summarize modes of transmission, treatments, and descriptionsof the most commonly occurring sexually transmitted infections (STIs). MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
17) While assisting a female client into the lithotomy position for a pelvic examination thenurse observes the following on the patient's perineum. For which health problem should the nurse expect orders to be written by the healthcare provider?
A) Syphilis B) Gonorrhea C) Chlamydia D) Human papillomavirus Answer: A Explanation: A) This is condylomata acuminata which is a skin change associated with secondary symptoms of syphilis. This finding is not associated with gonorrhea,chlamydia, or human papillomavirus. Page Ref: 81 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process. Learning Outcome: 2 Summarize modes of transmission, treatments, and descriptionsof the most commonly occurring sexually transmitted infections (STIs). MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
18) A pregnant patient is concerned about the development of several urinary tract infections (UTIs) over the last few months of her pregnancy. What should the nurseexplain as reasons for the development of these infections in this patient? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. 1. Decrease in bladder tone 2. Hyperemic bladder mucosa 3. Urethral stricture and loss of micturition reflex 4. Ureters elongate and are displaced by the uterus 5. Distal ureters hypertrophy leading to ureteral stenosis Answer: 1, 2, 4, 5 Explanation: A number of structural and functional changes occur during pregnancy that predisposepregnant women to urinary tract infections. Ureters elongate and are laterally displacedby the gravid uterus. Progesterone, which relaxes smooth muscles, can facilitate hypertrophy of the distal ureters with resulting ureteral stenosis and dilation, especially in the second half of pregnancy. Though the bladder has an increased capacity in pregnancy, it also has a decreased tone because progesterone relaxes the smooth muscle. Estrogen causes the bladder mucosa to become hyperemic and more susceptible to trauma and infection. Pregnancy does not cause urethral strictures and loss of the micturition reflex. Page Ref: 84—85 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 5 Contrast cystitis and pyelonephritis. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
19) The nurse suspects that a patient is experiencing bacterial vaginosis. What findingcaused the nurse to make this clinical determination? A) Dysuria B) Vaginal itching C) Thick white vaginal discharge D) Fishy odor to vaginal discharge Answer: D Explanation: D) The person with bacterial vaginosis may have a thin watery discharge with afishy odor. Dysuria, vaginal itching, and thick white vaginal discharge are manifestations of vulvovaginal candidiasis. Page Ref: 74 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 1. Conductcomprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 1 Compare vulvovaginal candidiasis and bacterial vaginosis. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
20) A patient in the 2nd trimester of pregnancy is diagnosed with bacterial vaginosis. Which medication regimen should the nurse expect to be prescribed for this patient? A) Metronidazole 500 mg orally one dose B) Metronidazole 250 mg orally once a day for 7 days C) Metronidazole 500 mg orally twice a day for 7 days D) Metronidazole 250 mg orally twice a day for 14 days Answer: C Explanation: C) The recommended treatment of bacterial vaginosis during pregnancy is Metronidazole 500 mg orally twice a day for 7 days. One dose of metronidazoleis not sufficient. Metronidazole 250 mg should be taken 3 times for 7 days to beeffective. Metronidazole 250 mg does not need to be taken for 14 days. Page Ref: 74 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in allhealthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning. Learning Outcome: 1 Compare vulvovaginal candidiasis and bacterial vaginosis. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
21) The nurse is concerned that a patient is at risk for developing vulvovaginal candidiasis (VVC). What assessment information caused the nurse to have thisconcern? Select all that apply. 1. 16 weeks pregnant 2. +3 glucose in the urine 3. Elevated blood pressure 4. Type 2 diabetes mellitus 5. Edematous lower extremities Answer: 1, 2, 4 Explanation: Predisposing factors to vulvovaginal candidiasis (VVC) infections include pregnancy,glycosuria, and diabetes mellitus. Elevated blood pressure and edematous lower extremities is more likely to be associated with preeclampsia in the pregnant patient. Page Ref: 76 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 1. Conductcomprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 1 Compare vulvovaginal candidiasis and bacterial vaginosis. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
22) A patient is being assessed for recurrent vulvovaginal candidiasis (VVC) infections. What should the nurse instruct this patient to do to help reduce the incidence ofinfection? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. 1. Avoid douching 2. Use vaginal sprays 3. Wear cotton underwear 4. Avoid tight-fitting clothing 5. Apply cornstarch to the vulva Answer: 1, 3, 4 Explanation: Ways to prevent the recurrence of VVC include avoiding douching, wearing cotton underwear and avoiding tight-fitting clothing. Vaginal sprays should be avoided sincethey can irritate the vulva. Applying cornstarch to the vulva could encourage itching. Page Ref: 76—77 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 1 Compare vulvovaginal candidiasis and bacterial vaginosis. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
23) A patient and her partner are being treated for trichomoniasis. What should thenurse emphasize when teaching the couple about this infection? A) Avoid intercourse until symptom free B) Ensure a repeat test is completed in 3 months C) Limit alcohol intake while taking metronidazole D) Have annual screening for recurrence of the infection Answer: A Explanation: A) In trichomoniasis, partners should avoid intercourse until both are cured. Retesting for gonorrhea is recommended 3 months following treatment secondary to increasing prevalence and the potential for PID. Alcohol should be avoided, not limited, for 48 hours after taking metronidazole because of an effectsimilar to that of alcohol and disulfiram (Antabuse). Annual screening for sexuallyactive individuals up to age 25 is recommended for chlamydia. Page Ref: 78 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 3 Describe the health teaching that a nurse needs to provide to awoman with an STI. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
24) A patient is being instructed on adverse effects of gonorrhea. For which reasonshould the nurse instruct the patient to contact the healthcare provider? A) Dysuria B) Urinary frequency C) Sharp abdominal pain D) Purulent, greenish-yellow vaginal discharge Answer: C Explanation: C) Women should be informed of signs that the infection is worsening, such as sharp abdominal pain, and be encouraged to seek further care. Dysuria, urinary frequency, and purulent, greenish-yellow vaginal discharge are manifestations ofgonorrhea and do not indicate that the infection is getting worse. Page Ref: 79—80 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 3 Describe the health teaching that a nurse needs to provide to awoman with an STI. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
25) The nurse is preparing instructions for a patient newly diagnosed with genitalherpes. What should the nurse encourage to promote healing of the lesions? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. 1. Take sitz baths 2. Use vaginal sprays 3. Wear cotton underwear 4. Douche after intercourse 5. Wear loose fitting clothing Answer: 1, 3, 5 Explanation: Actions to promote healing of genital herpes lesions include taking sitz baths, wearing cotton underwear, and wearing loose fitting clothing. Vaginal sprays and douching afterintercourse will not help heal genital herpes lesions. Page Ref: 80 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 3 Describe the health teaching that a nurse needs to provide to awoman with an STI. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
26) A college student is distraught after being diagnosed with pediculosis pubis. Whatshould the nurse instruct this student to do to help prevent future infections? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. 1. Both partners need to be treated 2. Take the prescribed medication for 10 days 3. Avoid all sexual contact until treated and cured 4. Wash bed linens in hot water and dry in a dryer for 20 minutes 5. Testing for other sexually transmitted infections is recommended Answer: 1, 3, 4, 5 Explanation: For pediculosis pubis, both partners need to be tested. All sexual contact should be avoided until treated and cured. Bed linens, towels, clothing, and other objects should be machine washed in hot water (at least 103°F) and dried in a hot dryer for 20 minutes.Both partners must be treated and tested for other STIs. The medication for pediculosis pubis is topical, and repeated if nits are still present. Page Ref: 81—82 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 3 Describe the health teaching that a nurse needs to provide to awoman with an STI. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
27) While reviewing data, the nurse determines that a patient is at risk for pelvic inflammatory disease. Which information did the nurse use to make this clinical determination? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. 1. Age 23 2. Douches weekly 3. Smokes cigarettes 1 ppd 4. IUD inserted 2 months ago 5. Received HPV vaccination Answer: 1, 2, 4 Explanation: Pelvic inflammatory disease (PID) occurs most often in sexually active women under age 25. Other risk factors include regular douching and recent insertion of an intrauterine device. Smoking and receiving the HPV vaccination are not risk factors forthe development of PID. Page Ref: 84 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 1. Conductcomprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 4 Relate the implications of pelvic inflammatory disease (PID) forfuture fertility to its pathologic origin, signs and symptoms, and treatment. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
28) After a pelvic examination, a patient is scheduled for tests to diagnose pelvic inflammatory disease. Which finding from the physical examination suggested to thenurse practitioner that further testing is required? A) Cervical tenderness B) Greenish vaginal discharge C) Open sores along the vagina D) Condylomata acuminata on the vulva Answer: A Explanation: A) Manifestations of pelvic inflammatory disease include cervical tenderness or thechandelier sign. Greenish vaginal discharge is associated with gonorrhea. Opensores along the vagina might be associated with genital herpes. Condylomata acuminata on the vulva are genital warts. Page Ref: 84 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 1. Conductcomprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 4 Relate the implications of pelvic inflammatory disease (PID) forfuture fertility to its pathologic origin, signs and symptoms, and treatment. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
29) The nurse is reviewing laboratory testing completed for a patient with suspectedpelvic inflammatory disease. Which test result should the nurse identify as supporting this diagnosis? A) Decreased hematocrit level B) Elevated sedimentation rate C) Decreased hemoglobin level D) Elevated white blood cell count Answer: B Explanation: B) In pelvic inflammatory disease the woman may have an elevated sedimentationrate. Decreased hematocrit and hemoglobin levels would indicate bleeding. An elevated white blood cell count indicates an infection, which may or may not occur with pelvic inflammatory disease. Page Ref: 84 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 1. Conductcomprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 4 Relate the implications of pelvic inflammatory disease (PID) forfuture fertility to its pathologic origin, signs and symptoms, and treatment. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
30) A patient schedules an appointment to be seen in the community clinic for dysuria, urgency, frequency, blood in the urine, and low back pain. For which health problemshould the nurse provide care for this patient? A) Cystitis B) Pyelonephritis C) Glomerulonephritis D) Asymptomatic bacteriuria Answer: A Explanation: A) The classic initial symptoms of cystitis include dysuria, urgency, frequency, low back pain and hematuria. Manifestations of acute pyelonephritis include a sudden onset with chills, high temperature, costovertebral angle tenderness or flank pain, nausea, vomiting, and general malaise. Manifestations of glomerulonephritis include periorbital edema, elevated blood pressure, and urinary changes. Asymptomatic bacteriuria has no characteristic manifestations. Page Ref: 85 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 1. Conductcomprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning. Learning Outcome: 5 Contrast cystitis and pyelonephritis. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
31) The nurse is caring for a client diagnosed with cystitis. When teaching the client about selfcare techniques, which foods or beverages will the nurse advise the clientto avoid? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. 1. Caffeine 2. Dairy products 3. Alcohol 4. Carbonated beverages 5. Acidic fruit juices Answer: 1, 3, 4 Explanation: The nurse should advise the client to avoid foods or beverages that are bladder irritants,such as caffeine, alcohol, or carbonated beverages. Dairy products and acidic fruit juices are not considered bladder irritants and would not be included when advising the client to avoid bladder irritants. Page Ref: 86 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation; Teaching/Learning. Learning Outcome: 5 Contrast cystitis and pyelonephritis. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
32) A patient treated for a urinary tract infection a month ago is experiencing symptomsof the same infection. What should the nurse suspect is the reason for the reoccurrence of the infection? A) Using oral contraceptives B) Wearing cotton underwear C) Cleansing from front to back D) Stopped antibiotics after 3 days Answer: D Explanation: D) Not completing a full course of prescribed antibiotics could cause remaining bacteria to grow, leading to another infection. Use of oral contraceptives is not arisk factor for the development of a urinary tract infection. Wearing cotton underwear and cleansing from front to back are actions that reduce the risk of developing urinary tract infections. Page Ref: 86 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 1. Conductcomprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 5 Contrast cystitis and pyelonephritis. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
33) A patient seeks medical attention after being exposed to blood during a gang fight several weeks ago. For which types of hepatitis should the nurse anticipate that thispatient will be tested? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. 1. A 2. B 3. C 4. D 5. E Answer: 2, 3, 4 Explanation: Hepatitis B, C, and D are transmitted through blood, body fluids, and blood products.Hepatitis A and E are transmitted through the oral-fecal route. Hepatitis A is also transmitted through contaminated food and water. Page Ref: 82 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 1. Conductcomprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning. Learning Outcome: 6 Compare the different types of viral hepatitis. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
34) The nurse is planning teaching for a patient diagnosed with hepatitis A. What shouldthe nurse emphasize when instructing the patient about this disease process? A) It is a chronic illness B) It is not a chronic illness C) A vaccination is not available D) It occurs in East and South Asia Answer: B Explanation: B) Hepatitis A is self-limiting and is not a chronic condition. Hepatitis B, C, and D infections are chronic. There is a vaccination available for hepatitis A. Hepatitis Eis common worldwide and occurs primarily in East and South Asia. Page Ref: 82 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 6 Compare the different types of viral hepatitis. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
35) The nurse suspects that a newly admitted patient is experiencing manifestations ofhepatitis A. What assessment findings did the nurse use to make this clinical determination? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. 1. Rash 2. Fever 3. Jaundice 4. Joint pain 5. Gray-colored stool Answer: 2, 3, 5 Explanation: Hepatitis A is characterized by symptoms of fever, jaundice, and gray-colored bowelmovements. A rash and arthritis are associated with hepatitis B, C, and D. Page Ref: 82 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 1. Conductcomprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment. Learning Outcome: 6 Compare the different types of viral hepatitis. MNL LO: Demonstrate use of the nursing process in the care of women with genital orurinary infections.
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 6 Women’s Health Problems 1) The nurse receives a phone call from a 25-year-old woman experiencing breast tenderness in the week prior to her menses, with palpable breast nodularity, without nipple discharge. What is the best response by the nurse? 1. “Please make an appointment at the breast cancer center as soon as possible.” 2. “How much salty food do you regularly consume?” 3. “As long as you don’t have nipple discharge, it isn’t a serious condition.” 4. “Eliminate caffeine and chocolate from your diet.” Answer:2. The client is describing fibrocystic breast changes. A salt restriction with a mild diuretic taken the week before menstrual bleeding often improves the condition. 2) A client describes breast swelling and tenderness. What piece of data would be most important for the nurse to gather initially? 1. Timing of the symptoms 2. Birth control method 3. Method of breast self-examination 4. Diet history Answer:1. The breast undergoes regular cyclical changes in response to hormonal stimulation. The nurse will want to determine when the swelling and tenderness occur within the menstrual cycle. 3) A client is concerned about her risk for breast cancer. Following the initial history, the nurse identifies which of the following as a high risk factor for breast cancer? 1. History of late menarche and early menopause 2. Sister who has had breast cancer 3. Mother with fibrocystic breast disease 4. Multiparity Answer:2. Family history of first-degree relative (mother, sister, or daughter) with breast cancer increases the risk of breast cancer with the number of first-degree relatives with breast cancer. 4) The nurse is educating a group of women about the manifestations of benign breast conditions. What information topics will the nurse include? Select all that apply. 1. Masses rapid in appearance or disappearance 2. Galactorrhea is common 3. Galactorrhea is seen with some psychiatric medications 4. Ulcerations or skin erosions are possible 5. An increased breast size with dimpling Answer: 1, 2, 3 1. Fluctuations in size and rapid appearance or disappearance of breast masses are common in fibrocystic breasts. 2. Galactorrhea is a benign change often associated with hormone therapy. 3. Galactorrhea is often seen in women who have nursed, who have fibrocystic changes in the breast, or are on some types of psychiatric medication.
5) A nurse is providing a client with instructions regarding breast self-examination (BSE). Which of the following statements by the client would indicate that the teaching has been successful? Select all that apply. 1. “I should perform BSE 1 week prior to the start of my period.” 2. “When I reach menopause, I will perform BSE every 2 months.” 3. “Knowing the density of my breast tissue is important.” 4. “I should inspect my breasts while standing with my arms down at my sides.” 5. “I should inspect my breasts while in a supine position with my arms at my sides.” Answer: 3, 4 3. The effectiveness of BSE is determined by the woman’s ability to perform the procedure correctly, by her knowledge of her own breast tissue, and by the density of her breast tissue. 4. The breasts should be inspected while standing with arms at sides. 6) The nurse is working with a woman who is undergoing chemotherapy for breast cancer. The client states, “First, the cancer seemed unreal. Now I feel like I can cope.” What is the nurse’s best response? 1. “Women with breast cancer often go through several stages of adjustment.” 2. “Women with breast cancer cope better than their partners cope.” 3. “Women with breast cancer seek multiple opinions before starting treatment.” 4. “Women with breast cancer become angry after treatment begins.” Answer:1. The course of adjustment confronting the woman with cancer has been described in four phases: shock, reaction, recovery, and reorientation. The client’s statement indicates shock followed by reaction. 7) A nurse is caring for a client admitted preoperatively for a bilateral mastectomy. Which statement indicates that this client is still in the shock phase of adjustment to her diagnosis? 1. “I can’t understand why this is happening to me.” 2. “I am so happy that my daughter graduates from high school this year.” 3. “I know that breast cancer is now part of my life.” 4. “I can’t believe that I need to lose both of my breasts.” Answer:1. In the shock phase, a client makes statements such as this. 8) A client is at a physician’s office following the end of treatment for breast cancer. The client is not scheduled to receive any more radiation or chemotherapy at this time. With treatment behind her, the client can now look again to the future. Which phase of psychological adjustment is this client experiencing? 1. Shock 2. Reaction 3. Recovery 4. Reorientation Answer:3. The recovery phase begins during convalescence following the completion of medical treatment.
9) The nurse interviews a 28-year-old client with a new medical diagnosis of endometriosis. Which question asked by the nurse is appropriate? Select all that apply. 1. “Are you having hot flashes?” 2. “Are you experiencing pain during intercourse?” 3. “Is a vaginal discharge present?” 4. “Are you having pain during your period?” 5. “Have you noticed any skin rashes?” Answer: 2, 4 2. The primary symptoms of endometriosis include dyspareunia. 4. The primary symptoms of endometriosis include dysmenorrhea. 10) The client has been found to have vitiligo on her vulva. Which client statement indicates that the client requires additional teaching on this condition? 1. “This can occur in other places on my body.” 2. “Vitiligo is only a decrease of pigmentation.” 3. “Other serious health conditions are common with vitiligo.” 4. “There usually are no other symptoms of this condition.” Answer:3. Vitiligo is an absence of melanin, which results in white patches that are especially noticeable on dark-skinned individuals. It can occur in multiple areas on the body, and has no associated symptoms or health conditions. 11) The nurse is teaching a client who has been diagnosed with vulvitis. Which statement by the client indicates that the nurse’s instruction has not been effective? 1. “I should stop having sexual intercourse.” 2. “Non-deodorized tampons could make this condition recur.” 3. “Wearing pantyhose daily will improve the problem.” 4. “A different brand of soap might eliminate the irritation.” Answer:3. Vulvitis is inflammation of the vulva. Tight clothing, especially if made of synthetic fibers, can predispose women to the condition. Pantyhose should not be worn. 12) The 22-year-old client is scheduled for her first gynecologic examination. What can the nurse do to make the client more comfortable during this exam? Select all that apply. 1. Create a trusting atmosphere. 2. Show the client what the speculum looks like. 3. Avoid telling the client what the exam involves. 4. Ask the client why she has delayed her first Pap test this long. 5. Provide a mirror for the client. Answer: 1, 2, 5 1. It is important to create a trusting atmosphere and incorporate practices that help the client maintain a sense of control. 2. Show the client all of the equipment to be used. 5. Provide a mirror to increase learning about anatomy and to create a trusting atmosphere.
13) The 12-year-old client reports that menarche occurred 5 months ago. She has had bleeding every day this month, and is very worried. The nurse should explain that the most common cause of this bleeding is which of the following? 1. Dysfunctional uterine bleeding (DUB) 2. Diabetes mellitus (DM) 3. Pregnancy 4. Von Willebrand’s disease Answer:1. Adolescents often experience DUB during the first 2 years following menarche due to hypothalamic immaturity after menarche. 14) The nurse is scheduling an ultrasound for a 51-year-old client with a suspected uterine tumor. The nurse includes in the client’s teaching that the most common benign uterine tumor seen in women in their 50s is which of the following? 1. Fibroid tumor 2. Fibroadenoma 3. Fibrocystic tumor 4. Lymphoma Answer:1. By the age of 50, 70% of Caucasian women and 80% of African American women have fibroids. 15) A nurse is teaching a class on the different types of uterine bleeding. The nurse explains that which of the following is one of the causes of abnormal uterine bleeding? 1. Iron-deficiency anemia 2. Polyps 3. Heavy periods every 2 months 4. Spotting between periods Answer:2. A classification system has been developed for the causes of AUB using the acronym PALM-COEIN. The P stands for Polyps. 16) The nurse is writing a care plan for a client with abnormal uterine bleeding (AUB). Whichgoals does the nurse include? Select all that apply. 1. Preventing or treating anemia 2. Preventing endometrial hyperplasia 3. Restoring quality of life 4. Conducting pelvic exams monthly 5. Analyzing liver and kidney function Answer: 1, 2, 3 1. One goal for the client with AUB is to prevent or treat anemia. 2. One goal for the client with AUB is to prevent endometrial hyperplasia. 3. One goal for a client with AUB is to restore quality of life. 17) The nurse walks in to find the client crying after the physician informed her of her diagnosis of human papilloma virus (HPV). Which statement by the nurse conveys an attitude of acceptance toward the client with a sexually transmitted infection?
1. “Don’t worry about it. In a few weeks, with treatment, the lesions will disappear.” 2. “You seem upset. I’ll get the doctor.” 3. “You seem upset. Can I help answer any questions?” 4. “I think you need to see a therapist.” Answer: 3. The nurse’s attitude of acceptance and matter-of-factness conveys to the client that she is still an acceptable person who happens to have an infection. 18) The nurse obtains a health history from four clients. To which client should she give priority for teaching about cervical cancer prevention? 1. Age 37, multiple partners 2. Age 22, abstains from sexual intercourse 3. Age 32, pregnant with twins 4. Age 27, uses female condom Answer:1. Having multiple partners increases the client’s risk of contracting sexually transmitted infections, including possible exposure to human papilloma virus (HPV). Contracting HPV increases risk of abnormal cervical cell changes and cervical cancer. 19) The nurse is about to tell a client that her Pap smear result was abnormal. Which statement should the nurse include? 1. “The Pap smear is used to diagnose cervical cancer.” 2. “A loop electrosurgical excision procedure (LEEP) is needed.” 3. “Colposcopy to further examine your cervix is the next step.” 4. “Your cervix needs to be treated with cryotherapy.” Answer:3. Colposcopy is an examination of the cervix through a magnifying device. 20) The client’s Pap smear result is ASC-US. Which statement is the best way for the nurse to explain this ASC-US result? 1. “Abnormal squamous cells of undetermined significance.” 2. “Cancer has invaded the upper cervix.” 3. “High-grade squamous intraepithelial lesion (HSIL), which includes CIN.” 4. “The focus of the Pap smear is the detection of high-risk pregnancy.” 5. “The cervical cells are abnormal and the reason why is severe dysplasia and carcinoma in situ.” Answer:1. ASC-US stands for abnormal squamous cells of undetermined significance. Preferred management is HPV testing; if positive, refer for colposcopy; if negative, repeat HPV co-testing in 3 years. 22) Which client in the gynecology clinic should the nurse see first? 1. 22-year-old with fever, hypotensive, using tampons 2. 15-year-old, no menses for past 4 months 3. 18-year-old seeking information on contraception methods 4. 31-year-old, reports increasing dyspareunia Answer:1. A client using tampons who has a fever, is dizzy, and hypotensive might have toxic shock syndrome.
23) The nurse in the emergency department is admitting a 22-year-old woman who complains of watery diarrhea, dizziness, and vomiting. She is in the middle of her period, and has a tampon in place. The nurse suspects toxic shock syndrome, and assesses for the manifestations of which symptom? Select all that apply. 1. Fever 2. Rash 3. Desquamation of skin 4. Bloating 5. Urinary frequency and urgency Answer: 1, 2, 3 1. A fever presents initially. 2. A rash on the trunk presents initially. 3. The fever and rash on the trunk present initially, followed by desquamation of the skin, especially the palms and soles, which usually occurs 1 to 2 weeks after the onset of symptoms. 24) The nurse is caring for a client diagnosed with endometriosis. Which statement by the client would require a need for perhaps another treatment option? 1. “I am having many hot flashes since I had the Lupron injection.” 2. “The pain I experience with intercourse is becoming more severe.” 3. “I have vaginal dryness, reduced libido, and my clitoris has become larger since taking danazol. Is this normal?” 4. “I’ve noticed I have not had my period on a regular basis since being on the GnRH analogs.“ Answer:3. Danazol is a testosterone derivative that suppresses ovulation and causes amenorrhea. It is intended for short-term therapy. Because of adverse effects, many clinicians have moved away from danazol to other treatment options. 25) The client diagnosed with endometriosis asks the nurse whether there are any long-term health risks associated with this condition. The nurse should include which statement in the client teaching about endometriosis? 1. “There are no other health risks associated with endometriosis.” 2. “Pain with intercourse rarely occurs as a long-term problem.” 3. “You are at increased risk for ovarian and breast cancer.” 4. “Most women with this condition develop severe migraines.” Answer: 3. An increased risk for cancer of the ovary and breast is associated with endometriosis. 26) The client is undergoing lab work and ultrasound for a possible diagnosis of polycystic ovarian syndrome (PCOS). Which problem does the nurse expect to find in the client’s history? 1. Multiple first-trimester fetal losses 2. Dyspareunia 3. Vulvitis 4. Oligomenorrhea
Answer:4. Irregular menses, ranging from total absence of periods (amenorrhea) to intermittent or infrequent periods (oligomenorrhea) are the hallmarks of PCOS. 27) The client with polycystic ovarian syndrome (PCOS) has been prescribed metformin (Glucophage). The nurse tells the client that the medication will do which of the following? Select all that apply. 1. “Decrease your excessive hair growth.” 2. “Make it easier to lose weight.” 3. “Increase your acne.” 4. “Improve your chances of pregnancy.” 5. “Make your menstrual periods irregular.” Answer: 1, 2, 4 1. Polycystic ovarian syndrome (PCOS) treatment with metformin decreases hirsutism. 2. Polycystic ovarian syndrome (PCOS) treatment with metformin improves weight loss success. 4. Polycystic ovarian syndrome (PCOS) treatment with metformin increases ovulation and therefore menstrual regularity and fertility. 28) A nurse is examining a client with a potential of polycystic ovarian syndrome. The nurse knows that which diagnostic is the most important indicator to support a diagnosis of polycystic ovarian syndrome? 1. Total estrogen level 2. Waist to chest ratio 3. Hyperandrogenism 4. Hypoinsulinemia Answer:3. Hyperandrogenism, as women with PCOS consistently have elevated serum androgen levels. These elevated androgen levels often lead to clinical manifestations such as hirsutism (excessive hair growth), acne, deepening voice, and increased muscle mass. 29) A 56-year-old client comes into the gynecology clinic with the complaints of constipation and a protrusion from her vagina. What does this client most likely have? 1. A cystocele 2. A prolapsed uterus 3. Polycystic ovarian syndrome 4. A rectocele Answer:4. This is the correct answer. The client often complains of constipation, and the anterior wall of the rectum protrudes through the vagina. 30) A client is diagnosed with a cystocele. The nurse actively listens as the client talks about which treatment choice to make. The treatment options available to the client are which of the following? Select all that apply. 1. Kegel exercises 2. Vaginal pessaries 3. Surgical intervention 4. Estrogen
5. Fine-needle aspiration Answer: 1, 2, 3, 4 1. One treatment option is to use Kegel exercises. 2. A treatment choice the client has is to have a pessary or ring inserted. 3. Surgical intervention is one approach to helping the client with a cystocele. 4. Estrogen may improve the condition of vaginal mucous membranes, especially in menopausal women. 31) Abdominal hysterectomy is generally recommended for which condition? 1. Severe endometriosis 2. Removal of the ovaries 3. Suspected or confirmed cancer removal 4. Abnormal uterine bleeding Answer:1. Abdominal hysterectomy is recommended for severe endometriosis. 32) The nurse educator is discussing abdominal and vaginal hysterectomy with the students. The nurse explains that the one main disadvantage of a vaginal hysterectomy is which of the following? 1. More blood loss with the surgery 2. Increased pain postoperatively 3. A longer recuperation period 4. Trauma to the bladder Answer: 4. The chance of doing some trauma to the bladder is greater with the vaginal hysterectomy. 33) Which of the following systems provides a uniform format and classification of terminology based on current understanding of cervical disease? 1. Levonorgestrel intrauterine 2. PALM-COEIN 3. Bethesda 4. BSE Answer:3. The Bethesda System for classifying Pap smears is a standardized method of reporting cytologic Pap smear findings and is the most widely used method in the United States. 34) The nurse working on a postoperative gynecology unit has to be knowledgeable of the psychological concerns of many of her clients. What will these concerns most often include? 1. Feelings of loss, grief, and anger 2. Feelings of euphoria and happiness 3. Feelings of control and calmness 4. Feelings of cheerfulness and satisfaction Answer:1. Many gynecological procedures have the potential to involve loss, so grieving, anger, sadness, and loss of control are just a few of the feelings the woman might experience.
35) The nurse has assessed a client who is to undergo gynecological surgery. Upon what will the nurse base the nursing diagnosis? Select all that apply. 1. The client’s attitudes toward motherhood 2. The client’s body image 3. The client’s attitudes about sexuality 4. The client’s long-term risk reduction 5. The client’s use of acupuncture Answer: 1, 2, 3 1. Reproductive surgery may also be seen as a threat to femininity in any social or cultural group that emphasizes childbearing and motherhood. 2. Surgery to alter or remove reproductive organs may be perceived as a threat to self-concept. Body image is affected whenever a body part is lost. 3. Many women fear postoperative changes such as masculinization, weight gain, loss of sexuality, and permanent loss of the ability to have a child.
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 7 Social Issues 1) When discussing the feminization of poverty, the nurse educator will inform the students of what fact? 1. The out-of-wedlock birth rate is above 40%. 2. In 2012, 25% of the households headed by single mothers lived in poverty. 3. Poverty is not directly linked to level of education attained. 4. Women work fewer hours for more pay than men do. Answer: 1. The reality is that many children will spend at least a portion of their lives in singleparent families. 2) The nurse is on a panel at a conference discussing poverty and health care for those living below the poverty level. Which statements should the nurse include? Select all that apply. 1. The poverty level is defined as a family of four living on less than $23,550 per year. 2. Two-thirds of Americans living in poverty are women and children. 3. The majority of single-parent families are headed by women. 4. The greatest number of people living under the poverty level are the elderly. 5. Parental race does not affect the level of poverty. Answer: 1, 2, 3 1. Increasing numbers of U.S. women and their children are attempting to live on $23,550 or less, which is the current income that defines the poverty level for a family of four. 2. Currently, two-thirds of Americans living in poverty are women and children. 3. The majority of single parent-families are headed by women, and these families are four times more likely to live in poverty than families with two parents. 3) There have been a number of historical trends that have contributed to this existing wage gap, including which of the following? 1. There was a perception that men were the sole breadwinners. 2. Women who were competitive in the work environment were viewed positively. 3. Women in past generations generally were not limited to certain occupations. 4. Increase in societal importance of women’s intellectual traits. Answer:1. Historically, there was a perception that men were the sole breadwinners, thus higher salaries for men were justified to support a family. 4) In a community clinic, a number of women working low-paying jobs come in for health care in the evening. The nurse knows that which of the following is true about the women’s working situations? Select all that apply. 1. They have no health insurance. 2. They have “pink collar” jobs. 3. They earn less pay than do their male counterparts. 4. They will be receiving a pension upon retirement. 5. They have no problem securing child care. Answer: 1, 2, 3 1. Lack of health insurance continues to be a major problem for the poor.
2. About one-third of women work in a cluster of “pink collar” occupations, which tend to be poorly paid when compared with male-dominated positions requiring comparable levels of responsibility, skill, and education. 3. Women are paid less than men for comparable work in virtually all occupations. 5) The nurse is planning a community educational presentation for people living below the poverty level. The nurse knows that which of the following is the largest population in this socioeconomic category? 1. Adults in communal living situations 2. Young married couples under the age of 20 3. Single women with children 4. Single adults Answer:3. Of households headed by single mothers, 40% live in poverty. 6) The community clinic nurse manager is working on a long-term budget. The manager understands that in the next few years, Medicaid is expected to pay for fewer births. This is, in part, because of which of the following? 1. The U.S. economy is becoming stronger. 2. More women are able to pay for private insurance. 3. New public policies are providing other forms of payment. 4. Rules for Medicaid have been changed. Answer:4. Women receiving Temporary Assistance for Needy Families (TANF) do not automatically receive Medicaid services when they become pregnant. 7) The nurse working at a homeless shelter is studying case statistics. Of the total homeless population served at the shelter, which group would the nurse’s statistics likely uncover as the fastest-growing group? 1. Unemployed women 2. Families with children 3. The mentally ill 4. The elderly Answer: 2. In 2012, the number of homeless individuals fell slightly, by 0.4%, with the exception of homeless families. 8) The nurse is working in an obstetrical clinic in an urban setting. The nurse knows that which certain facts affect the health care of this group of women? Select all that apply. 1. Women who receive adequate prenatal care are less likely to develop preterm labor. 2. Women who do not receive prenatal care are more likely to have low-birth-weight babies. 3. A lack of prenatal care is a risk for infant morbidity and mortality. 4. Decreases in health insurance coverage have led to declines in preventive health care. 5. Women who do not receive prenatal care are more likely to have high-birth-weight babies. Answer: 1, 2, 3, 4 1. Women who receive adequate prenatal care are less likely to develop severe complications, such as preterm labor.
2. Women who do not receive prenatal care are 3 times more likely to have low-birth-weight babies. 3. Lack of prenatal care is a risk for infant morbidity and mortality. 4. Decreases in health insurance coverage have led to declines in preventive health care. 9) The nurse working with a client who is seeking a family and medical leave knows that the employee must meet which eligibility requirement of the Family and Medical Leave Act (FMLA) of 1993? 1. Work at least 40 hours per week 2. Have been employed for at least 1 month 3. Work for a company with fewer than 50 employees 4. Be allowed parental leave for childbirth or adoption Answer:4. The Family and Medical Leave Act mandates parental leave for childbirth or adoption but applies only to companies with 50 or more employees. 10) A woman who works full-time approaches her employer after suddenly discovering that she and her husband will be receiving a child for adoption. The woman knows that she is entitled to certain rights as a result of the Family and Medical Leave Act (FMLA) of 1993. The nurse knows that which criteria of the act apply to this client? Select all that apply. 1. An employee is entitled to return to the former position or one considered comparable. 2. The employee is covered because she works more than 25 hours per week. 3. The employee is covered by this act because 25 employees work at the company. 4. The act is part of a larger national paid maternity leave program. 5. The employee’s medical coverage must continue during the leave. Answer: 1, 2, 5 1. Job security to return to the employee’s former position or one considered comparable is part of FLMA. 2. Employees must work at least 25 hours per week to be eligible. 5. Continued health insurance benefits are part of the protections and benefits to both men and women provided by FLMA. 11) The nurse manager is discussing the Family and Medical Leave Act with the staff. What correct statement does the nurse make about the act? 1. The act covers men as well as women, and they are allowed to take 12 weeks of unpaid leave and continue with their medical coverage. 2. Men can have 6 weeks under the act, where women can have 2. 3. Paid maternity and paternity leave does not occur in other countries. 4. The United States is the one country that has a paid maternity leave program. Answer:1. This is true. Men and women are covered under the act for up to 12 weeks of unpaid leave. 12) The pregnant client employed at a factory asks the nurse whether exposure to chemicals can cause harm to her fetus. The nurse should advise that exposure to which substance can lead to neurological damage?
1. Lead 2. Latex 3. Formaldehyde 4. Benzene Answer:1. Women exposed to lead during pregnancy are at risk for spontaneous abortion, prematurity, low birth weight, intrauterine growth restriction, and brain, kidney, and nervous system dysfunction. 13) A new nurse is teaching a class to expectant parents about environmental hazards at home. Which statement, if made by an expectant parent, would indicate the need for further teaching? 1. “Air pollution is an environmental hazard caused by the release of toxins into the air.” 2. “Indoor air pollution poses the more serious threat to women’s health.” 3. “Radon, a naturally occurring radioactive gas, is the leading cause of lung cancer, which kills more women than any other type of cancer, including breast.” 4. “Asthma is worsened by most forms of indoor air pollution.” Answer:3. Radon is the second-leading cause of lung cancer. Smoking is the first. 14) Pesticide exposure can be linked to a variety of adverse health outcomes, including which of the following? Select all that apply. 1. Increased risk of cancer 2. Endocrine abnormalities 3. Liver damage 4. Birth defects 5. Cardiovascular diseases Answer: 1, 2, 3, 4 1. Pesticide exposure can be linked to a variety of adverse health outcomes, including an increased risk of cancer. 2. Pesticide exposure can be linked to a variety of adverse health outcomes, including endocrine abnormalities. 3. Pesticide exposure can be linked to a variety of adverse health outcomes, including liver damage. 4. Pesticide exposure can be linked to a variety of adverse health outcomes, including birth defects. 15) Which of the following federal departments actively investigates and prosecutes individuals who cross state lines to avoid paying child support, and now intercepts delinquent parents’ income tax refunds? 1. U.S. Department of Health and Human Services 2. U.S. Department of Labor 3. U.S. Department of Justice 4. U.S. Equal Employment Opportunity Commission,
Answer:3. The U.S. Department of Justice actively investigates and prosecutes individuals who cross state lines to avoid paying child support, and now intercepts delinquent parents’ income tax refunds. 16) The nurse is leading a discussion among nursing students about differences in living conditions between men and women. Which statement, if made by the nursing student, would correctly depict the susceptibility of older women? 1. “Older women tend to have more educational preparation than older men.” 2. “Women typically earn less than men and often work in jobs without pension benefits or only limited benefits.” 3. “Intermittent employment is less common in women, increasing their Social Security and retirement benefits.” 4. “Women generally have fewer family caregiving responsibilities than men.” Answer:2. This is true. Many older women rely on Social Security payments as their primary source of income and often don’t receive private pensions due to having had fewer years in the workforce. 17) The nurse manager is preparing an educational in-service for staff nurses about elder abuse. The nurse manager develops a hypothetical situation: A wheelchair-bound client who lives with her daughter has experienced hunger because she cannot reach the cupboards to make lunch. Which category of elder abuse does this example describe? 1. Psychologic abuse 2. Physical abuse 3. Neglect 4. Financial abuse Answer:3. Neglect is a failure on the part of a caregiver, or any person having custody of an elder, to provide reasonable care, which is the degree of care that a reasonable person would provide. 18) Psychologic elder abuse includes, but is not limited to, which of the following? Select all that apply. 1. Verbal assaults 2. Humiliation 3. Desertion 4. Intimidation 5. Failure to provide reasonable care Answer: 1, 2, 4 1. Psychologic abuse includes verbal assaults. 2. Psychologic abuse includes humiliation. 4. Psychologic abuse includes intimidation. 19) A public health nurse, along with a student, is visiting the home of an elderly woman who is widowed and lives alone. Her 40-year-old son is her caregiver, and the public health nurses visit about once a week to follow up on her high blood pressure, recent surgery for a hip fracture,
and diabetes. The nurse and student find the home dirty, sink full of dirty dishes, and the client in clothes that are extremely soiled. She cannot reach her walker to get up, and she has been incontinent. The nurse recognizes this as which type of abuse? 1. Neglect 2. Abandonment 3. Physical abuse 4. Financial abuse Answer:1. The abuse described is called neglect. Assistance and personal hygiene have not been provided. 21) The nurse recognizes that what are the most common disabilities in women? 1. Asthma and headaches 2. Arthritis or rheumatism 3. Adverse kidney and nervous system functioning 4. Cardiovascular diseases Answer:2. The most common disabilities in women are arthritis or rheumatism and the incidence of disability increases with age. 22) A home care nurse is looking over the charts of four elderly female clients. The nurse knows that which client has the highest risk for developing diabetes and heart disease? 1. A woman who is 55 and is white 2. A woman who is 60 and from a middle class background 3. All women over 55 4. A woman over 65 who is African American Answer:4. Minority and low-income women 65 years old and older are more likely than white, higher income women to have serious health problems. 23) The nurse in a community clinic recognizes that older women face various barriers to obtaining health care. Which of the following are barriers that must be overcome? Select all that apply. 1. Transportation difficulties 2. Lack of private health care coverage 3. Excessive medical costs not covered by Medicare 4. Adequate research on chronic conditions 5. The Family and Medical Leave Act Answer: 1, 2, 3 1. Older women can face multiple barriers when obtaining healthcare services, and difficulty with transportation is one of them. 2. Older women can face multiple barriers when obtaining healthcare services, and lack of private health coverage is one of them. 3. Older women can face multiple barriers when obtaining health-care services, and excessive medical costs not covered by Medicare is one of them.
24) The nurse is caring for a 20-year-old labor client who is autistic. This client will not talk with the nurse, she wants her mother right at her side, and she obviously does not understand what is happening. Which term best describes the disability of this client? 1. Developmental 2. Learning 3. Neurological 4. Sensory Answer:1. Autism is classified as a developmental disability that manifests before 22 years of age and creates limitations in three or more areas. 25) The nurse is caring for a new mother who is intellectually disabled. She has chosen to keep her baby, and will live with her parents, who both work full-time. Public health nurses are going to be following this client and her baby closely. What is the main thing the nurse will have to remember when caring for this client? 1. This client will need to have a babysitter at all times. 2. This client is not going to be able to keep this baby, due to her disability. 3. The father of the baby needs to move in with the family to assist with care. 4. The nurse and the client’s family will have to give clear, concise, easy-to-understand directions multiple times. Answer:4. When working with clients with intellectual disabilities, it is important for the nurse to provide modified teaching materials and delivery to meet varying learning needs. 26) The nurse is teaching a group of parents of school-aged girls with intellectual disabilities. The nurse tells the parents which of the following? 1. The girls need education about STIs, contraception, and routine gynecological checkups. 2. The girls would be better off if they had permanent sterilization. 3. The girls will probably not be sexually active. 4. The girls are not able to understand about contraception and sex. Answer: 1. In contemporary society, the need for sexual health education is imperative because some girls and women with intellectual disabilities may face unplanned pregnancies. 27) The nurse is assessing a woman with a paralyzed arm who has lost her health insurance due to unemployment. The nurse recognizes that women with disabilities face which barriers to employment? Select all that apply. 1. No access to transportation 2. Lack of education and training 3. Lack of wheelchair access 4. Lack of wide door openings into buildings 5. Lack of readily available ramps Answer: 1, 2 1. People with disabilities might not have access to transportation. 2. Lack of education and training is a common factor related to unemployment among women with disabilities.
28) The nurse making home visits to a number of adult women with disabilities monitors the clients closely out of awareness of which of the following? 1. Healthcare services for women who are disabled are more than adequate. 2. They receive more preventive care than do women without disabilities. 3. These women seldom have sexual relations. 4. They receive less preventive care and have greater yearly health expenditures than do women without disabilities. Answer:4. Women who are disabled receive less preventive care than women without disabilities but have 2.5 times the yearly health expenditures of women without disabilities. 29) The nurse is caring for a client who is a lesbian. What should the well-educated nurse be aware of for this client? 1. She is at lesser risk for sexually transmitted diseases and cervical cancer than a heterosexual woman would be. 2. She is less likely to experience domestic violence than a heterosexual woman would be, and does not need to be asked about it. 3. She is at greater risk for breast cancer than a heterosexual woman would be. 4. She does not need to have a Pap smear as frequently as a heterosexual woman would. Answer:3. Lesbians are at a greater risk for breast cancer, especially if they have never given birth. 30) The lesbian woman who is pregnant by in vitro fertilization from an unknown donor comes to the obstetric clinic in her seventh month with her partner. When asked by the nurse why she has waited so long to come in, the client remarks, “Oh, you know why.” What does the nurse suspect? 1. The client is experiencing a fear of discrimination on the part of providers. 2. The client is without insurance, and is afraid she will be turned away. 3. The client is in good health, and did not need to come in any sooner. 4. The client is independent in her health care, and opted for self-care until now. Answer:1. The woman most likely has a fear of discrimination due to her sexual orientation. Women’s health services in particular have not shown acceptance of lesbian, bisexual, or transgender status. 31) The nurse at a women’s clinic is reviewing a new client health information questionnaire. Which question does she find to be insulting and discriminatory toward lesbian client? 1. Who should be contacted in case of emergency? 2. What method of birth control do you use? 3. How often do you drink alcohol? 4. Do you feel safe in your relationship? Answer:2. The assumption that all women are in need of contraception for birth control is often cited as a reason that lesbian women may conceal their sexual orientation. 32) Lesbian and bisexual women are greater risk for health and social disparities, including which of the following? Select all that apply.
1. Increased suicide risk 2. Increased risk of homelessness 3. Lack of screening for female-related cancers 4. Lack of screening for lung cancers 5. Increased divorce rates Answer: 1, 2, 3 1. Healthy People 2020 recognizes that health disparities continue to exist for lesbian, gay, bisexual, and transgendered individuals, which includes increased suicide risk. 2. Healthy People 2020 recognizes that health disparities continue to exist for lesbian, gay, bisexual, and transgendered individuals, which includes increased risk of homelessness. 3. Healthy People 2020 recognizes that health disparities continue to exist for lesbian, gay, bisexual, and transgendered individuals, which includes lack of screening for female-related cancers. 33) A lesbian woman tells her nurse that she has begun to work for a new company. The woman’s biggest fear is that her new employer will find out about her sexual orientation. Why is this woman afraid of this discovery? 1. The Employment Non-Discrimination Act was passed into law. 2. It is still legal in many states to fire a lesbian on the basis of sexual orientation. 3. Fortune 500 companies have not enacted antidiscrimination workplace regulations for sexual orientation. 4. No state prohibits discrimination based on gender identity. Answer: 2. Employment discrimination is the most frequent complaint the American Civil Liberties Union (ACLU) receives from gay and lesbian individuals. 34) The nurse is working with a group of recent immigrants from a country in which female genital mutilation (FGM) is practiced. In order to be effective in teaching about gynecologic care in the U.S., the nurse must keep which issues in mind? Select all that apply. 1. Women might undergo FGM willingly to support the status quo of society. 2. Women might undergo the procedure to be considered for marriage. 3. Women who immigrate to other countries feel a sense pride once the procedure has been performed. 4. Women might undergo the procedure to be gain greater sexual pleasure. 5. Women might undergo the procedure to lose their virginity. Answer: 1, 2 1. The ritual is performed by various ethnic groups for a variety of reasons including perceived improved social acceptance. 2. The ritual is performed by various ethnic groups for a variety of reasons including marriageability. 35) The culturally competent nurse recognizes that female genital mutilation (FMG) can include which health implications? Select all that apply. 1. Hemorrhage 2. Infertility
3. Urinary tract infections 4. Increased sexual pleasure 5. Easier childbirth Answer: 1, 2, 3 1. FGM can cause a variety of health problems, including bleeding. 2. FGM can cause a variety of health problems, including infertility. 3. FGM can cause a variety of health problems, including urinary tract infections.
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 8 Violence Against Women 1) The client has been a victim of a violent, sadistic rape. She is crying, and asks the nurse “Why would someone do something like that?” The nurse should explain that which of the following is the primary purpose of sadistic rape? 1. Take pleasure from the victim’s struggle and pain 2. Express feelings of rage 3. Feel a sense of power or mastery 4. Relieve intolerable anxiety Answer:1. In sadistic rape, the assailant has an antisocial personality and delights in torture and mutilation. In this type of rape, the victim and assailant are generally strangers, and the assault is planned. Sadistic rapes cause the most injuries, including homicide. 2) The nurse is teaching an in-service educational presentation about working with battered women. The nurse should explain that it is often frustrating for nurses to work with battered women for which reasons? Select all that apply. 1. There is little the nurse can really do to help. 2. Healthcare policies and practices are not supportive of abused women. 3. Both husband and wife must agree to therapy. 4. These women might return to the abusive situation. 5. Women often believe that they are the cause of the abuse. Answer: 4, 5 4. Women often believe that escape is futile, or escape and then return when the crisis is over. 5. Women are often convinced by the abusers that it is their own behavior that causes the abuse. 3) The nurse is addressing a college class on the topic of domestic violence. Which information would the nurse be sure to convey to her students? 1. The American Nurses Association advocates client advocacy for all nurses to help identify and prevent violence against women. 2. The American Nurses Association has concluded that there is little nurses can do to eliminate violence. 3. The nurse who suspects abuse should ask the doctor to deal with it, per American Nurses Association guidelines. 4. The nurse who suspects abuse should ask the hospital’s social work department to deal with it, per American Nurses Association guidelines. Answer:1. This is a true statement. Nurses can follow and become involved in legislative advocacy for issues related to domestic violence and other issues related to women’s health through participation in their local and state chapters of the American Nurses Association. 4) The nurse working in the emergency department of a hospital is caring for a woman whom the nurse suspects is the victim of domestic violence. The nurse knows that which of the following are contributing factors to domestic violence? Select all that apply. 1. Experiencing or witnessing abuse as a child 2. Strong patriarchal family traditions
3. Linking masculinity to male honor 4. Low levels of marital conflict 5. Alcohol and drug abuse cause the violence Answer: 1, 2, 3 1. Children who witness or experience abuse and battering are more likely to become batterers (men) or to be abused (women) in their own relationships. 2. Men raised in patriarchal families (those that encourage traditional gender roles) are more likely to engage in domestic violence. 3. Cultures that link definitions of manhood to dominance, toughness, or male honor are more likely to demonstrate violence against women. 5) The nurse is planning a community education presentation on battering. Which statement about battering should the nurse include? 1. Battering occurs in a small percentage of the population. 2. Battering is mainly a lower-class, blue collar problem. 3. Battered women are at greatest risk for severe violence when they leave the batterer. 4. If the batterer stops drinking, the violence usually stops. Answer:3. Battered women are at greatest risk for injury or domestic homicide when they leave the abuser. 6) The nurse at a shelter is counseling a group of battered women. What will the nurse will emphasize? 1. Battering will not stop or decrease if the woman becomes pregnant. 2. About 1 of every 5 women will experience abuse in her lifetime. 3. When these women go back to the situation after the abuser has cooled down, it will be better. 4. The battered woman can readily leave the situation. Answer: 1. Pregnancy does not stop the abuser, and sometimes it increases the intensity of the abuse. 7) The nurse in the emergency department is caring for a pregnant woman who presents with bruised breasts and abdomen. When asked how this happened, she states she fell down the stairs. The husband stays very close to his wife and does most of the talking. Of what is the nurse aware? 1. The client likely did fall down the stairs. 2. The husband is being attentive and trying to help her feel better. 3. The husband could have battered her and possibly caused her to fall down the stairs. 4. This client is safe to return home after her wrist is fixed. Answer:3. Battering may occur for the first time during pregnancy or may escalate in intensity if the woman is already being abused. The injury is frequently aimed at the breasts, abdomen, or vagina. 8) The nurse is interviewing a client who has admitted to being a victim of domestic violence. What is the most typical description of how the domestic violence developed in a relationship?
1. “He changed overnight. Everything was fine, and all of a sudden he flipped out and beat me up; he nearly killed me.” 2. “It was severe from the beginning. As soon as we got married, he began hitting me and threatening to kill me.” 3. “We’ve both always dated other people. I thought that was understood. He was as emotionally abusive in the beginning as he is now.” 4. “I don’t know when it started, really. It was gradual. First, just yelling, blaming, and shoving. Then the beatings started; and now they’re more frequent.” Answer:4. Typically, these forms of abuse begin slowly and subtly after some form of commitment, such as engagement, onset of a sexual relationship, marriage, pregnancy, or first childbirth. 9) The nurse working in the emergency department is admitting a woman who has been battered for a second time, and recognizes that the woman is again in the cycle of violence. Thenurse knows that which of the following are characteristics of the phases of the cycle of violence? Select all that apply. 1. Batterer demonstrates power and control 2. Active battering from some event 3. A loving, contrite period 4. Defeat and admission of guilt by the victim 5. Blame and punishment for inferiority Answer: 1, 2, 3 1. In the tension-building phase in the cycle of violence, the batterer demonstrates power and control. 2. The acute battering incident is typically triggered by some external event or internal state of the batterer. 3. The tranquil phase in the cycle of violence is also sometimes called the honeymoon period. This phase may be characterized by extremely loving, kind, and contrite behaviors by the batterer. 10) The nurse working in the emergency department knows that many batterers have feelings of ambivalence. In what way might this be evident? 1. The abuser alternates episodes of unmerciful beatings with periods of remorse and loving attention. 2. The abuser has alternating periods of sadness and happiness. 3. The abuser has alternating periods of maturity and immaturity. 4. The abuser alternates letting the person he abuses be independent and then dependent. Answer: 1. Extremes in behavior and overreacting are typical patterns. 11) A nurse in the emergency department recognizes in the husband of a client one of which of the following common characteristics of batterers? Select all that apply. 1. Emotionally immature 2. Tend to express their overwhelming feelings of inadequacy through violence 3. Feelings of insecurity and inferiority
4. A lack of respect in the community 5. Limited jealousy or possessiveness Answer: 1, 2, 3 1. Batterers tend to be emotionally immature. 2. Because they tend to be emotionally immature and aggressive, batterers have a tendency to express their overwhelming feelings of inadequacy through violence. 3. Batterers are insecure, and feel inferior, often feeling that they are undeserving of their partner. 12) The nurse is presenting a session on intimate partner violence. Which statement by a client indicates a need for further education? 1. “My daughter is not to blame for the violence in her marriage.” 2. “Everyone experiences anger and hitting in a relationship.” 3. “Abusers can be either husbands or boyfriends or girlfriends.” 4. “The ‘honeymoon period’ follows an episode of violence.” Answer: 2. Violence is not a normal part of intimate relationships. Domestic violence, also called intimate partner violence (IPV), is defined as a pattern of coercive behaviors and methods used to gain and maintain power and control by one individual over another in an adult intimate relationship. This statement indicates that the client has likely been a victim of domestic violence. 13) When a woman seeks care for an injury, the nurse should be alert to which clues of abuse? Select all that apply. 1. Defensive injuries 2. Immediate reporting of symptoms or seeking care for injuries 3. Lack of eye contact 4. Providing too much detailed information about the injury 5. Vague complaints without accompanying pathology Answer: 1, 3, 5 1. Defensive injuries may be a sign of abuse. 3. Lack of eye contact may be a sign of abuse. 5. Vague complaints without accompanying pathology may be a sign of abuse. 14) A woman who has been abused for a number of years asks the nurse for assistance in leaving the relationship. What response by the nurse is most appropriate? 1. Comment that she should have left long ago. 2. Remind the client that that fault was not likely all attributable to her abuser. 3. Encourage her to be sure with her decision, as her abuser will be difficult to deal with. 4. Assist the client to develop a safety plan. Answer:4. The nurse should provide women who have been abused with information that empowers them in decision making and provide critical assistance in safety planning for women and their children.
15) A woman with multiple bruises on her face and arms is seen in the emergency department. Her significant other is with her. When asked about her injuries, the woman states, “I ran into a door.” Which action by the nurse is of highest priority? 1. Take the woman’s vital signs. 2. Document the location of the bruises. 3. Assess for additional bruising. 4. Interview the woman in private. Answer:4. Screening for women experiencing domestic violence must be done privately, with only yourself and the client present, in a safe and quiet place. 16) A woman has come to the emergency department with multiple bruises over her body and a small laceration over her upper lip. She says she fell down the stairs while doing her housework. Which observation would most likely cause the nurse to suspect that she has been a victim of battering? 1. The client is hesitant to provide details about how the injuries occurred. 2. The client was accompanied to the emergency department by her mother instead of her partner. 3. The client has sought care quickly after the incident. 4. The client does not seem to be in pain. Answer:1. Hesitation to provide detailed information about the injury and how it occurred is a common sign of abuse. 17) The client with limited English language skills has a black eye, and bruises across her face and arms. The client’s husband has been acting as an interpreter for her, and answers all of the questions the nurse asks, often without talking to his wife first. The nurse suspects the client has been a victim of domestic abuse. What should the nurse do next? 1. Ask the husband whether he has beaten his wife. 2. Ask the husband to have a female friend come in with his wife. 3. Provide written materials in English for the client to read at home. 4. Ask the husband to step out of the room, and obtain an interpreter. Answer:4. Screening for women experiencing domestic violence must be done privately. An interpreter should also be provided as necessary. 18) A woman is seen in the prenatal clinic. The nurse notices that the woman has a swollen eye and a bruise on her cheek. Which statement is most appropriate for the nurse to make? 1. “You must leave your partner before you are injured again.” 2. “It is important that you refrain from doing things that anger your partner.” 3. “Women who are abused often have injuries like yours.” 4. “I am required by law to notify the police department of your injuries.” Answer: 3.This is an appropriate statement to make. 19) A home health nurse is making a home visit to a new mother who is diabetic and requires some follow-up to make sure her baby is doing well and that her diabetes is in control while sheis breastfeeding. The client meets her at the door, crying, with bruises on her face and legs. The
nurse knows the client has been in a questionable relationship. What is the first responsibility of the nurse for this client at this time? 1. Assist in getting the client and her baby to a safe situation. 2. Check her blood sugar and make sure it is within normal limits. 3. Ask her how she is doing with the breastfeeding. 4. Check the baby’s heart rate and other vital signs. Answer:1. Providing the abused woman with information that empowers her in decision making and providing critical assistance in safety planning for her and her baby is the nurse’s first responsibility. 20) The nurse suspects that a pregnant client might be experiencing abuse when the client does which of the following? Select all that apply. 1. Gives an inappropriate explanation for the injuries 2. Hesitates in providing detailed information about the injury 3. Makes eye contact with the nurse while answering questions 4. Allows her partner to answer the nurse’s questions 5. Frequently calls to change appointment times Answer: 1, 2, 4, 5 1. Whenever a client gives an inappropriate explanation for injuries, such as being accident prone, the nurse should suspect abuse. 2. Clients experiencing abuse often hesitate in providing detailed information about an injury and how it occurred. 4. The client experiencing abuse may show signs of increased anxiety in the presence of the possible batterer, who frequently does most of the talking or hovers around the woman. 5. If a client has injuries sustained from abuse, she will often delay reporting of symptoms or seeking care for injuries. 21) If a woman returns to an abusive situation, the nurse should encourage her to develop an exit, or safety, plan for herself and her children, if she has any. What should the plan include? Select all that apply. 1. Identify friends and family who know about the situation and will help her. 2. Call the police if violence begins. 3. Pack a change of clothes for herself and the children. 4. Have a plan for where she will go. 5. Have a planned escape route. Answer: 1, 3, 4, 5 1. She should identify friends and family who know about the situation and will help her. Ask that she establish a code word for danger with those family and friends. 3. She should pack a change of clothes for herself and the children, including toilet articles and an extra set of car and house keys stored away from her house with a friend or neighbor. 4. She should have a plan for where she will go, regardless of the day or time. 5. She should have a planned escape route and emergency telephone numbers she can call.
22) The nurse is caring for an abused mother in the postpartum department. The client is afraid to go home, but has no money to do anything else. What can the nurse do to assist this individual and her baby? 1. Work with community services to have the client and her baby go to a safe place, complete paperwork to obtain financial assistance, and obtain some temporary assistance. 2. Explain that she will have to go home at this time, but provide her with paperwork to complete to obtain assistance. 3. Offer to have her partner come in and attend a counseling session with her. 4. Suggest that once she gets home, she should pursue getting a restraining order against her abuser. Answer: 1. Nurses and medical personnel need to be alert to symptoms of battering, recognize these cues, and encourage women to seek assistance from community agencies. The most innovative and effective domestic violence programs in hospitals and urgent care facilities work collaboratively with domestic violence service agencies, develop a comprehensive community referral network, and work with multidisciplinary intervention teams. 23) When evaluating the care given a battered woman, the nurse analyzes care plan components to determine which of the following? Select all that apply. 1. Compassionate, respectful care was delivered. 2. The woman has the necessary information to make decisions. 3. Medical records are deliberately vague. 4. Psychological care was given in the hospital. 5. The woman identifies culturally appropriate resources. Answer: 1, 2, 5 1. One expected outcome of nursing care is that the woman receives compassionate, respectful, and individualized medical attention. 2. One expected outcome of nursing care is that the woman has the information she needs to make a decision about her future based on thoughtful consideration of alternatives. 5. Two expected outcomes of nursing care are that the woman is able to identify culturally appropriate community resources available to her and develops strategies for keeping herself, her children, and her family as safe as possible. 24) The nurse has been talking to a woman about the reorganization phase following a rape. Which response would indicate that the client understands this phase? 1. “By using denial and suppression in this phase, I will eventually be able to accept what has happened to me.” 2. “During this time, I won’t talk much about the rape, because I am examining my inward feelings regarding the rape.” 3. “During this time, I will repeatedly replay the role of the victim until I come to terms with the experience.” 4. “My perception of a normal sexual relationship will be similar to my perception prior to the rape.” Answer:3. During reorganization, a victim adjusts her self-concept to include the rape.
25) The nurse suspects that a client has been physically abused, but the woman refuses to report the abuse to the police. Which statement by the client suggests to the nurse that the relationship might be in the “honeymoon period” of the cycle of violence? 1. “My boyfriend says he will never hurt me again.” 2. “My boyfriend only drinks alcohol on the weekends.” 3. “My boyfriend yells less than he used to.” 4. “My boyfriend has frequent bouts of insomnia.” Answer:1. This is an example of a statement made during the honeymoon period of the cycle of violence. 26) Among women who have been sexually assaulted, which of the following are the most frequently diagnosed sexually transmitted infections (STIs)? Select all that apply. 1. Bacterial vaginosis 2. HIV 3. Chlamydia 4. Syphilis 5. Gonorrhea Answer: 1, 3, 5 1. Among women who have been sexually assaulted, trichomoniasis, bacterial vaginosis, gonorrhea, and chlamydia are the most frequently diagnosed sexually transmitted infections (STIs). 3. Among women who have been sexually assaulted, trichomoniasis, bacterial vaginosis, gonorrhea, and chlamydia are the most frequently diagnosed sexually transmitted infections (STIs). 5. Among women who have been sexually assaulted, trichomoniasis, bacterial vaginosis, gonorrhea, and chlamydia are the most frequently diagnosed sexually transmitted infections (STIs). 27) When a woman who has been raped is admitted to the emergency department, the nurse caring for the woman knows that which of the following is the priority nursing intervention? 1. Explaining exactly what will need to be done to preserve legal evidence 2. Assuring the woman that everything will be all right 3. Creating a safe, secure environment for her 4. Contacting family members Answer:3. The first priority in caring for a survivor of a sexual assault is to create a safe, secure environment. 28) What is the most important aspect of care for the nurse to remember when screening a woman for partner abuse? 1. Ensuring privacy and confidentiality 2. Conveying warmth and empathy 3. Asking specific, direct questions about abuse 4. Clarifying her myths about battering
Answer:1. Screening for women experiencing domestic violence must be done privately, with only the nurse and the client present, in a safe and quiet place. 29) A client comes to the reproductive health clinic and reports that she woke up in a strange room this morning, her perineal area is sore, and she can’t clearly remember what happened the previous evening. The client says that she is afraid that she was a victim of a drug-facilitated sexual assault. Which statement should the nurse include when discussing this possibility with the client? 1. “Drinking alcohol can lead to uninhibited sexual behavior, which is not the same as rape.” 2. “Some men use drugs mixed into a drink to subdue a potential victim prior to a rape.” 3. “It is rare that a woman doesn’t remember what happened if she is actually raped.” 4. “We need to check for forensic evidence of rape before we can be sure what happened.” Answer:2. Drug-facilitated sexual assault occurs when a drug such as Rohypnol, which dissolves easily and is odorless, is slipped into the drink of an unsuspecting woman. 30) The nurse is caring for a battered woman in the emergency department. Which nursing guidelines are used in the care of this client? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Letting the woman tell her story at her own pace 2. Anticipating ambivalence toward the batterer 3. Acknowledging the woman’s feelings as reasonable 4. Letting the woman figure out how to identify specific problems on her own 5. Allowing her to believe in false beliefs if it makes her feel more secure Answer: 1, 2, 3 1. The nurse should let the woman work through her story, problems, and situation at her own pace. 2. The nurse should anticipate ambivalence in the woman’s love-hate relationship with the batterer. 3. The nurse should let the woman know that she is believed, and that her feelings are reasonable and normal. 31) Vicarious trauma is a phenomenon nurses might experience. What are the signs indicating this problem that the nurse should be aware of? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Reduced sense of accomplishment 2. A positive effect on commitment to one’s work 3. Questioning of personal belief systems 4. Balance of time for family, self, friends, and work 5. Frustration with the judicial system Answer: 1, 3
1. Vicarious trauma refers to a gradual internal transformation that can negatively affect commitment to one’s work, reduce any sense of accomplishment, and lead to a questioning of personal belief systems. 3. Vicarious trauma refers to a gradual internal transformation that can negatively affect commitment to one’s work, reduce any sense of accomplishment, and lead to a questioning of personal belief systems. 32) In educating a group of women at a community center, the nurse talks about the myths surrounding sexual assault. What topics would the nurse include? Select all that apply. 1. Older women are less likely to be sexually assaulted. 2. Rape is universal, and all societies have rape. 3. Women who party and do drugs set themselves up for sexual assault. 4. If the woman just relaxes, it will be over, and she might even like it. 5. Women lie about rape as an act of revenge. Answer: 2, 4, 5 2. Rape is not universal to all societies, and not all men rape women. 4. Rape is an act of violence in which the perpetrator uses sex as a weapon to control, intimidate, and violate the victim. 5. While false allegations of rape do occur, they are the exception, not the rule. 33) The emergency department nurse is admitting a client who has been sexually assaulted. The nurse is explaining how the physical evidence will be collected. Which statement by the client indicates that teaching has been effective? 1. “All the evidence will be kept in a locked cupboard until the police arrive.” 2. “You collect urine samples to make sure the rapist did not get me pregnant.” 3. “The evidence you collect might be able to identify the rapist.” 4. “Blood samples are taken to help identify whether the rapist had HIV.” Answer:3. DNA can be obtained from collected evidence to identify the rapist. 34) The nurse is conducting a rape exam on a client in the emergency department after a sexual assault. What specimens will the nurse collect? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Swabs of body stains and secretions 2. Samples of pubic hair 3. Toenail scrapings 4. Samples of head hair 5. Sputum, for disease analysis Answer: 1, 2, 4 1. The nurse will take swabs of body stains and secretions to analyze for semen or sperm. 2. The nurse will take pubic hair samples to analyze root structure and identify foreign hairs that might have been transferred from the rapist. 4. The nurse will take head hair samples to analyze root structure and identify foreign hairs that might have been transferred from the rapist.
35) A client arrives at the emergency department stating that she was raped, but she felt so “dirty” that she went home and showered. She states that she has on clean clothes but has her other clothes in a bag. What will the nurse tell the client? 1. “I understand why you felt dirty, but you know you should not have taken a shower.” 2. “We will probably never find out who raped you because you destroyed evidence.” 3. “Do you want an emergency contraceptive pill?” 4. “I understand that was important to you. We will see what we can get from your clothes, and give them to the authorities.” Answer:4. This is the correct statement. This is not the time to tell her what she did wrong, as she is psychologically upset. The ability to collect evidence that is comprehensive, appropriate, and reliable contributes to successful prosecution of perpetrators of sexual assault. 36) The nurse is counseling a rape victim on her choices in pursuing legal action. The nurse will explain which of the following to the client? Select all that apply. 1. Prosecution procedures are described as a second rape. 2. The prosecution will victimize her in court during testimony. 3. Publicity can intensify her feelings of humiliation. 4. Prosecution of the assailant is a community responsibility. 5. The client’s sexual history will be publicized. Answer: 1, 3, 4 1. Many sexual assault survivors who have gone through the judicial process refer to it as a second rape—and sometimes a more damaging one. 3. Publicity can intensify her feelings of humiliation. 4. Prosecution of the assailant is a community responsibility in which the prosecuting attorney will act on the victim’s behalf.
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 9. Reproductive Physiology, Conception, and Fetal Development 1. A newly married couple plans to use the natural family planning method of contraception. Understanding how long an ovum can live after ovulation is important to them. The nurse knows that his or herteaching was effective when the couple responds that an ovum is considered fertile for which period of time? 6 to 8 hours a. b.
24 hours
c.
2 to 3 days
1 week d. ANS: B Most ova remain fertile for approximately 24 hours after ovulation,much longer than 6 to 8 hours. However, ova do not remain fertilefor 2 to 3 days or are viable for 1 week. If unfertilized by a sperm after 24 hours, the ovum degenerates and is reabsorbed. DIF: Cognitive Level: Understand REF: p. 266 TOP: Nursing Process: PlanningMSC: Client Needs: Health Promotion and Maintenance 2. What kind of fetal anomalies are most often associated with oligohydramnios? Renal a. b.
Cardiac
c.
Gastrointestinal
Neurologic d. ANS: A An amniotic fluid volume of less than 300 ml (oligohydramnios) isoften associated with fetal renal anomalies. The amniotic fluid volume has no bearing on the fetal cardiovascular system. Gastrointestinal anomalies are associated with hydramnios or an amniotic fluid volume greater than 2 L. The amniotic fluid volumehas no bearing on the fetal neurologic system. DIF: Cognitive Level: Remember REF: p. 276 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
3. A pregnant woman at 25 weeks of gestation tells the nurse thatshe dropped a pan last week and her baby jumped at the noise.Which response by the nurse is most accurate? That must have been a coincidence; babies cant respond like that. a. b.
The fetus is demonstrating the aural reflex.
c.
Babies respond to sound starting at approximately 24 weeks of gestati
Let me know if it happens again; we need to report that to your midwif d. ANS: C Babies respond to external sound starting at approximately 24 weeks of gestation. Acoustic stimulations can evoke a fetal heart rate response. There is no such thing as an aural reflex. The last statement is inappropriate and may cause undue psychologic alarmto the client. DIF: Cognitive Level: Apply REF: p. 276 TOP: Nursing Process: EvaluationMSC: Client Needs: Health Promotion and Maintenance 4. At a routine prenatal visit, the nurse explains the development of the fetus to her client. At approximately weeks of gestation, lecithin is forming on the alveolar surfaces, the eyelids open, and the fetus measures approximately 27 cm crown to rump and weighsapproximately 1110 g. The client is how many weeks of gestation attodays visit? 20 a. b.
24
c.
28
30 d. ANS: C These milestones in human development occur at 28 weeks of gestation. These milestones have not occurred by 20 or 24 weeks ofgestation but have been reached before 30 weeks of gestation. DIF: Cognitive Level: Understand REF: p. 280 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 5. Which statement regarding the structure and function of theplacenta is correct? Produces nutrients for fetal nutrition a. b.
Secretes both estrogen and progesterone
c.
Forms a protective, impenetrable barrier to microorganisms such as ba viruses
Excretes prolactin and insulin d. ANS: B As one of its early functions, the placenta acts as an endocrine gland, producing four hormones necessary to maintain the pregnancy and to support the embryo or fetus: human chorionic gonadotropin (hCG), human placental lactogen (hPL), estrogen, and progesterone. The placenta does not produce nutrients. It functionsas a means of metabolic exchange between the maternal and fetal blood supplies. Many bacteria and viruses can cross the placental membrane. DIF: Cognitive Level: Understand REF: p. 271 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 6. A woman in labor passes some thick meconium as her amniotic fluid ruptures. The client asks the nurse where the baby makes themeconium. What is the correct response by the nurse? Fetal intestines a. b.
Fetal kidneys
c.
Amniotic fluid
Placenta d. ANS: A As the fetus nears term, fetal waste products accumulate in the intestines as dark green-to-black, tarry meconium. Meconium is notproduced by the fetal kidneys nor should it be present in the amniotic fluid, which may be an indication of fetal compromise. Theplacenta does not produce meconium. DIF: Cognitive Level: Apply REF: p. 275 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotionand Maintenance 7. A woman asks the nurse, What protects my babys umbilical cordfrom being squashed while the babys inside of me? What is the nurses best response? Your babys umbilical cord is surrounded by connective tissue called Wh which prevents compression of the blood vessels. a. b.
Your babys umbilical cord floats around in blood and amniotic fluid.
c.
You dont need to be worrying about things like that. The umbilical cord is a group of blood vessels that are very well protec placenta.
d. ANS: A Explaining the structure and function of the umbilical cord is the most appropriate response. Connective tissue called Whartons jellysurrounds the umbilical cord, prevents compression of the bloodvessels, and ensures continued nourishment of the embryo or fetus.The umbilical cord does not float around in blood or fluid. Telling the client not to worry negates her need for information and discounts her feelings. The placenta does not protect the umbilical cord. DIF: Cognitive Level: Apply REF: p. 270 TOP: Nursing Process: PlanningMSC: Client Needs: Health Promotion and Maintenance 8. Which structure is responsible for oxygen and carbon dioxidetransport to and from the maternal bloodstream? Decidua basalis a. b.
Blastocyst
c.
Germ layer
Chorionic villi d. ANS: D Chorionic villi are fingerlike projections that develop out of the trophoblast and extend into the blood-filled spaces of the endometrium. The villi obtain oxygen and nutrients from the maternal bloodstream and dispose carbon dioxide and waste products into the maternal blood. The decidua basalis is the portion of the decidua (endometrium) under the blastocyst where the villi attach. The blastocyst is the embryonic development stage after themorula; implantation occurs at this stage. The germ layer is a layer of the blastocyst. DIF: Cognitive Level: Understand REF: p. 270 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 9. A woman who is 8 months pregnant asks the nurse, Does my babyhave any antibodies to fight infection? What is the mostappropriate response by the nurse? Your baby has all the immunoglobulins necessary: immunoglobulin G (I immunoglobulin M (IgM), and immunoglobulin A (IgA). a.
b.
Your baby wont receive any antibodies until he is born and you breastf
c.
Your baby does not have any antibodies to fight infection.
Your baby has IgG and IgM. d. ANS: D During the third trimester, IgG is the only immunoglobulin that crosses the placenta; it provides passive acquired immunity to specific bacterial toxins. However, the fetus produces IgM by the end of the first trimester. IgA immunoglobulins are not produced bythe baby. Therefore, by the third trimester, the fetus has both IgG and IgM. Breastfeeding supplies the newborn infant with IgA. DIF: Cognitive Level: Apply REF: p. 277 TOP: Nursing Process: PlanningMSC: Client Needs: Health Promotion and Maintenance 10. The measurement of lecithin in relation to sphingomyelin (lecithin/sphingomyelin [L/S] ratio) is used to determine fetal lung maturity. Which ratio reflects fetal maturity of the lungs? 1.4:1 a. b.
1.8:1
c.
2:1
1:1 d. ANS: C The L/S ratio indicates a 2:1 ratio of lecithin to sphingomyelin, which is an indicator of fetal lung maturity and occurs at approximately themiddle of the third trimester. L/S ratios of 1.4:1, 1.8:1, and 1:1 each indicate immaturity of the fetal lungs. DIF: Cognitive Level: Remember REF: p. 275 TOP: Nursing Process: DiagnosisMSC: Client Needs: Health Promotion and Maintenance 11. A client arrives for her initial prenatal examination. This is her first child. She asks the nurse, How does my baby get air inside myuterus? What is the correct response by the nurse? The babys lungs work in utero to exchange oxygen and carbon dioxide a. b.
The baby absorbs oxygen from your blood system.
c.
The placenta provides oxygen to the baby and excretes carbon dioxide bloodstream.
d. ANS: C
The placenta delivers oxygen-rich blood through the umbilical artery to abdomen.
The placenta delivers oxygen-rich blood through the umbilical vein, not the artery, to the fetus and excretes carbon dioxide into the maternal bloodstream. The fetal lungs do not function as respiratorygas exchange in utero. The baby does not simply absorb oxygen from a womans blood system; rather, blood and gas transport occur through the placenta. DIF: Cognitive Level: Apply REF: p. 271 TOP: Nursing Process: PlanningMSC: Client Needs: Health Promotion and Maintenance 12. What is the most basic information that a nurse should be able toshare with a client who asks about the process of conception? Ova are considered fertile 48 to 72 hours after ovulation. a. b.
Sperm remain viable in the womans reproductive system for an averag hours.
c.
Conception is achieved when a sperm successfully penetrates the me surrounding the ovum.
Implantation in the endometrium occurs 6 to 10 days after conception. d. ANS: D After implantation, the endometrium is called the decidua. Ova are considered fertile for approximately 24 hours after ovulation. Spermremain viable in the womans reproductive system for an average of2 to 3 days. Penetration of the ovum by the sperm is calledfertilization. Conception occurs when the zygote, the first cell of the new individual, is formed. DIF: Cognitive Level: Remember REF: p. 267 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 13. The maternity nurse is cognizant of what important structure andfunction of the placenta? As the placenta widens, it gradually thins to allow easier passage of ai nutrients. a. b.
As one of its early functions, the placenta acts as an endocrine gland. The placenta is able
c.
to keep out most potentially toxic substances, suc cigarette smoke, to which the mother is exposed.
d. ANS: B
Optimal blood circulation is achieved through the placenta when the w on her back or standing.
The placenta produces four hormones necessary to maintain the pregnancy: hCG, hPL, estrogen, and progesterone. The placenta widens until 20 weeks of gestation and continues to grow thicker. Toxic substances such as nicotine and carbon monoxide readily crossthe placenta into the fetus. Optimal circulation occurs when the woman is lying on her side. DIF: Cognitive Level: Understand REF: p. 271 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 14. Which statement regarding the development of the respiratorysystem is a high priority for the nurse to understand? The respiratory system does not begin developing until after the embr a. b.
The infants lungs are considered mature when the L/S ratio is 1:1, at a 32 weeks of gestation.
c.
Maternal hypertension can reduce maternal-placental blood flow, acce maturity. Fetal respiratory movements are not visible on ultrasound scans until a weeks of gestation.
d. ANS: C A reduction in placental blood flow stresses the fetus, increases blood levels of corticosteroids, and thus accelerates lung maturity. The development of the respiratory system begins during the embryonic phase and continues into childhood. The infants lungs areconsidered mature when the L/S ratio is 2:1, at approximately 35 weeks of gestation. Lung movements have been visualized on ultrasound scans at 11 weeks of gestation. DIF: Cognitive Level: Understand REF: p. 275 TOP: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance 15. The various systems and organs of the fetus develop at differentstages. Which statement is most accurate? Cardiovascular system is the first organ system to function in the deve human. a. b.
Hematopoiesis originating in the yolk sac begins in the liver at 10 wee gestation.
c.
Body changes from straight to C-shape occurs at 8 weeks of gestation.
d. ANS: A
Gastrointestinal system is mature at 32 weeks of gestation.
The heart is developmentally complete by the end of the embryonicstage. Hematopoiesis begins in the liver during the sixth week. The body becomes C-shaped at 21 weeks of gestation. The gastrointestinal system is complete at 36 weeks of gestation. DIF: Cognitive Level: Remember REF: p. 273 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 16. Which statement concerning neurologic and sensorydevelopment in the fetus is correct? Brain waves have been recorded on an electroencephalogram as early of the first trimester (12 weeks of gestation). a. b.
Fetuses respond to sound by 24 weeks of gestation and can be soothe sound of the mothers voice.
c.
Eyes are first receptive to light at 34 to 36 weeks of gestation.
At term, the fetal brain is at least one third the size of an adult brain. d. ANS: B Hearing develops early and is fully developed at birth. Brain waveshave been recorded at week 8. Eyes are receptive to light at 28 weeks of gestation. The fetal brain is approximately one fourth thesize of an adult brain. DIF: Cognitive Level: Remember REF: p. 276 TOP: Nursing Process: PlanningMSC: Client Needs: Health Promotion and Maintenance 17. A womans cousin gave birth to an infant with a congenital heart anomaly. The woman asks the nurse when such anomalies occur during development. Which response by the nurse is most accurate? We dont really know when such defects occur. a. b.
It depends on what caused the defect.
c.
Defects occur between the third and fifth weeks of development.
They usually occur in the first 2 weeks of development. d. ANS: C The cardiovascular system is the first organ system to function in the developing human. Blood vessel and blood formation begins inthe third week, and the heart is developmentally complete in the fifth week. We dont really know when such defects occur is an inaccurate statement. Regardless of the cause, the heart is vulnerable during its period of developmentin the third to fifth
weeks; therefore, the statement, They usually occur in the first 2weeks of development is inaccurate. DIF: Cognitive Level: Apply REF: p. 273 TOP: Nursing Process: EvaluationMSC: Client Needs: Health Promotion and Maintenance 18. Which information regarding amniotic fluid is important for thenurse to understand? Amniotic fluid serves as a source of oral fluid and a repository for wast fetus. a. b.
Volume of the amniotic fluid remains approximately the same through of a healthy pregnancy.
c.
The study of fetal cells in amniotic fluid yields little information. A volume of more than 2 L of amniotic fluid is associated with fetal ren abnormalities.
d. ANS: A Amniotic fluid serves as a source of oral fluid, serves as a repository for waste from the fetus, cushions the fetus, and helps maintain a constant body temperature. The volume of amniotic fluid constantly changes. The study of amniotic fluid yields information regarding thesex of the fetus and the number of chromosomes. Too much amniotic fluid (hydramnios) is associated with gastrointestinal and other abnormalities. DIF: Cognitive Level: Understand REF: p. 270 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 19. An expectant couple attending childbirth classes have questionsregarding multiple births since twins run in the family. What information regarding multiple births is important for the nurse to share? Twinning and other multiple births are increasing because of the use of drugs and delayed childbearing. a. b.
Dizygotic twins (two fertilized ova) have the potential to be conjoined t
c.
Identical twins are more common in Caucasian families.
Fraternal twins are the same gender, usually male. d. ANS: A If the parents-to-be are older and have taken fertility drugs, then they would be very interested to know about twinning and other multiple births. Conjoined twins are monozygotic; that is, they are
from a single fertilized ovum in which division occurred very late. Identical twins show no racial or ethnic preference, and fraternal twins are more common among African-American women. Fraternaltwins can be different genders or the same gender, and identical twins are the same gender. DIF: Cognitive Level: Understand REF: p. 277 TOP: Nursing Process: PlanningMSC: Client Needs: Health Promotion and Maintenance
20. The nurse caring for a pregnant client is evaluating his or her health teaching regarding fetal circulation. Which statement from the client reassures the nurse that his or her teaching has been effective? Optimal fetal circulation is achieved when I am in the side-lying positio a.
Optimal fetal circulation is achieved when I am on my back with a pillo b.
knees.
c.
Optimal fetal circulation is achieved when the head of the bed is eleva
Optimal fetal circulation is achieved when I am on my abdomen. d. ANS: A Optimal circulation is achieved when the woman is lying at rest on her side. Decreased uterine circulation may lead to intrauterine growth restriction. Previously, it was believed that the left lateral position promoted maternal cardiac output, enhancing blood flow to the fetus. However, it is now known that the side-lying position enhances uteroplacental blood flow. If a woman lies on her back withthe pressure of the uterus compressing the vena cava, then blood return to the right atrium is diminished. Although having the head of the bed elevated is recommended and ideal for later in pregnancy, the woman still must maintain a lateral tilt to the pelvis to avoid compressing the vena cava. Many women find lying on their abdomen uncomfortable as pregnancy advances. Side-lying is the ideal position to promote blood flow to the fetus. DIF: Cognitive Level: Analyze REF: p. 273 TOP: Nursing Process: EvaluationMSC: Client Needs: Health Promotion and Maintenance 21. Some of the embryos intestines remain within the umbilical cordduring the embryonic period. What is the rationale for this development of the gastrointestinal system? Umbilical cord is much larger at this time than it will be at the end of p a. b.
Intestines begin their development within the umbilical cord.
c.
Nutrient content of the blood is higher in this location.
Abdomen is too small to contain all the organs while they are developi d. ANS: D The abdominal contents grow more rapidly than the abdominal cavity; therefore, part of their development takes place in the umbilical cord. By 10 weeks of gestation, the abdomen is large enough to contain them. Intestines begin their development within the umbilical cord but only because the liver and kidneys occupy most of the abdominal cavity. Blood supply is adequate in all areas.DIF: Cognitive Level: Understand REF: p. 275 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 22. A woman is 15 weeks pregnant with her first baby. She asks howlong it will be before she feels the baby move. What is the nursesbest answer? You should have felt the baby move by now. a. b.
Within the next month, you should start to feel fluttering sensations.
c.
The baby is moving; however, you cant feel it yet.
Some babies are quiet, and you dont feel them move. d. ANS: B Maternal perception of fetal movement usually begins 16 to 20 weeks after conception. Because this is her first pregnancy, movement is felt toward the later part of the 16- to 20-week time period. Stating, you should have felt the baby move by now is incorrect and may be an alarming statement to the client. Fetal movement should be felt by 16 to 20 weeks. If movement is not feltby the end of that time, then further assessment is necessary. DIF: Cognitive Level: Comprehend REF: p. 277 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotionand Maintenance 23. A new mother asks the nurse about the white substance coveringher infant. How should the nurse explain the purpose of vernix caseosa? Vernix caseosa protects the fetal skin from the amniotic fluid. a. b.
Vernix caseosa promotes the normal development of the peripheral ne system.
c.
Vernix caseosa allows the transport of oxygen and nutrients across the
Vernix caseosa regulates fetal temperature. d. ANS: A Prolonged exposure to the amniotic fluid during the fetal period could result in the breakdown of the skin without the protection of the vernix caseosa. Normal development of the peripheral nervous system was dependent on nutritional intake of the mother. The amnion was the inner membrane that surrounded the fetus and was not involved in the oxygen and nutrient exchange. The amniotic fluidhelped maintain fetal temperature. DIF: Cognitive Level: Remember REF: p. 277 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 24. A woman who is 16 weeks pregnant asks the nurse, Is it possibleto tell by ultrasound if the baby is a boy or girl yet? What is thebest answer? A babys sex is determined as soon as conception occurs. a. b.
The baby has developed enough to enable us to determine the sex by the genitals through an ultrasound scan.
c.
Boys and girls look alike until approximately 20 weeks after conception they begin to look different.
It might be possible to determine your babys sex, but the external orgsimilar right now. d. ANS: B Although gender is determined at conception, the external genitaliaof males and females look similar through the ninth week. By the twelfth week, the external genitalia are distinguishable as male or female. DIF: Cognitive Level: Understand REF: pp. 276, 278 TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotionand Maintenance 25. Which development related to the integumentary systemis correct? Very fine hairs called lanugo appear at 12 weeks of gestation. a. b.
Eyelashes, eyebrows, and scalp hair appear at 28 weeks of gestation.
c.
Fingernails and toenails develop at 28 weeks of gestation.
d. ANS: A
By 32 weeks, scalp hair becomes apparent.
Very fine hairs, called lanugo appear first at 12 weeks of gestational age on the fetus eyebrows and upper lip. By 20 weeks of gestation, lanugo covers the entire body. By 20 weeks of gestation the eyelashes, eyebrows, and scalp hair also begin to grow. By 28 weeksof gestation, the scalp hair is longer than these fine hairs, which is thin and may disappear by term. Fingernails and toenails develop from thickened epidermis, beginning during the 10th week. Fingernails reach the fingertips at 32 weeks of gestation, and thetoenails reach the toe tips at 36 weeks of gestation. DIF: Cognitive Level: Remember REF: p. 277 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 26. The pancreas forms in the foregut during the 5th to 8th week of gestation. A client with poorly controlled gestational diabetes asks the nurse what the effects of her condition will be on the fetus. Whatis the best response by the nurse? Poorly controlled maternal gestational diabetes will: produce fetal hypoglycemia. a. b.
result in a macrocosmic fetus.
c.
result in a microcosmic fetus.
enhance lung maturation. d. ANS: B Insulin is produced by week 20 of gestation. In the fetus of a motherwith uncontrolled diabetes, maternal hypoglycemia produces fetal hypoglycemia and macrocosmia results. Hyperinsulinemia blocks lung maturation, placing the neonate at risk for respiratory distress. DIF: Cognitive Level: Understand REF: p. 276 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. Congenital disorders refer to those conditions that are present at birth. These disorders may be inherited and caused by environmental factors or maternal malnutrition. Toxic exposures have the greatest effect on development between 15 and 60 days ofgestation. For the nurse to be able to conduct a complete assessment of the newly pregnant client, he or she should be knowledgeable regarding known human teratogens. Which substances might be considered a teratogen? (Select all that apply.)
a.
Cytomegalovirus (CMV)
b.
Ionizing radiation
c.
Hypothermia
d.
Carbamazepine
Lead e. ANS: A, B, D, E Exposure to radiation and a number of infections may result in profound congenital deformities. These include but are not limited tovaricella, rubella, syphilis, parvovirus, CMV, and toxoplasmosis. Certain maternal conditions such as diabetes and phenylketonuria (PKU) may also affect organs and other parts of the embryo duringthis developmental period. Drugs such as antiseizure medications (e.g., carbamazepine) and some antibiotics, as well as chemicals including lead, mercury, tobacco, and alcohol, may also result in structural and functional abnormalities. DIF: Cognitive Level: Remember REF: p. 273 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 2. Relating to the fetal circulatory system, which special characteristics allow the fetus to obtain sufficient oxygen from thematernal blood? (Select all that apply.) Fetal hemoglobin (Hb) carries 20% to 30% more oxygen than maternal a. b.
Fetal Hb carries 40% to 50% more oxygen than maternal Hb.
c.
Hb concentration is 50% higher than that of the mother.
d.
Fetal heart rate is 110 to 160 beats per minute.
Fetal heart rate is 160 to 200 beats per minute. e. ANS: A, C, D The following three special characteristics enable the fetus to obtain sufficient oxygen from maternal blood: (1) the fetal Hb carries 20% to 30% more oxygen; (2) the concentration is 50% higher than that of the mother; and (3) the fetal heart rate is 110 to 160 beats per minute, a cardiac output that is higher than that of an adult. DIF: Cognitive Level: Understand REF: p. 274 TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 11. Physical and Psychologic Changes of Pregnancy 1) A client with a normal prepregnancy weight asks why she has been told to gain 25-35 pounds during her pregnancy while her underweight friend was told to gain more weight. What should the nurse tell the client the recommended weight gain is during pregnancy? 1. 25-35 pounds, regardless of a client's prepregnant weight 2. More than 25-35 pounds for an overweight woman 3. Up to 40 pounds for an underweight woman 4. The same for a normal weight woman as for an overweight woman Answer: 3 Explanation: 3. Prepregnant weight determines the recommended weight gain during pregnancy. Underweight women are advised to gain 28-40 pounds. Page Ref: 229 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, cultural, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1 Identify the anatomic and physiologic changes that occur during pregnancy. MNL LO: 2.1.2 Explain the expected maternal physiologic adaptations to pregnancy.
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 12. Antepartum Nursing Assessment 1) While completing the medical and surgical history during the initial prenatal visit, the 16-yearold primigravida interrupts with “Why are you asking me all these questions? What difference does it make?” Which statement would best answer the client’s questions?” 1. “We ask these questions to detect anything that happened in your past that might affect the pregnancy.” 2. “We ask these questions to see whether you can have prenatal visits less often than most clients do.” 3. “We ask these questions to make sure that our paperwork and records are complete and up to date.” 4. “We ask these questions to look for any health problems in the past that might affect your parenting.” Answer: 1 Explanation: 1. The course of a pregnancy depends on a number of factors, including the past pregnancy history (if this is not a first pregnancy), prepregnancy health of the woman, presence of disease/illness states, family history, emotional status, and past health care. 2) During a client’s initial prenatal visit, the nurse must assess and document the client’s current medical history, including which information? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Body mass index 2. Infections before the last menstrual period 3. Homeopathic or herbal medication use 4. Blood type and Rh factor 5. History of previous pregnancies
Answer: 1, 3, 4 Explanation: 1. The body mass index is an important part of the current medical history to be assessed and documented. 3. Homeopathic and herbal medication use is important for the nurse to assess and document in the current medical history. 4. The blood type must be assessed and documented in the current medical history, as must the Rh factor. Page Ref: 245 3) During the initial prenatal visit, the nurse obtains a weight of 42 kg (92.4 lb). The nurse must further assess the client for information about which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Eating habits 2. Foods regularly eaten 3. Income limitations 4. Blood pressure and pulse rate 5. Weight loss during pregnancy Answer: 1, 2, 3 Explanation: 1. For a client whose weight is less than 100 lb, the nurse would obtain information on eating habits. 2. For a client whose weight is less than 100 lb, the nurse would obtain information on foods regularly eaten. 3. For a client whose weight is less than 100 lb, the nurse would obtain information on income limitations. Page Ref: 250 4) A woman gave birth last week to a fetus at 18 weeks’ gestation after her first pregnancy. She is in the clinic for follow-up, and notices that her chart states she has had one abortion. The client is upset over the use of this word. How can the nurse best explain this terminology to the client?
1. “Abortion is the obstetric term for all pregnancies that end before 20 weeks.” 2. “Abortion is the word we use when someone has miscarried.” 3. “Abortion is how we label babies born in the second trimester.” 4. “Abortion is what we call all babies who are born dead.” Answer: 1 Explanation: 1. The term abortion means a birth that occurs before 20 weeks’ gestation or the birth of a fetus-newborn who weighs less than 500 g. An abortion may occur spontaneously or it may be induced by medical or surgical means. Page Ref: 244 5) The clinic nurse is compiling data for a yearly report. Which client would be classified as a primigravida? 1. A client at 18 weeks’ gestation who had a spontaneous loss at 12 weeks 2. A client at 13 weeks’ gestation who had an ectopic pregnancy at 8 weeks 3. A client at 14 weeks’ gestation who has a 3-year-old daughter at home 4. A client at 15 weeks’ gestation who has never been pregnant before Answer: 4 Explanation: 4. Primigravida means a woman who is pregnant for the first time. Page Ref: 244 6) The client has delivered her first child at 37 weeks. The nurse would describe this to the client as what type of delivery? 1. Preterm 2. Postterm 3. Early term 4. Near term Answer: 3
Explanation: 3. Early term births extend from 37 to 38 weeks’ gestation. Page Ref: 244 7) The nurse in the OB-GYN clinic is working with a client who is seeking her initial prenatal visit. The nurse will use the acronym TPAL to document the client’s number of which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Term infants born 2. Children living in the home 3. Pregnancies ending in abortion 4. Preterm infants born 5. Pregnancies that occurred Answer: 1, 3, 4 Explanation: 1. T: number of term births the woman has experienced 3. A: number of pregnancies ending in either spontaneous or therapeutic abortion 4. P: number of preterm births Page Ref: 244 8) The prenatal clinic nurse is designing a new prenatal intake information form for pregnant clients. Which question is best to include on this form? 1. Where was the father of the baby born? 2. Do genetic diseases run in the family of the baby’s father? 3. What is the name of the baby’s father? 4. Are you married to the father of the baby? Answer: 2
Explanation: 2. This question has the highest priority because it gets at the physiologic issue of inheritable genetic diseases that might directly impact the baby. Page Ref: 245 9) During the initial prenatal visit, the nurse assesses the history of the father of the child for which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Stability of living conditions 2. Blood type and Rh type 3. Significant health problems 4. Nutritional history 5. Current use of tobacco Answer: 2, 3, 5 Explanation: 2. The father of the fetus should be assessed for blood type and Rh factor. 3. The father of the fetus should be assessed for significant health problems. 5. The father of the fetus should be assessed for current alcohol intake, drug use, and tobacco use. Page Ref: 245 10) A 25-year-old primigravida is at 20 weeks’ gestation. The nurse takes her vital signs and notifies the healthcare provider immediately because of which finding? 1. Pulse 88/minute 2. Rhonchi in both bases 3. Temperature 37.4° C (99.3° F) 4. Blood pressure 122/78 Answer: 2
Explanation: 2. Any abnormal breath sounds should be reported to the healthcare provider. Page Ref: 251 MNL LO: 2.2.2 Assess maternal assessment data for potential risk factors. 11) The clinic nurse is assisting with an initial prenatal assessment. The following findings are present: spider nevi present on lower legs; dark pink, edematous nasal mucosa; mild enlargement of the thyroid gland; mottled skin and pallor on palms and nail beds; heart rate 88 with murmur present. What is the best action for the nurse to take based on these findings? 1. Document the findings on the prenatal chart. 2. Have the physician see the client today. 3. Instruct the client to avoid direct sunlight. 4. Analyze previous thyroid hormone lab results. Answer: 2 Explanation: 2. Mottling of the skin is indicative of possible anemia. These abnormalities must be reported to the healthcare provider immediately. Page Ref: 250 12) The nurse begins a prenatal assessment on a 25-year-old primigravida at 20 weeks’ gestation and immediately contacts the healthcare provider because of which finding? 1. Pulse 88/minute 2. Respirations 30/minute 3. Temperature 37.4° C (99.3° F) 4. Blood pressure 118/82 Answer: 2 Explanation: 2. Tachypnea is not a normal finding and requires medical care. Page Ref: 250 13) The nurse is seeing prenatal clients in the clinic. Which client is exhibiting expected findings?
1. 12 weeks’ gestation, with fetal heart tones heard by Doppler fetoscope 2. 22 weeks’ gestation, client reports no fetal movement felt yet 3. 16 weeks’ gestation, fundus three finger breadths above umbilicus 4. Marked edema Answer: 1 Explanation: 1. This is an expected finding because fetal heart tones should be heard by 12 weeks using a Doppler fetoscope. Page Ref: 257 14) The nurse working in an outpatient obstetric clinic assesses four primigravida clients. Which client findings would the nurse tell the physician about? 1. 17 weeks’ gestation and client denies feeling fetal movement 2. 24 weeks’ gestation and fundal height is at the umbilicus 3. 4-6 weeks’ gestation and softening of the cervix 4. 34 weeks’ gestation and complains of hemorrhoidal pain Answer: 2 Explanation: 2. The fundal height at 24 weeks should be 24 cm. The fundal height is usually at the umbilicus at 20-22 weeks. Page Ref: 252, 256 15) What signs would indicate that a pregnant client’s urinalysis culture was abnormal? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. pH 4.6-8 2. Alkaline urine 3. Cloudy appearance 4. Negative for protein and red blood cells
5. Hemoglobinuria Answer: 2, 3, 5 Explanation: 2. Alkaline urine could indicate metabolic alkalemia, Proteus infection, or an old specimen. 3. A cloudy appearance could indicate an infection. 5. Hemoglobinuria would be indicated by an abnormal urine color. Page Ref: 254 16) The nurse receives a phone call from a client who claims she is pregnant. The client reports that she has regular menses that occur every 28 days and last 5 days. The first day of her last menses was April 10. What would the client’s estimated date of delivery (EDD) be if she is pregnant? 1. Nov. 13 2. Jan. 17 3. Jan. 10 4. Dec. 3 Answer: 2 Explanation: 2. The due date is Jan. 17. Nagele’s rule is to add 7 days to the last menstrual period and subtract 3 months. The last menstrual period is April 10, therefore Jan. 17 is the EDD. Page Ref: 256 17) The nurse is seeing a client who asks about the accuracy of Nagele’s rule. The nurse explains that accuracy can be compromised under which conditions? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. There is a history of regular menses every 28 days. 2. Amenorrhea is present and ovulation occurs with breastfeeding. 3. Oral contraception was discontinued, but no regular menstruation was established.
4. There has been 1 or more months of amenorrhea. 5. There is an accurate date for the last menstrual period. Answer: 2, 3, 4 Explanation: 2. Nagele’s rule is not always accurate for women who have amenorrhea but are ovulating and conceive while breastfeeding. 3. Nagele’s rule is not always accurate for women who conceive before regular menstruation is established following discontinuation of oral contraceptives or termination of a pregnancy. 4. Nagele’s rule is not always accurate for women with markedly irregular periods that include 1 or more months of amenorrhea. Page Ref: 256 18) The primigravida at 22 weeks’ gestation has a fundal height palpated slightly below the umbilicus. Which of the following statements would best describe to the client why she needs to be seen by a physician today? 1. “Your baby is growing too much and getting too big.” 2. “Your uterus might have an abnormal shape.” 3. “The position of your baby can’t be felt.” 4. “Your baby might not be growing enough.” Answer: 4 Explanation: 4. The fundal height at 20-22 weeks should be about even with the umbilicus. At 22 weeks’ gestation, a fundal height below the umbilicus and the size of the uterus that is inconsistent with length of gestation could indicate fetal demise. Page Ref: 252 19) The nurse is explaining to a new prenatal client that the certified nurse-midwife will perform clinical pelvimetry as a part of the pelvic exam. The nurse knows that teaching has been successful when the client makes which statement about the reason for the exam? 1. “It will help us know how big a baby I can deliver vaginally.” 2. “Doing this exam is a part of prenatal care at this clinic.” 3. “My sister had both of her babies by cesarean.”
4. “I am pregnant with my first child.” Answer: 1 Explanation: 1. By performing a series of assessments and measurements, the examiner assesses the pelvis vaginally to determine whether the size and shape are adequate for a vaginal birth; this procedure is called clinical pelvimetry. Page Ref: 257 20) The nurse is explaining clinical pelvimetry to a client. The nurse explains that the anteroposterior diameters consist of which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Diagonal conjugate 2. Transverse diameter 3. Conjugata vera 4. Obstetric conjugate 5. Oblique diameter Answer: 1, 3, 4 Explanation: 1. The diagonal conjugate is a part of the anteroposterior diameter measurement. 3. The conjugata vera is a part of the anteroposterior diameter measurement. 4. The obstetric conjugate is a part of the anteroposterior diameter measurement. Page Ref: 258, 259 21) The nurse is assessing a newly pregnant client. Which finding does the nurse note as a normal psychosocial adjustment in this client’s first trimester? 1. An unlisted telephone number 2. Reluctance to tell the partner of the pregnancy 3. Parental disapproval of the woman’s partner
4. Ambivalence about the pregnancy Answer: 4 Explanation: 4. Ambivalence toward a pregnancy is a common psychosocial adjustment in early pregnancy. Page Ref: 255 22) The nurse is assessing a primiparous client who indicates that her religion is Judaism. Why is this information is pertinent for the nurse to assess? 1. Religious and cultural background can impact what a client eats during pregnancy. 2. It provides a baseline from which to ask questions about the client’s religious and cultural background. 3. Knowing the client’s beliefs and behaviors regarding pregnancy is not important. 4. Clients sometimes encounter problems in their pregnancies based on what religion they practice. Answer: 2 Explanation: 2. Nurses have an obligation to be aware of other cultures and develop a culturally sensitive plan of care to meet the needs of the childbearing woman and her family. Page Ref: 246 23) What would the nurse include as part of a routine physical assessment for a second-trimester primiparous patient whose prenatal care began in the first trimester and is ongoing? 1. Pap smear 2. Hepatitis B screening (HBsAg) 3. Fundal height measurement 4. Complete blood count Answer: 3 Explanation: 3. At each prenatal visit, the blood pressure, pulse, and weight are assessed, and the size of the fundus is measured. Fundal height should be increasing with each prenatal visit. Page Ref: 250, 252
24) If a woman has the pre-existing condition of diabetes, the nurse knows that she would be prone to what high-risk factor when pregnant? 1. Vasospasm 2. Postpartum hemorrhage 3. Episodes of hypoglycemia and hyperglycemia 4. Cerebrovascular accident (CVA) Answer: 3 Explanation: 3. Episodes of hypoglycemia and hyperglycemia would be a high-risk factor for a client with pre-existing diabetes. Page Ref: 247 25) Which third-trimester client would the nurse suspect might be having difficulty with psychological adjustments to her pregnancy? 1. A woman who says, “Either a boy or a girl will be fine with me” 2. A woman who puts her feet up and listens to some music for 15 minutes when she is feeling too stressed 3. A woman who was a smoker but who has quit at least for the duration of her pregnancy 4. A woman who has not investigated the kind of clothing or feeding methods the baby will need Answer: 4 Explanation: 4. By the third trimester, the client should be planning and preparing for the baby (for example, living arrangements, clothing, feeding methods). Page Ref: 265 26) A client comes into the prenatal clinic accompanied by her boyfriend. When asked by the nurse why she is there, the client looks down, and the boyfriend states, “She says she is pregnant. She constantly complains of feeling tired, and her vomiting is disgusting.” What is a priority for the nurse to do at this point? 1. Ask the client what time of the day her fatigue is more common. 2. Recommend that the woman have a pregnancy test done as soon as possible.
3. Continue the interview of the client in private. 4. Give the woman suggestions on ways to decrease the vomiting. Answer: 3 Explanation: 3. The nurse should suspect that the client is in an abusive relationship. The priority is for the nurse to get the client away from the boyfriend and continue the interview. Page Ref: 245, 265 27) A pregnant client calls the clinic nurse to say she is worried about symptoms she is experiencing. The nurse advises the client to come immediately to the clinic because of which reported symptoms? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Vaginal bleeding 2. Abdominal pain 3. Constipation 4. Epigastric pain 5. Blurring of vision Answer: 1, 2, 4, 5 Explanation: 1. Vaginal bleeding can indicate abruptio placentae, placenta previa, or lesions of cervix or vagina, or it can be “bloody show,” and requires that the client be seen. 2. Abdominal pain can signal premature labor or abruptio placentae, and requires that the client be seen. 4. Epigastric pain must be evaluated, as it can indicate preeclampsia or ischemia in a major abdominal vessel. 5. Dizziness, blurring of vision, double vision, or spots before the eyes can indicate either hypertension and/or preeclampsia and requires the client be seen. Page Ref: 263
28) A nurse examining a prenatal client recognizes that a lag in progression of measurements of fundal height from week to week and month to month could signal what condition? 1. Twin pregnancy 2. Intrauterine growth restriction 3. Hydramnios 4. Breech position Answer: 2 Explanation: 2. A lag in progression of measurements of fundal height from month to month could signal intrauterine growth restriction (IUGR). Page Ref: 257 29) The nurse at the prenatal clinic has four calls to return. Which phone call should the nurse return first? 1. Client at 32 weeks, reports headache and blurred vision. 2. Client at 18 weeks, reports no fetal movement in this pregnancy. 3. Client at 16 weeks, reports increased urinary frequency. 4. Client at 40 weeks, reports sudden gush of fluid and contractions. Answer: 1 Explanation: 1. Headache and blurred vision are signs of preeclampsia, which is potentially lifethreatening for both mother and fetus. This client has top priority. Page Ref: 263 30) The nurse is providing guidance for a woman in her second trimester of pregnancy and telling her about some of the signs and symptoms that she might experience. Which statement by the client indicates that further teaching is necessary? 1. “During the third trimester, I might have frequent urination.” 2. “During the third trimester, I might have heartburn.” 3. “During the third trimester, I might have back pain.”
4. “During the third trimester, I might have a persistent headache.” Answer: 4 Explanation: 4. A persistent headache is not normal or expected. This could be related to the complication of preeclampsia. Page Ref: 263 31) The nurse in the prenatal clinic is seeing a pregnant 16-year-old for the first time. What comment by the young client is the most critical for the nurse to address first? 1. “My favorite lunch is burger and fries.” 2. “I’ve been dating my new boyfriend for 2 weeks.” 3. “On weekends, we go out and drink a few beers.” 4. “I dropped out of school about 3 months ago.” Answer: 3 Explanation: 3. The nurse responds to this most critical statement because of the danger of fetal alcohol syndrome. Page Ref: 247 32) The nurse is providing health teaching to a group of women of childbearing age. One woman states that she is a smoker, and asks about the effect of smoking on her fetus. The nurse tells her that which fetal complication can occur when the mother smokes? 1. Genetic changes in the fetal reproductive system 2. Extensive central nervous system damage 3. Addiction to the nicotine inhaled from the cigarette 4. Low birth rate Answer: 4 Explanation: 4. Smoking can cause low birth rate. Page Ref: 247
33) A pregnant client has a hemoglobin of 10 g/dL and a Hct of 30%. The clinic nurse recognizes the fetus is at risk for which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Macrosomia 2. Respiratory distress syndrome 3. Low birth weight 4. Prematurity 5. Fetal death Answer: 3, 4, 5 Explanation: 3. Anemia places the fetus at risk for a low birth weight. 4. Anemia places the fetus at risk for premature birth. 5. Anemia places the fetus at risk for fetal death. Page Ref: 247 34) Screening for gestational diabetes mellitus (GDM) is typically completed between which of the following weeks of gestation? 1. 36 and 40 weeks 2. Before 20 weeks 3. 24 and 28 weeks 4. 30 and 34 weeks Answer: 3 Explanation: 3. Screening for gestational diabetes mellitus (GDM) is typically completed between 24 and 28 weeks’ gestation. Page Ref: 260
35) A pregnant client at 30 weeks’ gestation has had a steady rise in blood pressure. She is now 20 mmHg above her systolic baseline. The nurse advises her to immediately report which symptoms? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Dizziness 2. Even a small amount of dependent edema 3. Spots before her eyes 4. Persistent nausea and vomiting 5. Vaginal spotting Answer: 1, 3 Explanation: 1. Dizziness can be a sign of hypertension or preeclampsia, and should be reported immediately. 3. Spots before the eyes can be a sign of hypertension or preeclampsia, and should be reported immediately. Page Ref: 263
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 13. The Expectant Family: Needs and Care
1) The nurse is presenting a class to women who are currently pregnant or are planning pregnancy in the nearfuture. Which client statement indicates that additional teaching is required?
1. “The older a woman is when she conceives, the safer thepregnancy is.” 2. “Pregnant teens can have additional nutritional needs.” 3. “A woman whose sisters all had hypertension will bewatched carefully.” 4. “Pregnancy may be more difficult to achieve in my 40s.”Answer: 1 Explanation: 1. The health risks associated with pregnancy vary by age. The risk for maternal death is significantly higher for women over age 35 and even higher for women age 40 and older. The incidence of low-birth-weight infants, preterm births, miscarriage, stillbirth, and perinatal morbidityand mortality is higher among women age 35 or older. Page Ref: 302
2) During home care of a low-risk pregnant client, the nurseprovides care by assessing which of the following? Note: Credit will be given only if all correct and no incorrectchoices are selected. Select all that apply.
1. Urine 2. Weight 3. Diet 4. Pelvic measurements 5. Physical activity Answer: 1, 2, 3, 5 Explanation: 1. Assessment of the client’s urine can be donein the home setting.
2. Obtaining the client’s weight can be done in the homesetting. 3. Assessing the client’s dietary intake can be done in thehome setting. 5. The client’s physical activity can be assessed in the homesetting. Page Ref: 272
3) A couple in their late 30s are pregnant for the first time. In evaluating the care delivered, the nurse assesses the mother for which of the following? Note: Credit will be given only if all correct and no incorrectchoices are selected. Select all that apply.
1. Makes appropriate healthcare choices 2. Receives effective healthcare through the pregnancy 3. Has a partner who is not interested in child care 4. Cannot cope with her life change 5. Wishes to have amniocentesis doneAnswer: 1, 2 Explanation: 1. Expected outcomes of nursing care for a pregnant couple over 35 include that the client and her partner are knowledgeable about the pregnancy and makeappropriate healthcare choices. 2. Expected outcomes of nursing care for a pregnant couple over 35 include the client and her partner receive effective health care throughout the pregnancy, birth, and postpartumperiod. Page Ref: 303
4) The nurse is caring for a pregnant client. The client’s husband has come to the prenatal visit. Which question is the
best for the nurse to use to assess the father’s adaptation tothe pregnancy?
1. “What kind of work do you do?” 2. “What furniture have you gotten for the baby?” 3. “How moody has your wife been lately?” 4. “How are you feeling about becoming a father?”Answer: 4 Explanation: 4. A husband’s adaptation to pregnancy includeshis feelings about impending fatherhood. Page Ref: 273
5) The nurse is preparing a class for expectant fathers. Whichinformation should the nurse include? 1. Siblings adjust readily to the new baby.
2. Sexual activity is safe for normal pregnancy. 3. The expectant mother decides the feeding method. 4. Fathers are expected to be involved in labor and birth.Answer: 2 Explanation: 2. In a healthy pregnancy, there is no medicalreason to limit sexual activity. Page Ref: 295
6) The prenatal period should be used to expose theprospective parents to up-to-date, evidence-based information about which of the following topics? Note: Credit will be given only if all correct and no incorrectchoices are selected. Select all that apply.
1. Breastfeeding 2. Pain relief 3. Obstetric complications and procedures 4. Toddler care 5. Antepartum adjustment
Answer: 1, 2, 3 Explanation: 1. The prenatal period should expose prospective parents to up-to-date, evidence-basedinformation about breastfeeding.
2. The prenatal period should expose prospective parents toup-to-date, evidencebased information about pain relief.
3. The prenatal period should expose prospective parents toup-to-date, evidencebased information about obstetric complications and procedures. Page Ref: 280
7) A Navajo client who is 36 weeks pregnant meets with atraditional healer as well as her physician. What does the nurse understand this to mean?
1. The client is seeking spiritual direction. 2. The client does not trust her physician. 3. The client will not adapt to mothering well. 4. The client is experiencing complications of pregnancy.Answer: 1 Explanation: 1. Navajo clients are aware of the mind-soul connection, and might try to follow certain practices to havea healthy pregnancy and birth. Practices could include focuson peace and positive thoughts as well as certain types of prayers and ceremonies. A traditional healer may assist them. Page Ref: 275
8) A Chinese woman who is 12 weeks pregnant reports to thenurse that ginseng and bamboo leaves help reduce her anxiety. How should the nurse respond to this client?
1. Advise the client to give up the bamboo leaves but tocontinue taking ginseng.
2. Advise the client to give up all herbal remedies.
3. Tell the client that her remedies have no scientificfoundation. 4. Assess where the client obtains her remedy, andinvestigate the source. Answer: 2 Explanation: 2. In some cases, the nurse might want to suggest remedies that may be more effective than herbal remedies. However, if the home remedy is not harmful, thereis no reason for the nurse to ask a client to discontinue this practice. Page Ref: 275
9) The OB-GYN nurse works in a clinic with a culturally diverse group of clients whose specific actions during pregnancy are often determined by cultural beliefs. The nurserecognizes that these beliefs about pregnancy and childbirth fall into which categories? Note: Credit will be given only if all correct and no incorrectchoices are selected. Select all that apply.
1. Prescriptive beliefs 2. Restrictive beliefs 3. Taboos 4. Cultural humility 5. Folk treatment beliefsAnswer: 1, 2, 3 Explanation: 1. Prescriptive beliefs or requirements describeexpected behaviors.
2. Restrictive beliefs are stated negatively and limitbehaviors. 3. Taboo beliefs refer to specific supernatural consequences.Page Ref: 274
10) Which of the following are specific culturally sensitive nursing considerations the nurse integrates into care of thepregnant client? Note: Credit will be given only if all correct and no incorrectchoices are selected. Select all that apply.
1. Counseling about home remedies 2. Discussing components of a balanced diet 3. Refusing to discuss birthing choices 4. Encouraging use of support systems 5. Instructing the client to use no home remediesAnswer: 1, 2, 4 Explanation: 1. The culturally sensitive nurse should find out what medications and home remedies the client is using, andcounsel the client regarding overall effects. 2. The culturally sensitive nurse will discuss the importance of a well-balanced diet during pregnancy with considerationof the client’s cultural beliefs and practices. 4. Encouraging the use of support systems and spiritual aids that provide comfort for the mother is important in culturallysensitive care. Page Ref: 275
11) The primiparous client has told the nurse that she is afraid she will develop hemorrhoids during pregnancy because her mother did. Which statement would be best forthe nurse to make?
1. “It is not unusual for women to develop hemorrhoidsduring pregnancy.” 2. “Most women don’t have any problem until after they’vedelivered.” 3. “If your mother had hemorrhoids, you will get them, too.”
4. “If you get hemorrhoids, you probably will need surgery toget rid of them.” Answer: 1 Explanation: 1. Many pregnant women will develop hemorrhoids. Hemorrhoids are varicosities of the veins in the lower end of the rectum and anus. During pregnancy, the gravid uterus presses on the veins and interferes with venouscirculation. As the pregnancy progresses, the straining that accompanies constipation can contribute to the developmentof hemorrhoids. Page Ref: 286
12) Which statement, if made by a pregnant client, wouldindicate that she understands health promotion during pregnancy?
1. “I lie down after eating to relieve heartburn.” 2. “I try to limit my fluid intake to 3 or 4 glasses each day.” 3. “I elevate my legs while sitting at my desk.” 4. “I am avoiding exercise to stay well rested.”Answer: 3 Explanation: 3. Elevating the legs can help decrease lower legedema. Page Ref: 285, 289
13) The nurse is teaching an early pregnancy class for clientsin the first trimester of pregnancy. Which statement by a client requires immediate intervention by the nurse?
1. “When my nausea is bad, I will drink some ginger tea.” 2. “The fatigue I am experiencing will improve in the secondtrimester.” 3. “It is normal for my vaginal discharge to be green.” 4. “I will urinate less often during the middle of mypregnancy.”
Answer: 3 Explanation: 3. Increased whitish vaginal discharge, called leukorrhea, is common in pregnancy. Green discharge is not anormal finding, and indicates a vaginal infection. Page Ref: 283
14) A client at 36 weeks’ gestation is complaining of dyspneawhen lying flat. What is the clinical reason for this complaint? 1. Maternal hypertension
2. Fundal height 3. Hydramnios 4. Congestive heart failureAnswer: 2 Explanation: 2. The dyspnea is resulting from the pressure ofthe enlarging uterus on the diaphragm. Page Ref: 290
15) The nurse assessing a pregnant African American womanin the first trimester understands that a cultural practice is which of the following?
1. Use of herbs like dandelion during pregnancy to increaselactation 2. Drinking ginseng tea for faintness 3. Eating clay to supply dietary minerals 4. Consulting a spiritual advisor to ensure a healthypregnancy and birth Answer: 3 Explanation: 3. African American pregnant women may be guided by their extended family into common practices suchas geophagia, the ingestion of dirt or clay, which is believed to alleviate mineral deficiencies. Page Ref: 274
16) Remedies for back pain in pregnancy that are supported by research evidence and may safely be taught to any pregnant woman by the nurse include which of the following?Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.
1. Pelvic tilt 2. Water aerobics 3. Sit-ups 4. Proper body mechanics 5. Maintaining good postureAnswer: 1, 2, 4, 5 Explanation: 1. The pelvic tilt can help restore proper bodyalignment and relieve back pain. 2. Exercise is an effective treatment for lower back pain.Exercise in water seems to provide benefits while being physically comfortable for expectant mothers.
4. The use of proper posture and good body mechanicsthroughout pregnancy is important.
5. Good posture is important because it allows more room forthe stomach to function. Page Ref: 287, 292, 293
17) A client in her third trimester of pregnancy reportsfrequent leg cramps. What strategy would be most appropriate for the nurse to suggest?
1. Point the toes of the affected leg 2. Increase intake of protein-rich foods 3. Limit activity for several days 4. Flex the foot to stretch the calfAnswer: 4 Explanation: 4. The nurse should advise the client to practicedorsiflexion of feet to stretch affected muscle. Page Ref: 290
18) The nurse in a prenatal clinic finds that four clients havecalled with complaints related to their pregnancies. Which call should the nurse return first?
1. Pregnant woman at 7 weeks’ gestation reporting nasalstuffiness 2. Pregnant woman at 38 weeks’ gestation experiencingrectal itching and hemorrhoids
3. Pregnant woman at 15 weeks’ gestation with nausea andvomiting and a 15pound weight loss
4. Pregnant woman at 32 weeks’ gestation treatingconstipation with prune juice Answer: 3 Explanation: 3. The nurse should return this call first becausethis patient is the highest priority. A 15-pound weight loss is not an expected finding. Although some nausea is common, the woman who suffers from extreme nausea coupled with vomiting requires further assessment. Page Ref: 282
19) A 38-year-old client in her second trimester states a desire to begin an exercise program to decrease her fatigue.What is the most appropriate nursing response?
1. “Fatigue should resolve in the second trimester, butwalking daily might help.”
2. “Avoid a strenuous exercise regimen at your age. Drinkcoffee to combat fatigue.”
3. “Avoid an exercise regimen due to your pregnancy. Try tonap daily.” 4. “Fatigue will increase as pregnancy progresses, butrunning daily might help.” Answer: 1
Explanation: 1. Even mild to moderate exercise is beneficial during pregnancy. Regular exercise–at least 30 minutes of moderate exercise daily or at least most days of the week–ispreferred. Page Ref: 292
20) A client at 34 weeks’ gestation complains about pyrosis. The nurse teaches the patient that approaches to relieve thepyrosis include which of the following? Note: Credit will be given only if all correct and no incorrectchoices are selected. Select all that apply.
1. Eat small, frequent meals 2. Use high-sodium antacids 3. Avoid fried, fatty foods 4. Take sodium bicarbonate after meals 5. Do not lie down after eatingAnswer: 1, 3, 5 Explanation: 1. Pyrosis (heartburn) can be relieved by eatingsmall, more frequent meals. 3. Avoiding fatty, fried foods can relieve pyrosis. 5. Sitting up after meals will help decrease the pyrosis.Page Ref: 289
21) The pregnant client in her second trimester states, “I didn’t know my breasts would become so large. How do I finda good bra?” The best answer for the nurse to make would bewhich of the following?
1. “Avoid cotton fabrics and get an underwire bra; they fiteveryone best.” 2. “Just buy a bra one cup size bigger than usual, and it willfit.”
3. “Look for wide straps and cups big enough for all of yourbreast tissue.” 4. “There isn’t much you can do for comfort. Try not wearinga bra at all.” Answer: 3 Explanation: 3. The nurse should instruct the client to get a bra that fits with straps that are wide and do not stretch anda cup that holds all breast tissue comfortably. Page Ref: 290
22) A pregnant client who swims 3-5 times per week asks thenurse whether she should stop this activity. What is the appropriate nursing response?
1. “You should decrease the number of times you swim perweek.” 2. “Continuing your exercise program would be beneficial.” 3. “You should discontinue your exercise programimmediately.” 4. “You should consider a less strenuous type of exercise.”Answer: 2 Explanation: 2. Mild to moderate exercise is beneficial during pregnancy. Regular exercise–at least 30 minutes of moderate exercise daily or at least most days of the week–is preferred. Page Ref: 292
23) The nurse is presenting a class of important “dos and don’ts” during pregnancy, including travel considerations. What method of travel does the nurse recommend as mostappropriate for a client in her 25th week of pregnancy?
1. Automobile 2. Airplane 3. Train 4. None; this client should not travel
Answer: 3 Explanation: 3. As pregnancy progresses, travel by train isgenerally recommended for long distances. Page Ref: 291
24) After teaching a pregnant client about the effects of smoking on pregnancy, the nurse knows that the client needsfurther education when she makes which statement?
1. “I am at increased risk for preeclampsia.” 2. “I am at increased risk for preterm birth.” 3. “I am at increased risk for placenta previa.” 4. “I am at increased risk for abruptio placentae.”Answer: 1 Explanation: 1. Smoking is not associated with increased riskfor preeclampsia. Page Ref: 299
25) Which of the following drugs and drug categories can cause multiple fetal central nervous system (CNS), facial, andcardiovascular anomalies?
1. Category C: Zidovudine 2. Category B: Penicillin 3. Category X: Isotretinoin 4. Category A: Vitamin C Answer: 3 Explanation: 3. Isotretinoin (Accutane), the acne medication, can cause multiple central nervous system (CNS), facial, and cardiovascular anomalies. Page Ref: 299
26) The prenatal client in her third trimester tells the clinicnurse that she works 8 hours a day as a cashier and standswhen at work. What response by the nurse is best?
1. “No problem. Your baby will be fine.” 2. “Do you get regular breaks for eating?” 3. “Your risk of preterm labor is higher.” 4. “Standing might increase ankle swelling.”Answer: 3 Explanation: 3. Pregnant women who are employed in jobs that require prolonged standing (more than 3 hours) do havea higher incidence of preterm birth. Page Ref: 291
27) The pregnant client has asked the nurse what kinds of medications cause birth defects. Which statement would bestanswer this question?
1. “Birth defects are very rare. Don’t worry; your doctor willwatch for problems.” 2. “To be safe, don’t take any medication without talking toyour doctor.” 3. “Too much vitamin C is one of the most common issues.” 4. “Almost all medications will cause birth defects in the firsttrimester.” Answer: 2 Explanation: 2. The nurse should remind the client of the need to check with her caregiver about medications. If a woman has taken a drug in category D or X, she should beinformed of the risks associated with that drug and of her alternatives. Page Ref: 299
28) A pregnant client complains to the clinic nurse that her varicose veins are causing more discomfort than before. Which recommendations does the nurse make to the client?Note: Credit will be given only if all correct and no incorrect choices are selected.
Select all that apply.
1. Increase the time she stands. 2. Walk on a daily basis. 3. Not cross her legs at the knees. 4. Wear support hose. 5. Hyperextend her knee with her feet up.Answer: 2, 3, 4 Explanation: 2. Regular exercise, such as swimming, cycling,or walking, promotes venous return, which helps prevent varicosities.
3. The client should avoid crossing her legs at the kneesbecause of the pressure it puts on her veins.
4. Supportive hose or elastic stockings may be extremelyhelpful. Page Ref: 285
29) Absolute contraindications to exercise while pregnantinclude which of the following? Note: Credit will be given only if all correct and no incorrectchoices are selected. Select all that apply.
1. Abruptio placentae 2. Placenta previa after 26 weeks’ gestation 3. Preeclampsia-eclampsia 4. Cervical insufficiency (cerclage) 5. Intrauterine growth restriction (IUGR)Answer: 2, 3, 4 Explanation: 2. Placenta previa after 26 weeks’ gestation isan absolute contraindication to exercise.
3. Preeclampsia-eclampsia is an absolute contraindication toexercise. 4. Cervical insufficiency (cerclage) is an absolutecontraindication to exercise.
Page Ref: 292
30) Intercourse is contraindicated if the pregnancy isvulnerable because of which diagnosis?
1. Gestational diabetes 2. Cervical insufficiency (cerclage) 3. Abruptio placentae 4. Placenta previa Answer: 4 Explanation: 4. Intercourse is contraindicated if the pregnancy is vulnerable because of the diagnosis of threatened spontaneous abortion, placenta previa, or the riskof preterm labor. Page Ref: 295
31) The nurse is discussing sexual intimacy with a pregnantcouple. What should be included in the teaching plan?
1. Intercourse should stop by the beginning of the thirdtrimester. 2. Breast fondling should be discouraged due to the potentialfor preterm labor. 3. The couple might need to experiment with differentpositions. 4. Use vaginal lubricant sparingly.Answer: 3 Explanation: 3. As the uterus enlarges, the couple will have toexperiment with different positions. Page Ref: 295, 296
32) The nurse is preparing a brochure for couples consideringpregnancy after the age of 35. Which statements should beincluded?
Note: Credit will be given only if all correct choices and noincorrect choices are selected. Select all that apply.
1. There is a decreased risk of Down syndrome. 2. Preexisting medical conditions can complicate pregnancy. 3. Preterm births are more common. 4. Amniocentesis can be performed to detect geneticanomalies. 5. The increased fertility of women over age 35 makesconception easier. Answer: 2, 3, 4 Explanation: 2. Preexisting medical conditions, such as hypertension or diabetes, probably play a more significantrole than age in maternal well-being and the outcome of pregnancy.
3. The incidence of low-birth-weight infants, preterm births, miscarriage, stillbirth, and perinatal morbidity and mortalityis higher among women age 35 or older.
4. Amniocentesis is offered to all women over age 35 to permit the early detection of several chromosomal abnormalities, including Down syndrome; noninvasive analysis of fetal nucleic acid is now commonly recommendedto women of advanced maternal age. Page Ref: 302
33) The nurse is presenting a prenatal class to a group of women pregnant for the first time who are all over 35 yearsof age. The nurse knows that the advantage of waiting untillater to start a family is which of the following?
1. That the woman will have an easier labor and delivery. 2. That the baby will be at less of a risk for congenitalanomalies. 3. That the woman is more likely to be financially secure.
4. That the woman will be more fertile than a younger womanwould. Answer: 3 Explanation: 3. This delay in starting a family allows womento pursue advanced educational degrees and prepare financially for the impact children will have on their lives. Page Ref: 301
34) The nurse working with mothers over 35 having their firstbaby knows there are some disadvantages. For what disadvantage would the nurse carefully assess in each client?
1. What kind of insurance the client has for maternity care 2. Whether the client is married 3. Whether the client will continue working after the babyarrives 4. Whether the client has any chronic disease that will haveto be addressed Answer: 4 Explanation: 4. It is important for the nurse to question andassess for any chronic illnesses. The risk of pregnancy complications is higher in women over age 35 who have a chronic condition such as hypertension or diabetes, or who are in poor general health. Page Ref: 302
35) A 43-year-old client has just had a positive pregnancy test. She cries, and states, “I just don’t know what I’ll do. I can’t be pregnant.” Which nursing diagnosis would be the most appropriate?
1. Decisional Conflict related to unexpected pregnancy 2. Knowledge, Deficient related to advanced maternal age 3. Depression related to unexpected pregnancy
4. Health Maintenance, Ineffective related to advancedmaternal age Answer: 1 Explanation: 1. Decisional Conflict related to unexpectedpregnancy is the most appropriate nursing diagnosis. Page Ref: 303
36) What self-care measures would a nurse recommend for a client in her first trimester to reduce the discomfort of nauseaand vomiting? Note: Credit will be given only if all correct and no incorrectchoices are selected. Select all that apply.
1. Avoid odors or causative factors. 2. Have small but frequent meals. 3. Drink carbonated beverages. 4. Drink milk before arising in the morning. 5. Eat highly seasoned food.Answer: 1, 2, 3 Explanation: 1. The nurse would recommend for a client inher first trimester to avoid odors and caustic factors to reduce the discomfort of nausea and vomiting.
2. The nurse would recommend for a client in her first trimester to have small but frequent meals to reduce thediscomfort of nausea and vomiting.
3. The nurse would recommend for a client in her first trimester to drink carbonated beverages to reduce thediscomfort of nausea and vomiting. Page Ref: 289
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 14. Maternal Nutrition 1) A pregnant teenage client is diagnosed with iron-deficiency anemia. Which nutrient should the nurse encourage her to take to increase iron absorption? 1. Vitamin A 2. Vitamin C 3. Vitamin D 4. Vitamin E Answer: 2 Explanation: 2. Vitamin C is known to enhance the absorption of iron from meat and nonmeat sources. 2) The pregnant client cannot tolerate milk or meat. What would the nurse recommend to the client to assist in meeting protein needs? 1. Wheat bread and pasta 2. Ice cream and peanut butter 3. Eggs and tofu 4. Beans and potatoes Answer: 3 Explanation: 3. The best food choices that are nondairy and complete proteins alone are eggs and tofu. 3) The pregnant client states she does not want to take all these supplements. What recommendations could the nurse make for the client? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Folic acid has been found to be essential for minimizing the risk of neural tube defects. 2. You do not have to take these supplements if you think you are healthy enough. 3. Most women do not have adequate intake of iron pre-pregnancy, and iron needs increase with pregnancy. 4. These medications do the same thing. I will call your physician to cancel one of your medications. 5. You should take the folic acid, but the vitamins are not that important. Answer: 1, 3 Explanation: 1. An inadequate intake of folic acid has been associated with neural tube defects (NTDs) (e.g., spina bifida, anencephaly). 3. Iron is essential because many pregnant women do not have adequate intake of iron before pregnancy. 4) The nurse is planning an early-pregnancy class session on nutrition. Which information should the nurse include? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Protein is important for fetal development. 2. Iron helps both mother and baby maintain the oxygen-carrying capacity of the blood. 3. Calcium prevents constipation at the end of pregnancy. 4. Zinc facilitates synthesis of RNA and DNA. 5. Vitamin A promotes development of the babys eyes. Answer: 1, 2, 4, 5 Explanation: 1. During pregnancy, the woman needs increased amounts of protein to provide amino acids for fetal development. 2. Iron deficiency anemia is associated with an increased incidence of preterm birth, low-birth-weight infants, and maternal and infant mortality. 4. Zinc is involved in RNA and DNA synthesis, and milk production during lactation.
5.
Vitamin A promotes healthy formation and development of the fetal eyes.
5) The nurse is presenting a preconception counseling class. The nurse instructs the participants that niacin intake should increase during pregnancy to promote metabolic coenzyme activity. The nurse will know that teaching has been effective if a client suggests which food as a source of niacin? 1. Fish 2. Apples 3. Broccoli 4. Milk Answer: 1 Explanation: 1. Dietary sources of niacin include meats, fish, and whole grains. Page Ref: 331 6) The nurse evaluates the diet of a pregnant client and finds that it is low in zinc. The nurse knows that zinc intake should increase during pregnancy to promote protein metabolism. Which food should the nurse suggest in order to increase intake of zinc? 1. Shellfish 2. Bananas 3. Yogurt 4. Cabbage Answer: 1 Explanation: 1. Zinc is found in greatest concentration in meats, shellfish, and poultry. Other good sources include whole grains and legumes. 7) In early-pregnancy class, the nurse emphasizes the importance of 8-10 glasses of fluid per day. How many of these should be water? 1. 1 to 2 2. 2 to 4 3. 4 to 6 4. 3 to 5 Answer: 3 Explanation: 3. A pregnant woman should consume at least 8 to 12 (8 oz) glasses of fluid each day, of which 4 to 6 glasses should be water. Page Ref: 332 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patients support network. | NLN Competencies: Knowledge and Science: Translate research into practice in order to promote quality and improve practices. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2 Explain the significance of specific nutrients in the diet of the pregnant woman. MNL LO: 2.5.1 Recognize nutritional requirements specific to pregnancy. 8) What would the nurse do to accurately assess a pregnant clients food intake? 1. Assess her most recent laboratory values. 2. Ask her to complete a nutritional questionnaire. 3. Observe for signs of hunger. 4. Ask about her cooking facilities. Answer: 2 Explanation: 2. Diet may be evaluated using a food frequency questionnaire, which lists common categories of foods and asks the woman how frequently in a day (or week) she consumes foods from the list. Page Ref: 337
9) Postpartum nutritional status is determined primarily by assessing which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Dietary history 2. Menstrual history 3. Mothers weight 4. Hemoglobin levels 5. Mothers height Answer: 1, 3, 4 Explanation: 1. Postpartum nutritional status is determined by assessing the new mothers dietary history. 3. Postpartum nutritional status is determined by assessing the new mothers weight. 4. Postpartum nutritional status is determined by assessing the new mothers hemoglobin levels. 10) The breastfeeding mother is concerned that her milk production has decreased. The nurse knows that further client teaching is needed based on which statement? 1. I am drinking a minimum of 8 to 10 glasses of liquid a day. 2. I have started cutting back on my protein intake. 3. At least three times a day, I drink a glass of milk. 4. My calorie intake is higher than during the pregnancy. Answer: 2 Explanation: 2. An adequate protein intake is essential while breastfeeding because protein is an important component of breast milk. 11) The nurse is preparing for a postpartum home visit. The client has been home for a week, is breastfeeding, and experienced a third-degree perineal tear after vaginal delivery. The nurse should assess the client for which of the following? 1. Dietary intake of fiber and fluids 2. Dietary intake of folic acid and prenatal vitamins 3. Return of hemoglobin and hematocrit levels to baseline 4. Return of protein and albumin to predelivery levels Answer: 1 Explanation: 1. This mother needs to avoid the risk of constipation. She might be hesitant to have a bowel movement due to anticipated pain from the perineal tear, and constipation will decrease the healing of the laceration. 12) The nurse is counseling a group of first-trimester clients on diet increases that are necessary during pregnancy. Which information would be necessary to tell the pregnant women? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. An increase of protein is necessary to provide amino acids necessary for fetal development. 2. Protein contributes to the bodys overall energy metabolism. 3. The recommended protein during pregnancy is 70 grams each day. 4. The increased amount of protein that a pregnant woman needs is 15 grams a day. 5. The quality of protein is as important as the amount. Answer: 1, 2, 3, 5 Explanation: 1. During pregnancy, the woman needs increased amounts of protein to provide amino acids for fetal development, blood volume expansion, and growth of other maternal tissues. 2. Protein contributes to overall energy metabolism. 3. The amount of protein recommended each day during pregnancy is 70 grams. 5. Plant proteins can meet a womans protein needs; however, more of a given protein may be needed because animal proteins are of higher quality. 13) 1.
Which of the following is important for the development of the central nervous system of the fetus? Calcium and phosphorus
2. Essential fatty acids 3. Iron 4. Vitamin D Answer: 2 Explanation: 2. Essential fatty acids are important for the development of the central nervous system of the fetus. Of particular interest are the omega-3 fatty acids and their derivatives. 14) The nurse is instructing a pregnant client on her nutritional needs. The nurse tells the client that nutrition is needed for fetal development because fetal growth occurs in overlapping stages from increases of which of the following? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply. 1. Cell numbers 2. Cell membranes 3. Cell size and number 4. Cell size alone 5. Vitamin and mineral intake Answer: 1, 3, 4 Explanation: 1. Fetal growth occurs by an increase in cell numbers in one stage. 3. Fetal growth occurs by an increase in cell size and number during one stage. 4. Fetal growth occurs by an increase in cell size alone during one stage. 15) A pregnant client who was of normal prepregnancy weight is now 30 weeks pregnant. She asks the nurse what appropriate weight gain for her should be. What is the nurses best response? 1. 25-35 pounds 2. 30-40 pounds 3. 17-18 pounds 4. Less than 15 pounds Answer: 1 Explanation: 1. An appropriate weight gain for a woman of normal weight before pregnancy would be 25-35 pounds. Page Ref: 324 16) A client presents to the antepartum clinic with a history of a 20-pound weight loss. Her pregnancy test is positive. She is concerned about gaining the weight back, and asks the nurse if she can remain on her diet. What is the nurses best response? 1. As long as you supplement your diet with the prenatal vitamin, the amount of weight you gain in pregnancy is not significant. 2. I understand that gaining weight after such an accomplishment might not look attractive, but weight gain during pregnancy is important for proper fetal growth. 3. Dieting during pregnancy is considered child neglect. 4. Excessive weight gain in pregnancy is due to water retention, so weight loss following birth will not be an issue. Answer: 2 Explanation: 2. Maternal weight gain is an important factor in fetal growth and in infant birth weight. An adequate weight gain over time indicates an adequate caloric intake. 17) The prenatal clinic nurse is caring for a 15-year-old client who is at 8 weeks gestation. The client asks the nurse why she is supposed to gain so much weight. What is the best response by the nurse? 1. Gaining 25-35 pounds is recommended for healthy fetal growth. 2. Its what your certified nurse-midwife recommended for you. 3. Inadequate weight gain delays lactation after delivery. 4. Weight gain is important to ensure that you get enough vitamins. Answer: 1 Explanation: 1. For an appropriate-weight woman, 25-35 pounds of weight gain is recommended for optimal
fetal growth and development. 18) The nurse is planning an educational session for pregnant vegans. What information should the nurse include? 1. Eating beans and rice provides complete protein needs. 2. Soy is not a good source of protein for vegans. 3. Rice contains a high level of vitamin B12. 4. Vegan diets are excessively high in iron. Answer: 1 Explanation: 1. Adequate dietary protein can be obtained by consuming a varied diet with adequate caloric intake and plant-based proteins. Consuming an assortment of plant proteins throughout the day such as beans and rice, peanut butter on whole-grain bread, and whole-grain cereal with soy milk ensures that the expectant mother obtains all essential amino acids.
9) A pregnant client who is a lacto-vegetarian asks the nurse for assistance with her diet. What instruction should the nurse give? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Protein is important; therefore, the addition of one serving of meat a day is necessary. 2. A daily supplement of vitamin B12 is important. 3. The high fiber in a vegetarian diet is dangerous for pregnant women. 4. Eggs are important to add to your diet. Eat six eggs per week. 5. Milk products contain protein, but they are very low in iron. Answer: 2, 5 Explanation: 2. Supplementation may be recommended for vegans who have difficulty meeting the recommended amounts of vitamin B12 through food sources. 20) A pregnant client confides to the nurse that she is eating laundry starch daily. The nurse should assess the client for which of the following? 1. Alopecia 2. Weight loss 3. Iron deficiency anemia 4. Fecal impaction Answer: 3 Explanation: 3. Iron deficiency anemia is the most common concern with pica. The ingestion of laundry starch or certain types of clay may contribute to iron deficiency by replacing iron-containing foods from the diet or by interfering with iron absorption. 21) 1.
The kosher diet followed by many Jewish people forbids the eating of what foods? Pig products and shellfish
2. Dairy products 3. All animal products 4. Dairy products and eggs Answer: 1 Explanation: 1. The kosher diet followed by many Jewish people forbids the eating of pig products and shellfish. Certain cuts of meat from sheep and cattle are allowed, as are fish with fins and scales. In addition, many Jews believe that meat and dairy products should not be mixed or eaten at the same meal. 22) 1. 2.
A woman confides to the nurse that she has pica. What alternative could the nurse suggest to the client? Replace laundry starch with salt. Replace ice with frozen fruit pops.
3. Replace soap with cream cheese. 4. Replace soil with nuts. Answer: 2 Explanation: 2. Some women are able to switch to frozen fruit pops instead of ice.
23) The nurse is working with a pregnant 14-year-old. Which statement indicates that additional education is required? 1. Because I am still growing, I need more calories than a pregnant adult. 2. I need to eat fruit and vegetables every day to get enough vitamins. 3. My favorite food is pizza, and I eat it once a week. 4. Because I dont eat breakfast, Ill have to eat more at supper. Answer: 4 Explanation: 4. Pregnant young adolescents should eat breakfast to ensure the adequate calorie and protein intake needed. In assessing the diet of the pregnant adolescent, the nurse should consider the eating pattern over time, not simply a single days intake. 24) When preparing nutritional instruction, which pregnant client would the nurse consider the highest priority? 1. 40-year-old gravida 2 2. 22-year-old primigravida 3. 35-year-old gravida 4 4. 15-year-old nulligravida Answer: 4 Explanation: 4. An expectant adolescent must meet the nutritional needs for her own growth in addition to the nutritional needs of pregnancy. 25) Which statement is best to include when teaching a pregnant adolescent about nutritional needs of pregnancy? 1. It is important to eat iron-rich foods like meat every day. 2. Calcium and milk arent needed until the third trimester. 3. Folic acid intake is the key to having a healthy baby. 4. You just need to pay attention to what you eat now. Answer: 1 Explanation: 1. An inadequate iron intake is a major concern with the adolescent diet. Iron needs are high for the pregnant teen because of the requirement for iron by the enlarging maternal muscle mass and blood volume. Giving specific examples is helpful when giving nutritional information. 26) The school nurse is planning a class about nutrition for pregnant teens, several of whom have been diagnosed with iron-deficiency anemia. In order to increase iron absorption, the nurse would encourage the teens to consume more of what beverage? 1. Gatorade 2. Orange juice 3. Milk 4. Green tea Answer: 2 Explanation: 2. Vitamin C is found in citrus fruits and juices, and is known to enhance the absorption of iron from meat and non-meat sources.
28) The nurse is preparing a prenatal class about infant feeding methods. The maternal nutritional requirements for breastfeeding and formula-feeding will be discussed. What statement should the nurse include? 1. Breastfeeding requires a continued high intake of protein and calcium. 2. Formula-feeding mothers should protect their health with a lot of calcium.
3. Producing breast milk requires calories, but any source of food is fine. 4. Formula-feeding mothers need a high protein intake to avoid fatigue. Answer: 1 Explanation: 1. Lactation requires calories, along with increased protein and calcium intake. 27) The pregnant teen who was prescribed prenatal vitamins at her initial prenatal visit states that she does not like to take them. How should the nurse respond? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Folic acid has been found to be essential for minimizing the risk of neural tube defects. 2. You do not have to take these supplements if you think you are healthy enough. 3. These medications do the same thing. I will call your doctor to cancel one of your medications. 4. You can trust your doctor to know what you need. 5. You need the supplements because your dietary intake may not be adequate for fetal development. Answer: 1, 5 Explanation: 1. The CDC estimates that most neural tube defects could be prevented if women followed folic acid supplementation recommendations before they know they are pregnant. 5. One role of the nurse is educator, and this client needs additional information on why she needs the supplements. This response answers the clients concerns. 29) Women with eating disorders who become pregnant are at risk for a variety of complications including which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Premature birth 2. Too many nutrients available for the fetus 3. Miscarriage 4. High birth weight 5. Perinatal mortality Answer: 1, 3, 5 Explanation: 1. Risks to the mother and baby include premature birth. 3. Risks to the mother and baby include miscarriage. 5. Risks to the mother and baby include perinatal mortality. 30) A pregnant client is lactose intolerant. Which alternative food could this client eat to get sufficient calcium? 1. Turnip greens 2. Green beans 3. Cantaloupe 4. Nectarines Answer: 1 Explanation: 1. Turnip greens are rich in calcium.
31) Carbohydrates provide the bodys primary source of energy as well as fiber necessary for proper bowel functioning. If the carbohydrate intake is not adequate, the body will use which of the following for energy? 1. Iron 2. Protein 3. Vitamin C 4. Vitamin D Answer: 2 Explanation: 2. If the carbohydrate intake is not adequate, the body uses protein for energy. Protein then becomes unavailable for growth needs.
32) A nurse is discussing the serving sizes in the grains food group with a new prenatal patient in the clinic. Which food equals one serving size from the grains food group? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. One hamburger roll 2. One slice of bread 3. One cup of pasta 4. One tortilla 5. One ounce of dry cereal Answer: 2, 4, 5 Explanation: 2. One slice of bread is one serving. 4. One tortilla is one serving. 5. One ounce of dry cereal is one serving. 33) A nurse is discussing diet with a pregnant woman. Which food should the nurse advise the client to avoid during her pregnancy? 1. Bologna 2. Cantaloupe 3. Spinach 4. Cornbread Answer: 1 Explanation: 1. Hot dogs and other luncheon meats should not be eaten during pregnancy unless they are fully cooked. 34) A client tells the nurse that she does not like citrus fruits, and would like suggestions for alternate vitamin C sources. What should the nurse suggest as good sources of vitamin C? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Barley and brown rice 2. Strawberries and potatoes 3. Buckwheat and lentils 4. Wheat flour and figs 5. Blueberries and broccoli Answer: 2, 5 Explanation: 2. Strawberries and potatoes are very good sources of vitamin C. 5. Cantaloupes and broccoli are very good sources of vitamin C.
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 16.
Assessment of Fetal Well-being
MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1)A woman is at 32 weeks' gestation. Her fundal height measurement at this clinic appointment is 26 centimeters. After reviewing her ultrasound results, the healthcare provider asks the nurse to schedule the client for a series of sonograms to be done every two weeks. The nurse should make sure that the client understands that the main purpose for this is to A) assess for congenital anomalies. B) evaluate fetal growth. C) determine fetal presentation. D) rule out a suspected hydatidiform mole. Answer: B 2)In assisting with an abdominal ultrasound procedure for determination of fetal age, the nurse A) asks the woman to sign an operative consent form prior to the procedure. B) has the woman empty her bladder before the test begins. C) assists the woman into a supine position on the examining table. D) instructs the woman to eat a fat-free meal two hours before the scheduled test time. Answer: C 3) Each of the following pregnant women is scheduled for a 14-week antepartal visit. In planning care, the nurse would give priority teaching on amniotic fluid alpha-fetoprotein (AFP) screening to which client? A) 28-year-old with history of rheumatic heart disease B)18-year-old with exposure to HIV C) 20-year-old with a history of preterm labor D) 35-year-old with a child with spina bifida Answer: D 4) A woman at 28 weeks' gestation is asked to keep a fetal activity diary and to bring the results with her to her next clinic visit. One week later, she calls the clinic and anxiously tells the nurse that she has not felt the baby move for over 30 minutes. The most appropriate initial comment by the nurse would be A) "You need to come to the clinic right away for further evaluation." B) "Have you been smoking?" C) "When did you eat last?" D) "Your baby may be asleep." Answer: D 5) At 32 weeks' gestation, a woman is scheduled for a second nonstress test (in addition to the one she had at 28 weeks' gestation). Which response by the client would indicate an adequate understanding of this procedure? A) "I can't get up and walk around during the test." B) "I'll have an IV started before the test."
C) "I must avoid drinks containing caffeine for 24 hours before the test." D) "I need to have a full bladder for this test." Answer: A 6) During a nonstress test, the nurse notes that the fetal heart rate decelerates about 15 beats during a period of fetal movement. The decelerations occur twice during the test and last 20 seconds each. The nurse realizes these results will be interpreted as A) a negative test. B) a reactive test. C) a nonreactive test. D) an equivocal test. Answer: C 7) A pregnant woman is having a nipple-stimulated contraction stress test. Which result indicates hyperstimulation? A) The fetal heart rate decelerates when three contractions occur within a 10-minute period. B) The fetal heart rate accelerates when contractions last up to 60 seconds. C) There are more than five fetal movements in a 10-minute period. D) There are more than three uterine contractions in a 6-minute period. Answer: D 8) Which response would indicate that a client clearly understands the risks of an amniocentesis? A) "I might go into labor early." B) "It could produce a congenital defect in my baby." C) "Actually, there are no real risks to this procedure." D) "The test could stunt my baby's growth." Answer: A 9) The nurse knows that a lecithin/sphingomyelin (L/S) ratio finding of 21 on amniotic fluid means A) fetal lungs are still immature. B) the fetus has a congenital anomaly. C) fetal lungs are mature. D) the fetus is small for gestational age. Answer: C 10) Which client has indications that most warrant fetal monitoring in the third trimester? A) gravida 4, para 3, 39 weeks, with a history of one spontaneous abortion at 8 weeks B) gravida 1, para 0, 40 weeks, with a history of endometriosis and a prior appendectomy C) gravida 3, para 2, with a history of gestational diabetes controlled by diet D) gravida 2, para 1, 36 weeks, with hypertension disorder of pregnancy Answer: D 11) A type I diabetic who is at 32 weeks' gestation is having a nonstress test for fetal well-being since she has been having problems with glucose control. Which meets the criteria for her test to be considered reactive? A) fetal heart rate baseline of 150 with two accelerations to 160 for 10 seconds within 20 minutes. B) fetal heart rate baseline of 140 with one acceleration to 160 for 15 seconds within 30 minutes. C) fetal heart rate baseline of 140 with two accelerations to 155 for 15 seconds within 20 minutes. D) fetal heart rate baseline of 130 with two accelerations to 140 for 15 seconds within 20 minutes. Answer: C
12) The client is having a nonstress test the next day. Which instructions should the nurse give to the client? A) "Be sure to come in with a full bladder." B) "Remember not to eat anything before the test." C) "You will feel some contractions during the test." D) "The test should last no longer than 30 minutes." Answer: D 13) A client at 37 weeks' gestation has a mildly elevated blood pressure. Her antenatal testing demonstrates a fetal heart rate baseline of 150 with three contractions in 10 minutes, no decelerations, and accelerations four times in one hour. This test would be considered a A) positive nonstress test. B) negative contraction stress test. C) positive contraction stress test. D) negative nonstress test. Answer: B 14) Out of all the clients who have been scheduled to have a biophysical profile, the nurse would clarify the order for which client? A) a gravida with intrauterine growth restriction B) a gravida with mild hypertension of pregnancy C) a gravida who is post-term D) a gravida who complains of decreased fetal movement for two days Answer: B SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 15) The nurse is preparing the client for an amniocentesis. The ultrasound shows the fetus to be positioned as in the picture. At what site would the nurse prep the client for the amniocentesis? Answer
C 1) B 2) C 3) D 4) D 5) A 6) C 7) D 8) A 9) C 10) D 11) C
12) D 13) B 14) B 15) C
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 17. Pregnancy at Risk: Pregestational Problems Question 1 The nurse is caring for a pregnant woman who admits to using cocaine and ecstasy on a regular basis. The patient states, "Everybody knows that alcohol is bad during pregnancy, but what's the big deal about ecstasy?" The best response by the nurse is: 1. "Ecstasy can cause a high fever in you and therefore cause the baby harm." 2. "Ecstasy leads to deficiencies of thiamine and folic acid, which help the baby develop." 3. "Ecstasy produces babies with small heads and short bodies with brain function alterations." 4. "Ecstasy produces intrauterine growth restriction and meconium aspiration." Correct Answer: 1 Rationale 1: High body temperature is a side effect of MDMA (ecstasy). Increased body temperature increases fetal oxygen needs, which can lead to hypoxia and subsequent brain and major organ damage. Rationale 2: Alcohol, not ecstasy, causes deficiencies of thiamine and folic acid. Folic acid helps prevent neural tube defects. Rationale 3: Cocaine, not ecstasy, causes these fetal effects. Rationale 4: Heroin, not ecstasy, causes these fetal effects. Question 2 The nurse is doing preconception counseling with a 28-year-old woman with no prior pregnancies. Which statement made by the patient indicates to the nurse that the patient has understood the teaching? 1. "I can continue to drink alcohol until I am diagnosed as pregnant." 2. "I need to stop drinking alcohol completely when I start trying to get pregnant." 3. "A beer once a week will not damage the fetus." 4. "I can drink alcohol while breastfeeding, since it doesn't pass into breast milk." Correct Answer: 2 Rationale 1: Women should discontinue drinking alcohol when they start to attempt pregnancy. Rationale 2: Women should discontinue drinking alcohol when they start to attempt pregnancy.
Rationale 3: It is not known how much alcohol will cause fetal damage; therefore, alcohol during pregnancy is contraindicated. Rationale 4: Alcohol passes readily into breast milk; therefore, it should be avoided, or the milk should be pumped and dumped after alcohol consumption. Question 3 A woman's history and appearance suggest drug abuse. The nurse's best approach would be to: 1. Ask the woman directly, "Do you use any street drugs?" 2. Ask the woman whether she would like to talk to a counselor. 3. Ask some questions about over-the-counter medications and avoid mention of illicit drugs. 4. Explain how harmful drugs can be for her baby. Correct Answer: 1 Rationale 1: The best method of dealing with a patient whom the nurse suspects of using drugs is to ask the question in a direct fashion without prejudice, bias, or negative body language. Lack of judgmental attitudes and body language typically results in honest answers. Rationale 2: Advising the patient to seek counseling would not occur until the nurse verifies that the woman uses street drugs. Rationale 3: The nurse is responsible for ascertaining whether the patient uses street drugs, and should not avoid the issue. Rationale 4: When talking to patients in a therapeutic manner, it is important not to be threatening or judgmental; an example of the latter behavior would be stating that the drugs will harm the baby. Question 4 A 20-year-old woman is at 28 weeks' gestation. Her prenatal history reveals past drug abuse, and urine screening indicates that she has recently used heroin. The nurse should recognize that the woman is at increased risk for: 1. Erythroblastosis fetalis. 2. Diabetes mellitus. 3. Abruptio placentae. 4. Pregnancy-induced hypertension. Correct Answer: 4
Rationale 1: Erythroblastosis fetalis is secondary to physiological blood disorders such as Rh incompatibility. Rationale 2: Diabetes is an endocrine disorder that is unrelated to drug use/abuse. Rationale 3: Abruptio placentae is seen more commonly with cocaine/crack use. Rationale 4: Women who use heroin are at risk for poor nutrition, anemia, and pregnancy-induced hypertension (or preeclampsia). Question 5 The nurse is working with a woman who abuses stimulants. The nurse is aware that the fetus is at risk for: Standard Text: Select all that apply. 1. Withdrawal symptoms. 2. Cardiac anomalies. 3. Sudden infant death syndrome. 4. Being small for gestational age. 5. Fetal alcohol syndrome. Correct Answer: 1,2,3,4 Rationale 1: Infants born to mothers who abuse stimulants such as amphetamines can have withdrawal symptoms. Rationale 2: Infants born to mothers who abuse stimulants such as cocaine can be born with cardiac anomalies. Rationale 3: Infants born to mothers who abuse stimulants such as cocaine can have sudden infant death syndrome. Rationale 4: Infants born to mothers who abuse stimulants such as nicotine can be small for gestational age. Rationale 5: Fetal alcohol syndrome is associated with abuse of alcohol, which is a depressant. Question 6 The nurse is assessing a woman at 10 weeks’ gestation who is addicted to alcohol. The woman asks the nurse, “What is the point of stopping drinking now if my baby probably has been hurt by it already?” What is the best response by the nurse? 1. “It won’t help your baby, but you will feel better during your pregnancy if you stop now.”
2. “If you stop now, you can still have a normal pregnancy.” 3. “If you limit your drinking to once a week, your baby will be okay.” 4. “You might as well stop it now, because once your baby is born, you’ll have to give up alcohol if you plan on breastfeeding.” Correct Answer: 2 Rationale 1: The baby’s well-being, not the mother’s feelings, is the primary issue. Alcohol withdrawal during pregnancy can still result in a normal pregnancy if abstinence is practiced. Rationale 2: Women who suffer alcohol addiction or abuse and who are contemplating pregnancy should be encouraged to undergo withdrawal prior to conception. However, alcohol withdrawal during pregnancy can still result in a normal pregnancy if abstinence is practiced. Rationale 3: There is no definitive answer as to how much alcohol a woman can safely consume during pregnancy. Even low levels of alcohol should be avoided during pregnancy. Rationale 4: Breastfeeding generally is not contraindicated, although alcohol is excreted in breast milk. It is more important for the woman to stop drinking during pregnancy than while breastfeeding. Question 7 The patient has just been diagnosed as diabetic. The nurse knows teaching was effective when the patient says: 1. "Ketones in my urine mean that my body is using the glucose appropriately." 2. "I should be urinating frequently and in large amounts to get rid of the extra sugar." 3. "My pancreas is making enough insulin, but my body isn't using it correctly." 4. "I might be hungry frequently because the sugar isn't getting into the tissues the way it should." Correct Answer: 4 Rationale 1: Ketones are produced when fat is being utilized for glucose, and this is not a desirable response. Rationale 2: Frequent urination is an indication of glucose above the renal threshold, and is not a good indicator of diabetic stability. Rationale 3: Diabetes is a result of lack of insulin production. If the insulin is being produced, the body will utilize it. Rationale 4: The patient who understands the disease process is aware that if the body is not getting the glucose it needs, the message of hunger will be sent to the brain.
Question 8 The patient with insulin-dependent type 2 diabetes and an HbA1c of 5.0% is planning to become pregnant soon. What anticipatory guidance should the nurse provide this patient? 1. Insulin needs decrease in the first trimester and increase during the third trimester. 2. The risk of ketoacidosis decreases during the length of the pregnancy. 3. Vascular disease that accompanies diabetes slows progression. 4. The baby is likely to have a congenital abnormality because of the diabetes. Correct Answer: 1 Rationale 1: Insulin needs frequently decrease early in the first trimester and increase after that. Rationale 2: The risk of ketoacidosis increases during pregnancy. Rationale 3: Vascular disease progresses more rapidly during pregnancy, especially if blood sugar control is not good. Problems such as nephropathy and retinopathy can result. Rationale 4: Infants of diabetic mothers have a 5% to 10% greater risk of having a congenital abnormality. This risk increases to 20% to 25% if the HbA1c is over 10%. Question 9 A newly diagnosed nsulin-dependent type 1 idiabetic with good blood sugar control is at 20 weeks' gestation. She asks the nurse how her diabetes will affect her baby. The best explanation would include: 1. "Your baby could be smaller than average at birth." 2. "Your baby will probably be larger than average at birth." 3. "As long as you control your blood sugar, your baby will not be affected at all." 4. "Your baby might have high blood sugar for several days." Correct Answer: 2 Rationale 1: Poorly controlled type 1 diabetics who have developed vascular problems will have infants who are small for gestational age (SGA) due to placental insufficiency. Rationale 2: The infant of a diabetic mother produces excessive amounts of insulin in response to the high blood sugar. This hyperinsulinism stimulates growth (or macrosomia) in the infant because the infant utilizes the glucose in the bloodstream.
Rationale 3: The demands of pregnancy will make it difficult for the best of patients to control blood sugar on a regular basis. Rationale 4: Within minutes of delivery, the baby of an insulin-dependent diabetic can begin to have low blood sugar. Question 10 A 26-year-old multigravida is 28 weeks pregnant. She has developed gestational diabetes. She is following a program of regular exercise, which includes walking, bicycling, and swimming. What instructions should be included in a teaching plan for this patient? 1. "Exercise either just before meals or wait until 2 hours after a meal." 2. "Carry hard candy (or other simple sugar) when exercising." 3. "If your blood sugar is 120 mg/dl, eat 20 g of carbohydrate." 4. "If your blood sugar is more than 120 mg/dl, drink a glass of whole milk." Correct Answer: 2 Rationale 1: It is best to exercise just after the meal, in order to utilize the glucose. Rationale 2: A patient should be encouraged to continue any exercise programs in which she already is involved. She should keep hard candy (simple sugar) with her at all times, just in case the exercise induces hypoglycemia. Rationale 3: A finger stick result of 120 mg/dl is considered to be normal. Rationale 4: Such patients need no additional carbohydrate or protein intake. Question 11 A 26-year-old multipara is 26 weeks pregnant. Her previous births include two large-for-gestational-age babies and one unexplained stillbirth. Which tests would the nurse anticipate as being most definitive in diagnosing gestational diabetes? 1. A 50g, 1-hour glucose screening test 2. A single fasting glucose level 3. A 100g, 1-hour glucose tolerance test 4. A 100g, 3-hour glucose tolerance test Correct Answer: 4
Rationale 1: All women get the initial 50 g of glucose and a 1-hour screening. Rationale 2: A single fasting glucose level is not an adequate indicator of the glucose level in relation to food. Rationale 3: The 100g, 1-hour tolerance test is not an adequate indicator of the glucose level in relation to food. Rationale 4: A patient with a history of LGA infants or gestational diabetes will be given the 100 g of glucose and 3-hour glucose tolerance test. Question 12 A patient with type 1 diabetes is receiving preconception counseling. The nurse will emphasize that during the first trimester, the woman might experience: 1. The need for less insulin than she normally uses. 2. An increased risk for hyperglycemic episodes. 3. Signs and symptoms of hydramnios. 4. A need to be hospitalized for fetal testing. Correct Answer: 1 Rationale 1: Women with type 1 diabetes often require less insulin during the first trimester. Rationale 2: Women with type 1 diabetes have an increased risk for hypoglycemia. Rationale 3: Hydramnios does not develop until the second or third month. Rationale 4: They might be hospitalized or have fetal testing done as an outpatient, but not until the second or third trimester. Question 13 The nurse has written the nursing diagnosis Risk for Injury for a diabetic pregnant patient. Interventions for this diagnosis include: Standard Text: Select all that apply. 1. Assessment of fetal heart tones. 2. Perform oxytocin challenge test, if ordered. 3. Refer the patient to a diabetes support group. 4. Assist with the biophysical profile assessment.
5. Develop an appropriate teaching plan. Correct Answer: 1,2,4 Rationale 1: null Rationale 2: Perform oxytocin challenge test (OCT)/contraction stress test (CST) and nonstress tests as determined by physician. Rationale 3: Referring the patient to a diabetes support group is not appropriate at this time, and is more suitable for the nursing diagnosis Anxiety. Rationale 4: The nurse assists the physician in performing a biophysical profile assessment. Rationale 5: Developing an appropriate teaching plan is an intervention for Readiness for Enhanced Knowledge. Question 14 A diabetic patient goes into labor at 36 weeks’ gestation. Provided that tests for fetal lung maturity are successful, the nurse will anticipate: Standard Text: Select all that apply. 1. Administration of tocolytic therapy. 2. Beta-sympathomimetic administration. 3. Allowance of labor to progress. 4. Hourly blood glucose monitoring. 5. Cesarean birth if the HgbA1c is 7%. Correct Answer: 3,4 Rationale 1: Tocolytic therapy will not be used, as it can increase the maternal blood glucose. Rationale 2: B-sympathomimetics will not be administered, as they can increase the maternal blood glucose. Rationale 3: There will be no attempt to stop the labor, as this can compromise the mother and fetus. Rationale 4: A euglycemic state is desirable to avoid fetal hypoglycemia. Rationale 5: A cesarean birth would be considered if the HgbA1c were increasing, as this would indicate sustained hyperglycemia. Question 15
A woman asks her nurse what she can do before she begins trying to get pregnant to help her baby, since she is prone to anemia. The nurse correctly advises her to: 1. Get pregnant, then start iron supplementation. 2. Add more carbohydrates to her diet. 3. Begin taking folic acid supplements daily. 4. Have a hemoglobin baseline done now so her progress can be followed. Correct Answer: 3 Rationale 1: Waiting until one is pregnant to add iron or evaluate a diet is not being proactive. Rationale 2: Adding carbohydrates to her diet will not help to prevent anemia. Rationale 3: One of the most common problems in pregnancy is anemia. Folic acid–deficiency anemia can increase the incidence of neural tube defects in a fetus. Taking 400 mcg of folic acid daily will help reduce this incidence. Rationale 4: Having a hemoglobin baseline done will not help the patient prevent anemia in pregnancy. Question 16 The pregnant patient at 23 weeks' gestation has a hemoglobin of 9.5. Which diet choice indicates that teaching has been effective? 1. Tofu with mixed vegetables in curry, milk, and whole-wheat bun 2. Roast beef, steamed spinach, tomato soup, and orange juice 3. Pork chop, mashed potatoes and gravy, cauliflower, and tea 4. Broiled fish, lettuce salad, grapefruit half, and carrot sticks Correct Answer: 2 Rationale 1: This diet is high in calcium. The patient has iron-deficiency anemia, and requires a high-iron diet. Rationale 2: This patient is anemic and needs iron. This meal contains iron in the beef, folic acid in the spinach, and vitamin C in the tomato soup and orange juice. Vitamin C helps absorption of the iron; folic acid is needed for production of red cells. Rationale 3: The patient has iron-deficiency anemia, and requires a high-iron diet. This meal has a moderate amount of protein, but no vitamin C to help with iron absorption.
Rationale 4: The patient has iron-deficiency anemia, and requires a high-iron diet. This meal is high in fiber, low in fat, and moderately high in protein, but low in iron. Question 17 The patient with -thalassemia intermedia has a hemoglobin level of 9.0. The nurse is preparing an education session for the patient. Which statement should the nurse include? 1. "You need to increase your intake of meat and other iron-rich foods." 2. "Your low hemoglobin could put you into preterm labor." 3. "Increasing your vitamin C intake will help your hemoglobin level." 4. "You should not take iron or folic acid supplements." Correct Answer: 4 Rationale 1: Iron-rich foods and supplementation should be avoided to prevent iron overload. Rationale 2: Because the patient’s iron levels are normal, increasing dietary iron will not affect the hemoglobin. Rationale 3: Vitamin C increases iron absorption, but a patient with thalassemia does not need additional iron. Rationale 4: -thalassemia intermedia is due to an abnormal red blood cell structure, which leads to microcytic anemia with normal ferritin and iron levels. Question 18 The patient at 20 weeks' gestation has had an ultrasound that revealed a neural tube defect in her fetus. The patient's hemoglobin level is 8.5. The nurse should include which statement when discussing these findings with the patient? 1. "Your low iron intake has caused anemia, which leads to the neural tube defect." 2. "You should increase your vitamin C intake to improve your anemia." 3. "You are too picky about food. Your poor diet caused your baby's defect." 4. "You haven't had enough folic acid in your diet. You should take a supplement." Correct Answer: 4 Rationale 1: Low hemoglobin does not cause neural tube defects. Rationale 2: Vitamin C will increase iron absorption, but this patient is deficient in folic acid.
Rationale 3: Therapeutic communication requires that the nurse avoid judgmental statements. Rationale 4: Folic acid deficiency can cause both neural tube defects and megaloblastic anemia, in which the red cells are immature and abnormally large. Question 19 The clinic nurse is teaching a pregnant patient about her iron supplement. Information in the teaching plan includes: Standard Text: Select all that apply. 1. Iron does not affect the gastrointestinal tract. 2. A stool softener might be needed. 3. Start a low dose, and increase it gradually. 4. Expect the stools to be black and bloody. 5. Iron absorption is poor if taken with meals. Correct Answer: 2,3,5 Rationale 1: Nausea, vomiting, constipation, and diarrhea can be side effects of iron supplements. Rationale 2: Constipation can be a problem when taking iron, so a stool softener might be needed. Rationale 3: Starting with a low dose and increasing it gradually often alleviates the side effects of nausea and vomiting. Rationale 4: Bloody stools need to be reported immediately. Iron will cause the stools to turn black. Rationale 5: Iron absorption is reduced by 40% to 50% if taken with meals.
Question 20 The patient at 9 weeks' gestation has been told that her HIV test was positive. The patient is very upset, and tells the nurse, "I didn't know I had HIV! What will this do to my baby?" The nurse knows teaching has been effective when the patient states: 1. "I cannot take the medications that control HIV during my pregnancy, because they will harm the baby." 2. "My baby will probably be born with anti-HIV antibodies, but that doesn't mean my baby is infected." 3. "The pregnancy will increase the progression of my disease and will reduce my CD4 counts."
4. "The HIV won't affect my baby, and I will have a low-risk pregnancy without additional testing." Correct Answer: 2 Rationale 1: Most of the medications that control HIV progression are safe to take during pregnancy. Antiretroviral medications are recommended during pregnancy to prevent perinatal transmission. Rationale 2: Babies of HIV-positive women or women with AIDS are born with maternal anti-HIV antibodies. These antibodies clear over time, and an accurate test can be obtained by 15 months of age. Rationale 3: There is no evidence to indicate that pregnancy increases the progression of HIV/AIDS. Rationale 4: Pregnancy affected by HIV/AIDS is considered complicated, and the fetus is monitored closely. Fetal assessments include weekly nonstress tests beginning at 32 weeks. Question 21 During the history, the patient admits to being HIV-positive and says she knows that she is about 16 weeks pregnant. Which statements made by the patient indicate an understanding of the plan of care both during the pregnancy and postpartally? Standard Text: Select all that apply. 1. "During labor and delivery, I can expect the zidovudine (AZT) to be given in my IV." 2. "After delivery, the dose of zidovudine (AZT) will be doubled to prevent further infection." 3. "My baby will be started on zidovudine (AZT) within 12 hours of delivery." 4. "My baby's zidovudine (AZT) will be given in a cream form." 5. "My baby will not need zidovudine (AZT) if I take it during my pregnancy." Correct Answer: 1,3 Rationale 1: All HIV-positive patients are prescribed a three-part therapy after the first trimester. During the labor and delivery process, the doses will be given intravenously. Rationale 2: The mother will continue with her oral dosage of zidovudine (AZT) after delivery just as prior to delivery. Rationale 3: Within 8–12 hours after delivery, the infant is administered oral zidovudine (AZT) and kept on the medication a minimum of 6 weeks. Rationale 4: The initial treatment is zidovudine (AZT) orally every day. In order to keep the level consistent, it is recommended that dosages be taken consistently.
Rationale 5: The infant will be started on oral zidovudine (AZT) after birth for 6 weeks. Question 22 A woman is 32 weeks pregnant. She is HIV-positive but asymptomatic. What would be important in managing her pregnancy and delivery? 1. An amniocentesis at 30 and 36 weeks 2. Weekly nonstress testing beginning at 32 weeks' gestation 3. Application of a fetal scalp electrode as soon as her membranes rupture in labor 4. Administration of intravenous antibiotics during labor and delivery Correct Answer: 2 Rationale 1: All invasive procedures that would expose the uninfected infant to the HIV virus are avoided. Rationale 2: Patients who are HIV-positive are considered high-risk pregnancies. Therefore, beginning at about 32 weeks, these patients have weekly nonstress tests to assess for placental function, and an ultrasound every 2–3 weeks to assess for intrauterine growth retardation (IUGR). Rationale 3: All invasive procedures that would expose the uninfected infant to the HIV virus are avoided. Rationale 4: Antibiotics would be ineffective for either the mother or the infant who was HIV-positive. Question 23 A pregnant woman is married to an intravenous drug user. She had a negative HIV screening test just after missing her first menstrual period. What would indicate that the patient needs to be retested for HIV? 1. Hemoglobin of 11 g/dl and a rapid weight gain 2. Elevated blood pressure and ankle edema 3. Shortness of breath and frequent urination 4. null Correct Answer: 4 Rationale 1: Hemoglobin of 11 g/dl and a rapid weight gain do not indicate a need to be retested for HIV. Rationale 2: Elevated blood pressure and ankle edema do not indicate a need to be retested for HIV. Rationale 3: Shortness of breath and frequent urination do not indicate a need to retest for HIV.
Rationale 4: The patient who is HIV-positive has a suppressed immune system, and experiences symptoms of fatigue and opportunistic infections, such as Candida vaginitis. Question 24 The nurse is evaluating the goal “Patient will remain free of opportunistic infections” for an HIV-positive pregnant patient. The nurse determines the goal was met when the patient: Standard Text: Select all that apply. 1. Has an absolute CD4+ T-lymphocyte count below 200. 2. Has no complaint of chills or fever during the pregnancy. 3. Has a weight gain of 30 lbs. during the pregnancy. 4. Has a white blood cell count of 2500 at 30 weeks’ gestation. 5. Maintains a normal erythrocyte sedimentation rate during the pregnancy. Correct Answer: 2,3,5 Rationale 1: The absolute CD4+ T-lymphocyte count must remain above 200 to protect against opportunistic infections. Rationale 2: Not having chills, fever, or a sore throat throughout the pregnancy is an indication the patient did not have an infection. Rationale 3: Twenty-five to thirty pounds in weight gain is normal for a pregnancy. This patient met the goal for nutrition and remaining infection-free. Rationale 4: This is a low white blood cell count, and indicates the patient is at risk for developing an infection. Rationale 5: Having a normal erythrocyte sedimentation rate during the pregnancy is an expected outcome. Question 25 The clinic nurse is following the progress of a HIV-positive infant. The nurse will assess the infant for: Standard Text: Select all that apply. 1. Recurrent infections. 2. Cancer. 3. Delayed development.
4. Epstein-Barr manifestations. 5. Intact, normal central nervous system. Correct Answer: 1,3,4,5 Rationale 1: Recurrent infections would indicate the infant might be progressing to AIDS. Rationale 2: Cancer is rare in the HIV-positive infant. Rationale 3: Delayed development is a potential complication of HIV, as it can cause encephalopathy. Rationale 4: The HIV-positive infant can contract the Epstein-Barr virus. Rationale 5: The nurse will be assessing for normal nervous system function, as it indicates the virus is under control. Question 26 A 21-year-old at 12 weeks' gestation with her first baby has known cardiac disease, class III, as a result of childhood rheumatic fever. During a prenatal visit, the nurse reviews the signs of cardiac decompensation with her. The nurse will know that the patient understands these signs and symptoms if she states, "I would notify my doctor if I had: 1. "A pulse rate increase of 10 beats per minute." 2. "Breast tenderness." 3. "Mild ankle edema." 4. "A frequent cough." Correct Answer: 4 Rationale 1: In most pregnant patients , the heart rate will increase. Rationale 2: Most pregnant patients will develop breast tenderness. Rationale 3: The patient with rheumatic heart disease who develops congestive heart failure would have severe ankle edema. Rationale 4: With the increased workload of the heart with pregnancy and the increase in blood volume, this patient is at risk for developing congestive heart failure. This would result in the frequent cough. Question 27
A patient is at 12 weeks' gestation with her first baby. She has cardiac disease, class III. She states that she had been taking sodium warfarin (Coumadin), but her physician changed her to heparin. She asks the nurse why this was done. The nurse's response should be: 1. "Heparin may be given by mouth, while Coumadin must be injected." 2. "Heparin is safer because it does not cross the placenta." 3. "They are the same drug, but heparin is less expensive." 4. "Coumadin interferes with iron absorption in the intestines." Correct Answer: 2 Rationale 1: Heparin is an injectable and Coumadin is a pill. Rationale 2: Heparin is safest for the patient to take because it does not cross the placental barrier. Rationale 3: Heparin does not cost less than Coumadin. Rationale 4: Coumadin does not interfere with iron absorption in the intestines. Question 28 A 21-year-old woman is at 12 weeks' gestation with her first baby. She has cardiac disease, class III, as a result of having had childhood rheumatic fever. Which planned activity would indicate to the nurse that the patient needs further teaching? 1. "I will be sure to take a rest period every afternoon." 2. "I would like to take childbirth education classes in my last trimester." 3. "I will have to cancel our trip to Disney World." 4. "I am going to start my classes in water aerobics next week." Correct Answer: 4 Rationale 1: Because the heart disease is class III, this patient is encouraged to get adequate rest. Rationale 2: Childbirth classes would be helpful for the patient as long as she were careful not to overexert herself. Rationale 3: Travel during the pregnancy would be based upon the tolerance of the patient. However, a trip to Disney World would involve a large amount of activity, which would stress the pregnancy.
Rationale 4: With the slightest exertion, the patient’s heart rate will rise, and she will become symptomatic. Therefore, she should not establish a new exercise program. Question 29 The nurse is reviewing prenatal charts. A patient at 24 weeks’ gestation has a history of class II heart disease secondary to rheumatic fever. What would the nurse expect to see in the chart? 1. Dyspnea and chest pain with mild exertion 2. Elective cesarean birth scheduled for 37 weeks 3. Discussed need for labor epidural and vacuum extraction 4. Respiratory rate 28, pulse 110, 3+ pre-tibial edema bilaterally Correct Answer: 3 Rationale 1: Dyspnea and angina with mild exertion are not expected with class II heart disease even during pregnancy, but are symptoms seen in class IV heart disease. Rationale 2: Cesarean birth is undertaken only for cardiac patients for fetal or maternal intrapartal indications, not for cardiac reasons alone. Rationale 3: Lumbar epidural analgesia decreases the stress response during labor, while vacuum extraction or forceps decreases maternal pushing efforts. Both of these decrease stress on the heart during birth. Rationale 4: 3+ pre-tibial edema is never an expected finding during pregnancy. Pulse over 100 and respiratory rate over 24 are indicators of cardiac decompensation. Question 30 The nurse is evaluating the plan of care for a pregnant patient with a heart disorder. The nurse concludes that the plan was successful when data indicate that the woman: Standard Text: Select all that apply. 1. Gave birth to a healthy baby. 2. Did not develop congestive heart failure. 3. Developed thromboembolism. 4. Identified manifestations of potential complications. 5. Can identify her condition and its impact on her pregnancy, labor and birth, and postpartum period.
Correct Answer: 1,2,4,5 Rationale 1: Giving birth to a healthy baby is an expected outcome of the pregnancy. Rationale 2: An expected outcome is that the woman does not develop congestive heart failure, thromboembolism, or infection. Rationale 3: An expected outcome is that the woman does not develop congestive heart failure, thromboembolism, or infection. Rationale 4: An expected outcome is that the woman is able to identify potential complications and notify the healthcare provider. Rationale 5: The woman must be able to discuss her condition and its possible impact on her pregnancy, labor and birth, and the postpartum period. Question 31 The prenatal clinic nurse has received four phone calls. Which patient should the nurse call back first? 1. Primip at 28 weeks with history of asthma reporting difficulty breathing and shortness of breath 2. Multip at 6 weeks with a seizure disorder inquiring which foods are good folic acid sources for her 3. Primip at 35 weeks with a positive HBsAG wondering what treatment her baby will receive after birth 4. Multip at 11 weeks with untreated hyperthyroidism describing the onset of vaginal bleeding Correct Answer: 1 Rationale 1: Asthma exacerbations are most common between 24 and 36 weeks. Asthma attacks can lead to maternal hypoxia, which can lead to fetal hypoxia. This patient is the top priority. Rationale 2: Women with seizure disorders should be started on folic acid supplements prior to pregnancy, and should continue throughout pregnancy. However, this patient is not the highest priority. Rationale 3: A patient with a positive HBsAG is contagious for hepatitis B. The risk of transmission to the fetus at birth is reduced by bathing the neonate as soon as possible after birth and giving the infant immunoprophylaxis and the first HBsAG vaccine dose. However, this patient is not the highest priority. Rationale 4: Pregnant women with untreated hyperthyroidism have an increased risk of fetal loss. Vaginal bleeding at 11 weeks could indicate that spontaneous abortion is taking place. However, this patient is not the highest priority. Question 32
The nurse is working with a pregnant woman who has systemic lupus erythematosus (SLE). The nurse anticipates the infant might be born with: Standard Text: Select all that apply. 1. A tendency to bleed excessively. 2. An increased chance of developing infections. 3. A hemoglobin less than optimal for good health. 4. Problems with vision. 5. Hearing loss. Correct Answer: 1,2,3 Rationale 1: This is true, as the infant might be born with thrombocytopenia. Rationale 2: This is true, as the infant might be born with neutropenia. Rationale 3: This is true, as the infant might be born with anemia. Rationale 4: Vision problems are not associated with SLE. Rationale 5: Loss of hearing not associated with SLE. Question 33 A pregnant asthmatic patient is being seen for her initial prenatal visit. The nurse knows that the fetal implications of maternal asthma are: Standard Text: Select all that apply. 1. Prematurity. 2. Low birth weight. 3. Hypoxia with maternal exacerbation. 4. Congenital anomalies from the medications. 5. Perinatal transfer of the asthma. Correct Answer: 1,2,3 Rationale 1: One implication of maternal asthma is that the infant is at risk for prematurity.
Rationale 2: One implication of maternal asthma is that the infant is at risk for low birth weight. Rationale 3: One implication of maternal asthma is that the infant is at risk for hypoxia if the mother has an exacerbation of her asthma. Rationale 4: Congenital anomalies can occur with anti-epileptic medications. None are known for asthma medications. Rationale 5: Perinatal transfer of asthma does not occur. Question 34 While doing a prenatal assessment on a woman who has hepatitis B and intends to become pregnant, the nurse explains the impact of the hepatitis B on pregnancy and birth. Which statement does the nurse include in the teaching? 1. “Your baby contracted hepatitis B from you when she was conceived.” 2. “Don’t worry about your baby during the birth. You’re more likely to be affected then by the hepatitis B.” 3. “Your baby will be immune to your hepatitis B.” 4. “Hepatitis B does not usually affect the course of pregnancy.” Correct Answer: 4 Rationale 1: Rationale 2: Chronic carriers can develop long-term sequelae, such as chronic liver disease and liver cancer. However, the nurse should not dismiss the impact of the mother’s hepatitis B infection on the baby. Rationale 3: Chronic HBV carriers have a great potential for infecting others when exposure to blood and body fluids occurs. The baby can be infected during birth. Rationale 4: Most women with hepatitis B experience pregnancies with no problems caused by the infection.
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 18. Pregnancy at Risk: Gestational Onset Question 1 The nurse is caring for a patient who was just admitted to rule out ectopic pregnancy. Which orders are the most important for the nurse to perform? Standard Text:Select all that apply. 1. Assess the patient’s temperature. 2. Document the time of the patient’s last meal. 3. Obtain urine for urinalysis and culture. 4. Report complaints of dizziness or weakness. 5. Have lab draw blood for B-hCG level every 48 hours. Correct Answer: 4,5 Rationale 1: This is important, but not the most important to perform first. Rationale 2: This is not an important action. Rationale 3: This is not an important action. Rationale 4: This is important, as it can indicate hypovolemia from internal bleeding. Rationale 5: This is important, as the level rises much more slowly in ectopic pregnancy than normal pregnancy. Question 2 The nurse educator is presenting a class on the different kinds of miscarriages. Miscarriages, or spontaneous abortions, are classified clinically into different categories, including: Standard Text:select all that may apply 1. Threatened abortion. 2. Incomplete abortion. 3. Complete abortion.
4. Missed abortion. 5. Acute abortion. Correct Answer: 1,2,3,4 Rationale 1: Unexplained cramping, bleeding, or backache indicate the fetus might be in jeopardy. Rationale 2: Part of the products of conception is retained, usually the placenta. Rationale 3: All the products of conception are expelled in a complete abortion. Rationale 4: In a missed abortion, the fetus dies in utero but is not expelled. Rationale 5: There is no such thing as acute abortion. Question 3 The nurse is presenting a class on the pathophysiology of the different abortions. Some of the causes are: Standard Text:select all that may apply 1. Chromosomal defects. 2. Insufficient or excessive hormonal levels. 3. Sexual intercourse in the first trimester. 4. Infections in the first trimester. 5. Cervical insufficiency. Correct Answer: 1,2,4,5 Rationale 1: Chromosomal defects are usually the cause of abortions between 4 and 8 weeks. Rationale 2: Insufficient or excessive hormone levels usually cause an abortion by the 10th week. Rationale 3: Sexual intercourse does not cause miscarriage. Rationale 4: Infections can cause fetal loss in the first trimester. Rationale 5: Later abortions usually have a maternal cause, such as an insufficient cervix. Question 4
A woman is hospitalized with severe preeclampsia. The nurse is meal-planning with the patient and encourages a diet that is high in: 1. Sodium. 2. Carbohydrates. 3. Protein. 4. Fruits. Correct Answer: 3 Rationale 1: It is important that the patient limit her intake of sodium. Rationale 2: While it is important that the patient have an adequate intake of carbohydrates, another food group is more important. Rationale 3: The client who experiences preeclampsia is losing protein. Rationale 4: It is important that the patient have adequate intake of fruits, but another food group is more important. Question 5 The nurse is assessing a client who has severe preeclampsia. The assessment finding that should be reported to the physician is: 1. Proteinuria. 2. Platelet count of 20,000. 3. Urine output of 50 ml per hour. 4. 21 DTRs. Correct Answer: 2 Rationale 1: The 11 spilling of protein is abnormal, but this is acceptable for a client with preeclampsia. Rationale 2: The client could be experiencing HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count). This condition is sometimes associated with severe preeclampsia, and women who experience this multiple-organ-failure syndrome have high morbidity and mortality rates. A platelet count lower than 20,000 is critically low. Rationale 3: A urine output of at least 30 ml/hour is normal.
Rationale 4: The DTRs of 21 are normal. Question 6 A woman is 16 weeks pregnant. She has had cramping, backache, and mild bleeding for the past 3 days. Her physician determines that her cervix is dilated to 2 centimeters, with 10% effacement, but membranes are still intact. She is crying, and says to the nurse, "Is my baby going to be okay?" In addition to acknowledging the patient's fear, the nurse should also say: 1. "Your baby will be fine. We'll start IV, and get this stopped in no time at all." 2. "Your cervix is beginning to dilate. That is a serious sign. We will continue to monitor you and the baby for now." 3. "You are going to miscarry. But you should be relieved, because most miscarriages are the result of abnormalities in the fetus." 4. "I really can't say. However, when your physician comes, I'll ask her to talk to you about it." Correct Answer: 2 Rationale 1: This is a serious situation. The patient should not be offered false hope of everything being fine. Rationale 2: A cerclage can be performed in the first trimester and early into the second trimester. Many interventions can be attempted to prevent further dilation and effacement. Rationale 3: The nurse should avoid justification of the miscarriage. Rationale 4: The nurse should not defer the conversation to someone else (e.g., the physician). Question 7 The nurse is supervising care in the emergency department. Which situation most requires an intervention? 1. Moderate vaginal bleeding at 36 weeks' gestation; client has an IV of lactated Ringer's solution running at 125 mL/hour 2. Spotting of pinkish-brown discharge at 6 weeks' gestation and abdominal cramping; ultrasound scheduled in 1 hour 3. Bright red bleeding with clots at 32 weeks' gestation; pulse = 110, blood pressure 90/50, respirations = 20 4. Dark red bleeding at 30 weeks' gestation with normal vital signs; patient reports an absence of fetal movement Correct Answer: 3
Rationale 1: Bleeding in the third trimester is usually a placenta previa or placental abruption. Blood loss can be heavy and rapid, so having an IV stabilizes the client's vascular volume. Rationale 2: Bleeding in the first trimester can be indicative of spontaneous abortion beginning, or of an ectopic pregnancy. An ultrasound will diagnose which situation is occurring, and will determine care. Rationale 3: Bleeding in the third trimester is usually a placenta previa or placental abruption. Blood loss can be heavy and rapid. This patient has a low blood pressure with an increased pulse rate, which indicates hypovolemic shock, which can be fatal to the mother and therefore the baby. Rationale 4: Watery, dark red bleeding in the third trimester can indicate placental abruption with ruptured membranes. Normal vital signs indicate a normal vascular volume. A lack of fetal movement could indicate fetal hypoxia or fetal demise. The fetus is at greatest risk in this situation; the mother is stable. Question 8 A patient who is 11 weeks pregnant presents to the emergency department with complaints of dizziness, lower abdominal pain, and right shoulder pain. Laboratory tests reveal a beta-hCG at a lower-than-expected level for this gestational age. An adnexal mass is palpable. Ultrasound confirms no intrauterine gestation. The patient is crying and asks what is happening. The nurse knows that the most likely diagnosis is an ectopic pregnancy. Which statement should the nurse include? 1. "You’re feeling dizzy because the pregnancy is compressing your vena cava." 2. "The pain is due to the baby putting pressure on nerves internally." 3. "The baby is in the fallopian tube; the tube has ruptured and is causing bleeding." 4. "This is a minor problem. The doctor will be right back to explain it to you." Correct Answer: 3 Rationale 1: Dizziness from vena cava compression occurs in the third trimester when women are supine. Rationale 2: The fetus is too small to be putting pressure on the nerves. Rationale 3: Dizziness and abdominal pain with shoulder pain are symptoms of internal bleeding. A lowerthan-expected beta-hCG indicates either an ectopic pregnancy or a pregnancy that is miscarrying; in this case, it is an ectopic pregnancy. Rationale 4: Therapeutic communication requires giving the patient an answer rather than referring the patient to someone else. Question 9
A patient at 18 weeks’ gestation has been diagnosed with a hydatidiform mole. In addition to vaginal bleeding, which signs or symptoms would the nurse expect to see? Standard Text:select all that may apply 1. Hyperemesis and hypertension 2. Diarrhea and hyperthermia 3. Uterine enlargement greater than expected 4. Polydipsia 5. Vaginal bleeding Correct Answer: 1,3,5 Rationale 1: These are often seen in patients with hydatidiform mole. Rationale 2: Neither of these is seen with hydatidiform mole. Rationale 3: This is a classic sign of hydatidiform mole. Rationale 4: This is not associated with hydatidiform mole. Rationale 5: This is a classic symptom of hydatidiform mole. Question 10 A woman at 7 weeks' gestation is diagnosed with hyperemesis gravidarum. Which nursing diagnosis would receive priority? 1. Fluid Volume Deficit 2. Decreased Cardiac Output 3. Risk for Injury 4. Alteration in Nutrition: Less than body requirements Correct Answer: 1 Rationale 1: The newly admitted patient with hyperemesis gravidarum has been experiencing excessive vomiting, and is in a fluid volume–deficit state. Rationale 2: Because no preexisting cardiac condition is present, the body has compensated for this fluid loss.
Rationale 3: The risk for injury is present due to the symptoms of fluid volume deficit; however, it is not the priority. Rationale 4: The nutrition status of the patient is compromised until the emesis and the fluid volume status are corrected. But it is not the first priority. Question 11 The prenatal clinic nurse is caring for a patient with hyperemesis gravidarum at 14 weeks' gestation. The vital signs are: blood pressure 95/48, pulse 114, respirations 24. Which order should the nurse implement first? 1. Weigh the client. 2. Give 1 liter of lactated Ringer's solution IV. 3. Administer 30 ml Maalox (magnesium hydroxide) orally. 4. Encourage clear liquids orally. Correct Answer: 2 Rationale 1: Weighing the client provides information on weight gain or loss, but is not the top priority in a patient with excessive vomiting during pregnancy. The vital signs indicate hypovolemia. Rationale 2: The vital signs indicate hypovolemia. Giving this patient a liter of lactated Ringer's solution intravenously will re-establish vascular volume and bring the blood pressure up, and the pulse and respiratory rate down. Rationale 3: The vital signs indicate hypovolemia. There is no indication that the patient has dyspepsia. Rationale 4: Lack of tolerance of oral fluids through excessive vomiting is what has led to the hypovolemia. Question 12 A patient has been admitted with a diagnosis of hyperemesis. Which orders written by the primary health care provider are the highest priority for the nurse to implement? Standard Text:select all that may apply 1. Obtain complete blood count. 2. Start intravenous with multivitamins. 3. Check admission weight. 4. Obtain urine for urinalysis.
5. Give a medication to stop the nausea and vomiting. Correct Answer: 2,5 Rationale 1: This is important, but not a priority. Rationale 2: This is a priority if the patient has been vomiting. Rationale 3: This is important, but not a priority. Rationale 4: This is important, but not a priority. Rationale 5: This is a priority to stop the nausea and vomiting. Question 13 The nurse on the high-risk antepartal unit has received the shift change report. Which patient should the nurse see first? 1. Primip at 26 weeks with prolonged premature rupture of membranes, experiencing chills 2. Multip at 28 weeks with premature rupture of membranes reporting leakage of clear vaginal fluid 3. Primip at 30 weeks with premature rupture of membranes due for a betamethasone injection 4. Multip at 32 weeks with prolonged premature rupture of membranes and a hemoglobin of 11.0 Correct Answer: 1 Rationale 1: Chills indicate fever, which in turn indicates infection. Prolonged premature rupture of membranes increases the risk of maternal infection, specifically chorioamnionitis. Intrauterine infection can be life-threatening to the fetus or to a neonate. This patient requires immediate intervention, including contacting the physician. Rationale 2: Premature rupture of membranes is the leakage of amniotic fluid; continued leaking of clear fluid does not indicate the development of further complications. Rationale 3: Scheduled medications are important, but when a patient is experiencing complications, medications are less important. Rationale 4: Although this patient has prolonged premature rupture of membranes, there is no indication of any further complications. This patient is a low priority. Question 14
A woman is being treated for preterm labor with magnesium sulfate. The nurse is concerned that the patient is experiencing early drug toxicity. What assessment finding by the nurse indicates early magnesium sulfate toxicity? 1. Patellar reflexes are weak or absent. 2. Complaints by the patient of feeling flushed and warm 3. Respiratory rate of 16 4. Fetal heart rate of 120 Correct Answer: 1 Rationale 1: Early signs of magnesium sulfate toxicity are related to a decrease in deep tendon reflexes. Rationale 2: The peripheral vasodilation will cause flushing and a feeling of warmth; this is a side effect, not a toxic effect. Rationale 3: Late signs of toxicity are a respiratory rate less than 12, urine output less than 30 cc/hour, and confusion. Rationale 4: Magnesium typically has no effect on fetal heart rate. Question 15 A patient has preeclampsia. She is 36 weeks pregnant, and comes to the high-risk screening center for a contraction stress test. The nurse should explain to the patient that the contraction stress test is being done to determine: 1. What effect her hypertension has had on the fetus. 2. Whether the fetus will be able to tolerate labor. 3. Whether fetal movement increases with contractions. 4. What effect contractions will have on her blood pressure. Correct Answer: 2 Rationale 1: The fetal heart rate response to movement is assessed in a non-stress test. Rationale 2: Contraction stress tests are performed to assess the ability of the fetus to tolerate labor. Rationale 3: With contractions, the nurse is assessing for a heart rate response, not for movement.
Rationale 4: The effect of contractions on blood pressure would be noted, but this is not the purpose. Question 16 The nurse identifies the following assessment findings on a client with preeclampsia: blood pressure 158/100; urinary output 50 mL/hour; lungs clear to auscultation; urine protein 11 on dipstick; and edema of the hands, ankles, and feet. On the next hourly assessment, which new assessment finding would be an indication of worsening of the preeclampsia? 1. Blood pressure 158/104 2. Urinary output 20 mL/hour 3. Reflexes 21 4. Platelet count 150,000 Correct Answer: 2 Rationale 1: The blood pressure has not had a significant rise. Rationale 2: The decrease in urine output is an indication of decrease in GFR, which indicates a loss of renal perfusion. The most abnormal and life-threatening assessment finding is the urine output change. Rationale 3: The reflexes are normal at 21. Rationale 4: The platelet count is normal, although it is at the lower end. Question 17 The community nurse is working with a patient at 32 weeks' gestation who has been diagnosed with preeclampsia. Which statement by the patient would indicate that additional information is needed? 1. "I should call the doctor if I develop a headache or blurred vision." 2. "Lying on my left side as much as possible is good for the baby." 3. "My urine could become darker and smaller in amount each day." 4. "Pain in the top of my abdomen is a sign my condition is worsening." Correct Answer: 3 Rationale 1: Headache and blurred vision or other visual disturbances are an indication of worsening preeclampsia and should be reported to the physician.
Rationale 2: The left lateral position maximizes uterine and renal blood flow, and therefore is the optimal position for a patient with preeclampsia. Rationale 3: Oliguria is a complication of preeclampsia caused by renal involvement, and is a sign that the condition is worsening. Oliguria should be reported to the physician. Rationale 4: Epigastric pain is an indication of liver enlargement, a symptom of worsening preeclampsia, and should be reported to the physician. Question 18 The nurse is reviewing labs on a new admit. The patient's hemoglobin is 8.0; platelets are 75,000, AST 75. Which nursing action is best? 1. Contact the physician. 2. Request the labs to be redrawn. 3. Assess blood pressure. 4. Determine the client's blood type and Rh. Correct Answer: 1 Rationale 1: This client has HELLP syndrome, a life-threatening condition. Further orders are needed from the physician. Rationale 2: Redrawing the labs is not the best action. Rationale 3: The blood pressure is likely to be high, but notifying the physician of this life-threatening set of labs is a higher priority. Rationale 4: Although blood type and Rh would need to be known after delivery to determine whether the client requires RhoGAM, this is not the highest priority. Question 19 A woman is experiencing preterm labor. The patient asks why she is on betamethasone (Celestone). The best response by the nurse would be "This medication: 1. “Will halt the labor process until the baby is more mature." 2. “Will relax the smooth muscles in the infant's lungs so the baby can breathe." 3. “Is effective in stimulating lung development in the preterm infant."
4. “Is an antibiotic that will treat your urinary tract infection, which caused preterm labor." Correct Answer: 3 Rationale 1: This medication has no effect on the labor process or on the smooth muscles in the lungs. Rationale 2: This medication has no effect on the labor process or on the smooth muscles in the lungs. Rationale 3: Betamethasone (Celestone) has been found to induce pulmonary maturation, and thereby decrease the risk of respiratory problems in the preterm infant. Rationale 4: This medication is not an antibiotic, and therefore will not help resolve a urinary tract infection. Question 20 A patient is being admitted to the labor area with the diagnosis of eclampsia. Which actions by the nurse are appropriate at this time? Standard Text:select all that may apply 1. Tape a tongue blade to the head of the bed. 2. Pad the siderails and head of the bed. 3. Provide the patient with needed stimulation. 4. Provide the patient with grief counseling. 5. Pull the blinds and provide a dark, quiet environment. Correct Answer: 2,5 Rationale 1: It is dangerous to insert a tongue blade into the mouth of a seizing patient. Rationale 2: The siderails and headboard should be padded. Rationale 3: Excess stimulation can precipitate a seizure. Rationale 4: There is no reason to provide grief counseling. Rationale 5: This patient’s room should be dark and quiet so as not to precipitate any seizure. Question 21 A clinic nurse is planning when to administer Rh immune globulin (RhoGAM) to an Rh-negative pregnant patient. When should the first dose of RhoGAM be administered?
1. After the birth of the infant 2. 1 month postpartum 3. During labor 4. At 28 weeks' gestation Correct Answer: 4 Rationale 1: After birth would be too late for the first dose of RhoGAM if transplacental hemorrhage, which is possible during pregnancy, has occurred. Rationale 2: 1 month postpartum would be too late for the first dose of RhoGAM if transplacental hemorrhage, which is possible during pregnancy, has occurred. Rationale 3: During labor would be too late for the first dose of RhoGAM if transplacental hemorrhage, which is possible during pregnancy, has occurred. Rationale 4: Since transplacental hemorrhage is possible during pregnancy, an antibody screen is performed on an Rh-negative woman at 28 weeks' gestation. If she has no antibody titer, she is given an IM injection of 300 mcg Rh immune globulin (RhoGAM). Question 22 The nurse receives the following report on a patient who delivered 36 hours ago: para 1, rubella-immune, Anegative, antibody screen negative, newborn B-positive, Coombs' negative, discharge orders are written for both mother and newborn. What should be the priority action by the nurse? 1. Ask whether the mother is breast- or bottle-feeding. 2. Administer rubella vaccine. 3. Determine whether RhoGAM has been given. 4. Discuss the discharge education with the patient. Correct Answer: 3 Rationale 1: This is important but is not the top priority. Rationale 2: The client is rubella-immune, and does not need the rubella vaccine. Rationale 3: The patient is A-negative and the newborn B-positive. The patient needs RhoGAM prior to discharge. Without RhoGAM, the patient will make antibodies against Rh-positive blood, and future pregnancies would be in jeopardy.
Rationale 4: Discharge education is always important, but in this case is not the most important action. Question 23 The patient with blood type A, Rh-negative, delivered yesterday. Her infant is blood type AB, Rh-positive. Which statement indicates that teaching has been effective? 1. "I need to get RhoGAM so I don't have problems with my next pregnancy." 2. "Because my baby is Rh-positive, I don't need RhoGAM." 3. "If my baby had the same blood type I do, it might cause complications." 4. "Before my next pregnancy, I will need to have a RhoGAM shot." Correct Answer: 1 Rationale 1: Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune globulin (RhoGAM) to prevent alloimmunization, which could cause fetal anemia and other complications during the next pregnancy. Rationale 2: If the baby is Rh-negative, the mother does not need RhoGAM. Rationale 3: It is specifically the Rh factor that causes complications; ABO grouping does not cause alloimmunization. Rationale 4: The injection must be given with 72 hours after delivery to prevent alloimmunization. Question 24 Which maternal-child patient should the nurse see first? 1. Blood type O, Rh-negative 2. Indirect Coombs' test negative 3. Direct Coombs' test positive 4. Blood type B, Rh-positive Correct Answer: 3 Rationale 1: This patient is Rh-negative, but there is no indication that the alloimmunization has occurred. Rationale 2: An indirect Coombs' test looks for Rh antibodies in the maternal serum; a negative result indicates the patient has not been alloimmunized.
Rationale 3: A direct Coombs' test looks for Rh antibodies in the fetal blood circulation. A positive result indicates that that there is an Rh incompatibility between mother and infant, and that the baby is making antiRh antibodies, which in turn leads to hemolysis. This infant is at risk for anemia and hyperbilirubinemia. Rationale 4: This patient's blood type creates no problems. Question 25 A patient is concerned because she has been told her blood type and her baby's are incompatible. The best response by the nurse would be: 1. "This is called ABO incompatibility, and if the baby becomes jaundiced, she can be treated with a special light treatment." 2. "This is a serious condition, and additional blood studies are currently in process to determine whether you need a medication to prevent it from occurring with a future pregnancy." 3. "This is a condition caused by a blood incompatibility between you and your husband, but does not affect the baby." 4. "This type of condition is very common, and the baby can receive a medication to prevent jaundice from occurring." Correct Answer: 1 Rationale 1: When blood types, not Rh, are incompatible, it is called ABO incompatibility. The mother has a blood type that has antibodies against the newborn blood cells and causes these cells to break down. Rationale 2: Although this can be serious, additional blood studies are not typically done. There is no medication that can be given to the mother to prevent this from occurring. Rationale 3: The incompatibility is not between the mother's and father's blood but between the mother's and the infant's blood. Rationale 4: ABO incompatibility is common, but there is no medication to give the baby that will prevent jaundice. Question 26 During her first prenatal visit to the clinic at 7 weeks' gestation, a 24-year-old primiparous patient comments, "My blood type is A negative, and my husband's blood type is B positive. Will that cause problems with my pregnancy?" The nurse's best response would be: 1. "There is no danger to your baby, but there could be a few minor complications for you. Let's talk about what we can do to prevent those."
2. "We will do a blood test to see whether your body is responding to the baby's blood type. If so, we will give the baby some medication to prevent harm." 3. "Because your partner is positive and you are negative, there is some risk to the baby, but because this is your first pregnancy, the risks are very small." 4. "If you were O negative, you might have ABO incompatibility because of your partner's blood type; but since you are type A, there should be no problem." Correct Answer: 3 Rationale 1: This patient is at risk for Rh incompatibility because she is Rh-negative and the father of the baby is Rh-positive. Rationale 2: It is recommended that a Coombs' blood test be drawn to assess for antibody formation at the first prenatal visit and again at 28 weeks. Rh immune globulin (RhoGAM) will be given to the mother (not the fetus) at 28 weeks. Rationale 3: This client is at risk for Rh incompatibility because she is Rh-negative and the father of the baby is Rh-positive. Because this is her first pregnancy, it is extremely unlikely that she has been exposed to Rhpositive blood, which would stimulate the development of antibodies. These antibodies cross the placenta and cause fetal hemolysis, which can lead to severe anemia that could cause fetal loss. It is recommended that a Coombs' blood test be drawn to assess for antibody formation at the first prenatal visit and again at 28 weeks. Rh immune globulin (RhoGAM) will be given to the mother (not the fetus) at 28 weeks, and again after delivery if the baby is Rh-positive, to prevent antibody formation. Rationale 4: This is not an issue of ABO incompatibility. Question 27 The patient presents to the clinic for an initial prenatal examination. She asks the nurse whether there might be a problem for her baby because she has type B Rh-positive blood and her husband has type O Rh-negative blood, or because her sister's baby had ABO incompatibility. What is the nurse's best answer? Standard Text:select all that may apply 1. "Your baby would be at risk for Rh problems if your husband were Rh-negative." 2. "Rh problems only occur when the mother is Rh-negative and the father is not." 3. "ABO incompatibility occurs only after the baby is born." 4. "We don't know for sure, but we can test for ABO incompatibility." 5. "Your husband’s being type B puts you at risk for ABO incompatibility."
Correct Answer: 2,3 Rationale 1: Rh incompatibility is a possibility when the mother is Rh-negative and the father is Rh-positive. Rationale 2: Rh incompatibility is a possibility when the mother is Rh-negative and the father is Rh-positive. Rationale 3: ABO incompatibility occurs when the mother is type O and the baby is type A or B or AB at the time the placenta delivers. Rationale 4: ABO incompatibility occurs when the mother is type O and the baby is type A or B or AB at the time the placenta delivers. Rationale 5: The husband's blood type is not an issue for ABO incompatibility, which causes hemolysis and jaundice in babies and does not affect mothers. Question 28 A woman has a hydatidiform mole (molar pregnancy) evacuated, and is prepared for discharge. The nurse should make certain that the patient understands that it is essential that she: 1. Not become pregnant until after the follow-up program is completed. 2. Receive RhoGAM with her next pregnancy and birth. 3. Have her blood pressure checked weekly for the next 30 days. 4. Seek genetic counseling with her partner before the next pregnancy. Correct Answer: 1 Rationale 1: Follow-up care consists of monitoring hCG levels weekly until they are negative three consecutive times, then monthly for 6 months. Patients are advised not to get pregnant due to potential confusion between tumor growth and pregnancy. Rationale 2: There is no indication for the administration of RhoGAM. Rationale 3: There is no indication of blood pressure problems or preeclampsia. Rationale 4: This is not a genetic defect that genetic counseling could/would resolve. Question 29 A patient at 10 weeks' gestation has developed cholecystitis. If surgery is required, the safest time during pregnancy would be: 1. Immediately, before the fetus gets any bigger.
2. Early in the second trimester. 3. As close to term as possible. 4. The risks are too high to do it anytime in pregnancy. Correct Answer: 2 Rationale 1: The risk of miscarriage is greater in the first trimester. Rationale 2: Early in the second trimester, the risk of spontaneous abortion and early labor is lower, and the fetus is not so large that it might interfere with the abdominal field. Rationale 3: A fetus close to term is so large that it might interfere with the abdominal field. Rationale 4: There is always a risk, but it is greater in the first and third trimesters. Question 30 The nurse is presenting a class to newly pregnant families. What form of trauma will the nurse describe as the leading cause of fetal and maternal death? 1. Falls 2. Domestic violence 3. Gun accidents 4. Motor vehicle accidents Correct Answer: 4 Rationale 1: Falls are not the leading cause of death. Rationale 2: Domestic violence is not the leading cause of death. Rationale 3: Gun accidents are not common in pregnancy. Rationale 4: The leading cause of fetal and maternal death in pregnancy is motor vehicle accidents. Question 31 During a prenatal exam, a patient describes several psychosomatic symptoms and has several vague complaints. What could these behaviors indicate? 1. Abuse
2. Mental illness 3. Depression 4. Nothing, they are normal. Correct Answer: 1 Rationale 1: Chronic psychosomatic symptoms and vague complaints can be indicators of abuse. Rationale 2: Chronic psychosomatic symptoms and vague complaints are not indicators of mental illness. Rationale 3: Chronic psychosomatic symptoms and vague complaints are not indicators of depression. Rationale 4: These signs should not be discounted as normal. Question 32 The nurse is caring for a patient at 35 weeks' gestation who has been critically injured in a shooting. Which statement by the paramedics bringing the woman to the hospital would cause the greatest concern? 1. "Blood pressure 110/68, pulse 90." 2. "Entrance wound present below the umbilicus." 3. "Patient is positioned in a left lateral tilt." 4. "Clear fluid is leaking from the vagina." Correct Answer: 2 Rationale 1: These are normal vital signs, indicating a hemodynamically stable client. Rationale 2: Penetrating abdominal trauma has a 59–80% fetal injury rate. This fetus is at great risk for injury. Rationale 3: Positioning the client in a lateral tilt position prevents vena cava syndrome. Rationale 4: Clear fluid from the vagina could be amniotic fluid from spontaneous rupture of the membranes. Although this is not a normal finding at 35 weeks, this fetus is near term, and would likely survive birth at this time. Question 33
The patient at 34 weeks' gestation has been stabbed in the low abdomen by her boyfriend. She is brought to the emergency department for treatment. Which statements indicate that the patient understands the treatment being administered? Standard Text:select all that may apply 1. "The baby needs to be monitored to check the heart rate." 2. "My bowel has probably been lacerated by the knife." 3. "I might need an ultrasound to look at the baby." 4. "The catheter in my bladder will prevent urinary complications." 5. "The IV in my arm will replace the amniotic fluid if it is leaking." Correct Answer: 1,3 Rationale 1: Penetrating trauma to the abdomen during advanced pregnancy often results in ruptured membranes, with external leaking of fluid. The baby will be evaluated with electronic fetal monitoring and ultrasound examination to determine hemodynamic stability and look for injuries. Rationale 2: The pregnancy usually sustains the majority of the damage, sparing the bowel from injury. Rationale 3: The baby will be evaluated with electronic fetal monitoring and ultrasound examination to determine hemodynamic stability and look for injuries. Rationale 4: The Foley catheter is placed to assess for hematuria. Rationale 5: The IV will replace intravascular volume, not amniotic fluid. Question 34 A patient is admitted to the labor suite. It is essential that the nurse assess the woman’s status in relation to which infectious diseases? Standard Text:select all that may apply 1. Hepatitis B 2. Rubeola 3. Varicella 4. Group B streptococcus
5. HIV/AIDS Correct Answer: 1,4,5 Rationale 1: Hepatitis B should be assessed. Rationale 2: This is not of immediate importance. Rationale 3: This is not of immediate importance. Rationale 4: Streptococcus B should definitely be assessed. Rationale 5: HIV/AIDS should be assessed. Question 35 The nurse knows that a mother who has been treated for Beta streptococcus passes this risk on to her newborn. Risk factors for neonatal sepsis caused by Beta streptococcus include: Standard Text:select all that may apply 1. Prematurity. 2. Maternal intrapartum fever. 3. Membranes ruptured for longer than 18 hours. 4. A previously infected infant with GBS disease. 5. An older mother having her first baby. Correct Answer: 1,2,3,4 Rationale 1: Prematurity is a risk factor. Rationale 2: Maternal intrapartum fever is a risk factor. Rationale 3: Prolonged rupture of membranes is a risk factor. Rationale 4: A previously infected infant increases the risk. Rationale 5: Young maternal age is a risk factor.
Old's Maternal-Newborn Nursing and Women's Health, 11e(Davidson/London/Ladewig) Chapter 19 Processes and Stages of Labor and Birth 1. How would the nurse best analyze the results from a client's sonogram that showsthe fetal shoulder as the presenting part? A) Breech, transverse B) Breech, longitudinal C) Breech, frank D) Vertex, transverse Answer: A Explanation: A) A shoulder presentation is one type of breech presentation, and is also called a transverse lie. B) A shoulder presentation is not a longitudinal lie. C) In a frank breech, the buttocks are the presenting part. D) A shoulder presentation is not vertex. Page Ref: 435 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅰ. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science andquality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Examine the five critical factors that affect the labor process. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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2. A clinic nurse is preparing diagrams of pelvic shapes. Which pelvic shapes are considered least adequate for vaginal childbirth? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Android B) Anthropoid C) Gynecoid D) Platypelloid E) Lambdoidal suture Answer: A, D Explanation: A) In the android and platypelloid types, the pelvic diameters are diminished. Laboris more likely to be difficult (longer) and a cesarean birth is more likely. B) The anthropoid pelvis type is considered favorable for vaginal childbirth. C) The gynecoid pelvis type is considered favorable for vaginal childbirth. D) In the android and platypelloid types, the pelvic diameters are diminished. Laboris more likely to be difficult (longer) and a cesarean birth is more likely. E) This is not a pelvis type. Page Ref: 431 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅰ. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science andquality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Examine the five critical factors that affect the labor process. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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3. The nurse is caring for laboring clients. Which women are experiencing problemsrelated to a critical factor of labor? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Woman at 7 cm, fetus in general flexion B) Woman at 3 cm, fetus in longitudinal lie C) Woman at 4 cm, fetus with transverse lie D) Woman at 6 cm, fetus at -2 station, mild contractions E) Woman at 5 cm, fetal presenting part is right shoulder Answer: C, D, E Explanation: A) Fetal attitude refers to the relation of the fetal body parts to one another and describes the posture the fetus assumes as it conforms to the shape of the uterine cavity. The normal attitude of the fetus is termed general flexion, where the head is flexed so that the chin is on the chest with the arms crossed over thechest, and the legs are flexed at the knees with the thighs on the abdomen. B) Fetal lie refers to the relationship of the long, or cephalocaudal, axis (spinal column) of the fetus to the long, or cephalocaudal, axis of the mother. The fetusmay assume either a longitudinal (vertical) or a transverse (horizontal) lie; a longitudinal lie is normal. C) A transverse lie occurs when the cephalocaudal axis of the fetal spine is at a rightangle to the woman's spine and is associated with a shoulder presentation and can lead to complications in the later stages of labor. D) Station refers to the relationship of the presenting part to an imaginary line drawn between the ischial spines of the maternal pelvis. If the presenting part is higher than the ischial spines, a negative number is assigned, noting centimeters abovezero station. A -2 station is high in the pelvis. Contractions should be strong to cause fetal descent. Mild contractions will not move the baby down or open the cervix. This client is experiencing a problem between the maternal pelvis and thepresenting part. E) When the fetal shoulder is the presenting part, the fetus is in a transverse lie andthe acromion process of the scapula is the landmark. This type of presentation occurs less than 1% of the time. This client is experiencing a problem between the maternal pelvis and the presenting part. Page Ref: 432 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅰ. 3. Use skillsof inquiry, analysis, and information literacy to address practice issues. | NLN
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Competencies: Quality and Safety: Communicate potential risk factors and actualerrors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Examine the five critical factors that affect the labor process. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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4. The charge nurse has received the shift change report. Which client requires immediate intervention? A) Woman at 6 cm undergoing induction of labor, strong contractions every 3 minutes B) Woman at 4 cm whose fetus is in a longitudinal lie with a cephalic presentation C) Woman at 10 cm and fetus at +2 station experiencing a strong expulsion urge D) Woman at 3 cm screaming in fear because her mother died during childbirth Answer: D Explanation: A) Strong contractions every 3 minutes constitute an adequate labor pattern during induction of labor. This client is experiencing no complications. B) Longitudinal lie with cephalic presentation is a head-down position. This is expected. C) 10 cm is fully dilated; a +2 station is low in the pelvis. A strong expulsion urge isthe urge to push, which will facilitate the birth of the child. These are expected. D) This client is most likely fearful that she will die during labor because her mother died during childbirth. This client requires education and a great deal of support, and is therefore the top priority. Page Ref: 443 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅴ. C. 6. Value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the healthcare team. | AACN Essentials Competencies: Ⅸ. 12. Create a safe environment that reflects high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Describe the physiologic and psychosocial changes that areindicative of the maternal progress during each of the stages of labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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5. Premonitory signs of labor include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Braxton Hicks contractions B) Cervical softening and effacement C) Weight gain D) Rupture of membranes E) Sudden loss of energy Answer: A, B, D Explanation: A) A premonitory sign of labor includes Braxton Hicks contractions. B) A premonitory sign of labor includes cervical softening and effacement. C) A premonitory sign of labor includes weight loss, not weight gain. D) A premonitory sign of labor includes rupture of membranes. E) A premonitory sign of labor includes a sudden burst of energy, not a loss ofenergy. Page Ref: 440 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅰ. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 4 Discuss premonitory signs of labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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6. A client arrives in the labor and delivery unit and describes her contractions as occurring every 10-12 minutes, lasting 30 seconds. She is smiling and very excitedabout the possibility of being in labor. On exam, her cervix is dilated 2 cm, 100% effaced, and -2 station. What best describes this labor? A) Second phase B) Latent phase C) Active phase D) Transition phase Answer: B Explanation: A) There is no phase of labor that is identified as the second phase. B) In the early or latent phase of the first stage of labor, contractions are usually mild. The woman feels able to cope with the discomfort. The woman is often talkative and smiling and is eager to talk about herself and answer questions. C) When the woman enters the early active phase, her anxiety tends to increase asshe senses the intensification of contractions and pain. During this phase the cervix dilates from about 4 to 7 cm. D) When the woman enters the transition phase, she may demonstrate significant anxiety. She becomes acutely aware of the increasing force and intensity of the contractions. She may become restless, frequently changing position. Page Ref: 443 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅰ. B. 3. Provide patient-centered care with sensitivityand respect for the diversity of human experience. | AACN Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Apply evidence to support decision making insituations characterized by ambiguity and uncertainty. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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7. The client has asked the nurse why her cervix has only changed from 1 to 2 cm in 3hours of contractions occurring every 5 minutes. What is the nurse's best response to the client? A) "Your cervix has also effaced, or thinned out, and that change in the cervix is alsolabor progress." B) "When your perineal body thins out, your cervix will begin to dilate much fasterthan it is now." C) "What did you expect? You've only had contractions for a few hours. Labor takestime." D) "The hormones that cause labor to begin are just getting to be at levels that willchange your cervix." Answer: A Explanation: A) With each contraction, the muscles of the upper uterine segment shorten and exert a longitudinal traction on the cervix, causing effacement. Effacement is thetaking up (or drawing up) of the internal os and the cervical canal into the uterineside walls. B) As the fetal head descends to the pelvic floor, the pressure of the presenting partcauses the perineal structure, which was once 5 cm in thickness, to change to a structure less than 1 cm thick. The perineal body's thinning primarily occurs during later stages of labor; it is not expected now. C) This reply is not therapeutic. The nurse must always be therapeutic in all communication. D) The hormones that cause labor contractions do not directly cause cervicalchange; the contractions cause the cervix to change. Page Ref: 440 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅰ. B. 15. Communicate care provided and needed ateach transition in care. | AACN Essentials Competencies: Ⅸ. 21. Engage in caring andhealing techniques that promote a therapeutic nurse-patient relationship. | NLN Competencies: Quality and Safety: Encourage patients and families to communicate their observations and concerns regarding safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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8. To identify the duration of a contraction, the nurse would do which of the following? A) Start timing from the beginning of one contraction to the completion of the same contraction. B) Time between the beginning of one contraction and the beginning of the next contraction. C) Palpate for the strength of the contraction at its peak. D) Time from the beginning of the contraction to the peak of the same contraction. Answer: A Explanation: A) The duration of each contraction is measured from the beginning of the contraction to the completion of the contraction. B) Duration is not measured this way. C) Duration is not measured this way. D) Duration is not measured this way. Page Ref: 437 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅰ. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science andexcellence in nursing. | Nursing/Integrated Concepts: Nursing Process: Implementation.Learning Outcome: 3 Describe the physiology of labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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9. The client at 40 weeks' gestation reports to the nurse that she has had increased pelvic pressure and increased urinary frequency. Which response by the nurse isbest? A) "Unless you have pain with urination, we don't need to worry about it." B) "These symptoms usually mean the baby's head has descended further." C) "Come in for an appointment today and we'll check everything out." D) "This might indicate that the baby is no longer in a head-down position." Answer: B Explanation: A) Increased pelvic pressure and urinary frequency are premonitory signs of labor.These are not signs of a urinary tract infection. B) This is the best response because it most directly addresses what the client hasreported. C) There is no need for an additional appointment. D) The fetus's changing to a breech presentation would be experienced as fetal movement that was formerly felt in the upper abdomen but now is down in thepelvis. Page Ref: 440 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. C. 10. Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care. | AACN Essentials Competencies: Ⅸ. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: RelationshipCentered Care: Communicate information effectively; listen openly andcooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Discuss premonitory signs of labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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10. The client at 39 weeks' gestation calls the clinic and reports increased bladder pressure but easier breathing and irregular, mild contractions. She also states thatshe just cleaned the entire house. Which statement should the nurse make? A) "You shouldn't work so much at this point in pregnancy." B) "What you are describing is not commonly experienced in the last weeks." C) "Your body may be telling you it is going into labor soon." D) "If the bladder pressure continues, come in to the clinic tomorrow." Answer: C Explanation: A) There is no indication that the client should decrease her work schedule. B) Lightening is a common and expected finding. C) One of the premonitory signs of labor is lightening: The fetus begins to settle intothe pelvic inlet (engagement). With fetal descent, the uterus moves downward, and the fundus no longer presses on the diaphragm, which eases breathing. D) Lightening does not indicate pathology, and therefore there is no need for theclient to come to the clinic if the symptoms continue. Page Ref: 440 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Discuss premonitory signs of labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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11.AA client calls the labor and delivery unit and tells the nurse that she is 39 weeks pregnant and over the last 4 or 5 days, she has noticed that although her breathing has become easier, she is having leg cramps, a slight amount of edema in her lowerlegs, and an increased amount of vaginal secretions. The nurse tells the client that she has experienced which of the following? A) Engagement B) Lightening C) Molding D) Braxton Hicks contractions Answer: B Explanation: A) Engagement of the presenting part occurs when the largest diameter of the fetal presenting part reaches or passes through the pelvic inlet. B) Lightening describes the effect occurring when the fetus begins to settle into thepelvic inlet. C) The fetal cranial bones overlap under pressure of the powers of labor and the demands of the unyielding pelvis. This overlapping is called molding. D) Braxton Hicks contractions occur before the onset of labor. Page Ref: 440 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment.Learning Outcome: 4 Discuss premonitory signs of labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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12.A A client who is having false labor most likely would have which of the following? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Contractions that do not intensify while walking B) An increase in the intensity and frequency of contractions C) Progressive cervical effacement and dilation D) Pain in the abdomen that does not radiate E) Contractions that lessen with rest and warm tub baths Answer: A, D, E Explanation: A) True labor contractions intensify while walking. B) The contractions of true labor produce progressive dilation and effacement of thecervix. They occur regularly and increase in frequency, duration, and intensity. C) True labor results in progressive dilation, increased intensity and frequency of contractions, and pain in the back that radiates to the abdomen. D) True labor results in progressive dilation, increased intensity and frequency of contractions, and pain in the back that radiates to the abdomen. E) In true labor, contractions do not lessen with rest and warm tub baths. Page Ref: 440 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment.Learning Outcome: 5 Differentiate between false and true labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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13. The nurse is preparing a client education handout on the differences between falselabor and true labor. What information is most important for the nurse to include? A) True labor contractions begin in the back and sweep toward the front. B) False labor often feels like abdominal tightening, or "balling up." C) True labor can be diagnosed only if cervical change occurs. D) False labor contractions do not increase in intensity or duration. Answer: C Explanation: A) Although this is a true statement, it is not the most important indication of truelabor. B) Although this is a true statement, it is not the most important fact about false andtrue labor. C) Cervical change is the only factor that actually distinguishes false from true labor.The contractions of true labor produce progressive dilation and effacement of thecervix. The contractions of false labor do not produce progressive cervical effacement and dilation. D) Although this is a true statement, it is not the most important fact about true andfalse labor. Page Ref: 440 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Differentiate between false and true labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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14. The nurse is teaching a prenatal class about false labor. The nurse should teachclients that false labor will most likely include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Contractions that do not intensify while walking B) An increase in the intensity and frequency of contractions C) Progressive cervical effacement and dilation D) Pain in the abdomen that does not radiate E) Contractions are at regular intervals Answer: A, D Explanation: A) True labor contractions intensify while walking. B) True labor results in increased intensity and frequency of contractions. C) True labor results in progressive dilation. D) The discomfort of true labor contractions usually starts in the back and radiatesaround to the abdomen. E) With false labor, contractions are irregular. Page Ref: 440 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment.Learning Outcome: 5 Differentiate between false and true labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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15.AA client is admitted to the labor and delivery unit with contractions that are 2 minutes apart, lasting 60 seconds. She reports that she had bloody show earlier thatmorning. A vaginal exam reveals that her cervix is 100 percent effaced and 8 cm dilated. The nurse knows that the client is in which phase of labor? A) Active B) Latent C) Transition D) Fourth Answer: C Explanation: A) In the active phase, the woman dilates from 4 to 7 centimeters. B) The latent phase is the beginning of labor contractions and the cervix may bedilated 0 to 3 centimeters. C) The transition phase begins with 8 cm to 10 cm of dilation, and contractions become more frequent, are longer in duration, and increase in intensity. D) There is no fourth phase. The fourth stage occurs after delivery of the placenta. Page Ref: 444 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅰ. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science andexcellence in nursing. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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16.AA client is admitted to the labor unit with contractions 1-2 minutes apart lasting 60-90 seconds. The client is apprehensive and irritable. This client is most likely in what phase of labor? A) Active B) Transition C) Latent D) Second Answer: B Explanation: A) During the active phase, the cervix dilates from about 4 to 7 cm. When the woman enters the early active phase, her anxiety tends to increase as she senses the intensification of contractions and pain. B) During transition, contractions have a frequency of 1 1/2 to 2 minutes, a durationof 60 to 90 seconds, and are strong in intensity. When the woman enters the transition phase, she may demonstrate significant anxiety. C) The latent phase is characterized by mild contractions lasting 20 to 40 secondswith a frequency of 3 to 30 minutes. In the latent stage, the woman may be relieved that labor has finally started. D) The second stage is the pushing stage, and the woman might feel relieved thatthe birth is near and she can push. There is no second phase of labor. Page Ref: 444 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅰ. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science andexcellence in nursing. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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17. The client in early labor asks the nurse what the contractions are like as labor progresses. What would the nurse respond? A) "In normal labor, as the uterine contractions become stronger, they usually alsobecome less frequent." B) "In normal labor, as the uterine contractions become stronger, they usually alsobecome less painful." C) "In normal labor, as the uterine contractions become stronger, they usually alsobecome longer in duration." D) "In normal labor, as the uterine contractions become stronger, they usually alsobecome shorter in duration." Answer: C Explanation: A) The uterine contractions of labor become more frequent as labor progresses. B) The uterine contractions of labor become more painful over time. C) During the active and transition phases, contractions become more frequent, arelonger in duration, and increase in intensity. D) The uterine contractions of labor do not become shorter in duration as labor progresses. Page Ref: 444 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly or cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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18. Four minutes after the birth of a baby, there is a sudden gush of blood from the mother's vagina, and about 8 inches of umbilical cord slides out. What action shouldthe nurse take first? A) Place the client in McRoberts position. B) Watch for the emergence of the placenta. C) Prepare for the delivery of an undiagnosed twin. D) Place the client in a supine position. Answer: B Explanation: A) Exercises aimed at adducting the legs into an extended McRoberts position, which is performed by flexing the mother's thighs toward her shoulders while sheis lying on her back, help enable the woman to stretch her hamstring muscles, a task usually required during the second stage of labor. B) Signs of placental separation usually appear around 5 minutes after birth of the infant, but can take up to 30 minutes to manifest. These signs are (1) a globular-shaped uterus, (2) a rise of the fundus in the abdomen, (3) a sudden gush or trickle of blood, and (4) further protrusion of the umbilical cord out of the vagina. C) The first placenta usually does not deliver before the birth of the second twin. D) Blood pressure may drop precipitously when the pregnant woman lies in a supineposition and experiences aortocaval compression. Page Ref: 445 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅰ. B. 3. Provide patient-centered care with sensitivityand respect for the diversity of human experience. | AACN Essentials Competencies: Ⅸ. 5. Deliver compassionate, patient-centered, evidence-based care that respectspatient and family preferences. | NLN Competencies: Relationship-Centered Care:Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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19.AA nurse needs to evaluate the progress of a woman's labor. The nurse obtains thefollowing data: cervical dilation 6 cm; contractions mild in intensity, occurring every 5minutes, with a duration of 30-40 seconds. Which clue in this data does not fit the pattern suggested by the rest of the clues? A) Cervical dilation 6 cm B) Mild contraction intensity C) Contraction frequency every 5 minutes D) Contraction duration 30-40 seconds Answer: A Explanation: A) Cervical dilation of 6 cm indicates the active phase of labor. During this phase thecervix dilates from about 4 to 7 cm and contractions and pain intensify. B) Mild contractions are consistent with most of the scenario. C) This contraction frequency is consistent with most of the scenario. D) This contraction duration is consistent with most of the scenario. Page Ref: 444 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅰ. B. 3. Provide patient-centered care with sensitivityand respect for the diversity of human experience. | AACN Essentials Competencies: Ⅸ. 5. Deliver compassionate, patient-centered, evidence-based care that respectspatient and family preferences. | NLN Competencies: Relationship-Centered Care:Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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20. The labor nurse would not encourage a mother to bear down until the cervix is completely dilated, to prevent which of the following? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Maternal exhaustion B) Cervical edema C) Tearing and bruising of the cervix D) Enhanced perineal thinning E) Having to perform an episiotomy Answer: A, B, C Explanation: A) If the cervix is not completely dilated, maternal exhaustion can occur. B) If the cervix is not completely dilated, cervical edema can occur. C) If the cervix is not completely dilated, tearing and bruising of the cervix can occur. D) Cervical dilation has nothing to do with perineal thinning. E) Not bearing down until the cervix is completely dilated has nothing to do with needing an episiotomy. Page Ref: 437 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: Ⅸ. 12. Create asafe environment that results in high-quality patient outcomes. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Describe the physiologic and psychosocial changes that areindicative of the maternal progress during each of the stages of labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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21. The nurse is caring for a laboring client. A cervical exam indicates 8 cm dilation. Theclient is restless, frequently changing position in an attempt to get comfortable. Which nursing action is most important? A) Leave the client alone so she can rest. B) Ask the family to take a coffee-and-snack break. C) Encourage the client to have an epidural for pain. D) Reassure the client that she will not be left alone. Answer: D Explanation: A) The client is in the transitional phase of the first stage of labor, and will not wantto be alone. B) The client is in the transitional phase of the first stage of labor. The family members might want to take a break, but the client will not want to be alone. C) The client is in the transitional phase of the first stage of labor. There is no indication that the client wants pain relief. D) Because the client is in the transitional phase of the first stage of labor, she will not want to be left alone; staying with the client and reassuring her that she will not be alone are the highest priorities at this time. Page Ref: 444 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Therapeutic Environment Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship. | NLN Competencies:Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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22. During the fourth stage of labor, the client's assessment includes a BP of 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubisand the umbilicus. What is the priority action of the nurse? A) Turn the client onto her left side. B) Place the bed in Trendelenburg position. C) Massage the fundus. D) Continue to monitor. Answer: D Explanation: A) A left lateral position is not necessary with a BP of 110/60 and a pulse of 90. B) The Trendelenburg position is not necessary with a BP of 110/60 and a pulse of90. C) The uterus should be midline and firm; massage is not necessary. D) The client's assessment data are normal for the fourth stage of labor, so monitoring is the only action necessary. During the fourth stage of labor, themother experiences a moderate drop in both systolic and diastolic blood pressure, increased pulse pressure, and moderate tachycardia. Page Ref: 449 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅰ. B. 3. Provide patient-centered care with sensitivityand respect for the diversity of human experience. | AACN Essentials Competencies: Ⅸ. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Quality and Safety: Relationshipsbetween knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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23. The nurse has just palpated a laboring woman's contractions. The uterus cannot be indented during a contraction. What would the intensity of these contractions best becharacterized as? A) Weak B) Mild C) Moderate D) Strong Answer: D Explanation: A) Weak contractions are not identified. B) If the uterine wall can be indented easily, the contraction is considered mild. C) Moderate intensity falls between these two ranges. When intensity is measured with an intrauterine catheter, the normal resting tonus (between contractions) is about 10 to 12 mmHg of pressure. During acme the intensity ranges from 25 to 40 mmHg in early labor, 50 to 70 mmHg in active labor, 80 to 100 mmHg during transition, and greater than 100 mmHg while the woman is pushing in the secondstage. D) Strong intensity exists when the uterine wall cannot be indented. Page Ref: 437 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅰ. B. 3. Provide patient-centered care with sensitivityand respect for the diversity of human experience. | AACN Essentials Competencies: Ⅸ. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Quality and Safety: Relationshipsbetween knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Describe the physiology of labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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24. The labor and delivery nurse is reviewing charts. The nurse should inform the supervisor about which client? A) Client at 5 cm requesting labor epidural analgesia B) Client whose cervix remains at 6 cm for 4 hours C) Client who has developed nausea and vomiting D) Client requesting her partner to stay with her Answer: B Explanation: A) Contacting the supervisor is required when an abnormal situation is present. Requests for medication are not abnormal. B) Average cervical change in the active phase of the first stage of labor is 1.2 c m/hour; thus, this client's lack of cervical change is unexpected, and should bereported to the supervisor. C) Nausea and vomiting are common during the transitional phase of the first stage of labor. Contacting the supervisor is required only when an abnormal situation ispresent. D) Clients in the transitional phase of the first stage of labor often fear being left alone; this is an expected finding. Contacting the supervisor is required only when an abnormal situation is present. Page Ref: 444 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: II. B. 9. Communicate with team members, adaptingown style of communicating to needs of the team and situation. | AACN Essentials Competencies: Ⅸ. 13. Revise the plan of care based on an ongoing evaluation of patient outcomes | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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25. Which client requires immediate intervention by the labor and delivery nurse? A) Client at 8 cm, systolic blood pressure has increased 35 mmHg B) Client who delivered 1 hour ago with WBC of 50,000/mm3 C) Client at 5 cm with a respiratory rate of 22 between contractions D) Client in active labor with polyuria Answer: B Explanation: A) In the first stage, systolic pressure may increase by 35 mmHg, and there may befurther increases in the second stage during pushing efforts. B) The white blood cell (WBC) count increases to between 25,000/mm3 to 30,000/mm3 during labor and early postpartum. This count is abnormally high,and requires further assessment and provider notification. C) Oxygen demand and consumption increase at the onset of labor because of thepresence of uterine contractions. This client requires no further intervention. D) Polyuria is common during labor. This results from the increase in cardiac output,which causes an increase in the glomerular filtration rate and renal plasma flow, and requires no further intervention. Page Ref: 450 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: Ⅸ. 12. Create asafe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts:Nursing Process: Assessment. Learning Outcome: 8 Summarize maternal systemic responses to labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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26. The labor and delivery nurse is preparing a prenatal class about facilitating the progress of labor. Which of the following frequent responses to pain should the nurse indicate is most likely to impede progress in labor? A) Increased pulse B) Elevated blood pressure C) Muscle tension D) Increased respirations Answer: C Explanation: A) Increased pulse is a manifestation of pain, but does not impede labor. B) Elevated blood pressure is a manifestation of pain, but does not impede labor. C) It is important for the woman to relax each part of her body. Be alert for signs ofmuscle tension and tightening. Dissociative relaxation, controlled muscle relaxation, and specified breathing patterns are used to promote birth as a normal process. D) Increased respiration is a manifestation of pain, but does not impede labor. Page Ref: 428 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 8 Summarize maternal systemic responses to labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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27. While caring for a client in labor, the nurse notices during a vaginal exam that thefetus's head has rotated internally. What would the nurse expect the next set of cardinal movements for a fetus in a vertex presentation to be? A) Flexion, extension, restitution, external rotation, and expulsion B) Expulsion, external rotation, and restitution C) Restitution, flexion, external rotation, and expulsion D) Extension, restitution, external rotation, and expulsion Answer: D Explanation: A) The next set of cardinal movements would not begin with flexion. B) This is not the correct order of fetal position changes. C) This is not the correct order of fetal position changes. D) The fetus changes position in the following order: descent, flexion, internal rotation, extension, restitution, external rotation, and expulsion. Page Ref: 445 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅰ. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science andquality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Describe the characteristics of the four stages of labor and their accompanying phases. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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28. When comparing the anterior and posterior fontanelles of a newborn, the nurseknows that both are what? A) Both are approximately the same size. B) Both close within 12 months of birth. C) Both are used in labor to identify station. D) Both allow for assessing the status of the newborn after birth. Answer: D Explanation: A) The anterior fontanelle measures approximately 2-3 cm. The posterior fontanelleis much smaller. B) The anterior fontanelle closes around the 18th month. The posterior fontanellecloses between 8 and 12 weeks after birth. C) In labor, the presenting part, not the fontanelles, is used to identify station. D) The anterior and posterior fontanelles are clinically useful in identifying the position of the fetal head in the pelvis and in assessing the status of the newbornafter birth. Page Ref: 432 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅰ. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science andquality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Examine the five critical factors that affect the labor process. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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29. The nurse is aware that labor and birth will most likely proceed normally when thefetus is in what position? A) Right-acromion-dorsal-anterior B) Right-sacrum-transverse C) Occiput anterior D) Posterior position Answer: C Explanation: A) Right-acromion-dorsal-anterior denotes a fetal position in a shoulder presentation, which would be a difficult delivery. B) Right-sacrum-transverse indicates a breech delivery, which would be a difficult delivery. C) The most common fetal position is occiput anterior. When this position occurs,labor and birth are likely to proceed normally. D) The fetal head presents a larger diameter in a posterior position than in an anterior position. A posterior position increases the pressure on the maternal sacral nerves, causing the laboring woman to experience backache and pelvicpressure. Page Ref: 436 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅰ. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science andquality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Examine the five critical factors that affect the labor process. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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30. The midwife performs a vaginal exam and determines that the fetal head is at a -2station. What does this indicate to the nurse about the birth? A) The birth is imminent. B) The birth is likely to occur in 1-2 hours. C) The birth will occur later in the shift. D) The birth is difficult to predict. Answer: D Explanation: A) Birth is not imminent at this time. B) Birth will not likely occur in 1-2 hours. C) Birth cannot really be predicted at this time. D) A -2 station means that the fetus is 2 cm above the ischial spines. The ischial spines as a landmark have been designated as zero station. If the presenting part is higher than the ischial spines, a negative number is assigned, noting centimeters above zero station. With the fetus's head that high in the pelvis, it isdifficult to predict when birth will occur. Page Ref: 436 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅰ. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science andquality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Examine the five critical factors that affect the labor process. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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31. Childbirth preparation offers several advantages including which of the following? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) It helps a pregnant woman and her support person understand the choices in thebirth setting. B) It promotes awareness of available options. C) It provides tools for a pregnant woman and her support person to use duringlabor and birth. D) Women who receive continuous support during labor require more analgesia,and have more cesarean and instrument births. E) Each method has been shown to shorten labor. Answer: A, B, C, E Explanation: A) Childbirth preparation offers several advantages. It helps a pregnant woman andher support person understand the choices in the birth setting, promotes awareness of available options, and provides tools for them to use during labor and birth. B) Childbirth preparation offers several advantages. It helps a pregnant woman andher support person understand the choices in the birth setting, promotes awareness of available options, and provides tools for them to use during labor and birth. C) Childbirth preparation offers several advantages. It helps a pregnant woman andher support person understand the choices in the birth setting, promotes awareness of available options, and provides tools for them to use during labor and birth. D) This is not true. Women who receive continuous support during labor require less analgesia, and have fewer cesarean and instrument births. E) Childbirth preparation offers several advantages. Each method has been shownto shorten labor. Page Ref: 428 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.
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Learning Outcome: 1 Compare methods of childbirth preparation. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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32. The nurse is reviewing educational material on newborn care with a patient in the 3rd trimester of pregnancy. Which area on the following diagram should the nurse point out as being the anterior fontanelle?
A) A B) B C) C D) D Answer: C Explanation: C) The greater, or anterior, fontanelle (bregma) is diamond shaped, measures 2 to 3cm, and is situated at the junction of the sagittal, coronal, and frontal sutures. It permits growth of the brain by remaining unossified for as long as 18 months. Choice 1 is the posterior fontanelle. Choice 2 is the sagittal suture. Choice 4 is the frontal suture. Page Ref: 432 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 1 Compare methods of childbirth preparation. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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33. The fetus of a patient in labor is determined to be in the brow presentation. Whichdiagram should the nurse provide to the patient to explain this position? A)
B)
C)
D)
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Answer: C Explanation: C) In the brow presentation, the fetal head is in partial (halfway) extension. The occipitomental diameter, which is the largest diameter of the fetal head, presentsto the pelvis. Choice 1 is the vertex presentation. Complete flexion of the head allows the suboccipitobregmatic diameter to present to the pelvis. Choice 2 is theSinciput (median vertex) prese ntation (also called military presentation) with no flexion or extension. The occipitofrontal diameter presents to the pelvis. Choice 4 is the face presentation. The fetal head is in complete extension, and the submentobregmatic diameter presents to the pelvis. Page Ref: 435 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 2 Examine the five critical factors that affect the labor process. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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34.AA pregnant patient's fetus is in the left-occiput-transverse position. Which diagram should the nurse use to explain this position to the patient? A)
B)
C)
D)
Answer: A 37 Copyright © 2020 Pearson Education, Inc.
Explanation: A) Choice 1 is the LOT or left-occiput-transverse position. Choice 2 is the LOP or leftocciput-posterior position. Choice 3 is the ROT or right-occiput-transverse position. Choice 4 is the LOA or left-occiput-anterior position. Page Ref: 436 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 9 Describe fetal adaptations to labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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35. The cervix of a laboring patient is measured as being 50% effaced. Which diagramshould the nurse use to explain this finding to the patient? A)
B)
C)
D) 39 Copyright © 2020 Pearson Education, Inc.
Answer: C Explanation: C) The cervix is about one half (50%) effaced and slightly dilated. The increasing amount of amniotic fluid below the fetal head exerts hydrostatic pressure on thecervix. Choice 1 is the beginning of labor, where there is no cervical effacementor dilation. The fetal head is cushioned by amniotic fluid. Choice 2 is the beginning of cervical effacement. As the cervix begins to efface, more amniotic fluid collects below the fetal head. Choice 4 is complete effacement and dilation. Page Ref: 441 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 9 Describe fetal adaptations to labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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36. The nurse is assisting in the delivery of a pregnant patient's placenta post-delivery. The placenta appears as follows. What term should the nurse use to document this placental delivery?
A) Schultz mechanism of delivery B) Duncan mechanism of delivery C) Complete mechanism of delivery D) Incomplete mechanism of delivery Answer: B Explanation: B) If the placenta separates from the outer margins inward, it will roll up and present sideways with the maternal surface delivering first. This is known as the Duncan mechanism of placental delivery and is commonly called dirty Duncan because the placental surface is rough. If the placenta separates from the inside to the outer margins, it is expelled with the fetal (shiny) side presenting. This is known as the Schultze mechanism of placental delivery or, more commonly, shiny Schultze. This diagram does not demonstrate complete or incomplete mechanisms of placental delivery. Page Ref: 448 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 4. Communicate effectively with all members of the healthcare team, including the patientand the patient's support network. | NLN Competencies: Relationship-Centered Care: Knowledge; effective communication. | Nursing/Integrated Concepts: Implementation: Communication and Documentation. Learning Outcome: 7 Describe the physiologic and psychosocial changes that areindicative of the maternal progress during each of the stages of labor. MNL LO: Demonstrate use of the nursing process in the care of a laboring patient.
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Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 20. Intrapartum Nursing Assessment Question 1 The nurse is admitting a patient to the birthing unit. What question should the nurse ask to gain a better understanding of the patient’s psychosocial status? 1. "How did you decide to have your baby at this hospital?" 2. "Who will be your labor support person?" 3. "Have you chosen names for your baby yet?" 4. "What feeding method will you use for your baby?" Correct Answer: 2 Rationale 1: The reason the patient is delivering at this facility is not an indication of psychosocial status. Rationale 2: Labor support is important for the laboring patient. In some cultures the father of the baby is the support person. In other cultures men are not involved in the birth, and older women who have given birth themselves provide labor support. Rationale 3: Naming the infant is influenced by culture, and is not an indicator of psychosocial status. Rationale 4: The chosen feeding method is not an indicator of psychosocial status. Question 2 The nurse is admitting a patient to the labor and delivery unit. Which aspect of the patient's history requires notifying the physician? 1. Blood pressure 120/88 2. Father a carrier of sickle-cell trait 3. Dark red vaginal bleeding 4. History of domestic abuse Correct Answer: 3 Rationale 1: Although the diastolic reading is slightly elevated, this blood pressure reading is not the top priority.
Rationale 2: The infant also might have sickle-cell trait, but it is not life-threatening at this time. Rationale 3: Third-trimester bleeding is caused by either placenta previa or abruptio placentae. Dark red bleeding usually indicates abruptio placentae, which is life-threatening to both mother and fetus. Rationale 4: This patient is at risk for harm after delivery but is not in a life-threatening situation at this time. This is not the highest priority for the patient. Question 3 The nurse is working with a pregnant adolescent. The patient asks the nurse how the baby's condition is determined during labor. The nurse’s best response is that during labor, the nurse will: 1. Check the patient’s cervix by doing a pelvic exam every 2 hours. 2. Assess the baby's heart rate with an electronic fetal monitor. 3. Look at the color and amount of bloody show that the patient has. 4. Verify that the patient’s contractions are strong but not too close together. Correct Answer: 2 Rationale 1: Although cervical exams are performed on a regular basis, the pelvic exam does not assess fetal status. Rationale 2: This statement best answers the question the patient has asked. Rationale 3: Although bloody show is monitored, doing so does not assess fetal status. Rationale 4: Although contraction strength is palpated abdominally, this procedure does not assess fetal status in labor. Question 4 During the initial intrapartal assessment of a patient in early labor, the nurse performs a vaginal examination. The patient's partner asks why this pelvic exam needs to be done. The nurse should explain that the purpose of the vaginal exam is to obtain information about the: Standard Text: Select all that apply. 1. Uterine contraction pattern. 2. Fetal position. 3. Presence of the mucous plug.
4. Cervical dilation and effacement. 5. Presenting part. Correct Answer: 4,5 Rationale 1: A vaginal exam would not provide information about the uterine contraction pattern. Rationale 2: Fetal position is assessed with Leopold's maneuvers. Rationale 3: A vaginal exam would not provide information about the mucous plug. Rationale 4: The vaginal examination of a laboring patient obtains information about the station of the presenting part and the dilation and effacement of the cervix. Rationale 5: The vaginal examination of a laboring patient obtains information about the fetal presenting part. Question 5 A primigravida patient has just arrived in the birthing unit. What steps would be most important for the nurse to perform to gain an understanding of the physical status of the patient and her fetus? Standard Text: Select all that apply. 1. Check for ruptured membranes and apply a fetal scalp electrode. 2. Auscultate the fetal heart rate between and during contractions. 3. Palpate contractions and resting uterine tone. 4. Assess the blood pressure, temperature, respiratory rate, and pulse rate. 5. Perform a vaginal exam for cervical dilation, and perform Leopold's maneuvers. Correct Answer: 2,3 Rationale 1: A fetal scalp electrode can be applied only if membranes have ruptured and the cervix is at least 3 cm dilated, and is indicated for high-risk pregnancies. Rationale 2: Fetal heart rate auscultation gives information about the physical status of the fetus. Rationale 3: Contraction palpation provides information about the frequency, duration, and intensity of the contractions. Rationale 4: Vital signs do not provide information on the well-being of the fetus.
Rationale 5: Neither Leopold's maneuvers nor a vaginal exam provides information on the well-being of the fetus. Question 6 The nurse is preparing to assess a laboring primiparous patient who has just arrived in the labor and birth unit. Which statement by the patient indicates that additional education is needed? 1. "You are going to do a vaginal exam to see how dilated my cervix is." 2. "The reason for a pelvic exam is to determine how low in the pelvis my baby is." 3. "When you check my cervix, you will find out how thinned out it is." 4. "After you assess my pelvis, you will be able to tell when I will deliver." Correct Answer: 4 Rationale 1: Cervical dilation is one aspect of the pelvic exam assessment. Rationale 2: Determining the station of the presenting part is one aspect of the pelvic exam assessment. Rationale 3: Cervical effacement, or the thinning of the cervix, is one aspect of the pelvic exam assessment. Rationale 4: An experienced labor and birth nurse can estimate the time of delivery based on the cervix, fetal position, station, and contraction pattern. However, during a pelvic exam, no information is obtained about contractions. The nurse will not have enough information following the cervical exam to estimate time of birth. Question 7 The primigravida has been pushing for 3 hours, and the fetus is making slow descent. The partner asks the nurse whether pushing for this long is normal. How should the nurse respond? 1. "Your baby is taking a little longer than average, but is making progress." 2. "First babies take a long time to be born. The next baby will be easier." 3. "The birth would go faster if you had taken prenatal classes and practiced." 4. "Every baby is different; there really are no norms for labor and birth." Correct Answer: 1 Rationale 1: Giving factual and reassuring advice using therapeutic communication techniques is best.
Rationale 2: Although subsequent childbirths are usually shorter and faster, telling the partner this does not answer the partner's question. Rationale 3: Prenatal classes teach relaxation, which can affect the overall length of labor but not the second stage. Rationale 4: Labor norms do exist for primigravidas and multigravidas. Question 8 During a maternal assessment, the nurse determines the fetus to be in a left occipitoanterior (LOA) position. Auscultation of the fetal heart rate should begin in the: 1. Right upper quadrant. 2. Left upper quadrant. 3. Right lower quadrant. 4. Left lower quadrant. Correct Answer: 4 Rationale 1: The fetus is head-down, so the heart rate will not be heard in an upper quadrant. Rationale 2: The fetus is head-down, so the heart rate will not be heard in an upper quadrant. Rationale 3: Due to the position of the fetus, the heart rate will not be heard on the right side. Rationale 4: The fetal heart rate is best heard at the fetal back. In a cephalic presentation, the heart rate is heard in the lower quadrants. Because this fetus is on the mother's left side, the heart tones will be heard on the mother's left lower quadrant. Question 9 A laboring patient asks the nurse, "Why does the physician want to use an intrauterine pressure catheter (IUPC) during my labor?" The nurse would accurately explain that the best rationale for using an IUPC is: 1. The IUPC can be used throughout the birth process. 2. A tocodynamometer is subject to artifacts. 3. The IUPC provides more accurate data than does the tocodynamometer. 4. The tocodynamometer can be used only after the cervix is dilated 2 cm.
Correct Answer: 3 Rationale 1: The IUPC is inserted only after membranes have ruptured. Rationale 2: The tocodynamometer, if used correctly, is not subject to artifact. Rationale 3: The IUPC, inserted only after membranes have ruptured, provides accurate measurement of uterine contraction intensity. The tocodynamometer does not accurately record the intensity of the uterine contraction. Rationale 4: The tocodynamometer can be used at any time; it is not related to cervix dilatation. Question 10 The charge nurse is looking at the charts of laboring patients. Which patient is in greatest need of further intervention? 1. Multip at 7 cm, fetal heart tones auscultated every 90 minutes 2. Primip at 10 cm and pushing, external fetal monitor applied 3. Multip with meconium-stained fluid, internal fetal scalp electrode in use 4. Primip in preterm labor, external monitor in place Correct Answer: 1 Rationale 1: During active labor, the fetal heart tones should be auscultated every 30 minutes; every 90 minutes is not frequent enough. Rationale 2: External monitoring can be done instead of auscultation of the fetal heart tones during labor. Rationale 3: Meconium-stained amniotic fluid is not an expected finding. Internal fetal monitoring with the internal fetal scalp electrode is often utilized when meconium-stained amniotic fluid is present. Rationale 4: External monitoring during preterm labor will assess both contractions and fetal status. Question 11 The laboring primiparous patient with meconium-stained amniotic fluid asks the nurse why the fetal monitor is necessary, as she finds the belt uncomfortable. Which response by the nurse is most important? "The monitor: 1. "Is necessary so we can see how your labor is progressing." 2. "Will prevent complications from the meconium in your fluid."
3. "Helps us to see how the baby is tolerating labor." 4. "Can be removed, and oxygen given instead." Correct Answer: 3 Rationale 1: The fetal monitor does not help visualize labor progress. Rationale 2: The fetal monitor does not prevent complications such as meconium aspiration syndrome. Rationale 3: Fetal monitoring is done to assess how the baby is tolerating labor. Rationale 4: Oxygen is an appropriate intervention for late decelerations, but no information is given about the fetal heart rate. Question 12 The nurse has just palpated contractions and compares the consistency to that of the forehead. The intensity of these contractions would be identified as: 1. Mild. 2. Moderate. 3. Strong. 4. Weak. Correct Answer: 3 Rationale 1: The consistency of mild contractions is similar to that of the nose. Rationale 2: The consistency of moderate contractions is similar to that of the chin. Rationale 3: The consistency of strong contractions is similar to that of the forehead. Rationale 4: Weak contractions are not identified. Question 13 Before performing Leopold's maneuvers, the nurse would: Standard Text: Select all that apply. 1. Have the patient empty her bladder.
2. Place the patient in Trendelenburg position. 3. Have the patient lie on her back with her feet on the bed and knees bent. 4. Turn the patient to her left side. 5. Have the patient lie flat with her ankles crossed. Correct Answer: 1,3 Rationale 1: Before performing Leopold's maneuvers, the nurse instructs the patient to empty her bladder. This prevents pressure on the bladder, and the fetal structures are more easily palpated when the bladder is empty. Rationale 2: Placing the patient in Trendelenburg position is not consistent with accurately performing Leopold's maneuvers. Rationale 3: Having the patient lie on her back with her feet on the bed and knees bent would be the second step. Rationale 4: Placing the patient on her left side is not consistent with accurately performing Leopold's maneuvers. Rationale 5: This is not the optimal position for the patient when performing Leopold’s maneuvers. Question 14 The student nurse is to perform Leopold's maneuvers on a laboring client. Which assessment requires intervention by the staff nurse? 1. The patient is assisted into supine position, and the position of the fetus is assessed. 2. The upper portion of the uterus is palpated, then the middle section. 3. After determining where the back is located, the cervix is assessed. 4. Following voiding, the patient's abdomen is palpated from top to bottom. Correct Answer: 3 Rationale 1: Determination of fetal position and station is the point of Leopold's maneuvers. The patient is supine to facilitate uterine palpation. Rationale 2: This is correct order of the first and second Leopold's maneuvers.
Rationale 3: The cervical exam is not part of Leopold's maneuvers. Abdominal palpation is the only technique used for Leopold's maneuvers. Rationale 4: The patient is instructed to void prior to beginning Leopold's maneuvers to enhance comfort. Leopold's maneuvers are essentially palpation of the uterus through the abdomen, beginning at the fundus and ending near the cervix. Question 15 The nurse is preparing to assess the fetus of a laboring patient. Which assessment should the nurse perform first? 1. Perform Leopold's maneuvers to determine fetal position. 2. Count the fetal heart rate for 30 seconds and multiply by 2. 3. Dry the maternal abdomen before using the Doppler. 4. Place the patient in a left lateral position. Correct Answer: 1 Rationale 1: Performing Leopold’s maneuvers is the first step, so that the Doppler device can be placed directly over the heart and multiple attempts to hear the heart rate are avoided. Rationale 2: This is how to auscultate the fetal heart rate, but it is not the first step in assessment. Rationale 3: Prior to using the Doppler device, a water-based gel is applied to the skin. Rationale 4: The fetal heart tone should be assessed while the patient is either supine with a lateral tilt or in left lateral position. Question 16 After several hours of labor, the electronic fetal monitor (EFM) shows repetitive variable decelerations in the fetal heart rate. The nurse would interpret the decelerations to be consistent with: 1. Breech presentation. 2. Uteroplacental insufficiency. 3. Compression of the fetal head. 4. Umbilical cord compression. Correct Answer: 4
Rationale 1: Breech presentations by themselves do not cause decelerations. Rationale 2: Uteroplacental insufficiency causes late decelerations. Rationale 3: Early decelerations occur with fetal head compression. Rationale 4: Variable decelerations occur when there is umbilical cord compression. Question 17 The nurse auscultates the FHR and determines a rate of 112 beats/min. Which action is appropriate? 1. Inform the maternal patient that the rate is normal. 2. Reassess the FHR in 5 minutes because the rate is low. 3. Report the FHR to the doctor immediately. 4. Turn the maternal patient on her side and administer oxygen. Correct Answer: 1 Rationale 1: A fetal heart rate of 112 beats/min. falls within the normal range of 110–160 beats/min., so there is no need to inform the doctor, reposition the patient, or reassess later. Rationale 2: There is no need to reassess later. Rationale 3: There is no need to inform the doctor. Rationale 4: There is no need to reposition the patient. Question 18 Upon assessing the FHR tracing, the nurse determines that there is increased variability. The increased variability would be caused by: Standard Text: Select all that apply. 1. Early mild hypoxia. 2. Fetal stimulation. 3. Alterations in placental blood flow. 4. Fetal sleep cycle.
5. Increased uterine contractions. Correct Answer: 1,2,3,5 Rationale 1: Early mild hypoxia can cause increased variability. Rationale 2: Fetal stimulation can cause increased variability. Rationale 3: Alterations in placental blood flow can cause increased variability. Rationale 4: The fetal sleep cycle does not cause increased variability. Rationale 5: Variability usually correlates with the contractions. Question 19 Persistent early decelerations are noted. The nurse's first action would be to: 1. Turn the mother on her left side and give oxygen. 2. Check for prolapsed cord. 3. Do nothing. This is a benign pattern. 4. Prepare for immediate forceps or cesarean delivery. Correct Answer: 3 Rationale 1: Early decelerations do not require any intervention. Rationale 2: Early decelerations do not indicate a prolapsed cord. Rationale 3: Early decelerations are considered benign, and do not require any intervention. Rationale 4: Early decelerations do not warrant an immediate delivery. Question 20 The laboring patient's fetal heart rate baseline is 120 beats per minute. Accelerations are present to 135 beats/min. During contractions, the fetal heart rate gradually slows to 110, and is at 120 by the end of the contraction. What nursing action is best? 1. Document the fetal heart rate. 2. Apply oxygen via mask at 10 liters.
3. Prepare for imminent delivery. 4. Assist the patient into Fowler's position. Correct Answer: 1 Rationale 1: The described fetal heart rate has a normal baseline, the presence of accelerations indicates adequate fetal oxygenation, and early decelerations are normal. No intervention is necessary. Rationale 2: No oxygen is necessary. Rationale 3: There is no indication that delivery will be occurring soon. Rationale 4: There is no need to put the patient in Fowler’s position. Question 21 The nurse is caring for a patient who is having fetal tachycardia. The nurse knows that possible causes include: Standard Text: Select all that apply. 1. Maternal dehydration. 2. Maternal hyperthyroidism. 3. Fetal hypoxia. 4. Prematurity. 5. Anesthesia or regional analgesia. Correct Answer: 1,2,3,4 Rationale 1: Maternal dehydration can cause fetal tachycardia. Rationale 2: Maternal hyperthyroidism can cause fetal tachycardia. Rationale 3: Fetal tachycardia can indicate fetal hypoxia. Rationale 4: Prematurity can cause fetal tachycardia. Rationale 5: Anesthesia and regional analgesia cause bradycardia. Question 22
The nurse is teaching a class on reading a fetal monitor to nursing students. The nurse explains that bradycardia is a fetal heart rate baseline below 110 and can be caused by: Standard Text: Select all that apply. 1. Maternal hypotension. 2. Prolonged umbilical cord compression. 3. Fetal dysrhythmia. 4. Central nervous system malformation. 5. Late fetal asphyxia. Correct Answer: 1,2,3,5 Rationale 1: Maternal hypotension results in decreased blood flow to the fetus. Rationale 2: Cord compression can cause fetal bradycardia. Rationale 3: This will cause fetal bradycardia if there is a fetal heart block. Rationale 4: This does not cause bradycardia. Rationale 5: This is a depression of cardiac muscle activity. Question 23 The nurse is caring for a patient in the transition phase of labor, and notes that the fetal monitor tracing shows average short-term and long-term variability with a baseline of 142 beats per minute. What actions should the nurse take in this situation? Standard Text: Select all that apply. 1. Provide caring labor support. 2. Administer oxygen via face mask. 3. Change the patient’s position. 4. Speed up the patient’s intravenous. 5. Reassure the patient and her partner that she is doing fine. Correct Answer: 1,5
Rationale 1: The tracing is normal, so the nurse can continue support of the labor. Rationale 2: No oxygen face mask is needed at this time. Rationale 3: There is no need to change the patient’s position. Rationale 4: There is no need to speed up the intravenous. Rationale 5: The nurse can reassure the patient at this time, as the tracing is normal. Question 24 A woman is in labor. The fetus is in vertex position. When the patient's membranes rupture, the nurse sees that the amniotic fluid is meconium-stained. The nurse should immediately: 1. Change the patient’s position in bed. 2. Notify the physician that birth is imminent. 3. Administer oxygen at 2 liters per minute. 4. Begin continuous fetal heart rate monitoring. Correct Answer: 4 Rationale 1: Changing the patient’s position is not indicated. Rationale 2: Meconium-stained amniotic fluid does not indicate that birth is imminent. Rationale 3: Oxygen administration is not indicated. Rationale 4: Meconium-stained amniotic fluid is an abnormal fetal finding, and is an indication for continuous fetal monitoring. Question 25 The primigravida in labor asks the nurse to explain the electronic fetal heart rate monitor strip. The fetal heart rate baseline is 150 with accelerations to 165, variable decelerations to 140, and moderate long-term variability. Which statement indicates that the patient understands the nurse's teaching? "The most important part of fetal heart monitoring is the: 1. “Absence of variable decelerations." 2. “Presence of variability." 3. “Fetal heart rate baseline."
4. “Depth of decelerations." Correct Answer: 2 Rationale 1: Variable decelerations indicate cord compression. Rationale 2: Variability is an indicator of the interplay between the sympathetic nervous system and the parasympathetic nervous system. Rationale 3: The fetal heart rate baseline does not indicate central nervous system function. Rationale 4: The depth of decelerations does not indicate central nervous system function. Question 26 The fetal heart rate baseline is 140 beats/min. When contractions begin, the fetal heart rate drops suddenly to 120, and rapidly returns to 140 before the end of the contraction. Which nursing intervention is best? 1. Assist the patient to change from Fowler's to left lateral position. 2. Apply oxygen to the patient at 2 liters per nasal cannula. 3. Notify the operating room of the need for a cesarean birth. 4. Determine the color of the leaking amniotic fluid. Correct Answer: 1 Rationale 1: The fetus is exhibiting variable decelerations, which are caused by cord compression. Repositioning the patient might get the fetus off the cord and eliminate the variable decelerations. Rationale 2: A nasal cannula is rarely used in labor and birth; face masks are preferable. Rationale 3: There is no indication that a cesarean delivery is needed. Rationale 4: There is no indication that the amniotic fluid is meconium-stained or bloody. Question 27 The nurse is caring for a patient who is showing a sinusoidal fetal heart rate pattern on the monitor. The nurse knows that possible causes for this pattern include: Standard Text: Select all that apply. 1. Fetal anemia.
2. Chronic fetal bleeding. 3. Maternal hypotension. 4. Twin-to-twin transfusion. 5. Umbilical cord occlusion. Correct Answer: 1,2,4,5 Rationale 1: Fetal anemia can cause a sinusoidal heart rate. Rationale 2: Chronic fetal bleeding can cause a sinusoidal heart rate. Rationale 3: This has nothing to do with a sinusoidal fetal heart rate. Rationale 4: Twin-to-twin transfusion will cause a sinusoidal heart rate. Rationale 5: Umbilical cord occlusion can cause a sinusoidal fetal heart rate. Question 28 The nurse is analyzing fetal cord blood results. If the fetal blood pH is below 7.25, the nurse can conclude that the fetus was: 1. Acidotic and hypoxic. 2. Alkalotic and hypoxic. 3. Well oxygenated. 4. Alkalotic but well oxygenated. Correct Answer: 1 Rationale 1: Normal fetal blood pH should be above 7.25. Lower levels indicate acidosis and hypoxia. Rationale 2: Fetal blood pH would need to be well above 7.25 to be alkalotic. Rationale 3: Normal fetal blood pH should be above 7.25. Rationale 4: Normal fetal blood pH should be above 7.25. Question 29
The labor and delivery nurse is assigned to four patients in early labor. Which electronic fetal monitoring finding would require immediate intervention? 1. Early decelerations with each contraction 2. Variable decelerations that recover to the baseline 3. Late decelerations with minimal variability 4. Accelerations Correct Answer: 3 Rationale 1: Early decelerations are usually benign. Rationale 2: Variable decelerations indicate cord compression, but those that recover to the baseline indicate that the fetus is tolerating the decelerations. Rationale 3: Late decelerations are considered a nonreassuring fetal heart rate (FHR) pattern, and therefore require immediate intervention. Rationale 4: Accelerations of the fetal heart rate indicate good oxygen reserve. Question 30 The nurse is analyzing several fetal heart rate patterns. The pattern that would be of most concern to the nurse would be: 1. Moderate long-term variability. 2. Early decelerations. 3. Late decelerations. 4. Accelerations. Correct Answer: 3 Rationale 1: Moderate long-term variability is a reassuring sign that the fetus is not suffering from cerebral asphyxia. Rationale 2: Early decelerations occur before the onset of the uterine contraction. Early deceleration is usually considered benign. Rationale 3: Late decelerations are caused by uteroplacental insufficiency. The late deceleration pattern is considered a nonreassuring sign.
Rationale 4: Accelerations are thought to be a sign of fetal well-being. Question 31 After noting meconium-stained amniotic fluid, fetal heart rate decelerations, and a fetal blood pH of 7.20, the physician diagnoses a severely depressed fetus. The appropriate nursing action at this time would be to: 1. Increase the mother's oxygen rate. 2. Turn the mother to the left lateral position. 3. Prepare the mother for a forceps or cesarean birth. 4. Increase the intravenous infusion rate. Correct Answer: 3 Rationale 1: Use of oxygen is not a nursing action that would change the status of the severely depressed fetus. Rationale 2: Position change to the left side is not a nursing action that would change the status of the severely depressed fetus. Rationale 3: Meconium-stained fluid, heart rate decelerations, and a pH of 7.20 are all indications that delivery must be performed without delay. Rationale 4: Increasing the IV rate is not a nursing action that would change the status of the severely depressed fetus. Question 32 The nurse is aware that a fetus that is not in any stress would respond to a fetal scalp stimulation test by showing which change on the monitor strip? 1. Late decelerations 2. Early decelerations 3. Accelerations 4. Increased long-term variability Correct Answer: 3 Rationale 1: Late decelerations indicate uteroplacental insufficiency. Rationale 2: Early decelerations are indicative of head compression.
Rationale 3: A fetus that is not experiencing stress responds to scalp stimulation with an acceleration of the FHR. Rationale 4: Increased long-term variability is a parameter assessed when there is a questionable FHR pattern because long-term variability, when normal, can indicate that the fetus is not suffering from cerebral asphyxia. Question 33 The primigravida patient is in the second stage of labor. The fetal heart rate baseline is 170, with minimal variability present. The nurse performs fetal scalp stimulation. The patient's partner asks why the nurse did that. What is the best response by the nurse? "I stimulated the top of the baby's head to: 1. “Wake him up a little." 2. “Try to get his heart rate to accelerate." 3. “Calm the baby down before birth." 4. “Find out whether he is in distress." Correct Answer: 2 Rationale 1: Waking the baby is not the goal or outcome of fetal scalp simulation. Rationale 2: Fetal scalp stimulation is done when there is a question regarding fetal status. An acceleration indicates fetal well-being. Rationale 3: Calming the baby is not the goal or outcome of fetal scalp simulation. Rationale 4: The nurse wants to assess what the fetus does with stimulation.
Question 34 The primary care provider is performing a fetal scalp stimulation test. What result would the nurse hope to observe? Standard Text: Select all that apply. 1. Spontaneous fetal movement 2. Fetal heart acceleration 3. Increase in fetal heart variability 4. Resolution of late decelerations
5. Reactivity associated with the stimulation Correct Answer: 2,5 Rationale 1: There is spontaneous fetal movement at all times. Rationale 2: The fetal heart rate should accelerate with stimulation. Rationale 3: Stimulation should not increase variability. Rationale 4: Stimulation is not related to decelerations. Rationale 5: There will be some reaction with the stimulation.
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 21. The Family in Childbirth: Needs and Care MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) The client presents to labor and delivery stating that her water broke 2 hours ago. Barring any abnormalities, how often would the nurse expect to take the client's temperature? A) every hour B) every 2 hours C) every 4 hours D) every shift Answer B 2) The laboring client presses the call light and reports that her water has just broke. The nurse's first action would be to A) check fetal heart tones. B) encourage the mother to go for a walk. C) change bed linen. D) call the physician. Answer A 3) Of the most frequent responses to pain, which of the following is most likely to impede your client's progress in labor? A) increased pulse B) elevated blood pressure C) muscle tension D) increased respirations Answer C 4) Why is it important for the nurse to assess the bladder regularly and encourage the laboring client to void every two hours? A) A full bladder impedes oxygen flow to the fetus. B) Frequent voiding prevents bruising of the bladder. C) Frequent voiding encourages sphincter control. D) A full bladder can impede fetal descent. Answer D 5) The laboring client is complaining of tingling and numbness in her fingers and toes, dizziness, and spots before her eyes. The nurse recognizes that these are clinical manifestations of A) hyperventilation. B) seizure auras. C) imminent birth. D)anxiety. Answer A 6) Upon delivery of the newborn, the nursing intervention that most promotes parental attachment is A) placing the newborn under the radiant warmer. B) placing the newborn on the maternal abdomen.
C) allowing the mother a chance to rest immediately after delivery. D) taking the newborn to the nursery for the initial assessment. Answer B SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 7) At one minute after birth, the infant has a heart rate of 100 bpm and is crying vigorously. His limbs are flexed, his trunk is pink, and his feet and hands are cyanotic. The infant cries easily when the soles of his feet are stimulated. The appropriate Apgar score would be . Answer 9 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 8) Before applying a cord clamp, the nurse assesses the umbilical cord for the presence of vessels. The expected finding is A) one artery, one vein. B) two arteries, one vein. C) two veins, one artery. D) two veins, two arteries. Answer B 9) As compared with admission considerations for an adult woman in labor, the nurse's priority for an adolescent in labor would be to assess A) cultural background. B) plans for keeping the infant. C) support persons. D) developmental level. Answer D 10) Breathing techniques used in labor provide which of the following? (Select all that apply.) A) a form of anesthesia B) a source of relaxation C) an increased ability to cope with contractions D) a source of distraction Answer B, C, D 11) Oxytocin 20 units was given to your client at the time of the delivery of the placenta. This was done primarily to A) contract the uterus and minimize bleeding. B) decrease breast milk production. C) decrease maternal blood pressure. D) increase maternal blood pressure. Answer A 12) Two hours after delivery a client's fundus is boggy and has risen to above the umbilicus. The first action the nurse would take is to A) massage the fundus until firm. B) express retained clots. C) increase the intravenous solution. D) call the physician.
Answer A 13) An expectant father has been at the bedside of his laboring partner for more than 12 hours. An appropriate nursing intervention would be to A) insist he leave the room for at least the next hour. B) tell him he is not being as effective as he was and needs to let someone else take over. C) offer to remain with his partner while he takes a break. D) suggest that the client's mother may be of more help. Answer C 14) A client's labor has progressed so rapidly that a precipitous birth is occurring. The nurse should A) go to the nurse's station and immediately call the physician. B) run to the delivery room for an emergency birth pack. C) stay with the client and ask for auxiliary personnel for assistance. D) try to delay the delivery of the infant's head until the physician arrives. Answer C 15) A client delivered 30 minutes ago. Which postpartal finding should the nurse continue to monitor closely? A) a soaked perineal pad since the last 15-minute check B) an edematous perineum C) a client with tremors D) a fundus located at the umbilicus Answer A 1)B 2) A 3) C 4) D 5) A 6) B 7) 9 8) B 9) D 10) B, C, D 11) A 12) A 13) C 14) C 15) A
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 20. Pharmacologic Pain Relief MULTIPLE CHOICE.
Choose the one alternative that best completes the statement or answers the question.
1) A client has just been admitted for labor and delivery. She is having mild contractions every 15 minutes lasting 30 seconds. The client wants to have a medication-free birth. When discussing medication alternatives, the nurse should be sure the client understands that A) in order to respect her wishes, no medication will be given. B) pain relief will allow a more enjoyable birth experience. C) the use of medications allow the client to rest and be less fatigued. D) maternal pain and stress can have a more adverse effect on the fetus than a small amount of analgesia. Answer D 2) After receiving nalbuphine hydrochloride (Nubain), a woman's labor progresses rapidly and the baby is born less than one hour later. The baby shows signs of respiratory depression. Which medication should the nurse be prepared to give to the newborn? A) fentanyl (Sublimaze) B) butorphanol tartrate (Stadol) C) naloxone (Narcan) D) pentobarbital (Nembutal) Answer C 3) After administration of an epidural anesthetic to a client in active labor, it is most important to assess the client immediately for A) hypotension. B) headache. C) urinary retention. D) bradycardia. Answer A 4) A laboring client has received an order for epidural anesthesia. In order to prevent the most common complication associated with this procedure, the nurse would expect to do which of the following? A) observe fetal heart rate variability B) rapidly infuse 500 to 1000 ml of intravenous fluids C) place the client in a right lateral position D) teach the client appropriate breathing techniques Answer B 5) Which of the following are common side effects of epidural anesthesia? (Select all that apply.) A) elevated maternal temperature B) urinary retention C) nausea D) long-term back pain Answer A, B, C 6) Prior to receiving lumbar epidural anesthesia, the nurse would anticipate placing the laboring client inwhich of the following positions? A) on her right side in the center of the bed, with her back curved B) lying prone, with a pillow under her chest C) on her left side, with the bottom leg straight and the top leg slightly flexed D) sitting on the edge of the bed, with her back slightly curved and her feet on a stool Answer D
7) A client is having contractions that are lasting 20 to 30 seconds and occurring every 8 to 20 minutes. The client is requesting something to help relieve the discomfort of contractions. The nurse should suggest A) a mild analgesic be administered. B) an epidural. C) a local anesthetic block. D) nonpharmacological methods for pain relief. Answer D 8) Narcotic analgesia is administered to a laboring mother at 1000 A.M. The infant is delivered at 1230. The nurse would expect the narcotic analgesia to do which of the following? A) be used in place of preoperative sedation B) result in neonatal respiratory depression C) prevent the need for anesthesia with an episiotom. D) enhance uterine contractions Answer B 9) Two hours after an epidural infusion has begun, a client complains of itching on the face and neck. The nurse should A) remove the epidural catheter and place a Band-Aid at the injection site. B) offer the client a cool cloth and let her know the itching is temporary. C)recognize this is a common side effect and follow protocol for administration of diphenhydramine (Benadryl). D) call the anesthesia care provider to re-dose the epidural catheter. Answer C 10) A nurse is checking the doctor's orders for a postpartum client. The doctor has written for the client to be on bedrest for 6 to 12 hours. The nurse knows this is an appropriate order if the client had which type of anesthesia? A)spinal B)pudendal C) general D) epidural Answer A 11) Toward the end of the first stage of labor, a pudendal block is administered transvaginally. The nurse anticipates the client's care to include A) monitoring for hypotension every 15 minutes. B) monitoring FHR every 15 minutes. C) monitoring for bladder distention. D) no additional assessments. Answer D 12) An analgesic medication has been administered intramuscularly to a client in labor. The nurse wouldevaluate the medication as effective if A) the client dozes between contractions. B) the client is moaning with contractions. C) the contractions decrease in intensity. D) the contractions decrease in frequency. Answer A 13) A primigravida dilated to 5 cm has just received an epidural for pain. She complains of feeling lightheaded and dizzy within 10 minutes after the procedure. Her blood pressure before the procedure was 120/80 and is now 80/52. In addition to the bolus of fluids she has been given, which medication is preferred to use to increase her BP? A) epinephrine B) terbutaline
C) ephedrine D) epifoam Answer C 14) A cesarean section is ordered for your client. Because she is to receive general anesthesia, the primary danger the nurse is concerned with is A) fetal depression. B) vomiting. C) maternal depression. D) uterine relaxation. Answer A 15) A client received an epidural anesthesia during the first stage of her labor. The epidural is discontinued immediately after delivery. This client is at increased risk for which of the following during the fourth stage of labor? A) nausea B) bladder distention C) uterine atony D) hypertension Answer B
1) D 2) C 3) A 4) B 5)A, B, C 6) D 7) D 8) B 9) C 10) A 11) D 12) A 13) C 14) A 15) B
Old's Maternal-Newborn Nursing and Women's Health, 11e(Davidson/London/Ladewig) Chapter 23 Childbirth at Risk: Prelabor Onset Complications 1) A client is admitted to the labor and delivery unit with a history of ruptured membranes for 2 hours. This is her sixth delivery; she is 40 years old, and smells ofalcohol and cigarettes. What is this client at risk for? A) Gestational diabetes B) Placenta previa C) Abruptio placentae D) Placenta accreta Answer: C Explanation: A) Gestational diabetes is not an issue with this client. B) Placenta previa is not an issue with this client. C) Abruptio placentae is more frequent in pregnancies complicated by smoking, premature rupture of membranes, multiple gestation, advanced maternal age,cocaine use, chorioamnionitis, and hypertension. D) Placenta accreta is not an issue with this client. Page Ref: 565 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅴ. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting healthacross the lifespan. | NLN Competencies: Quality and Safety: Communicate potentialrisk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 4 Compare placenta previa and abruptio placentae, includingimplications for the mother and fetus and their nursing care. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
2) The nurse is caring for a client at 30 weeks' gestation who is experiencing preterm premature rupture of membranes (PPROM). Which statement indicates that the client needs additional teaching? A) "If I were having a singleton pregnancy instead of twins, my membranes would probably not have ruptured." B) "If I develop a urinary tract infection in my next pregnancy, I might rupture membranes early again." C) "If I want to become pregnant again, I will have to plan on being on bed rest forthe whole pregnancy." D) "If I have amniocentesis, I might rupture the membranes again." Answer: C Explanation: A) Multifetal gestation increases the risk for PPROM. B) A urinary tract infection (UTI) increases the risk for PPROM. C) There is no evidence that bed rest in a subsequent pregnancy decreases the riskfor PPROM. D) Amniocentesis increases the risk for PPROM. Page Ref: 562 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 2 Identify the causes and risk factors for premature rupture of membranes. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
3) A client was admitted to the labor area at 5 cm with ruptured membranes about 14 hours ago. What assessment data would be most beneficial for the nurse to collect? A) Blood pressure B) Temperature C) Pulse D) Respiration Answer: B Explanation: A) Blood pressure can assist in the diagnosis of infection, but is not the primary vitalsign. B) Rupture of membranes places the mother at risk for infection. The temperature isthe primary and often the first indication of a problem. C) Pulse can assist in the diagnosis of infection, but is not the primary vital sign. D) Respirations can assist in the diagnosis of infection, but are not the primary sign. Page Ref: 561 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: Ⅸ. 12. Create asafe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Identify the causes and risk factors for premature rupture ofmembranes. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
4) The nurse admits into the labor area a client who is in preterm labor. What assessment finding would constitute a diagnosis of preterm labor? A) Cervical effacement of 30% or more B) Cervical change of 0.5 cm per hour C) 2 contractions in 30 minutes D) 8 contractions in 1 hour Answer: D Explanation: A) Cervical effacement of 80% or more would define preterm labor. B) A cervical change of at least 1 cm per hour would define preterm labor. C) Uterine contractions every 5 minutes for 20 minutes would define preterm labor. D) 8 contractions in a 60-minute period does define a diagnosis of preterm labor. Page Ref: 556 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: Ⅸ. 12. Create asafe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 1 Analyze the implications and maternal and fetal risks of pretermlabor. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
5) During the nursing assessment of a woman with ruptured membranes, the nursesuspects a prolapsed umbilical cord. What would the nurse's priority action be? A) To help the fetal head descend faster B) To use gravity and manipulation to relieve compression on the cord C) To facilitate dilation of the cervix with prostaglandin gel D) To prevent head compression Answer: B Explanation: A) The fetal head's descent would put additional pressure on the umbilical cord andreduce blood flow and oxygenation to the fetus. B) The top priority is to relieve compression on the umbilical cord to allow blood flowto reach the fetus. It is because some obstetric maneuvers to relieve cord compression are complicated that cesarean birth is sometimes necessary. C) Further dilatation of the cervix is unnecessary in light of a possible cesareansection. D) Head compression is not a concern in the case of prolapsed umbilical cord. Thecord is what is compressed. Page Ref: 576 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: Ⅸ. 12. Create asafe environment that results in highquality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Identify the causes and risk factors for premature rupture ofmembranes. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
6) A client is admitted to the birth setting in early labor. She is 3 cm dilated, -2 station,with intact membranes, and FHR of 150 bpm. Her membranes rupture spontaneously, and the FHR drops to 90 bpm with variable decelerations. What would the nurse's initial response be? A) Perform a vaginal exam B) Notify the physician C) Place the client in a left lateral position D) Administer oxygen at 2 L per nasal cannula Answer: A Explanation: A) Prolapsed umbilical cord can occur when the membranes rupture. The fetus ismore likely to experience variable decelerations because the amniotic fluid is insufficient to keep pressure off the umbilical cord. A vaginal exam is the best way to confirm. B) A vaginal exam should be performed before the physician is notified. C) Positioning will not relieve the decreased heart rate if the cord is compromised. D) Oxygen will not relieve the decreased heart rate if the cord is compromised. Page Ref: 579, 581 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: Ⅸ. 12. Create asafe environment that results in highquality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Identify the causes and risk factors for premature rupture ofmembranes. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
7) The nurse has received end-of-shift reports in the high-risk maternity unit. Whichclient should the nurse see first? A) The client at 26 weeks' gestation with placenta previa experiencing blood ontoilet tissue after a bowel movement B) The client at 30 weeks' gestation with placenta previa whose fetal monitor stripshows late decelerations C) The client at 35 weeks' gestation with grade I abruptio placentae in labor who hasa strong urge to push D) The client at 37 weeks' gestation with pregnancy-induced hypertension whose membranes ruptured spontaneously Answer: A Explanation: A) Assessment of the woman with placenta previa must be ongoing to prevent ortreat complications that are potentially lethal to the mother and fetus. Painless,bright red vaginal bleeding is the best diagnostic sign of placenta previa. This client is the highest priority. B) Late decelerations are an abnormal finding, but put only the fetus at risk. Thisclient is not the highest priority. C) Grade I abruptio placentae creates slight vaginal bleeding. The urge to push indicates that delivery is near. This client is not the highest priority. D) Although pregnancy-induced hypertension puts a woman at risk for developing abruptio placentae, there is no indication that this client is experiencing this complication. This client is not the highest priority. Page Ref: 570 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅴ. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: Ⅸ. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential riskfactors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Compare placenta previa and abruptio placentae, includingimplications for the mother and fetus and their nursing care. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
8) A client in her second trimester is complaining of spotting. Causes for spotting in thesecond trimester are diagnosed primarily through the use of which of the following? A) A non-stress test B) A vibroacoustic stimulation test C) An ultrasound D) A contraction stress test Answer: C Explanation: A) A non-stress test is used to assess the well-being of the fetus. B) A vibroacoustic stimulation test is used to assess the well-being of the fetus. C) Indirect diagnosis is made by locating the placenta via tests that require novaginal examination. The most commonly employed diagnostic test is the transabdominal ultrasound scan. D) A contraction stress test is used to assess the well-being of the fetus. Page Ref: 568 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅰ. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science andquality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Describe the clinical therapy for premature rupture of membranes and preterm labor in determining hospital-based and community-basednursing management of the woman and her fetus-newborn. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
9) The nurse is performing a comprehensive assessment on a client admitted to the birthing unit with abruptio placentae. Which finding(s) contribute(s) to this condition? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) History of domestic violence B) Presence of uterine fibroids C) Alcohol consumption during pregnancy D) Hypertension E) Gestational diabetes mellitus Answer: A, B, C, D Explanation: A) Domestic violence contributes to the development of abruptio placentae. B) The presence of fibroids contributes to the development of abruptio placentae. C) Alcohol consumption contributes to the development of abruptio placentae. D) Maternal hypertension is the most common cause of abruptio placentae. E) Gestational diabetes mellitus is not considered a finding that contributes to abruptio placentae. Page Ref: 565 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅰ. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science andquality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Discuss the differences between developmental anddegenerative placental problems. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
10) The nurse is planning an in-service educational program to talk about disseminated intravascular coagulation (DIC). The nurse should identify which conditions as risk factors for developing DIC? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Diabetes mellitus B) Abruptio placentae C) Fetal demise D) Multiparity E) Preterm labor Answer: B, C Explanation: A) Diabetes does not cause the release of thromboplastin that triggers DIC. B) As a result of the damage to the uterine wall and the retroplacental clotting with covert abruption, large amounts of thromboplastin are released into the maternalblood supply, which in turn triggers the development of disseminated intravascular coagulation (DIC) and the resultant hypofibrinogenemia. C) Perinatal mortality associated with abruptio placentae is approximately 25%. If fetal hypoxia progresses unchecked, irreversible brain damage or fetal demisemay result. D) Multiparity does not cause the release of thromboplastin that triggers DIC. E) Preterm labor does not cause the release of thromboplastin that triggers DIC. Page Ref: 567 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: Ⅸ. 12. Create asafe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Compare placenta previa and abruptio placentae, includingimplications for the mother and fetus and their nursing care. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
11) The client at 30 weeks' gestation is admitted with painless late vaginal bleeding. Thenurse understands that expectant management includes which of the following? A) Limiting vaginal exams to only one per 24-hour period. B) Evaluating the fetal heart rate with an internal monitor. C) Monitoring for blood loss, pain, and uterine contractibility. D) Assessing blood pressure every 2 hours. Answer: C Explanation: A) Vaginal exams are contraindicated because the exam can stimulate bleeding. B) Fetal heart rate monitoring will be done with an external, not internal, fetal monitor. C) Blood loss, pain, and uterine contractibility need to be assessed for client comfortand safety. D) Blood pressure measurements every 2 hours are unnecessary. Page Ref: 569 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: Ⅸ. 12. Create asafe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Compare placenta previa and abruptio placentae, includingimplications for the mother and fetus and their nursing care. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
12) A client is admitted to the labor and delivery unit in active labor. What nursing diagnoses might apply to the client with suspected abruptio placentae? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Fluid Volume, Deficient, related to hypovolemia secondary to excessive bloodloss B) Tissue Perfusion: Peripheral, Ineffective, related to blood loss secondary touterine atony following birth C) Anxiety related to concern for own personal status and the baby's safety D) Knowledge, Deficient related to lack of information about inherited genetic defects E) Alteration in Respiratory Function related to blood loss Answer: A, B, C Explanation: A) Maternal and perinatal fetal mortality are concerns due to hypoxia. B) Maternal and perinatal fetal mortality are concerns due to blood loss. C) This mother would be anxious for herself and her baby. D) Abruptio placentae is a premature separation of the placenta, not a genetic abnormality. E) Respiratory function is not related to the blood loss. Also, this is not a nursing diagnosis. Page Ref: 568 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: Ⅸ. 12. Create asafe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 4 Compare placenta previa and abruptio placentae, includingimplications for the mother and fetus and their nursing care. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
13) What is the most significant cause of neonatal morbidity and mortality? A) A) Amenorrhea B) B) Posttraumatic stress disorder C) C) Prematurity D) D) Endometriosis Answer: C Explanation: A) Amenorrhea the absence of menses in a woman and does not affect neonatalmorbidity or mortality. B) Posttraumatic stress disorder does not affect neonatal morbidity or mortality. C) The most significant cause of neonatal morbidity and mortality is prematurity andits associated complications such as respiratory distress syndrome, necrotizing enterocolitis, and intraventricular hemorrhage. D) Endometriosis is a condition of a woman characterized by the presence of endometrial tissue outside the uterine cavity, and it does not affect neonatal morbidity or mortality. Page Ref: 563 Cognitive Level: Remembering Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅰ. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science andquality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 1 Analyze the implications and maternal and fetal risks of pretermlabor. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
14) What is the most significant maternal risk factor for preterm birth? A) Previous preterm birth B) Smoking C) Stress D) Substance abuse Answer: A Explanation: A) The most significant maternal risk factor for preterm birth is a previous pretermbirth. B) Modifiable risk factors, such as smoking, substance abuse, stress, alcohol use, and other behavioral factors are not the most significant maternal risk factors forpreterm birth. C) Modifiable risk factors, such as smoking, substance abuse, stress, alcohol use, and other behavioral factors are not the most significant maternal risk factors forpreterm birth. D) Modifiable risk factors, such as smoking, substance abuse, stress, alcohol use, and other behavioral factors are not the most significant maternal risk factors forpreterm birth. Page Ref: 555 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅰ. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science andquality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning.Learning Outcome: 1 Analyze the implications and maternal and fetal risks of preterm labor. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
15) A client admitted to the birthing unit with placenta previa asks the nurse, "What is thecause of my condition?" Which statement should be included in the nurse's response? A) "The placenta is improperly implanted in the lower uterus." B) "The placenta has separated prematurely." C) "The placenta has grown too large." D) "The placenta has prolapsed and is being compressed." Answer: A Explanation: A) This statement correctly describes placenta previa, when the placenta implantslow in the uterus or over the cervix. B) This statement describes abuptio placentae, another placental complication. C) Placenta previa is not when the placenta has grown too large; this statementshould not be used by the nurse. D) Placenta previa is not when the placenta becomes prolapsed and is being compressed; this statement should not be used by the nurse. Page Ref: 568 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Discuss the differences between developmental anddegenerative placental problems. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
16) The nurse is performing an assessment on a client in the birthing unit who has acquired cervical insufficiency. Which other finding(s) may contribute to the client'scondition? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Inflammation B) Infection C) Cervical trauma D) Cone biopsy E) HPV positivity Answer: A, B, C, D Explanation: A) Acquired cervical insufficiency may be related to inflammation. B) Acquired cervical insufficiency may be related to infection. C) Acquired cervical insufficiency may be related to cervical trauma. D) Acquired cervical insufficiency may be related to cone biopsy. E) Acquired cervical insufficiency is not related to HPV positivity. Page Ref: 576 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅰ. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science andquality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Identify the causes and risk factors of cervical insufficiency.MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
17) The nurse on the birthing unit is collecting the obstetric history of a client at risk for cervical insufficiency. Which findings increase the client's risk for this condition? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Multiple gestations B) Previous preterm births C) Progressively earlier births with each subsequent pregnancy D) Cervical manipulation E) Prolonged labors Answer: A, B, C, D Explanation: A) Multiple gestations increase the risk for cervical insufficiency. B) Previous preterm births increase the risk for cervical insufficiency. C) Progressively earlier births with each subsequent pregnancy increase the risk forcervical insufficiency. D) Cervical manipulation increases the risk for cervical insufficiency. E) Short labors, not prolonged labors, increase the risk for cervical insufficiency. Page Ref: 573 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅰ. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science andquality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Identify the causes and risk factors of cervical insufficiency.MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
18) The home health nurse is visiting a client at 18 weeks who is pregnant with twins. Which nursing action is most important? A) Teach the client about foods that are good sources of protein. B) Assess the client's blood pressure in her upper right arm. C) Determine whether the pregnancy is the result of infertility treatment. D) Collect a cervicovaginal fetal fibronectin (fFN) specimen. Answer: A Explanation: A) A daily intake of 4000 kcal (minimum) and 135 g protein is recommended for a woman with normal-weight twins. B) Blood pressure can be assessed in either arm. C) The cause of the multifetal pregnancy does not impact nursing care. D) Preterm labor is not diagnosed until 20 weeks. This client is only at 18 weeks.Fetal fibronectin (fFN) testing is not indicated at this time. Page Ref: 578 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 8 Analyze the maternal and fetal-newborn implications and clinical therapy in determining community-based and hospital-based nursing care of the woman with a multiple gestation. MNL L O: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
19) When counseling a newly pregnant client at 8 weeks' gestation with twins, the nurseteaches the woman about the need for increased caloric intake. What would the nurse tell the woman that the minimum recommended intake should be? A) 2500 kcal and 120 grams protein B) 3000 kcal and 150 grams protein C) 4000 kcal and 135 grams protein D) 5000 kcal and 190 grams protein Answer: C Explanation: A) 2500 kcal and 120 grams protein is less than the recommended caloric andprotein intake for a twin-gestation pregnancy. B) 3000 kcal and 150 grams protein is lower in calories but higher in protein than is recommended for a twin-gestation pregnancy. C) 4000 kcal and 135 grams protein is the recommended caloric and protein intakein a twin-gestation pregnancy. D) 5000 kcal and 190 grams protein is more than recommended caloric and proteinintake for a twin-gestation pregnancy. Page Ref: 578 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 8 Analyze the maternal and fetal-newborn implications and clinical therapy in determining community-based and hospital-based nursing care of the woman with a multiple gestation. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
20) Intervention to reduce preterm birth can be divided into primary prevention and secondary prevention. What does secondary prevention include? A) Diagnosis and treatment of infections B) Cervical cerclage C) Progesterone administration D) Antibiotic treatment and tocolysis Answer: D Explanation: A) Primary prevention includes diagnosis and treatment of infections, cervical cerclage, and progesterone administration. B) Primary prevention includes diagnosis and treatment of infections, cervical cerclage, and progesterone administration. C) Primary prevention includes diagnosis and treatment of infections, cervical cerclage, and progesterone administration. D) Secondary prevention strategies are antibiotic treatment and tocolysis. Page Ref: 559 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies toreduce risk of harm to self or others. | AACN Essentials Competencies: Ⅳ. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice. | NLN Competencies: Qualityand Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 3 Describe the clinical therapy for premature rupture of membranes and preterm labor in determining hospital-based and community-basednursing management of the woman and her fetus-newborn. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
21) The client is carrying monochorionic-monoamniotic twins. The nurse teaches the client what this is, and the implications of this finding. The nurse knows that teachingis successful when the client states which of the following? A) "My babies came from two eggs." B) "About two thirds of twins have this amniotic sac formation." C) "My use of a fertility drug led to this issue." D) "My babies have a lower chance of surviving to term than fraternal twins do." Answer: D Explanation: A) Monochorionic-monoamniotic twins lie in the same amniotic sac. B) About 2% of twins are of this type. C) The majority of twins conceived through in vitro fertilization are fraternal (dizygotic) because multiple fertilized ova are inserted into the uterus, and arenot monochorionic-monoamniotic twins. D) Monochorionic-monoamniotic twins are both in one amniotic sac. There is an increased risk of umbilical cords becoming tangled or knotted and a higher incidence of fetal demise. Page Ref: 575 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 8 Analyze the maternal and fetalnewborn implications and clinicaltherapy in determining community-based and hospital-based nursing care of the womanwith a multiple gestation. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
22) The nurse on the birthing unit is caring for a client who has an amputated cervix and is about to undergo a cerclage procedure. Which type of cerclage procedure should the nurse anticipate? A) Abdominal cerclage B) Rescue cerclage C) Emergency cerclage D) Elective cerclage Answer: A Explanation: A) An abdominal cerclage approach may be required for women with an amputatedcervix. B) A rescue cerclage is one that is placed for emergent reasons, when dilatationand effacement have already occurred. C) An emergency cerclage is one that is placed for emergent reasons, when dilatation and effacement have already occurred. D) An elective, or cervical, cerclage will not be performed for a client who has an amputated cervix. Page Ref: 574 Cognitive Level: Analyzing Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅰ. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science andquality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning.Learning Outcome: 7 Describe the clinical therapies and appropriate nursing interventions for the mother with cervical insufficiency and her unborn fetus. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
23) Slowly removing some amniotic fluid is a treatment for hydramnios. What consequence can occur with the withdrawal of fluid? A) Preterm labor B) Prolapsed cord C) Preeclampsia D) Placenta previa Answer: B Explanation: A) Preterm labor is not a known consequence of amniotic fluid reduction. B) A needle or a fetal scalp electrode is used to make a small puncture in the amniotic sac. There is a risk that the force of the fluid could make a larger hole inthe amniotic sac, thus increasing the risk of a prolapsed cord. C) Preeclampsia is not a known consequence of amniotic fluid reduction. D) Placenta previa would not be a result of amniotic fluid reduction. Page Ref: 579 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: Ⅸ. 12. Create asafe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 9 Describe the identification of the woman with hydramnios andthe maternal and fetal-neonatal implications. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
24) The nurse is admitting a client who was diagnosed with hydramnios. The client askswhy she has developed this condition. The nurse should explain that hydramnios is sometimes associated with which of the following? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Rh sensitization B) Postmaturity syndrome C) Renal malformation or dysfunction D) Maternal diabetes E) Large-for-gestational-age infants Answer: A, D Explanation: A) Hydramnios is associated with Rh sensitization. B) Postmaturity is associated with oligohydramnios. C) Renal malformation or dysfunction is associated with oligohydramnios. D) Hydramnios is associated with maternal diabetes. E) Large-for-gestational-age infants are not associated with hydramnios. Page Ref: 579 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: Ⅸ. 12. Create asafe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 9 Describe the identification of the woman with hydramnios andthe maternal and fetal-neonatal implications. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
25) The nurse is admitting a client with possible hydramnios. When is hydramnios mostlikely suspected? A) Hydramnios is most likely suspected when there is less amniotic fluid thannormal for gestation. B) Hydramnios is most likely suspected when the fundal height increases disproportionately to the gestation. C) Hydramnios is most likely suspected when the woman has a twin gestation. D) Hydramnios is most likely suspected when the quadruple screen comes backpositive. Answer: B Explanation: A) Hydramnios occurs when there is more amniotic fluid than normal for gestation. B) Hydramnios should be suspected when the fundal height increases out of proportion to the gestational age. C) Hydramnios is not suspected simply because of a twin gestation. D) A positive quadruple screen is not indicative of hydramnios. Page Ref: 579 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅰ. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science andquality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 11 Compare the clinical therapy and nursing management of thewoman with hydramnios and the woman with oligohydramnios. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
26) If oligohydramnios occurs in the first part of pregnancy, the nurse knows that there isa danger of which of the following? A) Major congenital anomalies B) Fetal adhesions C) Maternal diabetes D) Rh sensitization Answer: B Explanation: A) Major congenital anomalies are associated with hydramnios. B) If oligohydramnios occurs in the first part of pregnancy, there is a danger of fetal adhesions (one part of the fetus may adhere to another part). C) Maternal diabetes is associated with hydramnios. D) Rh sensitization is associated with hydramnios. Page Ref: 579 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies toreduce risk of harm to self or others. | AACN Essentials Competencies: Ⅳ. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 10 Describe the identification of the woman with oligohydramniosand the maternal and fetal-neonatal implications. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
27) When caring for a laboring client with oligohydramnios, what should the nurse beaware of? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Increased risk of cord compression B) Decreased variability C) Labor progress is often more rapid than average D) Presence of periodic decelerations E) During gestation, fetal skin and skeletal abnormalities can occur Answer: A, B, D, E Explanation: A) During the labor and birth, the lessened amounts of fluid reduce the cushioningeffect for the umbilical cord, and cord compression is more likely to occur. B) The nurse should evaluate the EFM tracing for the presence of nonperiodic decelerations or other nonreassuring signs (such as increasing or decreasingbaseline, decreased variability, or presence of periodic decelerations). C) Labor progress may be slower, not faster, than average due to the decreased amniotic fluid volume. Fetal movement can be impaired as a result of inadequateamniotic fluid volume. D) The nurse should evaluate the EFM tracing for the presence of nonperiodic decelerations or other nonreassuring signs (such as increasing or decreasingbaseline, decreased variability, or presence of periodic decelerations). E) During the gestational period, fetal skin and skeletal abnormalities may occur because fetal movement is impaired as a result of inadequate amniotic fluid volume. Page Ref: 579 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: Ⅸ. 12. Create asafe environment that results in high-quality patient outcomes. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 10 Describe the identification of the woman with oligohydramniosand the maternal and fetal-neonatal implications. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
28) The nurse knows that a baby born to a mother who had oligohydramnios could showsigns of which of the following? A) Respiratory difficulty B) Hypertension C) Heart murmur D) Decreased temperature Answer: A Explanation: A) Because there is less fluid available for the fetus to use during fetal breathing movements, pulmonary hypoplasia may develop. B) Hypertension has no relation to oligohydramnios. C) Heart murmur has no relation to oligohydramnios. D) Decreased temperature has no relation to oligohydramnios. Page Ref: 579 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 12. Create asafe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 11 Compare the clinical therapy and nursing management of thewoman with hydramnios and the woman with oligohydramnios. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
29) The client at 38 weeks' gestation has been diagnosed with oligohydramnios. Which statement indicates that teaching about the condition has been effective? A) "My gestational diabetes might have caused this problem to develop." B) "When I go into labor, I should come to the hospital right away." C) "This problem was diagnosed with blood and urine tests." D) "Women with this condition usually do not have a cesarean birth." Answer: B Explanation: A) Hydramnios, not oligohydramnios, is associated with such maternal disorders as diabetes. B) The incidence of cord compression and resulting fetal distress is high when there is an inadequate amount of amniotic fluid. The client with oligohydramnios should come to the hospital in early labor. C) Oligohydramnios is diagnosed when the largest vertical pocket of amniotic fluidvisible on ultrasound examination is 5 cm or less. D) The fetus is continually monitored during labor and birth. In the event that the fetal heart rate tracing is nonreassuring, late decelerations occur, and birth is notimminent, a cesarean birth may be performed. Page Ref: 579 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 11 Compare the clinical therapy and nursing management of the woman with hydramnios and the woman with oligohydramnios. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
30) A patient in preterm labor is prescribed magnesium sulfate 6 grams intravenous infusion now, followed by 5 grams per hour. The pharmacy prepares an infusion of 500 mL lactated Ringer's solution with 100 grams of magnesium sulfate. If the patient receives the loading dose and 3 hours of the medication, how many total mLof the infusion did the patient receive? Answer: 105 mL Explanation: The solution is 100 grams/500 mL or 1 gram in every 5 mL of solution. If the loading dose is 6 grams, then the patient received 6 grams × 5 mL =30 mL. For each hourly dose of 5 grams, the patient received 5 grams × 5 mL = 25 mL. Since the patient received the dose of 5 grams for 3 hours, then the patient received 25 mL × 3 = 75 mL.With the loading dose of 30 mL plus the three hours of infusion equaling 75 mL, the patient received 105 mL of the infusion. Page Ref: 559 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral TherapiesStandards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patientcentered care. | AACN Essentials Competencies: Ⅸ. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in allhealthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 3 Describe the clinical therapy for premature rupture of membranes and preterm labor in determining hospital-based and community-basednursing management of the woman and her fetus-newborn. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
31) A pregnant patient is diagnosed with premature separation of the placenta. The nurse provides the patient with the following diagram. What amount of placenta separation is this patient experiencing?
A) Central B) Marginal C) Complete D) Anticipated Answer: C Explanation: C) This diagram demonstrates complete separation with massive vaginal bleeding. In central separation the placenta separates centrally, and the blood is trapped between the placenta and the uterine wall. Entrapment of the blood results in concealed bleeding. In marginal separation blood passes between the fetal membranes and the uterine wall and escapes vaginally. Separation begins at theperiphery of the placenta; this marginal sinus rupture may or may not become more severe. Anticipated separation is not a type of placental separation. Page Ref: 566 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 1. Conductcomprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 4 Compare placenta previa and abruptio placentae, including
implications for the mother and fetus and their nursing care. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
32) The nurse is preparing teaching material for a pregnant patient with the following type of placenta previa. What information should the nurse provide the patient aboutthis health problem?
A) Internal os is partially covered by the placenta B) Internal os is covered completely by the placenta C) Edge of the placenta is at the margin of the internal os D) Placenta is implanted in the lower segment but does not reach the os Answer: A Explanation: A) The diagram is of a partial placenta previa. The internal os is partially covered by the placenta. In total placenta previa the internal os is covered completely by the placenta. In marginal placenta previa the edge of the placenta is at the margin of the internal os. In low-lying placenta previa the placenta is implanted in the lower segment but does not reach the os, although it is in close proximity of it. Page Ref: 569 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 4 Compare placenta previa and abruptio placentae, includingimplications for the mother and fetus and their nursing care. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
33) A pregnant patient is scheduled to have the procedure depicted in the diagram performed. What should the nurse explain is the purpose for this procedure?
A) Correct marginal placenta previa B) Prevent preterm cervical dilatation and pregnancy loss C) Reduce the risk of developing central abruptio placentae D) Assist the fetus to rotate into the appropriate position for delivery Answer: B Explanation: B) Cerclage is a surgical procedure in which a stitch is placed in the cervix to prevent a spontaneous abortion or premature birth. After placement, the string istightened and secured anteriorly. This procedure is not used to correct marginal placenta previa, reduce the risk of developing central abruptio placentae, or helpwith fetal rotation for delivery. Page Ref: 573 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multipledimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acuteand chronic care of patients and promoting health across the lifespan. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 7 Describe the clinical therapies and appropriate nursinginterventions for the mother with cervical insufficiency and her unborn fetus. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
34) A patient pregnant with twins late in the 3rd trimester has an ultrasound that shows the position of the fetuses as follows. What should the nurse expect will be planned for this patient?
A) Cesarean birth B) Vaginal delivery C) Spinal block during labor D) Continuous lumbar epidural Answer: A Explanation: A) Many practitioners choose to deliver any nonvertex presentation via cesarean birth. In 20% of cases, twin A is nonvertex and requires a cesarean birth. Approximately 40% of twins present in a vertex/vertex presentation. More than80% of twins in vertex/vertex presentation are born vaginally. Since the patientwill need a cesarean birth, spinal block and continuous lumbar epidural will notbe indicated. Page Ref: 577 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multipledimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acuteand chronic care of patients and promoting health across the lifespan. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process. Learning Outcome: 8 Analyze the maternal and fetal-newborn implications and clinicaltherapy in determining community-based and hospital-based nursing care of the woman
with a multiple gestation. MNL LO: Demonstrate use of the nursing process in the care of the woman with prelabor onset complications.
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 24. Childbirth at Risk: Labor-Related Complications 1) What would be a normal cervical dilatation rate in a first-time mother (“primip”)? 1. 1.5 cm per hour 2. Less than 1 cm cervical dilatation per hour 3. 1 cm per hour 4. Less than 0.5 cm per
hour Answer: 1 2) Dystocia encompasses many problems in labor. What is the most common? 1. Meconium-stained amniotic fluid 2. Dysfunctional uterine contractions 3. Cessation of contractions 4. Changes in the fetal heart
rate Answer: 2 3) Risk factors for tachysystole include which of the following? Select all that apply. 1. Cocaine use 2. Placental abruption 3. Low-dose oxytocin titration regimens 4. Uterine rupture 5. Smoking
Answer: 1, 2, 4 4) A woman has been having contractions since 4 a.m. At 8 a.m., her cervix is dilated to 5 cm.
Contractions are frequent, and mild to moderate in intensity. Cephalopelvic disproportion (CPD) has been ruled out. After giving the mother some sedation so she can rest, what would the nurse anticipate preparing for? 1. Oxytocin induction of labor 2. Amnioinfusion 3. Increased intravenous infusion 4. Cesarean section Answer: 1 5) Nonreassuring fetal status often occurs with a tachysystole contraction pattern.
Intrauterine resuscitation measures may become warranted and can include which of the following measures? Select all that apply. 1. Position the woman on her right side. 2. Apply oxygen via face mask. 3. Call for anesthesia provider for support. 4. Increase intravenous fluids by at least 700 mL bolus. 5. Call the physician/CNM to the bedside. Answer: 2, 3, 4 6) The nurse is making client assignments for the next shift. Which client is most likely to
experience a complicated labor pattern? 1. 34-year-old woman at 39 weeks’ gestation with a large-for-gestational-age (LGA) fetus 2. 22-year-old woman at 23 weeks’ gestation with ruptured membranes This study source was downloaded by 100000841359621 from CourseHero.com on 05-19-2022 04:49:56 GMT -05:00
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3. 30-year-old woman at 41 weeks’ gestation and estimated fetal weight 7 pounds 8 ounces 4. 43-year-old woman at 37 weeks’ gestation with
hypertension Answer: 1 7) Two hours ago, a client at 39 weeks’ gestation was 3 cm dilated, 40% effaced, and +1 station.
Frequency of contractions was every 5 minutes with duration 40 seconds and intensity 50 mmHg. The current assessment is 4 cm dilated, 40% effaced, and +1 station. Frequency of contractions is now every 3 minutes with 40-50 seconds’ duration and intensity of 40 mmHg. What would the priority intervention be? 1. Begin oxytocin after assessing for CPD. 2. Give terbutaline to stop the preterm labor. 3. Start oxygen at 8 L/min. 4. Have the anesthesiologist give the client an epidural. Answer: 1 8) What are the primary complications of placenta accrete? Select all that apply. 1. Maternal hemorrhage 2. Insomnia 3. Failure of the placenta to separate following birth of the infant 4. Autonomic dysreflexia 5. Shoulder
dystocia Answer: 1, 3 9) Risk factors for labor dystocia include which of the following? Select all that apply. 1. Tall maternal height 2. Labor induction 3. Small-for-gestational-age (SGA) fetus 4. Malpresentation 5. Prolonged latent
phase Answer: 2, 4, 5 10) In succenturiate placenta, one or more accessory lobes of fetal villi have developed on the
placenta, with vascular connections of fetal origin. What is the gravest maternal danger? 1. Cord prolapse 2. Postpartum hemorrhage 3. Paroxysmal hypertension 4. Brachial plexus injury Answer: 2 11) The nurse knows that the maternal risks associated with postterm pregnancy include which
of the following? Select all that apply. 1. Polyhydramnios 2. Maternal hemorrhage 3. Maternal anxiety 4. Forceps-assisted delivery 5. Perineal damage Answer: 2, 3, 4, 5 This study source was downloaded by 100000841359621 from CourseHero.com on 05-19-2022 04:49:56 GMT -05:00
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12) The client is at 42 weeks’ gestation. Which order should the nurse question? 1. Obtain biophysical profile today. 2. Begin nonstress test now. 3. Schedule labor induction for tomorrow. 4. Have the client return to the clinic in 1
week. Answer: 4 13) During labor, the fetus was in a brow presentation, but after a prolonged labor, the fetus
converted to face presentation and was delivered vaginally with forceps assist. What should the nurse explain to the parents? 1. The infant will need to be observed for meconium aspiration. 2. Facial edema and head molding will subside in a few days. 3. The infant will be given prophylactic antibiotics. 4. Breastfeeding will need to be delayed for a day or two. Answer: 2 14) The multiparous client at term has arrived to the labor and delivery unit in active labor
with intact membranes. Leopold maneuvers indicate the fetus is in a transverse lie with a shoulder presentation. Which physician order is most important? 1. Artificially rupture membranes. 2. Apply internal fetal scalp electrode. 3. Monitor maternal blood pressure every 15 minutes. 4. Alert surgical team of urgent cesarean. Answer: 4 15) The nurse should anticipate the labor pattern for a fetal occiput posterior position to be which
of the following? 1. Shorter than average during the latent phase 2. Prolonged as regards the overall length of labor 3. Rapid during transition 4. Precipitou s Answer: 2 16) Maternal risks of occiput posterior (OP) malposition include which of the
following? Select all that apply. 1. Blood loss greater than 1000 mL 2. Postpartum infection 3. Anal sphincter injury 4. Higher rates of vaginal birth 5. Instrument delivery Answer: 2, 3, 5 17) Which of the following potential problems would the nurse consider when planning care for
a client with a persistent occiput posterior position of the fetus? Select all that apply. 1. Increased fetal mortality 2. Severe perineal lacerations 3. Ceasing of labor progress 4. Fetus born in posterior position This study source was downloaded by 100000841359621 from CourseHero.com on 05-19-2022 04:49:56 GMT -05:00
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5. Intense back pain during
labor Answer: 2, 3, 4, 5 18) If the physician indicates a shoulder dystocia during the delivery of a macrosomic fetus,
how would the nurse assist? 1. Call a second physician to assist. 2. Prepare for an immediate cesarean delivery. 3. Assist the woman into McRoberts maneuver. 4. Utilize fundal pressure to push the fetus out. Answer: 3 19) The client has undergone an ultrasound, which estimated fetal weight at 4500 g (9
pounds 14 ounces). Which statement indicates that additional teaching is needed? 1. “Because my baby is big, I am at risk for excessive bleeding after delivery.” 2. “Because my baby is big, his blood sugars could be high after he is born.” 3. “Because my baby is big, my perineum could experience trauma during the birth.” 4. “Because my baby is big, his shoulders could get stuck and a collarbone broken.” Answer: 2 20) The client vaginally delivers an infant that weighs 4750 g. Moderate shoulder dystocia
occurred during the birth. During the initial assessment of this infant, what should the nurse look for? 1. Bell’s palsy 2. Bradycardia 3. Erb palsy 4. Petechia e Answer: 3 21) The nurse caring for a client in labor anticipates fetal macrosomia and shoulder dystocia.
Appropriate management of shoulder dystocia is essential in order to prevent which fetal complications? Select all that apply. 1. Brachial plexus injury 2. Fractured clavicle 3. Asphyxia 4. Neurological damage 5. Puerperal infection Answer: 1, 2, 3, 4 22) True postterm pregnancies are frequently associated with placental changes that cause a
decrease in the uterine-placental-fetal circulation. Complications related to alternations in placenta functioning include which of the following? Select all that apply. 1. Increased fetal oxygenation 2. Increased placental blood supply 3. Reduced nutritional supply 4. Macrosomia 5. Risk of shoulder dystocia Answer: 3, 4, 5 This study source was downloaded by 100000841359621 from CourseHero.com on 05-19-2022 04:49:56 GMT -05:00
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23) The nurse examines the client’s placenta and finds that the umbilical cord is inserted at the
placental margin. The client comments that the placenta and cord look different than they did for her first two births. The nurse should explain that this variation in placenta and cord is called what? 1. Placenta accreta 2. Circumvallate placenta 3. Succenturiate placenta 4. Battledore placenta Answer: 4 24) A woman is admitted to the birth setting in early labor. She is 3 cm dilated, -2 station, with
intact membranes and FHR of 150 beats/min. Her membranes rupture spontaneously, and the FHR drops to 90 beats/min with variable decelerations. What would the initial response from the nurse be? 1. Perform a vaginal exam. 2. Notify the physician. 3. Place the client in a left lateral position. 4. Administer oxygen at 2 L per nasal cannula. Answer: 1 25) The nurse is caring for a client in active labor. The membranes spontaneously rupture, with
a large amount of clear amniotic fluid. Which nursing action is most important to undertake at this time? 1. Assess the odor of the amniotic fluid. 2. Perform Leopold maneuvers. 3. Obtain an order for pain medication. 4. Complete a sterile vaginal exam. Answer: 4 26) During labor, the client at 4 cm suddenly becomes short of breath, cyanotic, and hypoxic.
The nurse must prepare or arrange immediately for which of the following? Select all that apply. 1. Intravenous access 2. Cesarean delivery 3. Immediate vaginal delivery 4. McRoberts maneuver 5. A crash cart Answer: 1, 2, 5 27) On assessment, a labor client is noted to have cardiovascular and respiratory collapse
and is unresponsive. What should the nurse suspect? 1. An amniotic fluid embolus 2. Placental abruption 3. Placenta accreta 4. Retained placenta Answer: 1 28) Five clients are in active labor in the labor unit. Which women should the nurse monitor This study source was downloaded by 100000841359621 from CourseHero.com on 05-19-2022 04:49:56 GMT -05:00
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carefully for the potential of uterine rupture? Select all that apply. 1. Age 15, in active labor 2. Age 22, with eclampsia 3. Age 25, last delivery by cesarean section
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4. Age 32, first baby died during labor 5. Age 27, last delivery 11 months
ago Answer: 3, 5 29) The nurse is caring for a client who could be at risk for uterine rupture. The nurse is
monitoring the fetus closely for which of the following? Select all that apply. 1. Late decelerations 2. Bradycardia 3. Loss of ability to determine fetal station 4. Tachycardia 5. Early decelerations Answer: 1, 2, 3 30) A 26-year-old client is having her initial prenatal appointment. The client reports to the
nurse that she suffered a pelvic fracture in a car accident 3 years ago. The client asks whether her pelvic fracture might affect her ability to have a vaginal delivery. What response by the nurse is best? 1. “It depends on how your pelvis healed.” 2. “You will need to have a cesarean birth.” 3. “Please talk to your doctor about that.” 4. “You will be able to delivery vaginally.” Answer: 1 31) In caring for a client with a uterine rupture, the nurse determines which nursing
diagnoses to be appropriate? Select all that apply. 1. Gas Exchange, Impaired 2. Fear related to unknown outcome 3. Coping, Ineffective 4. Mobility: Physical, Impaired 5. Anxiety Answer: 1, 2, 3, 5 32) A fetal weight is estimated at 4490 grams in a client at 38 weeks’ gestation. Counseling
should occur before labor regarding which of the following? 1. Mother’s undiagnosed diabetes 2. Likelihood of a cesarean delivery 3. Effectiveness of epidural anesthesia with a large fetus 4. Need for early delivery Answer: 2 33) A woman has been in labor for 16 hours. Her cervix is dilated to 3 cm and is 80% effaced.
The fetal presenting part is not engaged. The nurse would suspect which of the following? 1. Breech malpresentation 2. Fetal demise 3. Cephalopelvic disproportion (CPD) 4. Abruptio placentae Answer: 3 This study source was downloaded by 100000841359621 from CourseHero.com on 05-19-2022 04:49:56 GMT -05:00
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34) What is one of the most common initial signs of nonreassuring fetal status? 1. Meconium-stained amniotic fluid 2. Cyanosis 3. Dehydration 4. Arrest of
descent Answer: 1 35) The client gave birth to a 7 pound, 14 ounce female 30 minutes ago. The placenta has
not yet delivered. Manual removal of the placenta is planned. What should the nurse prepare to do? 1. Start an IV of lactated Ringer’s. 2. Apply anti-embolism stockings. 3. Bottle-feed the infant. 4. Send the placenta to pathology. Answer: 1 36) The client delivered 30 minutes ago. Her blood pressure and pulse are stable. Vaginal
bleeding is scant. The nurse should prepare for which procedure? 1. Abdominal hysterectomy 2. Manual removal of the placenta 3. Repair of perineal lacerations 4. Foley catheterization Answer: 2 37) Lacerations of the cervix or vagina may be present when bright red vaginal bleeding
persists in the presence of a well-contracted uterus. The incidence of lacerations is higher among which of the following childbearing women? Select all that apply. 1. Over the age of 35 2. Have not had epidural block 3. Have had an episiotomy 4. Have had a forceps-assisted or vacuum-assisted birth 5. Nulliparo us Answer: 3, 4 38) After delivery, it is determined that there is a placenta accreta. Which intervention should the
nurse anticipate? 1. 2 L oxygen by mask 2. Intravenous antibiotics 3. Intravenous oxytocin 4. Hysterectom y Answer: 4 39) What is required for any women receiving oxytocin (Pitocin)? 1. CPR 2. Continuous electronic fetal monitoring 3. Administering oxygen by mask 4. Nonstress This study source was downloaded by 100000841359621 from CourseHero.com on 05-19-2022 04:49:56 GMT -05:00
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test Answer: 2
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40) The client has delivered a 4200 g fetus. The physician performed a midline episiotomy,
which extended into a third-degree laceration. The client asks the nurse where she tore. Which response is best? 1. “The episiotomy extended and tore through your rectal mucosa.” 2. “The episiotomy extended and tore up near your vaginal mucous membrane.” 3. “The episiotomy extended and tore into the muscle layer.” 4. “The episiotomy extended and tore through your anal sphincter.” Answer: 4
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Old's Maternal-Newborn Nursing and Women's Health, 11e(Davidson/London/Ladewig) Chapter 25 Birth-Related Procedures 1) The client is undergoing an emergency cesarean birth for fetal bradycardia. The client's partner has not been allowed into the operating room. What can the nurse doto alleviate the partner's emotional distress? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Allow the partner to wheel the baby's crib to the newborn nursery. B) Allow the partner to be near the operating room where the newborn's first cry canbe heard. C) Have the partner wait in the client's postpartum room. D) Encourage the partner to be in the nursery for the initial assessment. E) Teach the partner how to take the client's blood pressure. Answer: A, B, D Explanation: A) Effective measures include allowing the partner to take the baby to the nursery. B) Effective measures include allowing the partner to be in a place near the operating room, where the newborn's first cry can be heard. C) The nurse should involve the partner in postpartum care in the recovery room,not have the partner wait in the client's postpartum room. D) Effective measures include involving the partner in postpartum care, such asbeing present for the initial assessment. E) The nurse must take the blood pressure as part of assessing the client. Page Ref: 633 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: Ⅰ. C. 13. Acknowledge the tension that may exist between patient rights and the organizational responsibility for professional, ethical care. | AACN Essentials Competencies: Ⅸ. 3. Implement holistic, patient-centered carethat reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health- illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 9 Explain the indications for cesarean birth, impact on the familyunit, preparation and teaching needs, and associated nursing management.
MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures. 2) The client tells the nurse that she has come to the hospital so that her baby's position can be changed. The nurse would begin to organize the supplies needed toperform which procedure? A) A version B) An amniotomy C) Leopold maneuvers D) A ballottement Answer: A Explanation: A) Version, or turning the fetus, is a procedure used to change the fetal presentationby abdominal or intrauterine manipulation. B) Amniotomy is the artificial rupture of membranes. C) Leopold maneuvers are a series of palpations performed to determine fetal position. D) Ballottement occurs when the fetus floats away and then returns to touch an examiner's hand during a vaginal exam. Page Ref: 609 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅰ. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science andquality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning.Learning Outcome: 2 Contrast the methods of external cephalic version and internal version and the related nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
3) A woman has been admitted for an external version. She has completed an ultrasound exam and is attached to the fetal monitor. Prior to the procedure, why willterbutaline be administered? A) To provide analgesia B) To relax the uterus C) To induce labor D) To prevent hemorrhage Answer: B Explanation: A) Terbutaline has no analgesic effect. B) Terbutaline is administered to achieve uterine relaxation. C) Terbutaline does not induce labor. D) Terbutaline does not prevent hemorrhage. Page Ref: 611 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across the lifespan, and in all healthcare settings. | NLN Competencies: Knowledge andScience: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Contrast the methods of external cephalic version and internalversion and the related nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
4) The nurse is scheduling a client for an external cephalic version (ECV). Whichfinding in the client's chart requires immediate intervention? A) Previous birth by cesarean B) Frank breech ballotable C) 37 weeks, complete breech D) Failed ECV last week Answer: A Explanation: A) Any previous uterine scar is a contraindication to ECV. Prior scarring of theuterus may increase the risk of uterine tearing or uterine rupture. B) There is no contraindication to ECV for this client. C) ECV is not attempted until 36 or 37 weeks. There is no contraindication for ECVfor this client. D) Although this client is less likely to have a successful ECV this week if it was unsuccessful last week, there is no contraindication to attempting the procedure. Page Ref: 611 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology andstandardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factorsand actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Contrast the methods of external cephalic version and internalversion and the related nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
5) A laboring client's obstetrician has suggested amniotomy as a method for inducing labor. Which assessment(s) must be made just before the amniotomy is performed? A) Maternal temperature, BP, and pulse B) Estimation of fetal birth weight C) Fetal presentation, position, station, and heart rate D) Biparietal diameter Answer: C Explanation: A) Maternal vital signs do not affect the decision to perform an amniotomy. B) Fetal birth weight does not affect the decision to perform an amniotomy. C) Before an amniotomy is performed, the fetus is assessed for presentation,position, station, and FHR. D) Biparietal diameter does not affect the decision to perform an amniotomy. Page Ref: 621 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factorsand actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Discuss the use of amniotomy in current maternal-newborn care.MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birthrelated procedures.
6) Amniotomy as a method of labor induction has which of the following advantages? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) The danger of a prolapsed cord is decreased. B) There is usually no risk of hypertonus or rupture of the uterus. C) The intervention can cause a decrease in pain. D) The color and composition of amniotic fluid can be evaluated. E) The contractions elicited are similar to those of spontaneous labor. Answer: B, D, E Explanation: A) The danger of a prolapsed cord is increased once the membranes have ruptured,especially if the fetal presenting part is not firmly pressed down against the cervix. B) There is usually no risk of hypertonus or rupture of the uterus, and this is an advantage of amniotomy. C) The intervention can cause an increase in pain, making labor more difficult to manage. D) The color and composition of amniotic fluid can be evaluated, and this is an advantage of amniotomy. E) The contractions elicited are similar to those of spontaneous labor, and this is an advantage of amniotomy. Page Ref: 621 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factorsand actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 3 Discuss the use of amniotomy in current maternal-newborn care.MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birthrelated procedures.
7) A laboring client's obstetrician has suggested amniotomy as a method for creatingstronger contractions and facilitating birth. The client asks, "What are the advantages of doing this?" What should the nurse cite in response? A) Contractions elicited are similar to those of spontaneous labor. B) Amniotomy decreases the chances of a prolapsed cord. C) Amniotomy reduces the pain of labor and makes it easier to manage. D) The client will not need an episiotomy. Answer: A Explanation: A) Contractions after amniotomy are similar to those of spontaneous labor. B) A disadvantage of amniotomy is the increased chance of prolapsed cord, especially if the fetal presenting part is not well applied against the cervix. C) A disadvantage of amniotomy is that it can increase pain and make labor moredifficult to manage. D) There is no correlation between amniotomy and episiotomy. Page Ref: 621 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Discuss the use of amniotomy in current maternal-newborn care.MNL LO: Demonstrate use of the nursing process in the care of the woman and fetus during birthrelated procedures.
8) After inserting prostaglandin gel for cervical ripening, what should the nurse do? A) Apply an internal fetal monitor. B) Insert an indwelling catheter. C) Withhold oral intake and start intravenous fluids. D) Place the client in a supine position with a right hip wedge. Answer: D Explanation: A) An internal fetal monitor cannot be applied until adequate cervical dilatation has occurred. B) The client should void on her own and not need a catheter. C) Until labor begins, there is no rationale for withholding all intake. D) After the gel, intravaginal insert, or tablet is inserted, the woman is instructed to remain lying down with a rolled blanket or hip wedge under her right hip to tip theuterus slightly to the left for the first 30 to 60 minutes to maintain the cervical ripening agent in place. Page Ref: 614 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Compare methods for inducing labor, explaining theiradvantages and disadvantages. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
9) Under which circumstances would the nurse remove prostaglandin from the client'scervix? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Contractions every 5 minutes B) Nausea and vomiting C) Uterine tachysystole D) Cardiac tachysystole E) Baseline fetal heart rate of 140-148 Answer: B, C, D Explanation: A) Contractions every 5 minutes are consistent with the plan of induction. B) A reason to remove prostaglandin from a client's cervix is the presence of nauseaand vomiting. C) A reason to remove prostaglandin from a client's cervix is uterine tachysystole. D) A reason to remove prostaglandin from a client's cervix is cardiac tachysystole. E) This is a good heart rate and would not warrant removing the prostaglandin. Page Ref: 615 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 4 Compare methods for inducing labor, explaining theiradvantages and disadvantages. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
10) The nurse knows that the Bishop scoring system for cervical readiness includeswhich of the following? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Fetal station B) Fetal lie C) Fetal presenting part D) Cervical effacement E) Cervical softness Answer: A, D, E Explanation: A) Fetal station is one of the components evaluated by the Bishop scoring system. B) Fetal lie is not one of the components evaluated by the Bishop scoring system. C) The presenting part is not one of the components evaluated by the Bishopscoring system. D) Cervical effacement is one of the components evaluated by the Bishop scoringsystem. E) Cervical consistency is one of the components evaluated by the Bishop scoringsystem. Page Ref: 616 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 4 Compare methods for inducing labor, explaining theiradvantages and disadvantages. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
11) The nurse knows that a contraindication to the induction of labor is which of the following? A) Placenta previa B) Isoimmunization C) Diabetes mellitus D) Premature rupture of membranes Answer: A Explanation: A) Placenta previa is a contraindication to the induction of labor. B) Isoimmunization is an indication for induction. C) Diabetes mellitus is an indication for induction. D) Premature rupture of membranes is an indication for induction. Page Ref: 614 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Compare methods for inducing labor, explaining theiradvantages and disadvantages. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
12) Induction of labor is planned for a 31-year-old client at 39 weeks due to insulindependent diabetes. Which nursing action is most important? A) Administer 100 mcg of misoprostol (Cytotec) vaginally every 2 hours. B) Place dinoprostone (Prepidil) vaginal gel and ambulate client for 1 hour. C) Begin Pitocin (oxytocin) 4 hours after 50 mcg misoprostol (Cytotec). D) Prepare to induce labor after administering a tap water enema. Answer: C Explanation: A) 100 mcg every 2 hours is too much medication administered too frequently. B) The client must remain recumbent for 2 hours after administration of dinoprostone (Prepidil) vaginal gel, during which time she is continuously monitored. C) Pitocin should not administered less than 4 hours after the last Cytotec dose. D) Enemas are not routinely used in labor. This order is not expected. Page Ref: 612 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factorsand actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Compare methods for inducing labor, explaining theiradvantages and disadvantages. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
13) The client presents for cervical ripening in anticipation of labor induction tomorrow. What should the nurse include in her plan of care for this client? A) Apply an internal fetal monitor. B) Monitor the client using electronic fetal monitoring. C) Withhold oral intake and start intravenous fluids. D) Place the client in an upright, sitting position. Answer: B Explanation: A) An internal fetal monitor cannot be applied until adequate cervical dilatation has occurred and the membranes are ruptured. B) The client should be monitored using electronic fetal monitoring for at least 30 minutes and up to 2 hours after placement to assess the contraction pattern andthe fetal status. C) Until labor begins, there is no rationale for withholding oral intake. D) The client is placed in a reclining position and bed rest is maintained to preventthe medication from leaking from the vagina. Page Ref: 613 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Compare methods for inducing labor, explaining theiradvantages and disadvantages. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
14) The nurse is caring for a client who is about to receive an amnioinfusion. For which complication(s) should the nurse monitor the client? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Umbilical cord prolapse B) Amniotic fluid embolism C) Uterine rupture D) Amnionitis E) Abruptio placentae Answer: A, B, C Explanation: A) Umbilical cord prolapse is a rare, but serious risk factor for the client receiving an amnioinfusion. B) Amniotic fluid embolism is a rare, but serious risk factor for the client receiving an amnioinfusion. C) Uterine rupture is a rare, but serious risk factor for the client receiving an amnioinfusion. D) The presence of amnionitis is a contraindication to amnioinfusion, but is not a condition that results from amnioinfusion. E) The presence of abruptio placentae is a contraindication to amnioinfusion, but isnot a condition that results from amnioinfusion. Page Ref: 621 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Discuss the use of transcervical intrapartum amnioinfusion. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
15) The client is having fetal heart rate decelerations. An amnioinfusion has been ordered to alleviate the decelerations. The nurse understands that the type of decelerations that will be alleviated by amnioinfusion is which of the following? A) Early decelerations B) Moderate decelerations C) Late decelerations D) Variable decelerations Answer: D Explanation: A) Early decelerations require no intervention. B) Moderate is not a descriptor used to identify decelerations. C) Late decelerations are consistent with head compression. Amnioinfusion doesnot relieve head compression. D) When cord compression is suspected, amnioinfusion (AI) may be considered. AI helps to prevent the possibility of variable decelerations by increasing the volumeof amniotic fluid. Page Ref: 621 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology andstandardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Discuss the use of transcervical intrapartum amnioinfusion. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
16) The nurse is completing discharge teaching for a client who delivered 2 days ago. Which statement by the client indicates that further information is required? A) "Because I have a midline episiotomy, I should keep my perineum clean." B) "I can use an ice pack to relieve some the pain from the episiotomy." C) "I can take ibuprofen (Motrin) when my perineum starts to hurt." D) "The tear I have through my rectum is unrelated to my episiotomy." Answer: D Explanation: A) A complication associated with an episiotomy is infection. Perineal hygiene is important when a client has an episiotomy to prevent infection and facilitate healing. B) Pain relief measures may begin immediately after birth with application of an icepack to the perineum. C) Healing episiotomies can be very painful, and pain medication should be provided for clients experiencing pain. D) This statement is incorrect. The major disadvantage is that a tear of the midlineincision may extend through the anal sphincter and rectum. Page Ref: 623 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 1. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 6 Describe the types of episiotomies performed, the rationale for each, and the associated nursing interventions. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
17) The client requires vacuum extraction assistance. To provide easier access to thefetal head, the physician cuts a mediolateral episiotomy. After delivery, the client asks the nurse to describe the episiotomy. How does the nurse respond? A) "The episiotomy goes straight back toward your rectum." B) "The episiotomy is from your vagina toward the urethra." C) "The episiotomy is cut diagonally away from your vagina." D) "The episiotomy extends from your vagina into your rectum." Answer: C Explanation: A) A midline episiotomy is straight back from the vagina toward the rectum. B) Episiotomies are not cut anteriorly toward the urethra. C) A mediolateral episiotomy is angled from the vaginal opening toward the buttock.It begins in the midline of the posterior fourchette and extends at a 45-degree angle downward to the right or left. D) Extension into the rectum is a fourth-degree laceration. Page Ref: 623 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Describe the types of episiotomies performed, the rationale foreach, and the associated nursing interventions. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
18) The client is recovering from a delivery that included a midline episiotomy. Her perineum is swollen and sore. Ten minutes after an ice pack is applied, the clientasks for another. What is the best response from the nurse? A) "I'll get you one right away." B) "You only need to use one ice pack." C) "You need to leave it off for at least 20 minutes and then reapply." D) "I'll bring you an extra so that you can change it when you are ready." Answer: C Explanation: A) Providing an additional ice pack before 20 minutes have passed would increasethe perineal edema. B) More than one ice pack must be used in order to apply ice for 20 minutes on followed by 20 minutes off. C) For optimal effect, the ice pack should be applied for 20 to 30 minutes and removed for at least 20 minutes before being reapplied. D) An ice pack that is provided now for use in 20 minutes would melt before beingused. Page Ref: 623 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Teaching and Learning. Learning Outcome: 6 Describe the types of episiotomies performed, the rationale foreach, and the associated nursing interventions. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
19) Major perineal trauma (extension to or through the anal sphincter) is more likely tooccur if what type of episiotomy is performed? A) Mediolateral B) Episiorrhaphy C) Midline D) Medical Answer: C Explanation: A) Major perineal trauma is more likely to occur if a midline episiotomy is performed. B) Episiorrhaphy is the repair of the episiotomy. C) Major perineal trauma is more likely to occur if a midline episiotomy is performed.The major disadvantage is that a tear of the midline incision may extend through the anal sphincter and rectum. D) Medical is not a type of episiotomy. Page Ref: 622 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acuteand chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 6 Describe the types of episiotomies performed, the rationale foreach, and the associated nursing interventions. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
20) The nurse is training a nurse new to the labor and delivery unit. They are caring for alaboring client who will have a forceps delivery. Which action or assessment finding requires intervention? A) Regional anesthesia is administered via pudendal block. B) The client is instructed to push between contractions. C) Fetal heart tones are consistently between 110 and 115. D) The client's bladder is emptied using a straight catheter. Answer: B Explanation: A) Adequate anesthesia must be given for the type of forceps procedure anticipated. Low forceps may be done with a pudendal block; however, midforceps or a rotation of more than 45 degrees requires an epidural, spinal-epidural, or general anesthesia. B) During the contraction, as the forceps are applied, the woman should avoid pushing. C) Fetal heart tones between 110 and 115 are normal. No intervention is needed. D) The maternal bladder should be emptied. Page Ref: 626 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅴ. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: Ⅸ. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals(team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Summarize the indications for forceps-assisted birth, types offorceps that may be used, complications, and related interventions. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
21) The need for forceps has been determined. The client's cervix is dilated to 10 cm, and the fetus is at +2 station. What category of forceps application would the nurseanticipate? A) Input B) Low C) Mid D) Outlet Answer: B Explanation: A) Input is not a term associated with the use of forceps. B) Low forceps are applied when the leading edge of the fetal head is at +2 station. C) Midforceps are applied when the fetal head is engaged. D) Outlet forceps are applied when the fetal skull has reached the perineum. Page Ref: 625 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Summarize the indications for forceps-assisted birth, types offorceps that may be used, complications, and related interventions. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
22) What type of forceps are designed to be used with a breech presentation? A) Midforceps B) Piper C) Low D) High Answer: B Explanation: A) The criterion for midforceps application is that the fetal head must be engaged,but the leading edge of the fetal skull is above a plus 2 (+2) station. B) Piper forceps are designed to be used with a breech presentation. They are applied after the birth of the body, when the fetal head is still in the birth canaland assistance is needed. C) The criterion for low forceps application is that the leading edge of the fetal skullmust be at a station of plus 2 (+2) or below, but not on the pelvic floor. D) High forceps are not indicated in current obstetric practice. Page Ref: 625 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Summarize the indications for forceps-assisted birth, types offorceps that may be used, complications, and related interventions. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
23) The physician has determined the need for forceps. The nurse should explain to theclient that the use of forceps is indicated because of which of the following? A) Her support person is exhausted B) Premature placental separation C) To shorten the first stage of labor D) To prevent fetal distress Answer: B Explanation: A) Exhaustion of the support person is not an indication for use of forceps. B) Fetal conditions indicating the need for forceps include premature placental separation, prolapsed umbilical cord, and nonreassuring fetal status. C) Forceps may be used electively to shorten the second stage of labor and sparethe woman's pushing effort, or when regional anesthesia has affected the woman's motor innervation, and she cannot push effectively. D) Indications for the use of forceps include premature placental separation and a nonreassuring fetal heart rate. Using forceps does not prevent fetal distress. Page Ref: 625 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Summarize the indications for forceps-assisted birth, types offorceps that may be used, complications, and related interventions. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
24) The physician/CNM opts to use a vacuum extractor for a delivery. What does thenurse understand? A) There is little risk with vacuum extraction devices. B) There should be further fetal descent with the first two "pop-offs." C) Traction is applied between contractions. D) The woman often feels increased discomfort during the procedure. Answer: B Explanation: A) The risk of complications rises with the use of a vacuum extraction device. B) If more than three "pop-offs" occur (the suction cup pops off the fetal head), the procedure should be discontinued. C) The physician/CNM applies traction in coordination with uterine contractions, not between contractions. D) If adequate regional anesthesia has been administered, the woman feels onlypressure during the procedure. Page Ref: 628 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Discuss the use of vacuum extraction, including indications,procedure, complications, and related nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
25) The client has been pushing for 2 hours and is exhausted. The physician is performing a vacuum extraction to assist the birth. Which finding is expected andnormal? A) The head is delivered after eight "pop-offs" during contractions. B) A cephalohematoma is present on the fetal scalp. C) The location of the vacuum is apparent on the fetal scalp after birth. D) Positive pressure is applied by the vacuum extraction during contractions. Answer: C Explanation: A) Use of the vacuum extraction for eight contractions is too many. If more thanthree "pop-offs" occur, the procedure should be discontinued. B) A cephalohematoma is a complication of vacuum extraction birth and is not an expected finding. C) The parents need to be informed that the caput (chignon) on the baby's head will disappear within 2 to 3 days. D) Negative pressure is suction, which is needed to facilitate the birth. Page Ref: 628 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Discuss the use of vacuum extraction, including indications,procedure, complications, and related nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
26) The client has been pushing for two hours, and is exhausted. The fetal head is visible between contractions. The physician informs the client that a vacuum extractor could be used to facilitate the delivery. Which statement indicates that theclient needs additional information about vacuum extraction assistance? A) "A small cup will be put onto the baby's head, and a gentle suction will be applied." B) "I can stop pushing and just rest if the vacuum extractor is used." C) "The baby's head might have some swelling from the vacuum cup." D) "The vacuum will be applied for a total of ten minutes or less." Answer: B Explanation: A) The vacuum extractor is a small cup-shaped device that is applied to the fetalscalp. B) Vacuum extraction is an assistive delivery. The physician/CNM applies traction in coordination with uterine contractions. C) The vacuum extractor might leave some swelling ("chignon") on the scalp wherethe device is placed. D) Research indicates that negative suction applied for more than 10 minutes is associated with a greater incidence of scalp injury. Page Ref: 628 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 8 Discuss the use of vacuum extraction, including indications, procedure, complications, and related nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
27) The laboring client participated in childbirth preparation classes that strongly discouraged the use of medications and intervention during labor. The client has been pushing for two hours, and is exhausted. The physician requests that a vacuum extractor be used to facilitate the birth. The client first states that she wantsthe birth to be normal, then allows the vacuum extraction. Following this, what should the nurse assess the client for after the birth? A) Elation, euphoria, and talkativeness B) A sense of failure and loss C) Questions about whether or not to circumcise D) Uncertainty surrounding the baby's name Answer: B Explanation: A) Elation, euphoria, and talkativeness are expected after birth. B) Clients who participate in childbirth classes that stress the normalcy of birth mayfeel a sense of loss or failure if an intervention is used during their labor or birth. C) Decisions on circumcision and naming are often encountered after birth, and arenot correlated with the use of intervention. D) Decisions on circumcision and naming are often encountered after birth, and arenot correlated with the use of intervention. Page Ref: 626 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 13. Acknowledge the tension that may exist between patient rights and the organizational responsibility for professional, ethical care. | AACN Essentials Competencies: Ⅸ. 5. Deliver compassionate, patient-centered,evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Discuss the use of vacuum extraction, including indications,procedure, complications, and related nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
28) The nurse is reviewing charts of clients who underwent cesarean births by request inthe last two years. The hospital is attempting to decrease costs of maternity care. What findings contribute to increased healthcare costs in clients undergoingcesarean birth by request? A) Increased abnormal placenta implantation in subsequent pregnancies B) Decreased use of general anesthesia with greater use of epidural anesthesia C) Prolonged anemia, requiring blood transfusions every few months D) Coordination of career projects of both partners leading to increased income Answer: A Explanation: A) Repeat cesarean births are associated with greater risks, including increasedincidence of abnormal placentation in subsequent pregnancies and increasedrisk of mortality secondary to surgery, which would contribute to increased healthcare costs. B) Which anesthesia method is used is not a significant factor in healthcare costs ofcesarean birth by request. C) Prolonged anemia is not a complication of cesarean birth by request. D) The income of the couple does not affect healthcare costs directly. Page Ref: 634 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅴ. 10. Articulate, through a nursing perspective, issues concerning healthcare delivery to decision makers within healthcare organizations and other policy arenas. | NLN Competencies: Knowledge and Science: Translate research into practice in order to promote quality and improve practices. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 9 Explain the indications for cesarean birth, impact on the familyunit, preparation and teaching needs, and associated nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
29) After being in labor for several hours with no progress, a client is diagnosed with CP D (cephalopelvic disproportion), and must have a cesarean section. The client is worried that she will not be able to have any future children vaginally. After sharing this information with her care provider, the nurse would anticipate that the client would receive what type of incision? A) Transverse B) Infraumbilical midline C) Classic D) Vertical Answer: A Explanation: A) The transverse incision is made across the lowest and narrowest part of the abdomen and is the most common lower uterine segment incision. B) The infraumbilical midline incision is a type of vertical incision, which carries an increased risk of uterine rupture with subsequent pregnancy, labor, and birth. C) The classic vertical incision, which is made into the upper uterine segment, wasthe method of choice for many years but is nearly never performed in modern obstetrics. It carries an increased risk of uterine rupture with subsequent pregnancy, labor, and birth. D) The classic vertical incision, which is made into the upper uterine segment, wasthe method of choice for many years but is nearly never performed in modern obstetrics. It carries an increased risk of uterine rupture with subsequent pregnancy, labor, and birth. Page Ref: 630 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 4. Communicate effectively with all members of the healthcare team,including the patient and the patient's support network. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 9 Explain the indications for cesarean birth, impact on the familyunit, preparation and teaching needs, and associated nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
30) The client demonstrates understanding of the implications for future pregnancies secondary to her classic uterine incision when she states which of the following? A) "The next time I have a baby, I can try to deliver vaginally." B) "The risk of rupturing my uterus is too high for me to have any more babies." C) "Every time I have a baby, I will have to have a cesarean delivery." D) "I can only have one more baby." Answer: C Explanation: A) This client will not be able to deliver vaginally in future pregnancies. B) There could be a risk of uterine rupture if the client were allowed to labor with thenext pregnancy. C) A classic uterine incision is made in the upper uterine segment and is associatedwith an increased risk of rupture in subsequent pregnancy, labor, and birth. Therefore, subsequent deliveries will be done by cesarean. D) The number of subsequent pregnancies is not limited to one. Page Ref: 630 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 9 Explain the indications for cesarean birth, impact on the family unit, preparation and teaching needs, and associated nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
31) In the operating room, a client is being prepped for a cesarean delivery. The doctor is present. What is the last assessment the nurse should make just before the clientis draped for surgery? A) Maternal temperature B) Maternal urine output C) Vaginal exam D) Fetal heart tones Answer: D Explanation: A) The supine position would not cause an abnormality in maternal temperature. B) The supine position would not cause an abnormality in maternal urine output. C) There is no indication that a vaginal exam should be performed. D) Ascertain fetal heart rate (FHR) before surgery and during preparation, becausefetal hypoxia can result from aortocaval compression. Page Ref: 632 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology andstandardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 9 Explain the indications for cesarean birth, impact on the familyunit, preparation and teaching needs, and associated nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
32) A client is consulting a certified nurse-midwife because she is hoping for a vaginal birth after cesarean (VBAC) with this pregnancy. Which statement indicates that theclient requires more information about VBAC? A) "I can try a vaginal birth because my uterine incision is a low segment transverse incision." B) "The vertical scar on my skin doesn't mean that the scar on my uterus goes inthe same direction." C) "There is about a 90% chance of giving birth vaginally after a cesarean." D) "Because my hospital has a surgery staff on call 24 hours a day, I can try a VBAC there." Answer: C Explanation: A) Only low segment transverse uterine incisions are recommended for attempting aVBAC. B) Abdominal skin incisions and uterine incisions are not always the same. C) Women whose previous cesarean was performed because of nonrecurring indications have been reported to have approximately a 60% to 80% chance ofsuccess with VBAC. D) VBAC should be attempted only in facilities that have in-house anesthesia personnel available for emergency cesarean births if warranted. Page Ref: 634 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 10 Examine the risks, guidelines, and nursing care of the woman undergoing vaginal birth after cesarean birth (VBAC) or a trial of labor after cesarean birth (TOLAC). MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
33) The nurse is teaching a class on vaginal birth after cesarean (VBAC). Which statement by a participant indicates that additional information is needed? A) "Because the scar on my belly goes down from my navel, I am not a candidatefor a VBAC." B) "My first baby was in a breech position, so for this pregnancy, I can try a VBAC ifthe baby is head-down." C) "Because my hospital is so small and in a rural area, they won't let me attempt aVBAC." D) "The rate of complications from VBAC is lower than the rate of complicationsfrom a cesarean." Answer: A Explanation: A) Skin incision is not indicative of uterine incision. Only the uterine incision is a factor in deciding whether VBAC is advisable. The classic vertical incision wascommonly done in the past and is associated with increased risk of uterine rupture in subsequent pregnancies and labor. B) Nonrecurring conditions such as any non-vertex presentation might make VBACa viable option as long as this pregnancy is vertex. C) For a VBAC to be safely attempted, the facilities must have in-house anesthesia personnel available for emergency cesarean births if warranted. Many small andrural hospitals do not have surgical and anesthesia staff available at night or on weekends and holidays, and therefore do not allow clients to have VBACs. D) The incidence of uterine rupture is 0.1% to 0.7%. Page Ref: 634 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 10 Examine the risks, guidelines, and nursing care of the woman undergoing vaginal birth after cesarean birth (VBAC) or a trial of labor after cesarean birth (TOLAC). MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
34) The healthcare provider of a laboring patient is considering a mediolateral episiotomy. On the following diagram, identify where this incision should be made.
A) A B) B C) C D) D Answer: B Explanation: B) The mediolateral episiotomy begins in the midline of the posterior fourchette (toavoid incision into the Bartholin gland) and extends at a 45-degree angle downward to the right or left (the direction depending on the handedness of theclinician). Page Ref: 624 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: Ⅰ. A. 1. | Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in allhealthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Planning: Nursing Process. Learning Outcome: 6 Describe the types of episiotomies performed, the rationale foreach, and the associated nursing interventions. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures. 35) The healthcare provider asks for forceps to aid in the delivery of a fetus that is
engaged, but the leading edge is at +1. Which type of forceps should be handed tothe healthcare provider for this delivery? A)
B)
C)
D)
Answer: B Explanation: B) The criterion for midforceps application is that the fetal head must be engaged (largest diameter of the head reaches or passes through the pelvic inlet), but the leading edge (presenting part) of the fetal skull is above a plus 2 (+2) station (for example, +1, 0, —1, —2). When midforceps are used, the goal is to apply traction and, frequently, to rotate the head and facilitate the vaginal birth. Kiellandforceps are used for midforceps rotations. Elliot and Simpson forceps are used
as outlet forceps. Piper forceps are used to provide traction and flexion of theaftercoming head of a fetus in breech presentation. Page Ref: 625 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice; conductpopulation-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 7 Summarize the indications for forceps-assisted birth, types offorceps that may be used, complications, and related interventions. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
36) Forceps are being used to deliver the fetus of a laboring patient, as identified in the diagram. In which direction should the healthcare provider use the forceps to guide the fetus for delivery?
A) Upward and outward B) Downward and outward C) Midline and towards the left D) Midline and toward the right Answer: B Explanation: B) During uterine contractions, traction is applied to the forceps in a downward and outward direction to follow the birth canal. Upward, midline, or towards the left or right do not follow the direction of the birth canal. Page Ref: 627 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in allhealthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 7 Summarize the indications for forceps-assisted birth, types offorceps that may be used, complications, and related interventions. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures. 37) The spouse of a laboring patient is concerned that the baby is taking too long to be
delivered and he has overhead some discussion about using a vacuum. Whichdiagram should the nurse show the spouse to explain the procedure being discussed? A)
B)
C)
D)
Answer: D Explanation: D) For vacuum extractor traction the cup is placed on the fetal occiput, creating suction. Traction is applied in a downward and outward direction. Choice 1 is adiagram of a forceps delivery. Choice 2 is a diagram showing locations of
episiotomies. Choice 3 is a diagram showing the location of the incision for aclassic cesarean section. Page Ref: 628 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 8 Discuss the use of vacuum extraction, including indications,procedure, complications, and related nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
38) A patient is scheduled to have the following type of incision for a cesarean birth. What advantage should the nurse explain to the patient that this type of incisionhas?
A) Easier to repair B) Less blood loss C) Expedites delivery of multiple fetuses D) Less likely to rupture with future pregnancies Answer: C Explanation: C) A lower uterine segment vertical incision (Sellheim) is preferred for multiple gestations. The lower uterine segment transverse incision (Kerr) is the most commonly used and easiest to repair, has less blood loss, and is less likely torupture with future pregnancies. Page Ref: 631 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 9 Explain the indications for cesarean birth, impact on the familyunit, preparation and teaching needs, and associated nursing management. MNL LO: Demonstrate use of the nursing process in the care of the woman and fetusduring birth-related procedures.
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 26. Physiologic Responses of the Newborn to Birth 1) The nurse is caring for a newborn 30 minutes after birth. After assessing respiratory function, the nurse would report which findings as abnormal? Select all that apply. 1. Respiratory rate of 66 breaths per minute 2. Periodic breathing with pauses of 25 seconds 3. Synchronous chest and abdomen movements 4. Grunting on expiration 5. Nasal flaring Answer: 2, 4, 5 Explanation: 2. Periodic breathing with pauses longer than 20 seconds (apnea) is an abnormal finding that should be reported to the physician. 4. Grunting on expiration is an abnormal finding that should be reported tothe physician. 5. Nasal flaring is an abnormal finding that should be reported to the physician. 2) A 2-day-old newborn is asleep, and the nurse assesses the apical pulse tobe 88 beats/min. What would be the most appropriate nursing action based on this assessment finding? 1. Call the physician. 2. Administer oxygen. 3. Document the finding. 4. Place the newborn under the radiant warmer. Answer: 3 Explanation: 3. An apical pulse rate of 88 beats/min is within the normal range of a sleeping full-term newborn. The average resting heart rate in thefirst week of life is 110 to 160 beats/min in a healthy full-term newborn but may vary significantly during deep sleep or active awake states. In full-termnewborns, the heart rate may drop to a low of 80 to 100 beats/min during deep sleep.
3) The nurse is assessing a newborn at 1 hour of age. Which finding requiresan immediate intervention? 1. Respiratory rate 60 and irregular in depth and rhythm 2. Pulse rate 145, cardiac murmur heard 3. Mean blood pressure 55 mm Hg 4. Pauses in respiration lasting 30 seconds Answer: 4 Explanation: 4. Pauses in respirations greater than 20 seconds areconsidered episodes of apnea, and require further intervention. 4) The nurse has assessed four newborns respiratory rates immediately following birth. Which respiratory rate would require further assessment bythe nurse? 1. 60 breaths per minute 2. 70 breaths per minute 3. 64 breaths per minute 4. 20 breaths per minute Answer: 4 Explanation: 4. If respirations drop below 20 when the baby is at rest theprimary care provider should be notified. 5) Marked changes occur in the cardiopulmonary system at birth includewhich of the following? Select all that apply. 1. Closure of the foramen ovale 2. Closure of the ductus venosus 3. Mean blood pressure of 31 to 61 mmHg in full-term resting newborns 4. Increased systemic vascular resistance and decreased pulmonary vascular resistance 5. Opening of the ductus arteriosus Answer: 1, 2, 4
Explanation: 1. Closure of the foramen ovale is a function of changing arterialpressures. 2. Closure of the ductus venosus is related to mechanical pressure changesthat result from severing the cord, redistribution of blood, and cardiac output. 4. Increased systemic vascular resistance and decreased pulmonary vascularresistance; with the loss of the low-resistance placenta, systemic vascular resistance increases, resulting in greater systemic pressure. The combinationof vasodilation and increased pulmonary blood flow decreases pulmonary vascular resistance. 6) The pediatric clinic nurse is reviewing lab results with a 2-month-old infants mother. The infants hemoglobin has decreased since birth. Whichstatement by the mother indicates the need for additional teaching? 1. My baby isnt getting enough iron from my breast milk. 2. Babies undergo physiologic anemia of infancy. 3. This results from dilution because of the increased plasma volume. 4. Delaying the cord clamping did not cause this to happen. Answer: 1 Explanation: 1. At 2 months of age, infants increase their plasma volume, which results in physiologic anemia. This condition is not related to iron inthe breast milk. 7) Which of the following is a benefit of delayed umbilical cord clamping forthe preterm infant? 1. Fewer infants require blood transfusion for anemia 2. Fewer infants require blood transfusion for high blood pressure 3. Increase in the incidence of intraventricular hemorrhage 4. Increase in incidence of infant breastfeeding Answer: 1 Explanation: 1. Clinical trials in preterm infants found that delaying umbilical cord clamping was associated with fewer infants who required blood transfusion for anemia.
extrauterine life. 8) In utero, what is the organ responsible for gas exchange? 1. Umbilical vein 2. Placenta 3. Inferior vena cava 4. Right atrium Answer: 2 Explanation: 2. In utero, the placenta is the organ of gas exchange. 9) A postpartum mother questions whether the environmental temperatureshould be warmer in the babys room at home. The nurse responds that the environmental temperature should be warmer for the newborn. This response is based on which newborn characteristics that affect the establishment of thermal stability? .Select all that apply. 1. Newborns have less subcutaneous fat than do adults. 2. Infants have a thick epidermis layer. 3. Newborns have a large body surface to weight ratio. 4. Infants have increased total body water. 5. Newborns have more subcutaneous fat than do adults. Answer: 1, 3, 4 Explanation: 1. Heat transfer from neonatal organs to skin surface is increased compared to adults due to the neonates decreased subcutaneousfat. 3. Heat transfer from neonatal organs to skin surface is increased comparedto adults due to the neonates large body surface to weight ratio. 4. Preterm infants have increased heat loss via evaporation due to increasedtotal body water. 10) The nurse is teaching new parents how to dress their newborn. Which statements indicate that teaching has been effective? Select all that apply.
1. We should keep our home air-conditioned so the baby doesnt overheat. 2. It is important that we dry the baby off as soon as we give him a bath orshampoo his hair. 3. When we change the babys diaper, we should change any wet clothing orblankets, too. 4. If the babys body temperature gets too low, he will warm himself upwithout any shivering. 5. Our baby will have a much faster rate of breathing if he is not dressedwarmly enough. Answer: 2, 3, 4, 5 Explanation: 2. The newborn is particularly prone to heat loss by evaporation immediately after birth and during baths; thus drying the newborn is critical. 3. Changing wet clothing or blankets immediately prevents evaporation, one mechanism of heat loss. 4. Nonshivering thermogenesis (NST), an important mechanism of heat production unique to the newborn, is the major mechanism through whichheat is produced. 5. A decrease in the environmental temperature of 2C is a drop sufficient todouble the oxygen consumption of a term newborn and can cause the newborn to show signs of respiratory distress. 11) The nurse is planning care for a newborn. Which nursing intervention would best protect the newborn from the most common form of heat loss? 1. Placing the newborn away from air currents 2. Pre-warming the examination table 3. Drying the newborn thoroughly 4. Removing wet linens from the isolette Answer: 3 Explanation: 3. The most common form of heat loss is evaporation. The newborn is particularly prone to heat loss by evaporation immediately after birth (when the baby is wet with amniotic fluid) and during baths; thus dryingthe newborn is critical.
12) The nurse is planning an educational presentation on hyperbilirubinemiafor nursery nurses. Which statement is most important to include in the presentation? 1. Conjugated bilirubin is eliminated in the conjugated state. 2. Unconjugated bilirubin is neurotoxic, and cannot cross the placenta. 3. Total bilirubin is the sum of the direct and indirect levels. 4. Hyperbilirubinemia is a decreased total serum bilirubin level. Answer: 3 Explanation: 3. Total serum bilirubin is the sum of conjugated (direct) and unconjugated (indirect) bilirubin. 13) A telephone triage nurse gets a call from a postpartum client who is concerned about jaundice. The clients newborn is 37 hours old. What datapoint should the nurse gather first? 1. Stool characteristics 2. Fluid intake 3. Skin color 4. Bilirubin level Answer: 3 Explanation: 3. Jaundice (icterus) is the yellowish coloration of the skin and sclera caused by the presence of bilirubin in elevated concentrations. Inspection of the skin would be the first step in assessing for jaundice. 14) The mother of a 3-day-old infant calls the clinic and reports that her babys skin is turning slightly yellow. What should the nurse explain to themother? 1. Physiologic jaundice is normal, and peaks at this age. 2. The newborns liver is not working as well as it should. 3. The baby is yellow because the bowels are not excreting bilirubin. 4. The yellow color indicates that brain damage might be occurring. Answer: 1 Explanation: 1. Physiologic jaundice occurs soon after birth. Bilirubin levels peak at 3 to 5 days in term infants.
15) A newborn is determined to have physiological jaundice. The nurse explains the steps involved in conjugation and excretion of bilirubin to theparents. Which factors would the nurse include in the explanation? Select all that apply. 1. At birth, the newborns liver begins to conjugate bilirubin or convert it froma yellow lipid-soluble pigment to a water-soluble pigment. 2. Unconjugated bilirubin can leave the bloodstream and enter the tissues,causing a yellow hue to the skin and sclera. 3. Unconjugated bilirubin results from the destruction of white blood cells. 4. The infant is able to excrete conjugated bilirubin, but not unconjugatedbilirubin. 5. The newborns liver has greater metabolic and enzymatic activity at birth than does an adult liver, increasing the newborns susceptibility to jaundice. Answer: 1, 2, 4 Explanation: 1. Conjugation, or the changing of bilirubin into an excretable form, is the conversion of the yellow lipid-soluble pigment (unconjugated, indirect) into watersoluble pigment (excretable, direct). 2. Jaundice (icterus) is the yellowish coloration of the skin and sclera causedby the presence of bilirubin in elevated concentrations. 4. Unconjugated bilirubin is fat soluble, has a propensity for fatty tissues, isnot in an excretable form, and is a potential toxin. 16) The visiting nurse evaluates a 2-day-old breastfed newborn at home andnotes that the baby appears jaundiced. When explaining jaundice to the parents, what would the nurse tell them? 1. Jaundice is uncommon in newborns. 2. Some newborns require phototherapy. 3. Jaundice is a medical emergency. 4. Jaundice is always a sign of liver disease. Answer: 2
Explanation: 2. Physiologic jaundice is a normal process that can occur after24 hours of life in about half of healthy newborns. It is not a sign of liver disease. Physiologic jaundice might require phototherapy. 17) Which of the following would be a newborn care procedure that will decrease the probability of high bilirubin levels? 1. Monitor urine for amount and characteristics. 2. Encourage late feedings to promote intestinal elimination. 3. All infants should be routinely monitored for iron intake. 4. Maintain the newborns skin temperature at 36.5C (97.8F) or above. Answer: 4 Explanation: 4. Maintain the newborns skin temperature at 36.5C (97.8F) orabove; cold stress results in acidosis. 18) Clinical risk factors for severe hyperbilirubinemia include which of the following? Select all that apply. 1. African American ethnicity 2. Female gender 3. Cephalohematoma 4. Bruising 5. Assisted delivery with vacuum or forceps Answer: 3, 4, 5 Explanation: 3. A clinical risk factor for severe hyperbilirubinemia includes cephalohematoma. 4. A clinical risk factor for severe hyperbilirubinemia includes bruising. 5. A clinical risk factor for severe hyperbilirubinemia includes assisted delivery with vacuum or forceps. 19) The home care nurse is examining a 3-day-old infant. The childs skin on the sternum is yellow when blanched with a finger. The parents ask the nursewhy jaundice occurs. What is the best response from the nurse?
1. The liver of an infant is not fully mature, and doesnt conjugate thebilirubin for excretion. 2. The infant received too many red blood cells after delivery because thecord was not clamped immediately. 3. The yellow color of your babys skin indicates that you are breastfeedingtoo often. 4. This is an abnormal finding related to your babys bowels not excretingbilirubin as they should. Answer: 1 Explanation: 1. Physiologic jaundice is a common occurrence, and peaks at 3to 5 days in term infants. The reduction in hepatic activity, along with a relatively large bilirubin load, decreases the livers ability to conjugate bilirubin and increases susceptibility to jaundice. . 20) Which of the following is the primary carbohydrate in the breastfeeding newborn? 1. Glucose 2. Fructose 3. Lactose 4. Maltose Answer: 3 Explanation: 3. Lactose is the primary carbohydrate in the breastfeedingnewborn and is generally easily digested and well absorbed. 21) At birth, an infant weighed 6 pounds 12 ounces. Three days later, he weighs 5 pounds 2 ounces. What conclusion should the nurse draw regardingthis newborns weight? 1. This weight loss is excessive. 2. This weight loss is within normal limits. 3. This weight gain is excessive. 4. This weight gain is within normal limits. Answer: 1
Explanation: 1. This newborn has lost more than 10% of the birth weight; thisweight loss is excessive. Following birth, caloric intake is often insufficient forweight gain until the newborn is 5 to 10 days old. During this time there may be a weight loss of 5% to 10% in term newborns. . 22) A new grandfather is marveling over his 12-hour-old newborn grandson. Which statement indicates that the grandfather needs additional education? 1. I cant believe he can already digest fats, carbohydrates, and proteins. 2. It is amazing that his whole digestive tract can move things along at birth. 3. Incredibly, his stomach capacity was already a cupful when he was born. 4. He will lose some weight but then miraculously regain it by about 10 days. Answer: 3 Explanation: 3. The newborns stomach has a capacity of 22 mL to 27 mL byday 3 of life. 23) A postpartum client calls the nursery to report that her 3-day-old newborn has passed a green stool. What is the nurses best response? 1. Take your newborn to the pediatrician. 2. There might be a possible food allergy. 3. Your newborn has diarrhea. 4. This is a normal occurrence. Answer: 4 Explanation: 4. The newborns stools change from meconium (thick, tarry,black) to transitional stools (thinner, brown to green). 24) A newborn who has not voided by 48 hours after birth should be assessed for which of the following? Note: Credit will be given only if all correct and no incorrect choices areselected. Select all that apply. 1. Restlessness 2. Pain 3. Kidney distention
4. Adequacy of fluid intake 5. Lethargy Answer: 1, 2, 4 Explanation: 1. A newborn who has not voided by 48 hours after birth shouldbe assessed for restlessness. 2. A newborn who has not voided by 48 hours after birth should be assessedfor pain. 4. A newborn who has not voided by 48 hours after birth should be assessedfor adequacy of fluid intake. 25) The parents of a newborn are receiving discharge teaching. The nurseexplains that the infant should have several wet diapers per day. Which statement by the parents indicates that further education is necessary? 1. Our baby was born with kidneys that are too small. 2. A babys kidneys dont concentrate urine well for several months. 3. Feeding our baby frequently will help the kidneys function. 4. Kidney function in an infant is very different from that in an adult. Answer: 1 Explanation: 1. Size of the kidneys is rarely an issue. 26) The student nurse notices that a newborn weighs less today comparedwith the newborns birth weight three days ago. The nursing instructor explains that newborns lose weight following birth due to which of the following? 1. A shift of intracellular water to extracellular spaces. 2. Loss of meconium stool. 3. A shift of extracellular water to intracellular spaces. 4. The sleep-wake cycle. Answer: 1 Explanation: 1. A shift of intracellular water to extracellular space andinsensible water loss account for the 5% to 10% weight loss.
27) Which of the following would be considered normal newborn urinalysisvalues? Note: Credit will be given only if all correct choices and no incorrect choicesare selected. Select all that apply. 1. Color bright yellow 2. Bacteria 0 3. Red blood cells (RBC) 0 4. White blood cells (WBC) more than 4-5/hpf 5. Protein less than 5-10 mg/dL Answer: 2, 3, 5 Explanation: 2. Bacteria value should be 0. 3. Red blood cells (RBC) should be 0. 5. Protein less than 5-10 mg/dL would be considered normal. 28) The mother of a 2-day-old male has been informed that her child hassepsis. The mother is distraught and says, I should have known that something was wrong. Why didnt I see that he was so sick? What is the nurses best reply? 1. Newborns have immature immune function at birth, and illness is veryhard to detect. 2. Your mothering skills will improve with time. You should take the newbornclass. 3. Your baby didnt get enough active acquired immunity from you during the pregnancy. 4. The immunity your baby gets in utero doesnt start to function until he is 4to 8 weeks old. Answer: 1 Explanation: 1. The immune responses in neonates are usually functionallyimpaired when compared with adults. 29) Which nonspecific immune mechanism has the ability of antibodies and phagocytic cells to clear pathogens from an organism?
1. Complement 2. Coagulation 3. Inflammatory response 4. Phagocytosis Answer: 1 Explanation: 1. Complement helps or complements the ability of antibodiesand phagocytic cells to clear pathogens from an organism. . 30) Specific cellular immunity is mediated by T lymphocytes, which enhance the efficiency of the phagocytic response. What do cytotoxic activated T cells do? 1. Enable T or B cells to respond to antigens 2. Repress responses to specific B or T lymphocytes to antigens 3. Kill foreign or virus-infected cells 4. Remove pathogens and cell debris Answer: 3 Explanation: 3. Cytotoxic activated T cells kill foreign or virus-infected cells. 31) The student nurse notices that the newborn seems to focus on the mothers eyes. The nursing instructor explains that this newborn behavior iswhich of the following? 1. Habituation 2. Orientation 3. Self-quieting 4. Reactivity Answer: 2 Explanation: 2. Orientation is the newborns ability to be alert to, to follow, and to fixate on complex visual stimuli that have a particular appeal and attraction. The newborn prefers the human face and eyes, and bright shinyobjects. 32) A new father asks the nurse to describe what his baby will experiencewhile sleeping and awake. What is the best response?
1. Babies have several sleep and alert states. Keep watching and youll noticethem. 2. You might have noticed that your child was in an alert awake state for anhour after birth. 3. Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep. 4. Birth is hard work for babies. It takes them a week or two to recover andbecome more awake. Answer: 3 Explanation: 3. Teaching the parents how to recognize the two sleep stageshelps them tune in to their infants behavioral states. 33) A new mother is holding her 2-hour-old son. The delivery occurred on thedue date. His Apgar score was 9 at both 1 and 5 minutes. The mother asks the nurse why her son was so wide awake right after birth, and now is sleeping so soundly. What is the nurses best response? 1. Dont worry. Babies go through a lot of these little phases. 2. Your son is in the sleep phase. Hell wake up soon. 3. Your son is exhausted from being born, and will sleep 6 more hours. 4. Your breastfeeding efforts have caused excessive fatigue in your son. Answer: 2 Explanation: 2. The first period of reactivity lasts approximately 30 minutes after birth. During this period the newborn is awake and active and may appear hungry and have a strong sucking reflex. After approximately half anhour, the newborns activity gradually diminishes, and the heart rate and respirations decrease as the newborn enters the sleep phase. The sleep phase may last from a few minutes to 2 to 4 hours. 34) The nurse is teaching a newborn care class to parents who are about togive birth to their first babies. Which statement by a parent indicates that teaching was effective? 1. My baby will be able to focus on my face when she is about a month old. 2. My baby might startle a little if a loud noise happens near him.
3. Newborns prefer sour tastes. 4. Our baby wont have a sense of smell until she is older. Answer: 2 Explanation: 2. Swaddling, placing a hand on the abdomen, or holdingthe arms to prevent a startle reflex are other ways to soothe the newborn.The settled newborn is then able to attend to and interact with the environment. 35) The nurse is teaching a group of new parents about newborn behavior.Which statement made by a parent would indicate a need for additional information? 1. Sleep and alert states cycle throughout the day. 2. We can best bond with our child during an alert state. 3. About half of the babys sleep time is in active sleep. 4. Babies sleep during the night right from birth. Answer: 4 Explanation: 4. Over time, the newborns sleep-wake patterns become diurnal, that is, the newborn sleeps at night and stays awake during the day. 36) When providing anticipatory guidance to a new mother, what informationdoes the nurse convey about the newborns neurologic and sensory/perceptual functioning? Select all that apply. 1. Newborns respond to and interact with the environment in a predictablepattern of behavior, reacting differently to a variety of stresses. 2. The usual position of the newborn is with extremities partially flexed, legsnear the abdomen. 3. Newborns do not react to bright light, and their eye movements do notpermit them to fixate on faces or objects until they are 3 months of age. 4. Newborns have the capacity to utilize self-quieting behaviors to quiet andcomfort themselves. 5. The newborn is very sensitive to being touched, cuddled, and held. Answer: 1, 2, 4, 5
Explanation: 1. Newborns respond to and interact with the environment in a predictable pattern of behavior that is shaped somewhat by their intrauterineexperience. 2. Normal newborns are usually in a position of partially flexed extremitieswith the legs near the abdomen. 4. Self-quieting ability is the ability of newborns to use their own resources toquiet and comfort themselves. 5. The newborn is very sensitive to being touched, cuddled, and held; thus touch may be the most important of all of the senses for the newborn infant.
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 27.
Nursing Assessment of the Newborn
MULTIPLE CHOICE.
Choose the one alternative that best completes the statement or answers the question. 1) A nursing instructor is demonstrating an assessment on a newborn for the nursing students using the Ballard gestational assessment tool. The nurse explains that which of the following tests should be performed after the first hour of birth? A) arm recoil B) square window sign C) scarf sign D) popliteal angle Answer A 2) Before the nurse begins to dry the newborn off after birth, which of the following assessment finings should the nurse document to insure an accurate gestational rating on the Ballard gestational assessment tool? A) amount and area of vernix coverage B) creases on the sole C) size of the areola D) body surface temperature Answer A 3) A new mother is concerned about a mass on the newborn's head. The nurse assesses this to be a cephalhematoma. Which of the following characteristics would indicate a cephalhematoma? (Select all that apply.) A) The mass appeared on the second day after birth. B) The mass appears larger when the newborn cries. C) The head appears asymmetrical. D) The mass appears only on one side of the head. E) The mass overrides the suture line. Answer A, D 4) During an assessment of a 12-hour-old newborn, the nurse notices pale pink spots on the nape of the neck. The nurse documents this finding as A) nevus vasculosus. B) nevus flammeus. C) telangiectatic nevi. D) a Mongolian spot. Answer C 5) The nurse desires to demonstrate to a new family their infant's individuality. Which assessment tool would be most appropriate for the nurse to use? A) Brazelton Neonatal Behavioral Assessment Scale B) Ballard Maturity Scale C) Dubowitz Gestational Age Scale
D) Ortolani maneuver Answer A 6) The nurse attempts to elicit the Moro reflex on a newborn and assesses movement of the right arm only. Based on this finding, the nurse immediately assesses the A) Ortolani maneuver. B) Babinski reflex. C) clavicle. D) Gallant reflex. Answer C 7) The nurse is making an initial assessment of the newborn. Which of the following data would be considered normal? A) chest circumference 32.5 cm, head circumference 31.5 cm B) chest circumference 30 cm, head circumference 29 cm C) chest circumference 38 cm, head circumference 31.5 cm D) chest circumference 32.5 cm, head circumference 36 cm Answer A 8) A new parent reports to the nurse that the baby looks cross-eyed several times a day. The nurse teaches the parents that this finding should resolve in A) 2 months. B) 2 weeks. C) 1 year. D) 4 months. Answer D 9) A nurse is instructing a new mother on how to take an axillary temperature. The nurse knows the mother understands when she states that the thermometer should be held in place for A) 1 minute. B) 3 minutes. C) 5 minutes. D) 10 minutes. Answer B 10) The nurse assesses the newborn's ears to be parallel to the outer and inner canthus of the eye. The nurse documents this finding to be A) a normal position. B) a possible chromosomal abnormality. C) facial paralysis. D) prematurity.. Answer A 11) The student nurse attempts to take the vital sign of the newborn, but the newborn is crying. What nursing intervention would be appropriate? A) placing a gloved finger in the newborn's mouth B) taking the vital signs C) waiting until the newborn stops crying
D) placing a hot water bottle in the isolette Answer A 12) The nurse suspects clubfoot in the newborn. It is appropriate to A) adduct the foot and listen for a click. B) move the foot to midline and determine resistance. C) extend the foot and observe for pain. D) dorsiflex the foot and release to observe for tremors. Answer B 13) A mother is concerned because the anterior fontanelle swells when the newborn cries. What would the nurse include in her teaching to a new mother about the normal findings concerning the fontanelles? (Select all that apply.) A) The fontanelles may swell with crying. B) The fontanelles may be depressed. C) The fontanelles may pulsate with the heartbeat. D) The fontanelles may bulge. E) The fontanelles may swell when stool is passed. Answer A, C, E 14) The nurse assesses four newborns. Which assessment finding would place a newborn at risk for developing physiologic jaundice? A) cephalhematoma B) Mongolian spots C) telangiectatic nevi D) molding Answer A 15) A mother of a 16-week-old infant calls the clinic and is concerned because she cannot feel the posterior fontanelle on her infant. Which of the responses by the nurse would be most appropriate? A) "It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth." B) "Bring your infant to the clinic immediately." C) "This is due to overriding of the cranial bones during labor." D) "Your baby must be dehydrated." Answer A 1) A 2) A 3) A, D 4) C 5) A 6)C 7) A
8) D 9) B 10) A 11) A 12) B 13) A, C, E 14) A 15) A
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 28. Normal Newborn Needs and Care MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answersthe question.
1) The nurse is caring for a newborn who recently was circumcised. Which nursing intervention is appropriate following the procedure? A) NPO for four hours following procedure B) observe for urine output C) wrap dry gauze tightly around the penis D) keep the newborn in the nursery for the next four hours Answer B 2) In planning care for a new family immediately after birth, which procedure would the nurse most likely withhold for one hour to allow time for the family to bond with the newborn? A) eye prophylaxis medication B) drying the newborn C) vital signs D) vitamin K injection Answer A 3) The nurse teaches the parents of an infant who recently was circumcised to observe for bleeding. What should the parents be taught to do if bleeding does occur? A) wrap the diaper tightly B) remove the Vaseline dressing and observe in one hour C) apply gentle pressure to the site with gauze D) apply a new Vaseline gauze dressing Answer C 4) A nurse is instructing the nursing students about the procedure for vitamin K administration. What information should be included? (Select all that apply.) A) gently massage the site after injection. B) use a 22 gauge 1-inch needle. C) inject in the vastus lateralis muscle. D) cleanse site with alcohol prior to injection. E) inject at a 45-degree angle. F) do not aspirate. Answer A, C, D 5) A postpartum mother is concerned that her newborn has not had a stool since birth. The newborn is 18 hours old. The nurse's best response is A) "I will call your pediatrician immediately." B) "Passage of the first stool within 48 hours is normal." C) "Your newborn may not have a stool until the third day." D) "Your newborn must be dehydrated." Answer B 6) The nurse is preparing a newborn for a circumcision. Which of the following data would be important for the nurse to report to the physician prior to the procedure? A) The mother took anticoagulants prenatally. B) The mother is breastfeeding the newborn. C) The newborn's Apgar scores were 8 and 9. D) The newborn has had six wet diapers within the last 12 hours. Answer A
7) Appropriate nursing interventions for the application of erythromycin ophthalmic ointment (Ilotycin Ophthalmic) include A) massaging eyelids gently following application. B) irrigating eyes after instillation. C) using a syringe to apply ointment. D) preceding instillation with irrigation. Answer A 8) The nurse assesses the newborn and the following behaviors are noted nasal flaring, facial grimacing, and excessive mucus. The nurse is most concerned about A) neonatal jaundice. B) polycythemia. C) neonatal hyperthermia. D) respiratory distress. Answer D 9) To promote infant security in the hospital, the nurse instructs the parents of a newborn to A) keep the baby in the room at all times. B) check identification of all personnel who transport the newborn. C) place a "No Visitors" sign on the door. D) keep the baby in the nursery at all times. Answer B 10) A nurse is instructing a new mother on circumcision care with a Plastibell. The nurse knows the mother understands when she states that the Plastibell should fall off within A) 2 days. B) 10 days. C) 8 days. D) 14 days. Answer A 11) A new family decides not to have their newborn circumcised. What should the nurse teach regarding uncircumcised care? A) The foreskin will be retractable at 2 months. B) Retract the foreskin and clean thoroughly. C) Avoid retracting the foreskin. D) Use soap and Betadine to cleanse the penis daily. Answer C 12) A postpartum client calls the nursery to report that her newborn's umbilical cord stump is draining and has a foul order. The nurse's best response is A) "Take your newborn to the pediatrician." B) "Cover the cord stump with gauze." C) "Apply Betadine around the cord stump." D) "This is normal during healing." Answer A 13) The nurse is analyzing various teaching strategies that can be used to teach new mothers about newborncare. To enhance learning, which teaching method should the nurse implement? A) select videos on various topics of newborn care B) organize a class that includes first-time mothers only C) have mothers return in one week when they feel more rested D) schedule time for one-to-one teaching in the mother's room Answer D 14) The nurse has just assisted the father in bathing the newborn 2 hours after birth. The nurse
explains to the father that the newborn must remain in the radiant warmer. This is based on which of the following assessment data? A) heart rate 120 B)temperature 96.8°F C) respiratory rate 50 D) temperature 99.6°F Answer B 15) The nurse has instructed a new mother on quieting activities for her newborn. The nurse knows the mother understands when she overhears the mother tell the father to A) hold the newborn in an upright position. B) massage the hands and feet. C) swaddle the newborn in a blanket. D) make eye contact while talking to the newborn. Answer C
1) B 2) A 3) C 4) A, C, D 5) B 6) A 7) A 8) D 9) B 10) A 11) C 12) A 13) D 14) B 15) C
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 29. Newborn Nutrition MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) A new mother is concerned her newborn is not gaining enough weight. To encourage proper weight gain, the mother should be instructed to A) dilute formula with water. B) offer 12 to 32 oz of formula every 24 hours. C) offer formula every 6 to 8 hours. D) provide skim milk exclusively. Answer B SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 2) A nurse is demonstrating the proper steps for breastfeeding a newborn to a client. Put these steps in a logical order that would assist the client in placing the newborn to her breast. tickle newborn's lips with the nipple. bring newborn to breast. newborn opens mouth wide. have newborn face mother tummy to tummy. position newborn so the newborn's nose is at level of the nipple. Answer e, d, a, c, b
MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 3) A premature newborn is unable to suck at the breast. The nurse plans care for the mother and has arranged for the mother to use an electric pump at least A)two times in a 24-hour period. B) four times in a 24-hour period. C) six times in a 24-hour period. D) eight times in a 24-hour period. Answer D 4) A nurse is teaching a new mother how to encourage a sleepy baby to breastfeed. All of the following activities are taught except A) providing skin-to-skin contact. B) swaddling the newborn in a blanket. C) unwrapping the newborn. D) allowing the newborn to feel and smell the mother's breast. Answer B 5) Which of the following mothers definitely should be counseled against breastfeeding? A) a mother with a poorly balanced diet B) a mother who is overweight C) a mother who is HIV-positive D) a mother who has twins Answer C
6) A mother states that her breasts leak between feedings. Which of the following may contribute to the letdown reflex in breastfeeding mothers? A) pain with breastfeeding B) number of hours passed since last feeding C) the newborn's cry D) maternal fluid intake Answer C 7) When a breastfeeding mother complains that her breasts are leaking milk, the nurse could offer which effective intervention? A) decrease the number of minutes the newborn is at the breast per feeding B) decrease the mother's fluid intake C) place absorbent pads in the bra D) administer oxytocin Answer C 8) To thaw breast milk that has been frozen, parents should be taught to A) run cool water over the bottle. B) use the microwave briefly. C) place the bottle in boiling water. D) place the bottle in the refrigerator for 24 hours. Answer A 9) A nurse is evaluating the diet plan of a breastfeeding mother and determines her intake of fruits and vegetables is inadequate. Which of the following strategies would be recommended to the mother that would be beneficial for the newborn? A) stop breastfeeding B) provide vitamin supplements to the newborn C) offer whole milk D) supplement with skim milk Answer B 10) A triage nurse receives a call from a mother of an obese infant who appears pale, sweaty, and irritable. What data would the nurse need to gather next? A) newborn's daily iron intake B) number of wet diapers a day C) skin color D) bilirubin level Answer A 11) The nurse encourages a new mother to feed the newborn as soon as the newborn shows interest. The nurse bases this recommendation on which of the following benefits of early feedings? (Select all that apply.) A) stimulates peristalsis B) colostrum is thinner than mature milk C) enhances maternal-infant attachment D) decreases the risk of jaundice E) Colostrum contains a high amount of calories. Answer A, C, D 12) A mother is concerned that her newborn doesn't appear to be alert enough to feed and is very irritable. Which of the following data documented in the mother's birth record might contribute to
this newborn's behavior? A) length of labor was eight hours B) epidural during labor C) blood pressure of 114/82 D) short second stage of labor Answer B 13) A nurse is performing an assessment on an infant whose mother states she props the bottle during feeding. Based on this information, what would the nurse include in her assessment? A) otoscopic exam of the ear drum B) bowel sounds C) vital signs D) skin assessment Answer A 14) The nurse is assisting a mother to feed her newborn. The newborn has been crying. The nurse suggests that prior to feeding, the mother should A) offer a pacifier. B) burp the newborn. C) unwrap the newborn. D) stroke the newborn's spine and feet. Answer B 15) The nurse is caring for a new breastfeeding mother who is from Pakistan. The nurse plans her care so that the newborn is offered the breast on the A) day of birth. B) first day after birth. C) second day after birth. D) third to fourth day after birth. Answer D
1) B 2) e, d, a, c, b 3) D 4) B 5) C 6) C 7) C 8) A 9) B 10) A
11) A, C, D 12) B 13) A 14) B 15) D
Old's Maternal-Newborn Nursing and Women's Health, 11e(Davidson/London/Ladewig) Chapter 30 The Newborn at Risk: Conditions Present at Birth 1) The nurse is caring for the newborn of a diabetic mother whose blood glucose levelis 39 mg/dL. What should the nurse include in the plan of care for this newborn? A) Offer early feedings with formula or breast milk. B) Provide glucose water exclusively. C) Evaluate blood glucose levels at 12 hours after birth. D) Assess for hyperthermia. Answer: A Explanation: A) IDMs whose serum glucose falls below 40 mg/dL should have early feedings with formula or breast milk (colostrum). B) If normal glucose levels cannot be maintained with oral feeding, an intravenous (IV) infusion of glucose will be necessary. C) Blood glucose determinations should be performed by heel stick hourly during the first 4 hours after birth and at 4-hour intervals until the risk period (about 48hours) has passed. D) Hypothermia is a potential problem for the SGA newborn due to decreasedbrown fat stores and minimal subcutaneous tissues. Page Ref: 758 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Explain the impact of maternal diabetes mellitus on the newborn.MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
2) The nurse is caring for several pregnant clients. Which client should the nurse anticipate is most likely to have a newborn at risk for mortality or morbidity? A) 37-year-old, with a history of multiple births and preterm deliveries who works ina chemical factory B) 23-year-old of low socioeconomic status, unmarried C) 16-year-old who began prenatal care at 30 weeks D) 28-year-old with a history of gestational diabetes Answer: A Explanation: A) This client is at greatest risk because she has multiple risk factors: age over 35,high parity, history of preterm birth, and exposure to chemicals that might be toxic. B) The main risk factor for this client is her low socioeconomic status. C) This client has two risk factors: young age and late onset of prenatal care. D) This client's only risk factor is the history of gestational diabetes. Page Ref: 754 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Assessment.Learning Outcome: 1 Explain the factors present at birth that indicate an at-risk newborn. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
3) The nurse is caring for an infant born at 37 weeks that weighs 1750 g (3 pounds 10ounces). The head circumference and length are in the 25th percentile. What statement would the nurse expect to find in the chart? A) Preterm appropriate for gestational age, symmetrical IUGR B) Term small for gestational age, symmetrical IUGR C) Preterm small for gestational age, asymmetrical IUGR D) Preterm appropriate for gestational age, asymmetrical IUGR Answer: C Explanation: A) Head circumference and length between the 10th and 90th percentiles indicate asymmetrical IUGR. B) Head circumference and length between the 10th and 90th percentiles indicate asymmetrical IUGR. C) The infant is preterm at 37 weeks. Because the weight is below the 10th percentile, the infant is small for gestational age. Head circumference and lengthbetween the 10th and 90th percentiles indicate asymmetrical IUGR. D) The infant is preterm at 37 weeks. Because the weight is below the 10th percentile, the infant is considered small for gestational age. Page Ref: 755 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅵ. B. 2. Apply technology and information management tools to support safe processes of care. | AACN Essentials Competencies: Ⅳ. 6. Evaluate data from all relevant sources, including technology, to inform the delivery of care. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 2 Compare the underlying etiologies of the physiologic complications of small-for-gestational-age (SGA) newborns and preterm appropriate-for-gestational-age (Pr AGA) newborns and the nursing management for each. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
4) A 38-week newborn is found to be small for gestational age (SGA). Which nursing intervention should be included in the care of this newborn? A) Monitor for feeding difficulties. B) Assess for facial paralysis. C) Monitor for signs of hyperglycemia. D) Maintain a warm environment. Answer: D Explanation: A) LGA, not SGA, newborns are more difficult to arouse to a quiet alert state, andcan have feeding difficulties. B) LGA, not SGA, newborns often are prone to birth trauma such as facial paralysis,due to cephalopelvic disproportion. C) SGA newborns are more prone to hypoglycemia. D) Hypothermia is a common complication in the SGA newborn; therefore, the newborn's environment must remain warm, to decrease heat loss. Page Ref: 756 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅴ. B. 2. Demonstrate effective use of technology andstandardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Describe the potential complications for large-for-gestational-age(LGA) newborns. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
5) The nurse is caring for a 2-hour-old newborn whose mother is diabetic. The nurse assesses that the newborn is experiencing tremors. Which nursing action has thehighest priority? A) Obtain a blood calcium level. B) Take the newborn's temperature. C) Obtain a bilirubin level. D) Place a pulse oximeter on the newborn. Answer: A Explanation: A) Tremors are a sign of hypocalcemia. Diabetic mothers tend to have decreasedserum magnesium levels at term. This could cause secondary hypoparathyroidism in the infant. B) Body temperature might be necessary to monitor, but obtaining a blood calciumlevel takes priority for this newborn. C) Bilirubin level might be necessary to monitor, but obtaining a blood calcium leveltakes priority for this newborn. D) Oxygen saturation might be necessary to monitor, but obtaining a blood calciumlevel takes priority for this newborn. Page Ref: 762 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Explain the impact of maternal diabetes mellitus on the newborn.MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
6) A 7 pound 14 ounce girl was born to an insulin-dependent type Ⅱ diabetic mother 2hours ago. The infant's blood sugar is 47 mg/dL. What is the best nursing action? A) To recheck the blood sugar in 6 hours B) To begin an IV of 10% dextrose C) To feed the baby 1 ounce of formula D) To document the findings in the chart Answer: D Explanation: A) Blood glucose determinations should be performed on blood by heel stick hourlyduring the first 4 hours after birth, and subsequently at 4-hour intervals. B) A blood sugar reading of 47 mg/dL is considered normal for a neonate. No IV is needed. C) Feeding would be appropriate if the infant's blood sugar was below 45 mg/dL, butthis infant's reading is 47. D) A blood sugar level of 47 mg/dL is a normal finding; documentation is an appropriate action. Page Ref: 762 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Explain the impact of maternal diabetes mellitus on the newborn.MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
7) The nurse is caring for the newborn of a diabetic mother. Which of the followingshould be included in the nurse's plan of care for this newborn? A) Offer early feedings. B) Administer an intravenous infusion of glucose. C) Assess for hypercalcemia. D) Assess for hyperbilirubinemia immediately after birth. Answer: A Explanation: A) Newborns of diabetic mothers may benefit from early feedings, as they are extremely valuable in maintaining normal metabolism and lowering the possibilityof such complications as hypoglycemia and hyperbilirubinemia. B) If normal glucose levels cannot be maintained with oral feeding, an intravenous (IV) infusion of glucose will be necessary. C) The newborn should be assessed for hypocalcemia. D) Hyperbilirubinemia can occur 48 to 72 hours after birth. Page Ref: 764 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Explain the impact of maternal diabetes mellitus on the newborn.MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
8) The nurse caring for a postterm newborn would not perform what intervention? A) Providing warmth B) Frequently monitoring blood glucose C) Observing respiratory status D) Restricting breastfeeding Answer: D Explanation: A) Provision of warmth is an important intervention for postterm newborns. B) Frequent monitoring of blood glucose is an important intervention for postterm newborns. C) Observation of respiratory status is an important intervention for postterm newborns. D) Breastfeeding is an appropriate means of feeding for the postterm newborn. Page Ref: 764 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Compare the characteristics and potential complications thatinfluence nursing management of the postterm newborn and the newborn with postmaturity syndrome. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
9) The pregnant client at 41 weeks is scheduled for labor induction. She asks the nursewhether induction is really necessary. What response by the nurse is best? A) "Babies can develop postmaturity syndrome, which refers to a number of complications that can occur after 42 weeks of pregnancy." B) "When infants are born 2 or more weeks after their due date, they have meconium in the amniotic fluid." C) "Sometimes the placenta ages excessively, and we want to take care of thatproblem before it happens." D) "The doctor wants to be proactive in preventing any problems with your baby ifhe gets any bigger." Answer: A Explanation: A) The term postmaturity applies to the infant who is born after 42 completed weeksof gestation and demonstrates characteristics of postmaturity syndrome. B) Although this statement is partially true, meconium-stained amniotic fluid is not always present or the only complication of postmaturity syndrome. C) Although this statement is true, it is too vague. It is better to be specific and call postmaturity syndrome by its name. D) Although this is true, the answer is incomplete. The risk of postmaturity syndromeis also an issue. Page Ref: 764 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Compare the characteristics and potential complications thatinfluence nursing management of the postterm newborn and the newborn with postmaturity syndrome. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
10) The mother of a premature newborn questions why a gavage feeding catheter is placed in the mouth of the newborn and not in the nose. What is the nurse's bestresponse? A) "Most newborns are nose breathers." B) "The tube will elicit the sucking reflex." C) "A smaller catheter is preferred for feedings." D) "Most newborns are mouth breathers." Answer: A Explanation: A) Orogastric insertion is preferable to nasogastric because most infants are obligatory nose breathers. B) The tube or gavage feeding method is used with preterm infants who lack orhave a poorly coordinated suck-swallow-breathing pattern. C) A small catheter is used for a nasogastric tube to minimize airway obstruction. D) Orogastric insertion is preferable to nasogastric because most infants are obligatory nose breathers. Page Ref: 772 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations tofoster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Compare the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and are used in the development of a plan of care that includes nutritional management. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
11) A 3-month-old baby who was born at 25 weeks has been exposed to prolonged oxygen therapy. The nurse explains to the parents that due to oxygen therapy, theirinfant is at a greater risk for which of the following? A) Visual impairment B) Hyperthermia C) Central cyanosis D) Sensitive gag reflex Answer: A Explanation: A) Extremely premature newborns are particularly susceptible to injury of the delicate capillaries of the retina, causing characteristic retinal changes known asretinopathy of prematurity (ROP). Judicious use of supplemental oxygen therapyin the premature infant has become the norm. B) Hypothermia is more common in premature infants. C) Central cyanosis can be caused by decreased oxygen. D) An absent or decreased gag reflex is more common in premature infants. Page Ref: 774 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Compare the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and are used in the development of a plan of care that includes nutritional management. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
12) A NICU nurse plans care for a preterm newborn that will provide opportunities for development. Which interventions support development in a preterm newborn in a NICU? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Schedule care throughout the day. B) Silence alarms quickly. C) Place a blanket over the top portion of the incubator. D) Do not offer a pacifier. E) Dim the lights. Answer: B, C, E Explanation: A) Nursing care should be planned to decrease the number of times the baby is disturbed. B) Noise levels can be lowered by replacing alarms with lights or silencing alarms quickly. C) Dimmer switches should be used to shield the baby's eyes from bright lights with blankets over the top portion of the incubator. D) Pacifiers can be offered because they provide opportunities for nonnutritive sucking. E) Dimming the lights may encourage infants to open their eyes and be more responsive to their parents. Page Ref: 779 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅰ. B. 3. Provide patient-centered care with sensitivityand respect for the diversity of human experience. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing theacute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Appreciate the patient as a whole person,with his or her own life story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Compare the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and are used in the development of a plan of care that includes nutritional management. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
13) The nurse assesses the gestational age of a newborn and informs the parents thatthe newborn is premature. Which of the following assessment findings is not congruent with prematurity? A) Cry is weak and feeble B) Clitoris and labia minora are prominent C) Strong sucking reflex D) Lanugo is plentiful Answer: C Explanation: A) Findings that indicate prematurity include a weak cry. B) Findings that indicate prematurity include a prominent clitoris and labia minora. C) Poor suck, gag, and swallow reflexes are characteristic of a preterm newborn. D) Findings that indicate prematurity include lanugo that is plentiful and widely distributed. Page Ref: 766 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Reduction of Risk Potential Standards: QSEN Competencies: Ⅴ. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacyconsiderations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Compare the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and are used in the development of a plan of care that includes nutritional management. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
14) The nurse is working with parents who have just experienced the birth of their firstchild at 34 weeks. Which statement(s) by the parents indicate that additional teaching is needed? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) "Our baby will be in an incubator to keep him warm." B) "Breathing might be harder for our baby because he is early." C) "The growth of our baby will be faster than if he were term." D) "Tube feedings will be required because his stomach is small." E) "Because he came early, he will not produce urine for 2 days." Answer: C, D, E Explanation: A) Preterm infants have little subcutaneous fat, and have difficulty maintaining theirbody temperature. An incubator or warmer is used to keep the baby warm. B) Surfactant production might not be complete at 34 weeks, which leads to respiratory distress syndrome. The infant may become hypoxic, pulmonary bloodflow may be inefficient, and the preterm newborn's available energy is depleted. C) Preterm infants grow more slowly than do term infants because of difficulty in meeting high caloric and fluid needs for growth due to small gastric capacity. D) Although tube feedings might be required, it would be because preterm babies have a marked danger of aspiration and its associated complications due to theinfant's poorly developed gag reflex, incompetent esophageal cardiac sphincter,and inadequate suck/swallow/breathe reflex. E) Although preterm babies have diminished kidney function due to incomplete development of the glomeruli, they can produce urine. Preterm infants usuallyhave some urine output during the first 24 hours of life. Page Ref: 766 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Reduction of Risk Potential Standards: QSEN Competencies: Ⅰ. B. 10. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations tofoster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 6 Compare the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and are used in the development of a plan of care that includes nutritional management.
MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
15) The neonatal special care unit nurse is overseeing the care provided by a nurse newto the unit. Which action requires immediate intervention? A) The new nurse holds the infant after giving a gavage feeding. B) The new nurse provides skin-to-skin care. C) The new nurse provides care when the baby is awake. D) The new nurse gives the feeding with room-temperature formula. Answer: D Explanation: A) If the infant cannot be held during a feeding, she should be held after feedings forcomfort. B) Skin-to-skin (kangaroo) care has become the norm in NICUs across the United States and is defined as the practice of holding infants skin to skin next to theirparents. C) Preterm babies spend more time in sleep cycles; it is best to not interrupt sleep when possible. D) Preterm babies have little subcutaneous fat, and do not maintain their body temperature well. Formula should be warmed prior to feedings to help the baby maintain its temperature. Page Ref: 766 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Compare the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and are used in the development of a plan of care that includes nutritional management. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
16) Benefits of skin-to-skin care as a developmental intervention include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Routine discharge B) Stabilization of vital signs C) Increased periods of awake-alert state D) Decline in episodes of apnea and bradycardia E) Increased growth parameters Answer: B, D, E Explanation: A) Early discharge is a benefit of skin-to-skin care as a developmental intervention. B) Stabilization of vital signs is a benefit of skin-to-skin care as a developmental intervention. C) Increased periods of quiet sleep is a benefit of skin-to-skin care as a developmental intervention. D) A decline in episodes of apnea and bradycardia is a benefit of skin-to-skin careas a developmental intervention. E) Increased growth parameters are a benefit of skin-to-skin care as a developmental intervention. Page Ref: 780 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 3. Provide patient-centered care with sensitivityand respect for the diversity of human experience. | AACN Essentials Competencies: Ⅸ. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: NursingProcess: Planning. Learning Outcome: 6 Compare the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and are used in the development of a plan of care that includes nutritional management. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
17) In caring for the premature newborn, the nurse must assess hydration status continually. Assessment parameters should include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Volume of urine output B) Weight C) Blood pH D) Head circumference E) Bowel sounds Answer: A, B Explanation: A) In order to assess hydration status, volume of urine output must be evaluated. B) In order to assess hydration status, the infant's weight must be evaluated. C) Blood pH is not an indicator of hydration. D) Head circumference is not an indicator of hydration. E) Bowel sounds are not an indicator of hydration. Page Ref: 777 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Compare the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and are used in the development of a plan of care that includes nutritional management. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
18) The nurse is planning care for a preterm newborn. Which nursing diagnosis has thehighest priority? A) Tissue Integrity, Impaired B) Infection, Risk for C) Gas Exchange, Impaired D) Family Processes, Dysfunctional Answer: C Explanation: A) Tissue Integrity, Impaired is related to fragile capillary network in the germinal matrix, but is not the highest priority. B) Infection, Risk for is related to lack of passive immunity and immature immune defenses due to preterm birth, but is not the highest priority. C) Gas Exchange, Impaired is related to immature pulmonary vasculature and inadequate surfactant production, and has the highest priority. D) Family Processes, Dysfunctional is related to anger or guilt at having given birth to a premature baby and is a psychosocial need, and is therefore a lower priority than are physiologic needs. Page Ref: 756 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Physiological Adaptation Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology andstandardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 6 Compare the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and are used in the development of a plan of care that includes nutritional management. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
19) The nurse is teaching the parents of an infant with an inborn error of metabolismhow to care for the infant at home. What information does teaching include? A) Specially prepared formulas B) Cataract problems C) Low glucose concentrations D) Administration of thyroid medication Answer: A Explanation: A) An afflicted PKU infant can be treated by a special diet that limits ingestion of phenylalanine. Special formulas low in phenylalanine, such as Phenyl-Free 1 andPhenex1, are available. B) Cataracts are associated with infants who have galactosemia. C) Low glucose concentrations are not an indication an inborn error of metabolism. D) Thyroid medication is given to infants with congenital hypothyroidism. Page Ref: 801 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 11 Explain the special care needed by a newborn diagnosed withan inborn error of metabolism. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
20) The nurse is caring for a newborn in the special care nursery. The infant has hydrocephalus, and is positioned in a prone position. The nurse is especially carefulto cleanse all stool after bowel movements. This care is most appropriate for an infant born with which of the following? A) Omphalocele B) Gastroschisis C) Diaphragmatic hernia D) Myelomeningocele Answer: D Explanation: A) Omphalocele is a herniation of abdominal contents into the base of the umbilicalcord. Hydrocephalus is not associated with an omphalocele. B) Gastroschisis is a full-thickness defect of the abdominal wall that results in the abdominal organs being located on the outside of the body. Hydrocephalus is not associated with a gastroschisis. C) Diaphragmatic hernia is a portion of the intestines in the thoracic cavity due to an abnormal opening in diaphragm, occurring commonly on the left side. Hydrocephalus is not associated with a diaphragmatic hernia. D) Myelomeningocele is a saclike cyst containing meninges, spinal cord, and nerve roots in the thoracic and/or lumbar area. Meticulous cleaning of the buttocks andgenitals helps prevent infection. The infant is positioned on his or her abdomen or side and restrained to prevent pressure and trauma to the sac. Hydrocephalusis often present with this condition. Page Ref: 786 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Summarize the nursing assessments and initial interventions fora newborn born with selected congenital anomalies. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
21) During discharge planning for a drug-dependent newborn, the nurse explains to themother how to do which of the following? A) Place the newborn in a prone position. B) Limit feedings to three a day to decrease diarrhea. C) Place the infant supine and operate a home apnea-monitoring system. D) Wean the newborn off the pacifier. Answer: C Explanation: A) Infants with neonatal abstinence syndrome are at a significantly higher risk for sudden infant death syndrome (SIDS) when the mother used heroin, cocaine, or opiates. The infant should sleep in a supine position, and home apnea monitoringshould be implemented. B) Small, frequent feedings are recommended. C) Infants with neonatal abstinence syndrome are at a significantly higher risk for sudden infant death syndrome (SIDS) when the mother used heroin, cocaine, or opiates. The infant should sleep in a supine position, and home apnea monitoringshould be implemented. D) A pacifier may be offered to provide nonnutritive sucking. Page Ref: 795 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 9 Explain the special care needed by an in utero alcohol- or drug-exposed newborn. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
22) The nurse is assessing a drug-dependent newborn. Which symptom would requirefurther assessment by the nurse? A) Occasional watery stools B) Spitting up after feeding C) Jitteriness and irritability D) Nasal stuffiness Answer: C Explanation: A) An occasional watery stool can be associated with the normal newborn. B) Spitting up after some feedings can be associated with the normal newborn. C) Jitteriness and irritability can be an indicator of drug withdrawal. D) Nasal stuffiness can be associated with the normal newborn. Page Ref: 795 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 9 Explain the special care needed by an in utero alcohol- or drug-exposed newborn. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
23) Parents have been told their child has fetal alcohol syndrome (FAS). Which statement by a parent indicates that additional teaching is required? A) "Our baby's heart murmur is from this syndrome." B) "He might be a fussy baby because of this." C) "His face looks like it does due to this problem." D) "Cuddling and rocking will help him stay calm." Answer: D Explanation: A) Valvular and septal defects are common in babies with FAS. B) FAS babies can be irritable and hyperactive in childhood. C) Facial characteristics of the FAS child include short palpebral fissures, epicanthalfolds, broad nasal bridge, flattened midface, short upturned or beaklike nose, micrognathia (abnormally small lower jaw) or hypoplastic maxilla, thin upper lip orvermilion border, and smooth philtrum (groove on upper lip). D) The FASD baby is most comfortable in a quiet, minimally stimulating environment. Page Ref: 791 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 9 Explain the special care needed by an in utero alcohol- or drug- exposed newborn. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
24) The nurse is caring for the newborn of a drug-addicted mother. Which assessmentfindings would be typical for this newborn? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Hyperirritability B) Decreased muscle tone C) Exaggerated reflexes D) Low pitched cry E) Transient tachypnea Answer: A, C, E Explanation: A) Newborns born to drug-addicted mothers exhibit hyperirritability. B) Newborns born to drug-addicted mothers show increased, not decreased,muscle tone. C) Newborns born to drug-addicted mothers exhibit exaggerated reflexes. D) Newborns born to drug-addicted mothers exhibit a high-pitched, not a lowpitched, cry. E) Newborns born to drug-addicted mothers exhibit transient tachypnea. Page Ref: 793 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 9 Explain the special care needed by an in utero alcohol- or drug-exposed newborn. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
25) In planning care for the fetal alcohol syndrome (FAS) newborn, which interventionwould the nurse include? A) Allow extra time with feedings. B) Assign different personnel to the newborn each day. C) Place the newborn in a well-lit room. D) Monitor for hyperthermia. Answer: A Explanation: A) Newborns with fetal alcohol syndrome have feeding problems. Because of their feeding problems, these infants require extra time and patience during feedings. B) It is important to provide consistency in the staff working with the baby and parents and to keep personnel and visitors to a minimum at any one time. C) The FASD baby is most comfortable in a quiet, minimally stimulating environment. D) Nursing care of the FASD newborn is aimed at avoiding heat loss. Page Ref: 791 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 9 Explain the special care needed by an in utero alcohol- or drug-exposed newborn. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
26) The nurse is teaching the parents of a newborn who has been exposed to HIV howto care for the newborn at home. Which instructions should the nurse emphasize? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Use proper hand-washing technique. B) Provide three feedings per day. C) Place soiled diapers in a sealed plastic bag. D) Cleanse the diaper changing area with a 1:10 bleach solution after each diaperchange. E) Take the temperature rectally. Answer: A, C, D Explanation: A) The nurse should instruct the parents on proper hand-washing technique. B) Small, frequent meals are recommended. C) The nurse should instruct parents to that soiled diapers are to be placed in plasticbags, sealed, and disposed of daily. D) The nurse should instruct parents that the diaper-changing areas should becleaned with a 1:10 dilution of household bleach after each diaper change. E) Taking rectal temperatures is to be avoided because it could stimulate diarrhea. Page Ref: 799 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 10 Relate the consequences of maternal HIV/AIDS to the management of and issues for caregivers of newborns at risk for HIV/AIDS in theneonatal period. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
27) A mother who is HIV-positive has given birth to a term female. What plan of care ismost appropriate for this infant? A) Test with an HIV serologic test at 8 months. B) Begin prophylactic AZT (Zidovudine) administration. C) Provide 4 to 5 large feedings throughout the day. D) Encourage the mother to breastfeed the child. Answer: B Explanation: A) Currently available HIV serologic tests (enzyme-linked immunosorbent assay [ELISA] and Western blot test) cannot distinguish between maternal and infant antibodies; therefore, they are inappropriate for infants up to 18 months of age. B) For infants, AZT is started prophylactically 2 mg/kg/dose PO every 6 hours beginning as soon after birth as possible and continuing for 6 weeks. C) Nutrition is essential because failure to thrive and weight loss are common.Small, frequent feedings and food supplementation are helpful. D) Breastfeeding should be avoided with an HIV-positive mother, as transmission ofthe HIV virus to the newborn in breast milk is well documented. Page Ref: 799 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 10 Relate the consequences of maternal HIV/AIDS to the management of and issues for caregivers of newborns at risk for HIV/AIDS in theneonatal period. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
28) An HIV-positive mother delivered 2 days ago. The infant will be placed in foster care. The nurse is planning discharge teaching for the foster parents on how to care forthe newborn at home. Which instructions should the nurse include? A) Do not add food supplements to the baby's diet. B) Place soiled diapers in a sealed plastic bag. C) Wash soiled linens in cool water with bleach. D) Shield the baby's eyes from bright lights. Answer: B Explanation: A) Small, frequent feedings are recommended, as well as food supplementation as necessary to support weight gain. B) The nurse should instruct the parents about proper hand-washing techniques, proper disposal of soiled diapers, and the importance of wearing gloves whendiapering. C) Soiled linens should be washed in hot, sudsy water with bleach. D) Shielding the baby's eyes from bright lights would be recommended for a preterm infant, not an infant with HIV. Page Ref: 800 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 10 Relate the consequences of maternal HIV/AIDS to the management of and issues for caregivers of newborns at risk for HIV/AIDS in theneonatal period. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
29) Many newborns exposed to HIV/AIDS show signs and symptoms of disease withindays of birth that include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Swollen glands B) Hard stools C) Smaller than average spleen and liver D) Rhinorrhea E) Interstitial pneumonia Answer: A, D, E Explanation: A) Signs that may be seen in the early infancy period include swollen glands. B) Signs that may be seen in the early infancy period include recurrent gastrointestinal (GI) problems that include diarrhea. C) Signs that may be seen in the early infancy period include enlarged spleen andliver. D) Signs that may be seen in the early infancy period include rhinorrhea. E) Signs that may be seen in the early infancy period include interstitial pneumonia. Page Ref: 798 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Diagnosis. Learning Outcome: 10 Relate the consequences of maternal HIV/AIDS to the management of and issues for caregivers of newborns at risk for HIV/AIDS in theneonatal period. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
30) The nurse is analyzing assessment findings on four newborns. Which finding mightsuggest a congenital heart defect? A) Apical heart rate of 140 beats per minute B) Respiratory rate of 40 C) Temperature of 36.5°C D) Visible, blue discoloration of the skin Answer: D Explanation: A) An apical heart rate of 140 is a normal assessment finding for newborns. B) A respiratory rate of 40 is a normal assessment finding for newborns. C) Temperature of 36.5°C is a normal assessment finding for newborns. D) Central cyanosis is defined as a visible, blue discoloration of the skin caused by decreased oxygen saturation levels and is a common manifestation of a cardiacdefect. Page Ref: 787 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 8 Identify physical examination findings during the early newbornperiod that would make the nurse suspect a congenital cardiac defect or congestive heart failure. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
31) The parents of a newborn have just been told their infant has tetralogy of Fallot. Theparents do not seem to understand the explanation given by the physician. What statement by the nurse is best? A) "With this defect, not enough of the blood circulates through the lungs, leading toa lack of oxygen in the baby's body." B) "The baby's aorta has a narrowing in a section near the heart that makes the leftside of the heart work harder." C) "The blood vessels that attach to the ventricles of the heart are positioned on thewrong sides of the heart." D) "Your baby's heart doesn't circulate blood well because the left ventricle issmaller and thinner than normal." Answer: A Explanation: A) Tetralogy of Fallot is a cyanotic heart defect that comprises four abnormalities: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricle hypertrophy. The severity of symptoms depends on the degree of pulmonary stenosis, the size of the ventricular septal defect, and the degree to which the aorta overrides the septal defect. B) This describes coarctation of the aorta and is characterized by a narrowed aortic lumen. The lesion produces an obstruction to the flow of blood through the aorta, causing an increased left ventricular pressure and workload, minimizing systemic circulation of blood. C) This describes complete transposition of great vessels and is an embryologic defect caused by a straight division of the bulbar trunk without normal spiraling. As a result, the aorta originates from the right ventricle, and the pulmonary arteryfrom the left ventricle resulting in a parallel circulatory system. An abnormal communication between the two circulations must be present to sustain life. D) This describes hypoplastic left heart syndrome which is the underdevelopment ofthe left side of the heart including aortic valve atresia, severe mitral valve stenosis, and small left ventricle. Page Ref: 787 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 8 Identify physical examination findings during the early newborn
period that would make the nurse suspect a congenital cardiac defect or congestiveheart failure. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
32) The nurse is preparing an educational session on phenylketonuria for a family whose neonate has been diagnosed with the condition. Which statement by a parentindicates that teaching was effective? A) "This condition occurs more frequently among Japanese people." B) "We must be very careful to avoid most proteins to prevent brain damage." C) "Carbohydrates can cause our baby to develop cataracts and liver damage." D) "Our baby's thyroid gland isn't functioning properly." Answer: B Explanation: A) Japanese people have a very low rate of PKU disease; it is most commonamong northern Europeans. B) PKU is the inability to metabolize phenylalanine, an amino acid found in most dietary protein sources. Excessive accumulation of phenylalanine and its abnormal metabolites in the brain tissue leads to progressive, irreversible intellectual disability. C) Galactosemia is a carbohydrate metabolism disease. D) Congenital hypothyroidism is the disorder of low thyroid function at birth. Page Ref: 801 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 11 Explain the special care needed by a newborn diagnosed with an inborn error of metabolism. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
33) The nurse is observed conducting the following measurement. For what will this measurement be used?
A) Determine fetal length B) Gauge stomach contents C) Placement of gavage tube D) Estimate chest circumference Answer: C Explanation: C) When measuring gavage tube length, measure the distance from the tip of theear to the nose to the midpoint between the xiphoid process and the umbilicus,and mark the point with a small piece of paper tape to ensure there is enough tubing to enter the stomach. Page Ref: 771 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multipledimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acuteand chronic care of patients and promoting health across the lifespan. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process. Learning Outcome: 2 Compare the underlying etiologies of the physiologic complications of small-for-gestational-age (SGA) newborns and preterm appropriate-for-gestational-age (Pr AGA) newborns and the nursing management for each. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
34) The nurse is caring for a newborn with the following anomaly. What actions shouldthe nurse take when caring for this infant?
Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. 1. Burp frequently 2. Assess patency of nares 3. Assist with parental coping 4. Clean the area with sterile water 5. Feed with a special nipple and bottle Answer: 1, 3, 4, 5 Explanation: The infant has a cleft lip. The nurse should feed with a special nipple and bottle, burp frequently, clean the cleft with sterile water to prevent crusting on cleft before repair, andsupport parental coping. Assessing patency of nares would be appropriate for choanal atresia. Page Ref: 782 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multipledimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acuteand chronic care of patients and promoting health across the lifespan. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 7 Summarize the nursing assessments and initial interventions fora newborn born with selected congenital anomalies. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
35) The nurse is preparing teaching material for the parents of a newborn with tracheoesophageal fistula. Where on the diagram should the nurse identify thelocation of this disorder?
A) A B) B C) C D) D Answer: C Explanation: C) In a tracheoesophageal fistula, the lower esophageal segment connects to thelower trachea, with the upper esophageal segment ending blindly. Page Ref: 783 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 7 Summarize the nursing assessments and initial interventions fora newborn born with selected congenital anomalies. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
36) The nurse is preparing teaching material for the parents of a newborn. For whichhealth problem should the nurse select the following diagram to be used for teaching?
A) Gastroschisis B) Omphalocele C) Diaphragmatic hernia D) Prune belly syndrome Answer: C Explanation: C) In a diaphragmatic hernia, a portion of the intestines enters the thoracic cavity through an abnormal opening in the diaphragm. This most commonly occurs onthe left side. An omphalocele is the herniation of abdominal contents into the base of the umbilical cord. Gastroschisis is a full-thickness defect in the abdominal wall that allows viscera outside the body to the right of an intact umbilical cord. Prune belly syndrome is the congenital absence of one or more layers of abdominal muscles. Page Ref: 784 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 7 Summarize the nursing assessments and initial interventions fora newborn born with selected congenital anomalies. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
37) An infant is diagnosed with an atrial-septal defect. When teaching the parents of thisinfant about the disorder, which diagram should the nurse use? A)
B)
C)
D)
Answer: A Explanation: A) Patent ductus arteriosus is a vascular connection that, during fetal life, bypassesthe pulmonary vascular bed and directs blood from the pulmonary artery to the aorta. After birth, blood shunts through the ductus from the aorta to the pulmonary artery (left-toright shunting). Coarctation of the aorta is characterizedby a narrowed aortic lumen. The lesion produces an obstruction to the flow of blood through the aorta, causing an increased left ventricular pressure and workload, minimizing systemic circulation of blood. In tetralogy of Fallot, the severity of symptoms depends on the degree of pulmonary stenosis, the size of the ventricular septal defect, and the degree to which the aorta overrides the septal defect. Complete transposition of great vessels is an embryologic defect caused by a straight division of the bulbar trunk without normal spiraling. As a result, the aorta originates from the right ventricle, and the pulmonary artery fromthe left ventricle resulting in a parallel circulatory system. An abnormal communication between the two circulations must be present to sustain life. Page Ref: 788 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 7 Summarize the nursing assessments and initial interventions fora newborn born with selected congenital anomalies. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
38) The nurse is preparing to gavage-feed a preterm infant. Put the steps in the order inwhich the nurse should provide this feeding. 1. Check pH of the gastric aspirate 2. Elevate the syringe 6-8 inches above the infant's head 3. Measure from the tip of the nose to the earlobe to the xiphoid process 4. Clear the tubing with 2-3 mL of air 5. Lubricate the tube by dipping it into sterile water Answer: 3, 5, 1, 2, 4 Explanation: Measurement occurs before inserting the tube into the infant. Lubricating the tube helpswith passage into the infant. After passage, the pH of gastric contents is determined. The syringe is elevated above the infant's head for the feeding. At the end of the feedingthe tube is cleared with 2-3 mL of air. Page Ref: 771 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multipledimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in allhealthcare settings. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 6 Compare the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and are used in the development of a plan of care that includes nutritional management. MNL LO: Demonstrate understanding of conditions present at birth that place the newborn at risk.
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 31. The Newborn at Risk Birth-Related Stressors MULTIPLE CHOICE.
Choose the one alternative that best completes the statement or answers the question. 1) The visiting nurse evaluates a 2-day-old breastfed newborn at home and notes the baby appears jaundiced. When explaining jaundice to the parents, the nurse would tell them A) "Jaundice is nothing to worry about." B) "Some newborns require phototherapy." c) "Jaundice is a medical emergency." D) "Jaundice is always a sign of liver disease." Answer B 2) A nurse explains to new parents that their newborn has developed respiratory distress syndrome (RDS). The nurse bases this assessment on all of the following data except A) grunting respirations. B) nasal flaring. C) respiratory rate of 40 during sleep. D) chest retractions. Answer C 3) A client in labor is found to have meconium-stained amniotic fluid upon rupture of membranes. At delivery, the nurse anticipates that the priority nursing intervention is to A) deliver the neonate on its side with head up, to facilitate drainage of secretions. B) suction the oropharynx when the newborn's head is delivered. C) prepare for the immediate use of positive pressure to expand the lungs. D) monitor the client's temperature. Answer B 4) The nurse is evaluating the effectiveness of phototherapy on a newborn. Which of the following evaluations indicate a therapeutic response to phototherapy? A) normal temperature is maintained by the newborn B) bilirubin level of 14mg/dL C) decreased reflexes D) skin blanches yellow Answer A 5) The parents of a preterm newborn desire to visit their baby in the NICU. All of the following statements by the nurse will support the parents as they visit their newborn except A) "Your newborn likes to be touched." B) "Stroking the newborn will help with stimulation." C) "Visits must be scheduled between feedings." D) "Your baby loves her pink blanket." Answer C 6) The nurse prepares to admit to the nursery a newborn whose mother had meconiumstained amniotic fluid. The nurse knows this newborn may require
A) initial resuscitation.
B) vigorous stimulation at birth. C) phototherapy immediately. D) an initial feeding of iron-enriched formula. Answer A 7) The nurse notes that a 36-hour-old newborn's serum bilirubin level is 14 mg/dL. What nursing intervention would be included in the plan of care for this newborn? A) continue to observe B) begin phototherapy C) begin blood exchange transfusion D) stop breastfeeding Answer B 8) Which of the following assessment findings by the nurse would require obtaining a blood glucose level on the newborn? A) jitteriness of the newborn B) newborn sucking on fingers C) lusty cry D) axillary temperature of 98 Answer A 9) A newborn is receiving phototherapy. Which intervention would be most important? A) measurement of head circumference B) encouraging the mother to stop breastfeeding C) stool guaiac testing D) assessment of hydration status Answer D 10) The nurse is caring for a newborn with jaundice. The parents question why the newborn is not under the phototherapy lights. The nurse explains that the fiber optic blanket is beneficial because (Select all that apply.) A) lights can stay on all of the time. B) the eyes do not need to be covered C) the lights will need to be removed for feedings D) newborns do not get overheated E) weight loss is not a complication of this system Answer A, B, D, E 11) During newborn resuscitation, effectiveness of bag and mask ventilations can be determined by A) the rise and fall of the chest. B) sudden wakefulness. C) urinary output. D) adequate thermoregulation. Answer A 12) A nurse is caring for a newborn on a ventilator who has respiratory distress syndrome (RDS). The nurse informs the parents that the newborn is improving. Which of the following data supports the nurse's assessment? A) decreased urination B) pulmonary vascular resistance increases C) increased
D) increased urination Answer D 13) A nursing instructor is demonstrating how to perform a heel stick on a newborn. To obtain an accurate capillary hematocrit reading, the nursing instructor tells the students to A) warm the heel prior to obtaining blood. B) use a previous puncture site. C) cool the heel prior to obtaining blood. D) use a sterile needle and aspirate. Answer A 14) Antibiotics have been ordered for a newborn with an infection. Which of the following interventions would the nurse prepare to implement? (Select all that apply.) A) obtain skin cultures B) restrict parental visits C) evaluate bilirubin levels D) administer oxygen as ordered E) observe for signs of hypoglycemia Answer A, C, D, E 15) The nurse assesses that a newborn's skin has a ruddy appearance and the peripheral pulses are decreased. The nurse suspects polycythemia. Which of the following lab reports might indicate that the newborn has polycythemia? A) venous hemoglobin level greater than 26 g/dL B) bilirubin level of 6 mg/dL C) venous hemoglobin level less than 12 g/dL D) blood glucose level of 44 mg/dL Answer A 1) B 2) C 3) B 4) A 5) C 6) A 7) B 8) A 9) D 10) A, B, D, E 11) A
12) D 13) A 14) A, C, D, E 15) A
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) 32. Postpartum Adaptation and Nursing Assessment 1) The nurse determines the fundus of a postpartum client to be boggy. Initially, what should the nurse do? 1. Document the findings. 2. Catheterize the client. 3. Massage the uterine fundus until it is firm. 4. Call the physician immediately. Answer: 3 2) The nurse is caring for a postpartum client who is experiencing afterpains following the birth of her third child. Which comfort measure should the nurse implement to decrease her pain? Select all that apply. 1. Offer a warm water bottle for her abdomen. 2. Call the physician to report this finding. 3. Inform her that this is not normal, and she will need an oxytocic agent. 4. Administer a mild analgesic to help with breastfeeding. 5. Administer a mild analgesic at bedtime to ensure rest. Answer: 1, 4, 5 3) The nurse would expect a physician to prescribe which medication to a postpartum client with heavy bleeding and a boggy uterus? 1. Methylergonovine maleate (Methergine) 2. Rh immune globulin (RhoGAM) 3. Terbutaline (Brethine) 4. Docusate (Colace) Answer: 1 4) A postpartum client has inflamed hemorrhoids. Which nursing intervention would be appropriate? 1. Encourage sitz baths. 2. Position the client in the supine position. 3. Avoid stool softeners. 4. Decrease fluid intake. Answer: 1 5) The nurse assesses the postpartum client who has not had a bowel movement by the third postpartum day. Which nursing intervention would be appropriate? 1. Encourage the new mother, saying, “It will happen soon.” 2. Instruct the client to eat a low-fiber diet. 3. Decrease fluid intake. 4. Obtain an order for a stool softener. Answer: 4 6) The nurse has received the end-of-shift report on the postpartum unit. Which client should the nurse see first? 1. Woman who is 2nd day post-cesarean, moderate lochia serosa 2. Woman day of delivery, fundus firm 2 cm above umbilicus 3. Woman who had a cesarean section, 1st postpartum day, 4 cm diastasis recti abdominis 4. Woman who had a cesarean section, 1st postpartum day, hypoactive bowel sounds all quadrants Answer: 2
7) The nurse expects an initial weight loss for the average postpartum client to be which of the following? 1. 5 to 8 pounds 2. 10 to 12 pounds 3. 12 to 15 pounds 4. 15 to 20 pounds Answer: 2 8) To assess the healing of the uterus at the placental site, what does the nurse assess? 1. Lab values 2. Blood pressure 3. Uterine size 4. Type, amount, and consistency of lochia Answer: 4 9) The nurse is providing discharge teaching to a woman who delivered her first child 2 days ago. The nurse understands that additional information is needed if the client makes which statement? 1. “I should expect a lighter flow next week.” 2. “The flow will increase if I am too active.” 3. “My bleeding will remain red for about a month.” 4. “I will be able to use a pantiliner in a day or two.” Answer: 3 10) Every time the nurse enters the room of a postpartum client who gave birth 3 hours ago, the client asks something else about her birth experience. What action should the nurse take? 1. Answer questions quickly and try to divert her attention to other subjects. 2. Review the documentation of the birth experience and discuss it with her. 3. Contact the physician to warn him the client might want to file a lawsuit, based on her preoccupation with the birth experience. 4. Submit a referral to Social Services because of possible obsessive behavior. Answer: 2 11) Which statement by a new mother 1 week postpartum indicates maternal role attainment? 1. “I don’t think I’ll ever know what I’m doing.” 2. “This baby feels like a real stranger to me.” 3. “It works better for me to undress the baby and to nurse in the chair rather than the bed.” 4. “My sister took to mothering in no time. Why can’t I?” Answer: 3 12) On the first postpartum day, the nurse teaches the client about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. The nurse understands this memory lapse to be related to which of the following? 1. The taking-hold phase 2. Postpartum hemorrhage 3. The taking-in period 4. Epidural anesthesia Answer: 3 13) The nursing instructor is conducting a class about attachment behaviors. Which statement by a student indicates the need for further instruction? 1. “The en face position promotes bonding and attachment.”
2. “Ideally, initial skin-to-skin contact occurs after the baby has been assessed and bathed.” 3. “In reciprocity, the interaction of mother and infant is mutually satisfying and synchronous.” 4. “The needs of the mother and of her infant are balanced during the phase of mutual regulation.” Answer: 2 14) The nurse is working with a new mother who follows Muslim traditions. Which expectations and actions are appropriate for this client? Select all that apply. 1. To be sure she gets a kosher diet. 2. Expect that most visitors will be women. 3. Uncover only the necessary skin when assessing. 4. The father will take an active role in infant care. 5. She will prefer a male physician. Answer: 2, 3 15) The community nurse is working with a client from Southeast Asia who has delivered her first child. Her mother has come to live with the family for several months. The nurse understands that the main role of the grandmother while visiting is to do which of the following? 1. Help the new mother by allowing her to focus on resting and caring for the baby. 2. Teach her son-in-law the right way to be a father because this is his first child. 3. Make sure that her daughter does not become abusive towards the infant. 4. Pass on the cultural values and beliefs to the newborn grandchild. Answer: 1 16) Which strategies would the nurse utilize to promote culturally competent care for the postpartum client? Select all that apply. 1. Examine one’s own cultural beliefs, biases, stereotypes, and prejudices. 2. Respect the values and beliefs of others. 3. Limit the alternative food choices offered clients to minimize conflicts. 4. Incorporate the family’s cultural practices into the care. 5. Evaluate whether the family’s cultural practices fit into Western norms. Answer: 1, 2, 4 17) How does the nurse assess for Homans’ sign? 1. Extending the foot and inquiring about calf pain. 2. Extending the leg and inquiring about foot pain. 3. Flexing the knee and inquiring about thigh pain. 4. Dorsiflexing the foot and inquiring about calf pain. Answer: 4 18) Which of the following symptoms would be an indication of postpartum blues? Select all that apply. 1. Overeating 2. Anger 3. Mood swings 4. Constant sleepiness 5. Crying Answer: 2, 3, 5 19) Nursing interventions that foster the process of becoming a mother include which of the following? 1. Encouraging detachment from the nurse-patient relationship 2. Promoting maternal-infant attachment
3. Building awareness of and responsiveness to infant interactive capabilities 4. Instruct about promoting newborn independence 5. Preparing the woman for the maternal social role Answer: 2, 3, 5 20) The postpartum nurse is caring for a client who gave birth to full-term twins earlier today. The nurse will know to assess for symptoms of which of the following? 1. Increased blood pressure 2. Hypoglycemia 3. Postpartum hemorrhage 4. Postpartum infection Answer: 3 21) The nurse is observing a new graduate perform a postpartum assessment. Which action requires intervention by the nurse? 1. Asking the client to void and donning clean gloves 2. Listening to bowel sounds and then asking when her last bowel movement occurred 3. Offering the patient pre-medication 2 hours before the assessment 4. Completing the assessment and explaining the results to the client Answer: 3 22) The client delivered her first child vaginally 7 hours ago. She has not voided since delivery. She has an IV of lactated Ringer’s solution running at 100 mL/hr. Her fundus is firm and to the right of midline. What is the best nursing action? 1. To massage the fundus vigorously 2. To assess the client’s pain level 3. To increase the rate of the IV 4. To assist the client to the bathroom Answer: 4 23) During a postpartum examination of a client who delivered an 8-pound newborn 6 hours ago, the following assessment findings are noted: fundus firm and at the umbilicus, and moderate lochia rubra with a steady trickle of blood from the vagina. What is the assessment finding that would necessitate follow-up? 1. Firm fundus 2. Fundus at the umbilical level 3. Moderate lochia rubra 4. Steady trickle of blood Answer: 4 24) Which of the following behaviors noted in the postpartum client would require the nurse to assess further? 1. Responds hesitantly to infant cries. 2. Expresses satisfaction about the sex of the baby. 3. Friends and family visit the client and give advice. 4. Talks to and cuddles with the infant frequently. Answer: 1 25) The nurse is performing a postpartum assessment on a newly delivered client. When checking the fundus, there is a gush of blood. The client asks why that is happening. What is the nurse’s best response? 1. “We see this from time to time. It’s not a big deal.”
2. “The gush is an indication that your fundus isn’t contracting.” 3. “Don’t worry. I’ll make sure everything is fine.” 4. “Blood pooled in the vagina while you were in bed.” Answer: 4 26) Which of the following conditions would predispose a client for thrombophlebitis? 1. Severe anemia 2. Cesarean delivery 3. Anorexia 4. Hypocoagulability Answer: 1 27) The community nurse is meeting a new mother for the first time. The client delivered her first child 5 days ago after a 12-hour labor. Neither the mother nor the infant had any complications during the birth or postpartum period. Which statement by the client would indicate to the nurse that the client is experiencing postpartum blues? 1. “I am so happy and blessed to have my new baby.” 2. “One minute I’m laughing and the next I’m crying.” 3. “My husband is helping out by changing the baby at night.” 4. “Breastfeeding is going quite well now that the engorgement is gone.” Answer: 2 28) The nurse is teaching a prenatal class about postpartum changes. The nurse explains that factors that might interfere with uterine involution include which of the following? Select all that apply. 1. Prolonged labor 2. Difficult birth 3. Full bladder 4. Breastfeeding 5. Infection Answer: 1, 2, 3, 5 29) When preparing for and performing an assessment of the postpartum client, which of the following would the nurse do? Select all that apply. 1. Ask the client to void before assessing the uterus. 2. Inform the client of the need for regular assessments. 3. Defer client teaching to another time. 4. Perform the procedures as gently as possible. 5. Take precautions to prevent exposure to body fluids. Answer: 1, 2, 4, 5 30) Which physical assessment findings would the nurse consider normal for the postpartum client following a vaginal delivery? Select all that apply. 1. Elevated blood pressure 2. Fundus firm and midline 3. Moderate amount of lochia serosa 4. Edema and bruising of perineum 5. Inflamed hemorrhoids Answer: 2, 4
31) The postpartum client is about to go home. The nurse includes which subject in the teaching plan? 1. Replacement of fluids 2. Striae 3. Diastasis of the recti muscles 4. REEDA scale Answer: 3 32) During the first several postpartum weeks, the new mother must accomplish certain physical and developmental tasks, including which of the following? Select all that apply. 1. Establish a therapeutic relationship with her physician 2. Adapt to altered lifestyles and family structure resulting from the addition of a new member 3. Restore her intellectual abilities 4. Restore physical condition 5. Develop competence in caring for and meeting the needs of her infant Answer: 2, 4, 5 33) The nurse is beginning the postpartum teaching of a mother who has given birth to her first child. What aspect of teaching is most important? 1. Describe the likely reaction of siblings to the new baby. 2. Discuss adaptation to grandparenthood by her parents. 3. Determine whether father-infant attachment is taking place. 4. Assist the mother in identifying the baby’s behavior cues. Answer: 4 34) At her 6-week postpartum checkup, a new mother voices concerns to the nurse. She states that she is finding it hard to have time alone to even talk on the phone without interruption. Her family lives in another state, and she has contact with them only by phone. She is still having difficulty getting enough sleep and worries that she will not be a good mother. Appropriate nursing interventions would include providing which of the following? Select all that apply. 1. Anticipatory guidance about the realities of being a parent. 2. Parenting literature and reference manuals. 3. Phone numbers and locations of local parenting groups. 4. Referral for specialized interventions related to postpartum blues. 5. Phone numbers and names of postpartum doulas. Answer: 1, 2, 3, 5 35) A nurse is caring for several postpartum clients. Which client is demonstrating a problem attaching to her newborn? 1. The client who is discussing how the baby looks like her father 2. The client who is singing softly to her baby 3. The client who continues to touch her baby with only her fingertips 4. The client who picks her baby up when the baby cries Answer: 3 36) The nurse is caring for a client who recently emigrated from a Southeast Asian country. The mother has been resting since the birth, while her sister has changed the diapers and fed the infant. What is the most likely explanation for this behavior? 1. The client is not attaching to her infant appropriately. 2. The client is not going to be a good mother, and the baby is at risk. 3. The client has no mother present to role-model behaviors.
4. The client is exhibiting normal behavior for her culture. Answer: 4 37) The community nurse is working with a client whose only child is 8 months old. Which statement does the nurse expect the mother to make? 1. “I have a lot more time to myself than I thought I would have.” 2. “My confidence level in my parenting is higher than I anticipated.” 3. “I am constantly tired. I feel like I could sleep for a week.” 4. “My baby likes everyone, and never fusses when she’s held by a stranger.” Answer: 3 38) The nurse is preparing a class for mothers and their partners who have just recently delivered. One topic of the class is infant attachment. Which statement by a participant indicates an understanding of this concept? Select all that apply. 1. “We should avoid holding the baby too much.” 2. “Looking directly into the baby’s eyes might frighten him.” 3. “Talking to the baby is good because he’ll recognize our voices.” 4. “Holding the baby so we have direct face-to-face contact is good.” 5. “We should only touch the baby with our fingertips for the first month.” Answer: 3, 4 39) Which factors would the nurse observe that would indicate a new mother’s early attachment to the newborn? Select all that apply. 1. Face-to-face contact and eye contact 2. Failure to choose a name for the baby 3. Decreased interest in the infant’s cues 4. Pointing out familial traits of the newborn 5. Displaying satisfaction with the infant’s sex Answer: 1, 4, 5
Old's Maternal-Newborn Nursing and Women's Health, 11e(Davidson/London/Ladewig) Chapter 33 The Postpartum Family: Needs and Care 1) The nurse assesses the postpartum client to have moderate lochia rubra with clots.Which nursing intervention would be appropriate? A) Assess fundus and bladder status. B) Catheterize the client. C) Administer Methergine IM per order. D) Contact the physician immediately. Answer: A Explanation: A) The amount, consistency, color, and odor of the lochia are monitored on an ongoing basis. Increased bleeding is most often related to uterine atony and responds to fundal massage, expression of any clots, and emptying the bladder. B) Catheterizing the client might be an intervention if the bladder is full and the clientis unable to void, but it is not the initial intervention. C) It is not necessary to administer Methergine IM per order; the situation does notwarrant this intervention. D) It is not necessary to contact the physician immediately; the situation does notwarrant this intervention. Page Ref: 888 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 7. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Discuss appropriate nursing interventions to promote maternalcomfort and well-being. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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2) The nurse is providing education to the new family. Which question by the nurse isbest? A) "Do you know how to give the baby a bath?" B) "You have diapers and supplies at home, right?" C) "How have your breastfeedings been going?" D) "How much formal education do you have?" Answer: C Explanation: A) This is a closed question; closed questions should be avoided. Also, bathing is alowerpriority need than is feeding. B) This is a leading question. Leading questions should be avoided. C) This is an open-ended question about an important physiologic issue. A discussion that includes both partners can facilitate an open dialog between themand can provide an opportunity for questions and answers. D) Although the family members' level of educational attainment helps when choosing written materials and words, it is rude to ask outright what educationthey have had. Page Ref: 888 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care; Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Identify patient teaching topics for promoting postpartum familywellness. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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3) The nurse is preparing to administer postpartum neuraxial morphine to a client whois morbidly obese. For which side effect related to morbid obesity should the nurse monitor? A) Respiratory depression B) Confusion C) Constipation D) Hypotension Answer: A Explanation: A) Women who are morbidly obese are at increased risk for respiratory depression, which is managed by administration of naloxone (Narcan), mask ventilation, and endotracheal intubation with mechanical ventilation, if necessary. B) The client is not at increased risk of confusion, as this is not affected by postpartum neuraxial morphine administration in the context of morbid obesity. C) The client is not at increased risk of constipation, as this is not affected by postpartum neuraxial morphine administration in the context of morbid obesity. D) The client is not at increased risk of hypotension, as this is not affected by postpartum neuraxial morphine administration in the context of morbid obesity. Page Ref: 905 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriatefor managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Factors that contribute toor threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 6 Identify critical physiologic, psychosocial, and safety needsrelated to the care of obese and morbidly obese postpartum women. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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4) A postpartum client has just received a rubella vaccination. The client demonstrates understanding of the teaching associated with administration of this vaccine when she states which of the following? A) "I will need another vaccination in 3 months." B) "I must avoid getting pregnant for 1 month." C) "This will prevent me from getting chickenpox." D) "This will protect my newborn from getting the measles." Answer: B Explanation: A) The client will not need another vaccination in 3 months. B) The client must avoid pregnancy for at least 1 month after receiving the rubella vaccine. C) The vaccination prevents measles, not chickenpox. D) The vaccination will only protect the client receiving it; therefore, the newborn willnot be protected until the child receives his own vaccination. Page Ref: 895 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 1 Delineate nursing responsibilities for patient teaching during theearly postpartum period. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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5) The incidence of complications and discomforts in the first year postpartum is common and women may experience which of the following? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Pain B) Excess energy C) Urinary incontinence D) Changes in mental health status E) Sleep deprivation Answer: A, C, D, E Explanation: A) Pain can be a discomfort in the first year postpartum. B) Fatigue, not excess energy, can be a discomfort in the first year postpartum. C) Urinary incontinence can be a complication in the first year postpartum. D) Changes in mental health status can be a complication in the first year postpartum. E) Sleep deprivation can be a complication in the first year postpartum. Page Ref: 884 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Communicate informationeffectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Discuss appropriate nursing interventions to promote maternalcomfort and well-being. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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6) A variety of drugs are used either alone or in combination to provide relief of postpartum pain. Which of the following would be an option for pain relief? A) Nonsteroidal anti-inflammatory agents B) Proquad C) Methergine D) Intravenous oxytocin Answer: A Explanation: A) A variety of drugs are used alone or in combination to provide relief of postpartum pain. An option would include nonsteroidal anti-inflammatory agentssuch as ibuprofen and ketorolac. B) Proquad is a measles, mumps, rubella, and varicella live virus vaccine. C) Methergine is prescribed to promote uterine contractions. D) Intravenous oxytocin (Pitocin) remains the first-line drug for excessive bleedingrelated to postpartum uterine atony. Page Ref: 897 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅰ. A. 3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. |AACN Essentials Competencies: Ⅸ. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 2 Discuss appropriate nursing interventions to promote maternalcomfort and well-being. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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7) On the 3rd day postpartum, a client who is not breastfeeding experiences engorgement. To relieve her discomfort, the nurse should encourage the client to dowhich of the following? A) Remove her bra B) Apply heat to the breasts C) Apply cold packs to the breasts D) Use a breast pump to release the milk Answer: C Explanation: A) A support bra is recommended. B) Applying heat would stimulate milk production. C) Applying cold packs to the breasts relieves discomfort and helps suppress lactation. D) Using a breast pump would stimulate milk production and delay the suppressionprocess. Page Ref: 894 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: Ⅰ. B. 7. Initiate effective treatments to relieve painand suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions asappropriate for managing the acute and chronic care of patients and promoting healthacross the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation.Learning Outcome: 2 Discuss appropriate nursing interventions to promote maternalcomfort and well-being. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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8) The nurse is caring for a client who had a cesarean birth 4 hours ago. Which interventions would the nurse implement at this time? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Administer analgesics as needed. B) Encourage the client to ambulate to the bathroom to void. C) Encourage leg exercises every 2 hours. D) Encourage the client to cough and deep-breathe every 2 to 4 hours. E) Encourage the use of breathing, relaxation, and distraction. Answer: A, C, D, E Explanation: A) The nurse continues to assess the woman's pain level and provide relief measures as needed. B) Ambulation should begin no later than 24 hours postoperatively and should be encouraged at least 2 to 3 times a day, but not in the first 4 hours. C) Within the first 12 hours postoperatively, unless medically contraindicated, the woman should be assisted to dangle her legs off the side of the bed. D) The woman is encouraged to cough and breathe deeply and to use incentive spirometry every 2 to 4 hours while awake for the first few days following cesarean birth. E) The nurse should encourage the use of breathing, relaxation, and distraction techniques. Page Ref: 904 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriatefor managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute tosafety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Compare the nursing needs of a woman who experienced acesarean birth with the needs of a woman who gave birth vaginally. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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9) A client who delivered 2 hours ago tells the nurse that she is exhausted and feelsguilty because her friends told her how euphoric they felt after giving birth. How should the nurse respond? A) "Everyone is different, and both responses are normal." B) "Most mothers do feel euphoria; I don't know why you don't." C) "It's good for me to know that because it might indicate a problem." D) "Let me bring your baby to the nursery so that you can rest." Answer: A Explanation: A) Following birth, some women feel exhausted and in need of rest. Other womenare euphoric and full of psychic energy, ready to retell their experience of birth repeatedly. B) The nurse should not imply that a mother's emotional response is not expected. C) Both euphoria and exhaustion are normal feelings after birth. Fatigue after birth isnot indicative of a problem. D) The client might want to be with her newborn, and the nurse should not encourage unnecessary separation of mother and child. Page Ref: 898 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Therapeutic Communication Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Delineate nursing responsibilities for patient teaching during theearly postpartum period. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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10) The breastfeeding client asks the nurse about appropriate contraception. What is thenurse's best response? A) "Breastfeeding has many effects on sexual intercourse." B) "IUDs are easy to use and easy to insert prior to sexual intercourse." C) "It's possible to get pregnant before your menstrual period returns. Let's talkabout some different options for contraception." D) "Breastfeeding hampers ovulation, so no contraception is needed." Answer: C Explanation: A) This answer does not address the client's question about contraception. B) IUDs can only be placed by a healthcare provider in a clinic situation. C) The nurse should discuss the importance of contraception during the early postpartum period and provide information on the advantages and disadvantagesof different methods, including special considerations for breastfeeding mothers. The woman's body needs adequate time to heal and recover from the stress of pregnancy and childbirth. D) Breastfeeding hampers ovulation, but to be safe, breastfeeding women shoulduse a contraceptive. The nurse should discuss the importance of contraceptionduring the early postpartum period and provide information on the advantages and disadvantages of different methods, including special considerations for breastfeeding mothers. Page Ref: 902 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Delineate nursing responsibilities for patient teaching during theearly postpartum period. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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11) The postpartum client expresses concern about getting back to her prepregnant shape, and asks the nurse when she will be able to run again. Which statement bythe client indicates that teaching was effective? A) "I can start running in 2 weeks, and can breastfeed as soon as I am done." B) "I should see how my energy level is at home, and increase my activity slowly." C) "Running is not recommended for breastfeeding women." D) "If I am getting 8 hours of sleep per day, I can start running." Answer: B Explanation: A) Running should not be initiated until after 6 weeks postpartum or with medical approval. The nurse can provide the new mother with suggestions for resumingher normal level of activity. Breastfeeding should take place prior to running to minimize chest discomfort. B) Women should be encouraged to limit the number of activities to prevent excessive fatigue, increase in lochia, and negative psychologic reactions, such as feeling overwhelmed. A regular exercise program including vigorous activities such as running, weight lifting, or competitive sports can usually be initiated afterthe 6-week postpartum examination or when approved by the client's physician/CNM. C) This statement is not true. It is more comfortable to nurse prior to running, but running is not contraindicated and can usually be initiated after the 6-week postpartum examination or when approved by the client's physician/C NM. D) This response does not address a more important factor, which is encouragingthe client to assess her own energy level and to gradually return to previous activity levels. Page Ref: 899 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Describe the nurse's role in promoting maternal rest and helpingthe mother to gradually resume an appropriate level of activity. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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12) The hospital is developing a new maternity unit. What aspects should be included inthe planning of the new unit to best promote family wellness? A) Normal newborn nursery centrally located to all client rooms B) A kitchen with a refrigerator stocked with juice and sandwiches C) Small, cozy rooms with a client bed and rocking chair D) A nursing care model based on providing couplet care Answer: D Explanation: A) Rooming-in provides the childbearing family with opportunities to interact withtheir newborn during the first hours and days of life. B) Although having snacks can be good for postpartum clients, some culturesprohibit drinking cold liquids after birth. C) Small rooms can become overly crowded when siblings and grandparents cometo visit. Larger rooms that facilitate family attachment are better. D) Couplet care, which is care of both the mother and her baby, is an important part of the family-centered care approach, in which the infant remains at the mother's bedside and both are cared for by the same nurse. Page Ref: 900 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogatesin active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 12. Create a safe environment that results in high-quality patient outcomes. | NLN Competencies: Teamwork: Contributions of other individuals and groups in helping patient/family achieve health goals. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Identify patient teaching topics for promoting postpartum familywellness. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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13) Which statement by a nursing student preparing to care for a postpartum lesbianmother would indicate that the student is prepared for the teaching? A) "I can't let the client know I've never worked with lesbian mothers." B) "I will have to adjust some of my discharge instruction for this mother." C) "I don't need to include the partner when I provide care and instruction." D) "Discharge teaching is exactly the same for lesbian mothers as for all others." Answer: B Explanation: A) The nurse should ask the patient for guidance regarding any special needs orrequests that she or her partner may have. B) The nurse should be aware that standardized postpartum instructions, particularly those related to intercourse and contraception, might need to beindividualized and amended. C) Providing quality patient-centered care for any postpartum woman involves acknowledging, welcoming, and involving her intimate partner in care and decision making. D) The nurse should be aware that standardized postpartum instructions, particularly those related to intercourse and contraception, might need to beindividualized and amended. Page Ref: 908 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 8 Describe possible approaches to sensitive, holistic nursing care for targeted populations of childbearing patients: Lesbian birth mothers and co-mothers,women with special needs, women who have experienced abuse, and women relinquishing their newborns. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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14) A new grandmother comments that when her children were born, they stayed in thenursery. The grandmother asks the nurse why her daughter's baby stays mostly in the room instead of the nursery. How should the nurse respond? A) "Babies like to be with their mothers more than they like to be in the nursery." B) "Contact between parents and babies increases attachment." C) "Budget cuts have decreased the number of nurses in the nursery." D) "Why do you ask? Do you have concerns about your daughter's parenting?" Answer: B Explanation: A) Although most newborns cry less when held than when in their cribs, this is notthe most important reason for encouraging mothers to spend time with their babies. B) In a mother-baby unit, the newborn's crib is placed near the mother's bed, where she can see her baby easily; this is conducive to an on-demand feeding schedulefor both breastfeeding and formula-feeding infants. C) Budget cuts are not a reason for babies' being in the nursery less than in thepast. D) It is not therapeutic to use the word "why." The grandmother has not indicatedthat she has any concerns about her daughter's parenting. Page Ref: 900 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Family Dynamics Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Discuss appropriate nursing interventions to promote maternalcomfort and well-being. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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15) What is the advantage of a client using a patient-controlled analgesia (P CA) following a cesarean birth? A) The client receives a bolus of the analgesia when pressing the button. B) The client experiences pain relief within 30 minutes. C) The client feels a greater sense of control, and is less dependent on the nursingstaff. D) The client can deliver as many doses of the medication as needed. Answer: C Explanation: A) With this approach, the woman is given a bolus of analgesia, often morphine, atthe beginning of therapy and is not repeated. B) IV pain medications provide rapid pain relief. C) Using a special intravenous (IV) pump system, the woman presses a button to selfadminister small doses of the medication as needed. For safety, the pump ispreset with a time lockout so that the pump cannot deliver another dose until a specified time has elapsed. Women using PCA feel less anxious and have a greater sense of control with less dependence on the nursing staff. D) For safety, the pump is preset with a time lockout so that the pump cannot deliveranother dose until a specified time has elapsed. Page Ref: 904 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: Ⅰ. C. 9. Recognize that patient expectations influence outcomes in management of pain or suffering. | AACN Essentials Competencies: Ⅸ. 5. Deliver compassionate, patient-centered, evidence-based carethat respects patient and family preferences. | NLN Competencies: Relationship- Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Compare the nursing needs of a woman who experienced acesarean birth with the needs of a woman who gave birth vaginally. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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16) The client having her second child is scheduled for a cesarean birth because the baby is in a breech presentation. The client states, "I'm wondering what will be different this time compared with my first birth, which was vaginal." What response isbest? A) "We'll take good care of you and your baby. You'll be home before you know it." B) "You'll be wearing a sequential compression device until you start walking." C) "You will have a lot of pain, but there are medications that we give when it getsreally bad." D) "You won't be able to nurse until the baby is 12 hours old, because of your epidural." Answer: B Explanation: A) This response focuses on the nurse, and does not provide specific information toanswer the client's question. B) The use of sequential compression devices (SCDs) and early ambulation are essential to the prevention of deep vein thrombosis, especially if the client had acesarean birth. C) Focusing on the pain is a negative emphasis and pain can also be a factor in avaginal birth. D) Epidural anesthesia prevents leg function, and therefore ambulation, but doesnot impact a mother's ability to breastfeed. Page Ref: 906 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Compare the nursing needs of a woman who experienced acesarean birth with the needs of a woman who gave birth vaginally. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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17) The nurse is caring for a client who delivered by cesarean birth. The client receiveda general anesthetic. To prevent or minimize abdominal distention, which of the following would the nurse encourage? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Increased intake of cold beverages B) Leg exercises every 2 hours C) Abdominal tightening D) Ambulation E) Using a straw when drinking fluids Answer: B, C, D Explanation: A) The woman should avoid carbonated or very hot or cold beverages, as theywould increase the distention through the increase of gas and constipation. B) Immobility increases the risk of abdominal distention and discomfort. Leg exercises serve to prevent or minimize abdominal distention in a surgical clientwho received a general anesthetic. C) Abdominal tightening serves to prevent or minimize abdominal distention in a surgical client who received a general anesthetic. D) Early ambulation prevents abdominal distention that can occur with excess accumulation of gas in the intestines. E) The woman should avoid the use of straws to avoid increasing the distentionthrough increase of gas and constipation. Page Ref: 903 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriatefor managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute tosafety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Compare the nursing needs of a woman who experienced acesarean birth with the needs of a woman who gave birth vaginally. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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18) A multiparous client delivered her first child vaginally 2 years ago, and delivered aninfant by cesarean yesterday due to breech presentation. Which statement would the nurse expect the client to make? A) "I can't believe how much more tired I was with the first baby." B) "I'm having significantly more pain this time than with my last birth." C) "It is disappointing that I can't breastfeed because of the cesarean." D) "Getting in and out of bed feels more comfortable than last time." Answer: B Explanation: A) Mothers who have experienced cesareans, particularly unanticipated ones that follow lengthy labors, may be fatigued, sleep deprived, and under the influence ofmedications that alter their level of consciousness. B) Women with cesarean births have special needs: increased need for rest andsleep; incisional care; self-care; and relief of pain and discomfort. C) Breastfeeding is not contraindicated by cesarean birth. D) Getting in and out of bed is more painful after cesarean birth than after vaginal birth. The nurse can assist the woman in identifying interventions to relieve discomfort or pain. The woman should be encouraged to take pain medication regularly, engage in frequent rest periods, avoid prolonged activity, and observefor signs of "overdoing it." Page Ref: 904 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅰ. A. 3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. |AACN Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 5 Compare the nursing needs of a woman who experienced acesarean birth with the needs of a woman who gave birth vaginally. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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19) The nurse is supervising a student nurse who is working with a 14-year-old client who delivered her first child yesterday. Which statement indicates that the nursingstudent understands the particular needs of an adolescent client? A) "This client will need less teaching, because she will have gotten the right information in school." B) "Because of her age, this client will require less frequent fundal checks to assessfor postpartal hemorrhage." C) "Because of her age, this client will probably need extra teaching about the terminology for her anatomy." D) "This client will need to have her grandmother provide day care and help raisethe baby." Answer: C Explanation: A) Public or private education likely does not cover the extent of the information thatthe adolescent needs to know about pregnancy and delivery. The nurse has many opportunities for teaching adolescent parents about their newborn in the postpartum unit and serves as a role model for new parents when responding to and caring for the newborn. B) Adolescent mothers have the same basic physical care needs as older mothers. C) Some adolescents may not have a working knowledge of their own anatomy and physiology or the related terminology, and they may require special assistance with postpartum hygiene and care. D) Although the client will require day care to continue with her education, the assistance does not have to come from her grandmother. Page Ref: 907 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 7 Summarize the nursing needs of the childbearing adolescentduring the postpartum period. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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20) The nurse is caring for a 15-year-old client who gave birth to her first child yesterday. What action is the best indicator that the nurse understands the parentingadolescent? A) The client's mother is included in all discussions and demonstrations. B) The father of the baby is encouraged to change a diaper and give a bottle. C) The nurse explains the characteristics and cues of the baby when assessing him. D) A discussion on contraceptive methods is the first topic of teaching. Answer: C Explanation: A) Although the grandmother or another family member may plan to assist with or provide much of the newborn care in some cases, the nurse should always ensure that the adolescent mother has the knowledge and demonstrates the skills to provide care for her newborn before discharge. B) The father, if he is involved, should be included as much as possible, but havingthe mother learn more about her new baby is a higher priority. C) A newborn physical examination performed at the bedside gives the parent(s) immediate feedback about the newborn's health and demonstrates methods ofhandling an infant. This action helps the client learn about her baby as an individual and facilitates maternal-infant attachment. This is the highest priority. D) The nurse should offer detailed teaching on contraception, as the young woman may have no prior experience with it and may not feel comfortable requesting thisinformation, but establishing rapport and facilitating understanding of and attachment to the newborn is a higher priority. Page Ref: 907 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Therapeutic Communication Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Summarize the nursing needs of the childbearing adolescentduring the postpartum period. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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21) The nurse is planning care for three newly delivered adolescents and their babies. What should the nurse keep in mind when planning their care? A) The baby's father should be encouraged to participate when the nurse is providing instruction. B) A class for all the adolescents would decrease teaching effectiveness. C) The schools that the adolescents attend will provide teaching on bathing. D) Adolescents understand the danger signals in newborns. Answer: A Explanation: A) The father, if he is involved, should be included as much as possible. If classes are offered in the hospital during the postpartum stay, the adolescent mother andfather should be strongly encouraged to attend and participate. B) If classes are offered in the hospital during the postpartum stay, the adolescentmother and father should be strongly encouraged to attend and participate. C) The nurse should never assume that basic newborn care education will be provided to a client elsewhere. D) Group classes for adolescent mothers should include infant care skills, information about growth and development, infant feeding, well-baby care, anddanger signals in the ill newborn. Page Ref: 907 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 7 Summarize the nursing needs of the childbearing adolescentduring the postpartum period. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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22) The nurse is preparing to receive a newly delivered client. The client is a youngsingle mother who is relinquishing custody of her newborn through an open adoption. What action is most important? A) Assign the client a room on the GYN surgical floor instead of on the postpartumfloor. B) Prepare to complete teaching in time for discharge at 24 hours post-delivery. C) Make an effort not to bring up the topic of the baby, and discuss the mother'shealth instead. D) Ask the client how much contact she would like with the baby, and whether shewants to feed it. Answer: D Explanation: A) Clients relinquishing their newborns should be given options concerning contactwith the infant, including where they would feel most comfortable if they opt for contact at all. B) Not all clients who relinquish their infants want early discharge. C) It is up to the client to decide how much she wants to talk about her birth, her newborn, or her decision to relinquish the child. D) Assessing the birth mother's preferences by respectfully asking questions andmaking no assumptions facilitates a more positive experience. Page Ref: 908 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: Ⅰ. C. 10. Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care. | AACN Essentials Competencies: Ⅸ. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 8 Describe possible approaches to sensitive, holistic nursing care for targeted populations of childbearing patients: Lesbian birth mothers and co-mothers,women with special needs, women who have experienced abuse, and women relinquishing their newborns. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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23) The nurse is caring for a client who plans to relinquish her baby for adoption. Thenurse would implement which approach to care? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) Encourage the client to see and hold her infant. B) Encourage the client to express her emotions. C) Respect any special requests for the birth. D) Acknowledge the grieving process in the client. E) Allow access to the infant, if the client requests it. Answer: B, C, D, E Explanation: A) Encouraging the client to see and hold her infant does not respect the client's right to refuse interaction. The amount of contact she chooses to have with hernewborn should be respected. B) The mother who decides to relinquish her baby needs emotional support and validation of her loss. C) The woman should decide whether to see and hold her baby and should haveany special requests regarding the birth honored. D) Perinatal nurses should be aware that relinquishing mothers are at risk for disenfranchised grief, in which they are unable to proceed through the grieving process and come to resolution with the loss. The nurse should acknowledge thewoman's loss and support her decision. E) The amount of contact she chooses to have with her newborn should be respected. Page Ref: 908 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 8 Describe possible approaches to sensitive, holistic nursing care for targeted populations of childbearing patients: Lesbian birth mothers and co-mothers,women with special needs, women who have experienced abuse, and women relinquishing their newborns. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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24) The nurse is planning discharge teaching for a postpartum woman. What recommendations should the woman receive before being discharged? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) To abstain from sexual intercourse for 6 months B) To avoid showers for 4 weeks C) To avoid overexertion D) To practice postpartum exercises E) To obtain adequate rest Answer: C, D, E Explanation: A) The client should abstain from sexual intercourse until lochia has ceased. B) The client may take a shower and may continue sitz baths at home if shedesires. C) The client should avoid overexertion. D) The client should receive information and instruction on postpartum exercises. E) The client should receive information on the need for adequate rest. Page Ref: 910 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Identify patient teaching topics for promoting postpartum familywellness. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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25) The nurse is preparing a teaching brochure for Spanish-speaking postpartum clients. Which topics are critical for this population? A) Baby baths and birth certificates B) Hygiene practices C) When and how to contact their healthcare provider D) Pain-relief options in labor and after birth Answer: C Explanation: A) Baby baths and birth certificates are necessary information, but not critical. B) It is important to consider cultural practices and realize that some women may prefer not to shower in the first few days following birth. Some Hispanic womenprefer to delay showering. Hygiene practices are important, but not critical. C) Knowing how to contact their healthcare provider at all times is critical so that clients receive appropriate advice and care in case of a problem or emergency.Knowing what to watch for and when to call the healthcare provider also facilitates safety. These are the highest priorities. D) Pain relief is important, but not critical. Page Ref: 899 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 10 Describe the nurse's role related to promoting safety for thepostpartum patient and family. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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26) To actively involve the postpartal client during discharge teaching, the postpartumnurse applies which learning principle? A) Reprints of magazine articles B) Classroom lectures C) Audiotapes D) Interactive nurse-patient relationships Answer: D Explanation: A) Providing magazine articles does not actively involve the client in learning. B) Classroom lectures do not actively involve the client in learning. C) Listening to audiotapes does not actively involve the client in learning. D) Effective parent learning requires precise timing of teaching, as well as choice ofa teaching method that is effective for the family, such as DVDs and return demonstration. Content on self-care, infant care, and anticipatory guidance is important. Page Ref: 911 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Identify patient teaching topics for promoting postpartum familywellness. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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27) The nurse is performing discharge teaching for a newly delivered first-time mother and her infant on the 2nd postpartum day. Which statement by the mother indicatesthat teaching has been successful? A) "Taking baths will help my perineum feel less sore each day." B) "If I develop heavy bleeding, I should take my temperature." C) "My bowel movements should resume in a week." D) "I will go back to the doctor in 4 days for my RhoGAM shot." Answer: A Explanation: A) A sitz bath or tub bath promotes healing and provides relief from perineal discomfort during the initial weeks following birth. B) If heavy bleeding begins, the client should call her healthcare provider immediately, not take her temperature. Postpartum hemorrhage can be lifethreatening. C) Bowel movements should resume in 2 to 3 days after birth. A week is too long atime frame, and indicates constipation. D) When RhoGAM is needed, it is given within 72 hours of birth, while still at the hospital. Page Ref: 891 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 4 Identify patient teaching topics for promoting postpartum familywellness. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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28) The nurse is assessing clients after delivery. For which client is early discharge at 24hours after delivery appropriate? A) Woman and baby who have had two successful breastfeedings B) Woman who is bottle-feeding her infant and has not voided since delivery C) Twins delivered at 35 weeks, bottle-feeding D) Cesarean birth performed for fetal distress Answer: A Explanation: A) Early discharge may be advantageous if mother and baby are doing well, help is available for the mother at home, and the family and physician/C NM agree that both clients are healthy and ready for discharge. Feeding successfully is one of the physiologic needs of the infant and both mother and infant appear to be doingwell. B) Early discharge may be advantageous if mother and baby are doing well. Voidingis a physiologic need of the mother and has not yet been accomplished. C) Preterm infants are not appropriate for early discharge. D) Infants who experienced distress in labor are not appropriate for early discharge. Page Ref: 882 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health andillness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 9 Delineate the nurse's responsibilities related to early postpartumdischarge. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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29) The nurse is preparing teaching material for a new mother. What should the nurseinclude when instructing on areas to include when observing the infant? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. 1. Touch 2. Vision 3. Hearing 4. Diaper care 5. General appearance Answer: 1, 2, 3, 5 Explanation: When teaching on observing the baby, the nurse should include general appearance and the five senses - vision, hearing, touch, smell, and taste. Diaper care is included when teaching about the skin. Page Ref: 886 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provideappropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 4 Identify patient teaching topics for promoting postpartum familywellness. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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30) The nurse is monitoring a postpartum patient receiving methylergonovine maleate (Methergine). Which assessment findings should the nurse identify as being expected adverse effects of this medication? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. 1. Nausea 2. Leg pain 3. Headache 4. Hypertension 5. Uterine cramping Answer: 1, 3, 4, 5 Explanation: Common adverse effects of methylergonovine maleate (Methergine) include nausea, headache, hypertension, and uterine cramping. Leg pain is not an identified adverse effect of this medication. Page Ref: 889 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 9. Monitorclient outcomes to evaluate the effectiveness of psychobiological interventions. | NLN Competencies: Context and Environment: Practice: conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Evaluation: Nursing Process. Learning Outcome: 2 Discuss appropriate nursing interventions to promote maternalcomfort and well-being. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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31) The nurse is preparing to administer a sitz bath to a postpartum patient. In whichorder should the nurse perform the steps of this procedure? 1. Open the clamp on the tubing 2. Anchor the infusion bag to the sitz bath basin, with the tube facing upward 3. Fill the drainage bag with warm or cool water up to the top line as indicated onthe bag 4. Close the clamp on the tubing, dry perineum with a clean towel, and apply newperipad 5. Secure the drainage bag from a hook over the toilet or from the handle used toflush the toilet Answer: 2, 3, 5, 1, 4 Explanation: When providing a sitz bath the nurse should: insert the large infusion bag or tube into the back of the sitz bath basin, anchoring it to the bottom of the basin with the small opening at the end of the tubing facing upward, toward the ceiling; fill the drainage bagwith warm or cool water up to the top line as indicated on the bag; secure the drainagebag from a hook over the toilet or from the handle used to flush the toilet if it is a few feet higher than the toilet; open the clamp on the tubing; once the sitz bath is complete,instruct the woman to close the clamp on the tubing, dry perineum with a clean towel, and apply new peri-pad. Page Ref: 892 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in allhealthcare settings. | NLN Competencies: Context and Environment: Practice; conductpopulation-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Nursing Process. Learning Outcome: 2 Discuss appropriate nursing interventions to promote maternalcomfort and well-being. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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32) A new mother is planning to bottle feed her infant and wants helps with suppressing lactation. What should the nurse suggest to help this new mother? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. 1. Wear a 24-hour support bra 2. Apply cabbage leaves to the breast tissue 3. Apply warm compresses every 4 to 6 hours 4. Massage lotion on the breasts 3 times a day 5. Avoid all nipple stimulation for 7 to 10 days Answer: 1, 2, 5 Explanation: Nurses should advise the non-breastfeeding mother to avoid any stimulation of her breasts and nipples by her baby, herself, breast pumps, or her sexual partner until the sensation of fullness has passed (usually in 7 to 10 days). Such stimulation will increasemilk production and delay the suppression process. Heat is avoided for the same reason. The wearing of a 24-hour support bra and the use of cabbage leaves and/or cold compresses should be helpful during this period of time. Page Ref: 894 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in allhealthcare settings. | NLN Competencies: Context and Environment: Practice; conductpopulation-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 2 Discuss appropriate nursing interventions to promote maternalcomfort and well-being. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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33) A postpartum patient who received epidural morphine prior to a cesarean birth is concerned about a severe headache that has persisted for several days. What should the nurse suggest to this patient? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. 1. Ingest fluids with caffeine 2. Engage in moderate exercise 3. Increase the intake of all fluids 4. Lie in bed in a quiet dark room 5. Restrict the intake of warm fluids Answer: 1, 3, 4 Explanation: For a spinal headache the nurse should instruct the patient to engage in bed rest in aquiet dark room. Caffeine and hydration are also helpful. Moderate exercise could exacerbate the headache. There is no reason to restrict the intake of warm fluids. Page Ref: 905 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across the lifespan, and in allhealthcare settings. | NLN Competencies: Context and Environment: Practice; conductpopulation-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 2 Discuss appropriate nursing interventions to promote maternalcomfort and well-being. MNL LO: Demonstrate use of the nursing process in the care of the postpartum family.
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Old's Maternal-Newborn Nursing and Women's Health, 11e(Davidson/London/Ladewig) Chapter 34 Home Care of the Postpartum Family 1) The nurse is speaking to a community group about the controversy regarding the length of the hospital stay for postpartum clients. Which statement indicates that aparticipant needs additional information? A) "As of 1998, there's a law that requires insurance to pay for a 48-hour stay afteran uncomplicated birth." B) "The length of stay was shortened by insurance companies to decrease healthcare costs." C) "Early discharge became more popular in the 1980s as an alternative to having ahome birth." D) "With current length-of-stay laws, newborns have no problems at home, and get recommended follow-up care." Answer: D Explanation: A) The Newborns' and Mothers' Health Protection Act, which took effect in January1998, provides for a guaranteed minimum stay of up to 48 hours following an uncomplicated vaginal birth and 96 hours following an uncomplicated cesareanbirth at the discretion of the new mother and her healthcare provider. B) The average LOS decreased during the early 1990s in an effort to contain healthcare costs, with third-party payers reimbursing only a 24-hour stay following an uncomplicated vaginal delivery. C) Early discharge became more popular in the 1980s as an alternative to homedelivery. D) Even with the current length-of-stay laws, many newborns do not always receivethe recommended follow-up care when they go home early. The health and stability of the mother and baby, the mother's ability and confidence regarding self and newborn care, support systems available, and access to follow-up care should form the basis of the decision. Page Ref: 915 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. 1 Copyright © 2020 Pearson Education, Inc.
Learning Outcome: 2 Identify the main purposes of home visits during the postpartumperiod. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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2) A new mother is concerned about spoiling her newborn. The home care nurseteaches the mother which of the following? A) Newborns can be manipulative, so caution is advised. B) Meeting the infant's needs develops a trusting relationship. C) An infant who is rocked to sleep every night is being spoiled. D) Crying is good for babies, and letting them cry it out is advised. Answer: B Explanation: A) This would be inappropriate and incorrect advice. B) Picking babies up when they cry teaches them that adults are responsive to theirneeds. This helps build a sense of trust and security. C) This would be inappropriate and incorrect advice. D) This would be inappropriate and incorrect advice. Page Ref: 928 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Describe assessment, care of the newborn, and reinforcement ofparent teaching in the home. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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3) The home care nurse is visiting a newborn-and-mother couplet. Which nursingaction has the highest priority? A) Establish rapport with the family members. B) Review the hospital medical records. C) Determine the newborn's sleeping arrangements. D) Examine the umbilical cord stump. Answer: A Explanation: A) It is critical to establish rapport with family members prior to beginning any assessments. The nurse can rely on the same characteristics of a caring relationship that have been integral to hospital-based practice–regard for patients, genuineness, empathy, and establishment of trust and rapport. B) Although this is important, record review should be done prior to arriving at thehome, so that the nurse is prepared. C) Determining the newborn's sleeping arrangements is less important than establishing rapport with the family members. D) Examining the umbilical cord stump is less important than establishing rapportwith the family members. Page Ref: 917 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: Ⅸ. 8. Implementevidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies:Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 4 Delineate aspects of fostering a caring relationship in the home.MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.
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4) The nurse is meeting with a new mother for the first time during a home visit. The client delivered her first child 3 days ago. She had a normal pregnancy and a vaginaldelivery. The infant is breastfeeding. Which statements by the mother indicate that she needs more information about the home visit? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) "You are going to check my baby's weight." B) "You are going to watch me nurse the baby and give me tips." C) "You are going to teach my mother about the baby." D) "You are checking for safety issues when my son starts crawling." E) "You are going to take blood samples from me and my son." Answer: C, D, E Explanation: A) The components of a postpartum home visit typically include weighing the infant. B) The components of a postpartum home visit typically include assessing a feeding, if possible. C) Teaching of family members might occur, but the main purpose of the visit is toassess the infant's physiologic stability. D) Safety when the infant crawls should be assessed later. E) Not all home visits require blood samples. If there were no pregnancy or birth complications, there may not be the need to draw blood from either the mother orthe child. Page Ref: 918 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 1 Discuss the components of postpartum home care. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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5) The nurse is at the home of a postpartum client for an initial assessment. The clientgave birth by cesarean section 1 week earlier. Which statements should the nurse include? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) "Because you had a cesarean, I'd like to assess your incision." B) "You aren't having any problems nursing, right?" C) "How rested do you feel since you came home?" D) "Because you are bottle-feeding, I won't assess your breasts." E) "You should remain at home for the first 3 weeks after delivery." Answer: A, C Explanation: A) The nurse should assess the cesarean incision. B) Therapeutic communication prohibits asking leading questions. C) The nurse should talk with the mother about her fatigue level and ability to restand sleep. D) Breasts should be assessed for engorgement even for bottle-feeding mothers. E) The nurse should talk with the mother about her activity level and self-care abilities. Page Ref: 932 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Management of Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Discuss the components of postpartum home care. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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6) Late preterm infants have higher infant morbidity and mortality rates than term infants. Which of the following complications can they experience? A) Hyperglycemia B) Jaundice C) Motor difficulties D) Sensory complications Answer: B Explanation: A) Late preterm infants can experience hypoglycemia, not hyperglycemia. B) Late preterm infants can experience jaundice. C) Motor difficulties are not one of the complications that late preterm infants experience. D) Sensory complications are not one of the issues that late preterm infants experience. Page Ref: 919 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅰ. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: Ⅸ. 1. Conduct comprehensiveand focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Discuss the components of postpartum home care. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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7) The nurse is teaching experienced postpartum nurses about home care visits. Which statements indicate that teaching was effective? Note: Credit will be given only if all correct choices and no incorrect choices areselected. Select all that apply. A) "I should tell the family to put any guns or knives away." B) "It is best to blend in with the community and not bring attention to myself on visits." C) "If I encounter a crime in progress, I should leave the area." D) "Wearing jewelry is a good way to demonstrate my professionalism." E) "Ignoring my 'gut' feelings might lead to an unsafe situation." Answer: A, C, E Explanation: A) The nurse should leave the home immediately if a weapon is visible and thepatient or a family member refuses requests to put it away. B) The nurse should wear a name tag and carry identification. C) Nurses should avoid entering areas where violence is in progress. In such cases,they should return to the car and contact the appropriate authorities by calling 911. D) The nurse should avoid wearing expensive jewelry. E) The nurse should terminate the visit if a situation arises that feels unsafe, or if theprevious requests are not honored. Page Ref: 918 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 3 Summarize actions the nurse should take to ensure personal safety during a home visit. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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8) The nurse is planning a home care visit to a mother who just recently delivered. The neighborhood is known to have a significant crime rate. What should the nurse do when planning this visit to facilitate personal safety? A) Be friendly to all pets encountered on the visit to build client rapport. B) Wait to find the exact location until arrival in the neighborhood. C) Put personal possessions in the trunk when leaving the office. D) Wear flashy jewelry to garner respect. Answer: C Explanation: A) The nurse should ask clients to keep threatening pets secured in a different areaof the home during the visit. B) The nurse should confirm the address, ask for directions during the previsit contact, and trace out the route to the client's home on a map or the Internet before leaving for the visit and take the map along; the nurse should use a GPSdevice if available. C) The nurse should lock personal belongings in the trunk of the car, out of sight,before starting out or before arriving at the home. D) The nurse should avoid wearing expensive or flashy jewelry. Page Ref: 918 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅴ. C. 5. Value relationship between national safety campaigns and implementation in local practices and practice settings. | AACN Essentials Competencies: Ⅸ. 12. Create a safe environment that results in high-qualitypatient outcomes. | NLN Competencies: Quality and Safety: Commit to a generative safety culture. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 3 Summarize actions the nurse should take to ensure personalsafety during a home visit. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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9) The postpartum home care client asks the nurse why the visit is taking place. Whichresponse is best? A) "We make home care visits to reinforce any teaching that you didn't quite graspin the hospital." B) "We make home care visits to verify that both you and the baby are safe anddoing well." C) "We make home care visits to ensure you are breastfeeding correctly." D) "We make home care visits to thoroughly assess your baby to make sure he is growing." Answer: B Explanation: A) Postpartum home care provides opportunities for expanding information and reinforcing self- and infant-care techniques initially presented in the birth setting. However, this response is not therapeutically worded. B) Family well-being should be determined through a comprehensive assessmentthat includes physical, emotional, and social functioning. C) Although this statement is true if the mother is breastfeeding, it is only one component of the entire home healthcare postpartum visit. D) Assessing the baby is only part of the reason home care visits are performedafter birth. Page Ref: 917 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 2 Identify the main purposes of home visits during the postpartumperiod. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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10) During a postpartum home visit, which step should the nurse take to establish acaring relationship? A) Ask family members how they want to be addressed. B) Do a portion of what the nurse agrees to do for the family, to avoid overwhelmingthem. C) Speak directly to the father when asking questions. D) Present information to the family instead of asking questions. Answer: A Explanation: A) Establishing a caring relationship starts with introducing yourself to the family andby calling the family members by their surnames until you have been invited to use the given or a less formal name. B) Trust will be built only if the nurse follows through and does whatever is promised. C) It is important to allow the mother to be the spokesperson. D) It is important to ask questions instead of talking at the family. Be prepared for the visit, honestly answer questions, provide information, and be truthful. If you do not know the answer to a question, tell the patient you will find the informationand report back. Page Ref: 917 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Therapeutic Communication Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 4 Delineate aspects of fostering a caring relationship in the home.MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.
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11) The nurse is making a postpartum home visit in the summer. The new father asks about taking the baby to a family outing this weekend. The nurse should encouragethe father to do which of the following? A) Cover the infant with dark blankets to block the sun. B) Keep the infant in the shade. C) Uncover the infant's head to prevent hyperthermia. D) Avoid taking the infant outdoors for 6 months. Answer: B Explanation: A) Covering the infant with dark blankets would cause overheating and is not necessary. The infant should wear a light layer of clothing. B) To prevent sunburn, the newborn should remain shaded, wear a light layer of clothing, or be protected with sunscreen specifically formulated for infants. C) Newborns should wear a head covering outdoors to protect their sensitive earsfrom drafts and to prevent heat loss. D) Avoiding taking the infant outdoors for 6 months is neither necessary nor practical. Page Ref: 923 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Describe assessment, care of the newborn, and reinforcement ofparent teaching in the home. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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12) The home care nurse is examining a newborn who is sleeping on a pillow in a basket, covered with a fluffy blanket. There is also a stuffed animal in the basket.The most important nursing action to do is which of the following? A) Remove the stuffed animal from the basket and place it on the floor. B) Teach the parents the risk of SIDS from soft items in the infant's bed. C) Make certain that the blanket is firmly tucked under the baby. D) Ask whether the color of the blanket has cultural significance. Answer: B Explanation: A) Although loose bedding and soft objects should be removed from the infant's cribduring sleep, the highest priority is teaching the parents that these items are safety hazards and about the risk of SIDS. B) Teaching the parents about the risk of sudden infant death syndrome (S IDS) isthe highest priority. C) Loose bedding and soft objects should be removed from the infant's crib duringsleep. D) Cultural significance is important, but the newborn's physical safety is a higher priority. Page Ref: 926 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: Ⅸ. 12. Create asafe environment that results in highquality patient outcomes. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Summarize actions the nurse should take to ensure personalsafety during a home visit. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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13) Babies should sleep in what position every time they are put down for sleep? A) On their backs B) On their stomachs C) On their left sides D) On their right sides Answer: A Explanation: A) Babies should sleep on their backs every time they are put down for sleep. B) Babies should sleep on their backs every time they are put down for sleep, nottheir stomachs. C) Babies should sleep on their backs every time they are put down for sleep; all caregivers should be informed that side positioning is unsafe. D) Babies should sleep on their backs every time they are put down for sleep; all caregivers should be informed that side positioning is unsafe. Page Ref: 926 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: Ⅸ. 12. Create asafe environment that results in high-quality patient outcomes. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Summarize actions the nurse should take to ensure personalsafety during a home visit. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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14) The nurse is performing a postpartum home care visit. Which teaching has thehighest priority? A) Teaching or reviewing how to bathe the baby B) Teaching how to thoroughly childproof the house C) How many wet diapers the baby should have daily D) Prevention of plagiocephaly Answer: C Explanation: A) Although knowing how to bathe a newborn is important, the number of wet diapers is the highest priority. B) Childproofing the home is not necessary until the baby begins to crawl. This is alow priority at this time. C) Assessment of intake, output, weight, and hydration status is imperative. The baby should have at least six diapers that are saturated with clear urine each dayby 1 week of age. Wet diapers are an indication of hydration of the newborn. Thisis the highest priority. D) Preventing flat spots on the back or side of the infant's head is primarily a cosmetic issue. The number of wet diapers would be a higher priority. Page Ref: 920 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅴ. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacyconsiderations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 5 Describe assessment, care of the newborn, and reinforcement ofparent teaching in the home. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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15) To prevent sudden infant death syndrome (SIDS), the nurse encourages the parentsof a term infant to place the infant in which position when the infant is sleeping? A) On the parents' waterbed B) Swaddled in the infant swing C) On the back D) On the sides Answer: C Explanation: A) Babies should sleep in the same room as their parent(s) or an adult care provider, but they should not share the bed with anyone. They should also sleepon a firm surface to help prevent SIDS. B) Babies should not sleep with commercial devices marketed to maintain position.Safety has not been established. C) Babies should sleep on their backs every time they are put down for sleep. D) Babies should sleep on their backs every time they are put down for sleep; all caregivers should be informed that side positioning is unsafe. Page Ref: 926 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅴ. B. 4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacyconsiderations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Summarize actions the nurse should take to ensure personalsafety during a home visit. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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16) The postpartum home care nurse is assessing a new mother, and finds her temperature to be 101.6°F. What is the most important nursing action? A) Ask the mother how often and how well the baby is nursing. B) Determine the frequency of the mother's voiding and stooling. C) Verify how many hours of sleep she is getting per day. D) Assess the odor and color of the lochia and perineum. Answer: D Explanation: A) A fever might indicate mastitis. Palpation of the breasts for warm or hardenedareas is much better than asking about feedings because mothers of good feeders can develop mastitis. B) If she is voiding frequently, she might have a urinary tract infection (U TI), but the frequency of bowel movements is not related to a UTI. C) Although it is common for new mothers to be fatigued, fatigue does not causefever. D) If the lochia is malodorous, or if the perineum is reddened or malodorous, an infection is present that could be causing the fever. Page Ref: 931 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: Ⅸ. 1. Conductcomprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 1 Discuss the components of postpartum home care. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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17) The nurse should explain to new parents that their infant's position should be changed periodically during the early months of life to prevent which of the following? A) Muscle contractures B) Respiratory distress C) Permanently flattened areas of the skull D) Esophageal reflux Answer: C Explanation: A) Preventing muscle contractures is not the rationale for periodically changing theinfant's position. B) Respiratory distress would indicate complications, and would not be affected by periodic position changes. C) The nurse can describe plagiocephaly as a flattened area on the head and can recommend that parents alternate their infant's head position between the rightand the left side when placing the infant supine for sleep. Placing the infant's head at alternate ends of the crib every few days is helpful as well. D) Esophageal reflux would indicate complications, and would not be affected by periodic position changes. Page Ref: 926 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 5 Describe assessment, care of the newborn, and reinforcement ofparent teaching in the home. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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18) Nurses should educate parents about which of the following AAP recommendationsto promote a safe sleep environment and decrease the risk of SIDS and SUID in infants less than 12 months of age? A) Babies should not be offered a pacifier while falling asleep. B) Babies should be bottle-fed unless contraindicated. C) Babies should be under many covers when sleeping to keep them warm. D) Babies should have "tummy time" when they are awake. Answer: D Explanation: A) Babies should be offered a pacifier while falling asleep. B) Babies should be breastfed unless contraindicated. Exclusive breastfeeding forat least 6 months is ideal, but any amount is better than none. C) Babies should not be overheated by the use of too many covers during sleep. D) Babies should have "tummy time" when they are awake and observed by anadult to prevent positional plagiocephaly and to promote motor development. Page Ref: 926 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations tofoster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 3 Summarize actions the nurse should take to ensure personalsafety during a home visit. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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19) The nurse is assessing a new mother 2 days after a normal vaginal delivery. Themother has chosen not to breastfeed. What would an abnormal finding be? A) Weight loss of 3 pounds B) Small amount of breast milk expressed C) Pink striae on the abdomen D) Lochia serosa Answer: A Explanation: A) Normal weight loss postpartum is in the range of 12 to 20-plus pounds. B) At 2 days after the birth, a non-breastfeeding mother might express a smallamount of milk. C) Pink, obvious striae on the abdomen are normal. D) At 2 days postpartum, lochia rubra or lochia serosa in decreasing quantities isnormal. Page Ref: 932 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 6 Discuss maternal and family assessment and anticipatedprogress after birth. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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20) The home care nurse is seeing a client at 6 weeks postpartum. Which statement bythe client indicates the need for immediate intervention? A) "The baby sleeps 7 hours each night now." B) "My flow is red, and I need to wear a pad." C) "My breasts no longer leak between feedings." D) "I started back on the pill 2 weeks ago." Answer: B Explanation: A) The baby sleeping 7 hours a night by this time is an expected finding, and doesnot require intervention. B) By 6 weeks postpartum, lochia should be absent or minimal in amount, requiringonly a pantiliner. Red, heavy flow is not an expected finding, and requires intervention. C) The mother's breasts no longer leaking between feedings is an expected finding,and does not require intervention. D) Six week postpartum is an appropriate time frame for restarting birth control pills,and does not require intervention. Page Ref: 933 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum andNewborn Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment.Learning Outcome: 6 Discuss maternal and family assessment and anticipated progress after birth. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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21) A new mother at 36 hours post-delivery has asked to be discharged to home. The nurse explains that criteria for discharge before the newborn is 48 hours old includewhich of the following? A) The newborn's respiratory rate is less than 60/min. B) Singleton birth at a minimum 35 weeks' gestation. C) The newborn has passed at least three spontaneous stools. D) The newborn has normal and stable vital signs for 24 hours before discharge. Answer: A Explanation: A) Minimal criteria include a respiratory rate in the newborn less than 60/min. B) Minimal criteria include a singleton birth at 37 to 41 weeks' gestation. C) Minimal criteria include the newborn's passing at least one spontaneous stool. D) Vital signs must be normal and stable for 12 hours prior to discharge. Page Ref: 916 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations tofoster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 6 Discuss maternal and family assessment and anticipatedprogress after birth. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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22) The postpartum client has chosen to bottle-feed her infant. Nursing actions that aidin lactation suppression include which of the following? A) Warm showers B) Pumping milk C) Ice packs to each breast D) Avoiding wearing a bra for 5 to 7 days Answer: C Explanation: A) A nonbreastfeeding mother should avoid warm showers to decrease the flow ofbreast milk. B) A nonbreastfeeding mother should avoid pumping milk or any stimulation of breasts to decrease the flow of breast milk. C) A nonbreastfeeding mother should use cooling packs for comfort and to decreasethe flow of breast milk. D) A nonbreastfeeding mother should wear a supportive, well-fitted bra to decreasethe flow of breast milk. Page Ref: 932 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: Ⅰ. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacyconsiderations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Describe appropriate nursing interventions for women who are experiencing breastfeeding difficulties. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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23) The postpartum nurse is performing a home care visit to a first-time mother on herthird day after delivery. She reports that her nipples are becoming sore. What statement indicates that further teaching is needed? A) "I can apply lanolin cream to help with the nipple pain." B) "Watching how much areola is visible will help me see whether my baby has agood mouthful of breast or not." C) "My nipples will heal if I switch to bottle feeding for about 3 days while I pump my breasts." D) "Rotating breastfeeding positions will allow the sore areas of my nipples to haveless friction." Answer: C Explanation: A) The application of highly purified anhydrous (HPA) lanolin and/or breast milk accompanied by air-drying at the end of feedings has been shown to be safe andeffective in treating nipple pain. B) When latched, the baby's lips should be flanged out, and the newborn shouldcover as much of the areola as possible. C) For severe cases in which the mother is unable to tolerate breastfeeding, themother will need to pump or hand-express the breast milk until the nipple condition improves. Bottle-feeding may not be necessary. D) Encouraging the mother to rotate positions when feeding the infant may decrease nipple soreness. Changing positions alters the focus of greatest stressand promotes more complete breast emptying. Page Ref: 937 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences,and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listenopenly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation. Learning Outcome: 7 Describe appropriate nursing interventions for women who are experiencing breastfeeding difficulties. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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24) The postpartum home care nurse has performed home visits to four breastfeedingmothers. Which mother is experiencing an expected outcome? A) Breasts are engorged; placing fresh cabbage leaves inside her bra B) Sore and cracked nipples; using hydrogel dressings to facilitate healing C) Breast engorgement; accompanied by erythema D) Concerns about milk supply; supplementing with formula Answer: A Explanation: A) A compress of fresh green cabbage leaves helps reduce engorgement. B) The use of hydrogel dressings cannot be recommended at this time due to concerns about infection. C) For breast engorgement accompanied by erythema, the nurse should instruct themother to keep the breast empty by frequent feeding, rest when possible with breasts elevated, take prescribed pain relief medication, and drink adequate fluids. D) Because milk production follows the principle of supply and demand, if breasts are not pumped, the milk supply will decrease. Supplementing with formula will decrease milk supply. Page Ref: 939 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: Ⅸ. 8. Implementevidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies:Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment. Learning Outcome: 7 Describe appropriate nursing interventions for women who are experiencing breastfeeding difficulties. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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25) A breastfeeding postpartum client reports sore nipples to the nurse during a homevisit. What intervention would be the highest priority? A) Infant positioning B) Use of the breast shield C) Use of breast pads D) Type of soap used Answer: A Explanation: A) Poor latch and/or suck are the primary causes of nipple soreness and the baby'sposition at the breast is a critical factor in nipple soreness. Encouraging the mother to rotate positions when feeding the infant may decrease nipple soreness. Changing positions alters the focus of greatest stress and promotes more complete breast emptying. B) Using a breast shield is not a critical factor in alleviating nipple soreness. C) Using breast pads is not a critical factor in alleviating nipple soreness. D) The type of soap used is not a critical factor in alleviating nipple soreness. Page Ref: 937 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: Ⅰ. B. 7. Initiate effective treatments to relieve painand suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: Ⅸ. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Respect the patient's dignity, uniqueness, integrity, andself-determination, and his or her own power and self-healing process. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 7 Describe appropriate nursing interventions for women who are experiencing breastfeeding difficulties. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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26) The nurse is making an initial visit to a postpartum family's home. The mother statesthat she is having difficulty with breastfeeding. Which resource should the nurse tell the family about? A) The lactation consultant at the hospital B) Free immunizations through the county public health department clinics C) Sources of free formula at a local food pantry D) A support group for mothers who are experiencing postpartum depression Answer: A Explanation: A) When the client specifies a problem with breastfeeding, the best resource for thenurse to inform the family about is the lactation consultant. B) Free immunizations do not help with breastfeeding. C) Providing a mother with formula undermines her breastfeeding efforts and sendsa message that she will not be successful with breastfeeding. D) There is no evidence that the client is experiencing postpartum depression. Page Ref: 937 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: Ⅰ. B. 3. Provide patient-centered care with sensitivityand respect for the diversity of human experience. | AACN Essentials Competencies: Ⅶ. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan. | NLN Competencies: Relationship-Centered Care: Respect thepatient's dignity, uniqueness, integrity, and self-determination, and his or her own powerand self-healing process. | Nursing/Integrated Concepts: Nursing Process: Implementation. Learning Outcome: 8 Identify postpartum resources that are available to new families.MNL LO: Demonstrate use of the nursing process in the care of the postpartum family at home.
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27) Before a newborn and mother are discharged from the hospital, the nurse informs the parents about routine screening tests for newborns. What is a good reason for having the screening tests done? A) The tests prevent infants from developing phenylketonuria. B) The tests detect such disorders as hypertension and diabetes. C) The tests detect disorders that cause physical, intellectual, and developmental complications or death if left undiscovered. D) The tests prevent sickle-cell anemia, galactosemia, and homocystinuria. Answer: C Explanation: A) Screening tests do not prevent any disorders. B) Screening tests do not detect hypertension or diabetes. C) Newborn screening tests use a few drops of the newborn's blood to detect disorders that are often asymptomatic at birth but cause irreversible harm if not detected early. Profound physical, intellectual, and developmental complicationsand even death can result from many of the conditions for which newborns are screened prior to discharge. D) Screening tests do not prevent any disorders. Page Ref: 930 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Management of Care Standards: QSEN Competencies: Ⅰ. B. 3. Provide patient-centered care with sensitivityand respect for the diversity of human experience. | AACN Essentials Competencies: Ⅶ. 5. Use evidence-based practices to guide health teaching, health counseling,screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan. | NLN Competencies: Context and Environment: health promotion/disease prevention. | Nursing/Integrated Concepts: Nursing Process: Planning. Learning Outcome: 1 Discuss the components of postpartum home care. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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28) The nurse is instructing a new mother on basic infant care. For which activitiesshould the nurse suggest that the mother use the following infant hold?
A) Burping B) Bottle feeding C) Shampooing hair D) Changing a diaper Answer: C Explanation: C) The football hold frees one of the caregiver's hands and permits eye contact. This hold is ideal for shampooing, carrying, or breastfeeding. The cradle hold is frequently used during feeding. The upright position is ideal for burping. The babyshould be supine for changing a diaper. Page Ref: 920 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 5 Describe assessment, care of the newborn, and reinforcement of 29 Copyright © 2020 Pearson Education, Inc.
parent teaching in the home. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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29) The nurse is reviewing the process of applying a pre-folded diaper with a newmother. In which order should the nurse provide these instructions? 1.
2.
3.
4.
Answer: 4, 2, 1, 3 Explanation: The nurse should review the figure in Choice 4 first. Then the three folds of material should be explained to the mother as identified in Choice 2. How the diaper should be placed is identified in Choice 1. And lastly, the application of the diaper onto the baby asshown in Choice 3. Page Ref: 924 31 Copyright © 2020 Pearson Education, Inc.
Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 5 Describe assessment, care of the newborn, and reinforcement ofparent teaching in the home. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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30) The nurse is preparing teaching material for a new mother. For which activity shouldthe nurse provide the following diagram?
A) Preparing to feed B) Wrapping the baby C) Preparing for a bath D) Changing the diaper Answer: B Explanation: B) This diagram is used to instruct a new mother on the process of wrapping thebaby. This diagram would not be appropriate to use when teaching feeding, bathing, or changing the diaper. Page Ref: 924 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 5 Describe assessment, care of the newborn, and reinforcement ofparent teaching in the home. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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31) The nurse is preparing an educational program for new parents. In which ordershould the nurse provide the Purple Crying information? 1. Unexpected 2. Long lasting 3. Pain-like face 4. Peak of crying 5. Resists soothing 6. Evening and late afternoon Answer: 4, 1, 5, 3, 2, 6 Explanation: The acronym PURPLE is derived from the character of the crying that some healthy infants experience between 2 and 4 months of age: P: Peak of crying; U: Unexpected;R: Resists soothing; P: Pain-like face; L: Long lasting; and E: Evening and late afternoon. Page Ref: 929 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: Ⅸ. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,patient preferences, and health literacy considerations to foster patient engagement intheir care. | NLN Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Teaching/Learning. Learning Outcome: 5 Describe assessment, care of the newborn, and reinforcement ofparent teaching in the home. MNL LO: Demonstrate use of the nursing process in the care of the postpartum familyat home.
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Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 35. The Postpartum Family at Risk Question 1 The charge nurse is assessing several postpartum patients. Which patient has the greatest risk for postpartum hemorrhage? 1. The patient who was overdue and delivered vaginally 2. The patient who delivered by scheduled cesarean delivery 3. The patient who had oxytocin augmentation of labor 4. The patient who delivered vaginally at 36 weeks Correct Answer: 3 Rationale 1: This patient has a lower risk for postpartum hemorrhage than would another patient. Rationale 2: This patient has a lower risk for postpartum hemorrhage than would another patient. Rationale 3: Uterine atony is a cause of postpartal hemorrhage. A contributing factor to uterine atony is oxytocin augmentation of labor. Rationale 4: This patient has a lower risk for postpartum hemorrhage than would another patient. Question 2 The nurse is assisting a multiparous woman to the bathroom for the first time since her delivery 3 hours ago. When the patient stands up, blood runs down her legs and pools on the floor. The patient turns pale and feels weak. The first action of the nurse is to: 1. Assist the patient to empty her bladder. 2. Help the patient back to bed to check the fundus. 3. Assess her blood pressure and pulse. 4. Begin an IV of lactated Ringer's solution. Correct Answer: 2 Rationale 1: Another action is more important.
Rationale 2: Massaging the fundus is the top priority because of the excessive blood loss. If the fundus is boggy, fundal massage will prevent further blood loss. Rationale 3: Blood pressure and pulse do not change until 1000–2000 ml of blood has been lost. Rationale 4: An IV might need to be started if the patient becomes symptomatic. Question 3 A patient is experiencing excessive bleeding immediately after the birth of her newborn. After speeding up the IV fluids containing oxytocin, with no noticeable decrease in the bleeding, the nurse should anticipate the physician requesting which medications? Standard Text: select all that apply; 1. Methergine 2. Stadol 3. Misoprostol 4. Betamethasone Correct Answer: 1,3 Rationale 1: Methergine is a drug of choice for postpartum hemorrhage. Rationale 2: Stadol is an analgesic, and is not used for postpartum hemorrhage. Rationale 3: Misoprostol is commonly used rectally for postpartum hemorrhage. Rationale 4: Betamethasone is a glucocorticoid used for preterm labor to decrease respiratory distress in the preterm infant. Question 4 The patient has experienced a postpartum hemorrhage at 6 hours postpartum. After controlling the hemorrhage, the patient's partner asks what would cause a hemorrhage. How should the nurse respond? 1. "Sometimes the uterus relaxes and excessive bleeding occurs." 2. "The blood collected in the vagina and poured out when your partner stood up." 3. "Bottle-feeding prevents the uterus from getting enough stimulation to contract." 4. "The placenta had embedded in the uterine tissue abnormally."
Correct Answer: 1 Rationale 1: Uterine atony, in which the uterus relaxes, is the most common cause of early postpartum hemorrhage (within the first 24 hours after delivery). Rationale 2: Although blood can pool in the vagina and thus pour out when the patient stands, this does not constitute a hemorrhage. Rationale 3: Although breastfeeding stimulates the release of oxytocin, which causes the uterus to contract, bottle-feeding does not cause hemorrhage. Rationale 4: Had the placenta embedded abnormally (as in placenta accreta), the hemorrhage would have occurred immediately after the placenta delivered. Question 5 The nurse is assessing a patient who has been diagnosed with an early postpartum hemorrhage. Which findings would the nurse expect? Standard Text:select all that apply. 1. A boggy fundus that does not respond to massage 2. Small clots and a moderate amount of lochia rubra on the pad 3. Decreased pulse and increased blood pressure 4. Hematoma formation or bulging/shiny skin in the perineal area 5. Rise in the level of the fundus of the uterus Correct Answer: 1,4,5 Rationale 1: A boggy fundus indicates that the uterus is not contracted and will continue to bleed. Rationale 2: These are normal findings in the postpartal period. Rationale 3: Increasing pulse and decreasing blood pressure are detected when the patient is bleeding. Rationale 4: Shiny or bulging skin could indicate the presence of a hematoma. Rationale 5: The uterine cavity can distend with up to 1000 ml or more of blood, causing the fundus to rise. Question 6 The nurse is caring for a postpartum patient who is at risk for developing early postpartum hemorrhage. What interventions would be included in the plan of care to detect this complication?
Standard Text: select all that apply; 1. Weigh perineal pads if the patient has a slow, steady, free flow of blood from the vagina. 2. Massage the uterus every 2 hours. 3. Maintain vascular access. 4. Obtain blood specimens for hemoglobin and hematocrit. 5. Encourage the patient to void if the fundus is displaced upward or to one side. Correct Answer: 1,4 Rationale 1: Weighing the perineal pads will indicate whether the patient is bleeding more than anticipated. Rationale 2: This intervention will help prevent hemorrhage if done when the nurse detects a boggy uterus. Rationale 3: This intervention should be done if the assessments are not reassuring. Rationale 4: The nurse reviews these findings when available, and compares them to the admission baseline. Rationale 5: This is necessary to empty the bladder, but will not detect excess bleeding. Question 7 A patient had a cesarean birth 3 days ago. She has tenderness, localized heat, and redness of the left leg. She is afebrile. As a result of these symptoms, the nurse recognizes that the patient will most likely be: 1. Encouraged to ambulate freely. 2. Given aspirin 650 mg by mouth. 3. Given Methergine IM. 4. Placed on bed rest. Correct Answer: 4 Rationale 1: Ambulation would increase the inflammation. Rationale 2: Aspirin 650 mg by mouth has anticoagulant properties, but usually is not necessary unless complications occur. Rationale 3: Methergine is given only for postpartum hemorrhage, and would only cause vasoconstriction of an already inflamed vessel.
Rationale 4: These symptoms indicate the presence of superficial thrombophlebitis. The treatment involves bed rest, elevation of the affected limb, analgesics, and use of elastic support hose. Question 8 The postpartum patient is concerned about mastitis because she experienced it with her last baby. Preventive measures the nurse can teach include: 1. Wearing a tight-fitting bra. 2. Limiting feedings to q.i.d. 3. Frequent breastfeeding. 4. Forcing fluids. Correct Answer: 3 Rationale 1: Although wearing a supportive bra is recommended, a tight-fitting bra would mechanically suppress lactation. Rationale 2: Limiting feedings to q.i.d. would suppress lactation. Rationale 3: Frequent breastfeeding is important because complete emptying of the breasts prevents engorgement and stasis. Rationale 4: Forcing fluids is not necessary. Question 9 A postpartum patient reports sharp, shooting pains in her nipple during breastfeeding and flaky, itchy skin on her breasts. The nurse suspects: 1. Nipple soreness. 2. Engorgement. 3. Mastitis. 4. Letdown reflex. Correct Answer: 3 Rationale 1: These are not symptoms of nipple soreness. Rationale 2: These are not symptoms of engorgement.
Rationale 3: Mastitis is characterized by late-onset nipple pain, followed by shooting pains during and between feedings. The skin of the affected breast becomes pink, flaking, and pruritic. Rationale 4: These are not symptoms of the letdown reflex. Question 10 Which relief measure would be most appropriate for a postpartum patient with superficial thrombophlebitis? 1. Urge ambulation. 2. Apply ice to the leg. 3. Elevate the affected limb. 4. Massage her calf. Correct Answer: 3 Rationale 1: Ambulation would increase discomfort. Rationale 2: Applying ice to the leg is contraindicated in thrombophlebitis treatment because it can cause vasoconstriction, increasing pain. Rationale 3: Elevating the limb promotes venous blood return and helps decrease edema, and thus increases comfort in the affected leg. Rationale 4: Massaging the calf is contraindicated because it can cause a breakup of a clot and put the patient at risk for a pulmonary embolus. Question 11 The nurse is caring for a postpartum patient who had an estimated blood loss of 500 ml following a vaginal birth. What is the best clinical measure of the patient's actual blood loss? 1. The clinical estimation of blood loss at time of birth 2. A decrease in the hematocrit of 10 points between the time of admission and the time of postbirth 3. The amount of saturation of the linens during and after the birth 4. A decrease in blood pressure and increase in pulse after birth Correct Answer: 2 Rationale 1: The clinical estimation of blood loss at the time of birth often is obscured by blood mixing with amniotic fluid and oozing onto the sterile drapes or getting sponged away.
Rationale 2: A decrease in the hematocrit of 10 points between the time of admission and the time of postbirth is seen by many clinicians as most reliable in estimating the actual blood loss. Rationale 3: The saturation of the linens during and after the birth represents a mixture of blood and amniotic fluid, and would not be accurate. Rationale 4: A decrease in blood pressure and an increasing pulse rate after birth do not appear until as much as 1000–2000 ml have been lost, and shortly before the woman becomes hemodynamically unstable. Question 12 Which findings would indicate the presence of a perineal wound infection? Standard Text: select all that apply; 1. Redness 2. Edema 3. Vaginal bleeding 4. Warmth 5. Purulent drainage Correct Answer: 1,2,4,5 Rationale 1: Redness is a classic sign of a perineal wound infection. Rationale 2: Edema is a classic sign of a perineal wound infection. Rationale 3: Vaginal bleeding is nonspecific to identifying a perineal wound infection. Rationale 4: Warmth is a classic sign of a perineal wound infection. Rationale 5: Purulent drainage, and later gaping of a wound that was previously well approximated, are classic signs of a perineal wound infection. Question 13 Which method of assessment would best indicate whether a patient has a urinary complication? 1. Urine pH 2. Calculation of output 3. Urine-specific gravity
4. Calculation of intake Correct Answer: 2 Rationale 1: Urine pH can be used to identify certain conditions, but would not be part of the initial assessment. Rationale 2: Calculation of output would provide the best assessment of complete emptying of the bladder, because overdistention can cause trauma to the bladder, displace the uterus, and cause infection. Rationale 3: Urine-specific gravity can be used to identify certain conditions, but would not be part of the initial assessment. Rationale 4: Monitoring intake is an intervention that could help prevent urinary complications, but calculating the intake itself would not reveal a complication. Question 14 The most appropriate nursing diagnosis for a patient with postpartum deep vein thrombosis is: 1. Fluid Volume excess related to tissue edema. 2. Sleep Pattern Disturbance related to tissue hypoxia. 3. Risk for Infection related to obstructed venous return. 4. Altered Tissue Perfusion related to obstructed venous return. Correct Answer: 4 Rationale 1: This diagnosis does not identify the underlying cause. Rationale 2: This diagnosis does not identify the underlying cause. Rationale 3: This might be a possible diagnosis if complications of infection are present. Rationale 4: This diagnosis identifies the underlying cause. Question 15 The nurse is calling patients at 4 weeks postpartum. The patient who should be seen immediately is the patient who: 1. Describes feeling sad all the time. 2. Reports hearing voices talking about the baby. 3. States she has no appetite and wants to sleep all day.
4. Says she needs a refill on her sertraline (Zoloft) next week. Correct Answer: 2 Rationale 1: This is an indication the patient is experiencing postpartum blues, and is not the highest priority. Rationale 2: This is an indication the patient is experiencing postpartum psychosis, and is the highest priority, because the voices might tell her to harm her baby. Rationale 3: This is an indication the patient is experiencing postpartum depression, but is not the highest priority. Rationale 4: A patient on medications needs refills on time, but right now she has medication, and therefore is not a high priority. Question 16 The home health nurse is visiting a new mother whose baby was delivered by emergency cesarean after a car accident. The mother seems dazed, irritable, and unaware of her surroundings. She tells the nurse she has had trouble sleeping. The nurse would suspect that the mother has: 1. Post-traumatic stress disorder. 2. Postpartum blues. 3. Postpartum psychosis. 4. Disenfranchised grief. Correct Answer: 1 Rationale 1: Because of the traumatic nature of the birth and the patient’s symptoms, this condition is most likely PTSD. Rationale 2: Postpartum blues are typically self-limiting, and are characterized by rapid mood swings, often without an identifiable cause. Rationale 3: Symptoms of postpartum psychosis include agitation, hyperactivity, mood lability, confusion, irrational thinking and behaviors, poor judgment, delusions, and hallucinations. Rationale 4: What the patient is feeling is not a type of grief. Question 17 To prevent the spread of infection, the nurse teaches the postpartum patient to: 1. Address pain early.
2. Change peripads frequently. 3. Avoid overhydration. 4. Report symptoms of uterine cramping. Correct Answer: 2 Rationale 1: Addressing pain early would not be a preventive action for infection. Rationale 2: Changing peripads frequently prevents contamination of the perineum and reduces the risk of infection. Wiping from front to back and good hygiene practices also are important. Rationale 3: Avoiding overhydration actually would increase the risk for infection by not providing adequate fluids to flush the kidneys and bladder. Rationale 4: Reporting symptoms of uterine cramping would not be a preventive action for infection. Question 18 A postpartal patient recovering from deep vein thrombosis is being discharged. What areas of teaching on selfcare and anticipatory guidance should the nurse discuss with the patient? Standard Text: select all that apply; 1. Avoid crossing the legs. 2. Avoid prolonged standing or sitting. 3. Take frequent walks. 4. Take a daily aspirin dose of 650 mg. 5. Avoid long car trips. Correct Answer: 1,2,3 Rationale 1: Crossing the legs puts pressure on them. Rationale 2: Prolonged standing or sitting contributes to venous stasis. Rationale 3: Frequent walks promote venous return. Rationale 4: Taking a daily aspirin increases anticoagulant activity, and should be avoided if the patient is being treated with other anticoagulants.
Rationale 5: Avoiding long car trips is not necessary. The patient should be told to take frequent breaks during car trips, but not to avoid them entirely. Question 19 The postpartum multipara is breastfeeding her new baby. The patient states that she developed mastitis with her first child, and asks whether there is something she can do to prevent mastitis this time. The best response of the nurse is: 1. "Massage your breasts on a daily basis, and if you find a hardened area, massage it towards the nipple to unblock that duct." 2. "Most first-time moms experience mastitis. It is really quite unusual for a woman having her second baby to get it again." 3. "Apply cabbage leaves to any areas that feel thickened or firm to relieve the swelling." 4. "Take your temperature once a day. This will help you to pick up the infection early, before it becomes severe." Correct Answer: 1 Rationale 1: A hardened area could indicate a blocked duct. Massage of the blocked duct toward the nipple will help to unplug the duct and relieve stasis of the milk, thereby preventing mastitis. Rationale 2: This statement is not accurate. Rationale 3: Cabbage leaves are applied to suppress lactation, not prevent mastitis. Rationale 4: The onset of mastitis is quite rapid, and taking the temperature daily is not likely to be helpful for catching early onset of the infection. Question 20 The postpartum patient states that she doesn't understand why she can't enjoy being with her baby. The nurse is concerned about: 1. Postpartum psychosis. 2. Postpartum infection. 3. Postpartum depression. 4. Postpartum blues. Correct Answer: 3
Rationale 1: Postpartum psychosis is more severe, and includes hallucinations and irrationality, which are not represented in this situation. Rationale 2: Postpartum infection is not related to this situation. Rationale 3: Postpartum depression is characterized by feelings such as failure and self-accusation, sadness, and, sometimes, irritability toward the newborn, among others. Rationale 4: Postpartum blues are characterized by mild depression interspersed with happier feelings, and is self-limiting. Question 21 The nurse understands that the classic symptom of endometritis in a postpartum patient is: 1. Purulent, foul-smelling lochia. 2. Sawtooth temperature spikes. 3. Profuse vaginal discharge. 4. Uterine tenderness. Correct Answer: 1 Rationale 1: Purulent and foul-smelling lochia is cited as the classic sign of endometriosis. Rationale 2: Sawtooth temperature spikes are a sign of endometritis, but not the classic symptom. Rationale 3: Scant or profuse vaginal discharge is a sign of endometritis, but not the classic symptom. Rationale 4: Uterine tenderness is a symptom of endometritis, but is not the classic symptom. Question 22 The patient delivered her 2nd child 1 day ago. The patient's temperature is 101.4° F, her pulse is 100, and her blood pressure is 110/70. Her lochia is moderate, serosanguinous, and malodorous. She is started on IV antibiotics. The nurse provides education for the patient and her partner. Which statement indicates that teaching has been effective? 1. "This condition is called parametritis." 2. "Gonorrhea is the most common organism that causes this type of infection." 3. "My Beta-strep culture’s being positive might have contributed to this problem." 4. "If I had walked more yesterday, this probably wouldn't have happened."
Correct Answer: 3 Rationale 1: Parametritis, or pelvic cellulitis, is an ascending complication of endometritis, and involves more extensive infection of tissue than does this condition. Rationale 2: Gonorrhea is not a common cause of endometritis, and especially not of early-onset endometritis. Rationale 3: A postpartum infection of the uterus is endometritis, and when it develops within 36 hours after delivery, it is most commonly caused by group B streptococcus. Rationale 4: Walking would prevent deep vein thrombophlebitis, not endometritis. Question 23 The postpartum patient has developed thrombophlebitis in her right leg. Which finding requires immediate intervention? 1. The patient reports she had this condition after her last pregnancy. 2. The patient develops pain and swelling in her left lower leg. 3. The patient appears anxious, and describes pressure in her chest. 4. The patient becomes upset that she cannot go home yet. Correct Answer: 3 Rationale 1: This is a risk factor for the development of thrombophlebitis, but is neither a predictor nor an indication of complications. Rationale 2: Development of bilateral thrombophlebitis is a complication, but not the top priority. Rationale 3: Anxiety and sudden onset of chest pain or pressure might indicate pulmonary embolus, which is a life-threatening complication of thrombophlebitis. This is the most abnormal finding, and requires immediate intervention. Rationale 4: Becoming upset is a psychosocial issue and far less important than another finding. Question 24 A nurse suspects that a postpartum patient has mastitis. Which data support this assessment? Standard Text: select all that apply; 1. Shooting pain in her nipple during breastfeeding 2. Late onset of nipple pain
3. Pink, flaking, pruritic skin of the affected nipple 4. Nipple soreness when the infant latches on 5. Pain radiating to the underarm area from the breast. Correct Answer: 1,2,3 Rationale 1: Mastitis is characterized by shooting pain during and between feedings. Rationale 2: Mastitis is characterized by late-onset nipple pain. Rationale 3: The skin of the affected breast becomes pink, flaking, and pruritic. Rationale 4: Nipple soreness when the infant latches on is not a symptom of mastitis. Rationale 5: The pain from mastitis does not radiate to the underarm area. Question 25 The postpartum patient who delivered 2 days ago has developed endometritis. Which entry would the nurse expect to find in this patient’s chart? 1. "Cesarean birth performed secondary to arrest of dilation." 2. "Rupture of membranes occurred 2 hours prior to delivery." 3. "External fetal monitoring used throughout labor." 4. "The patient has history of pregnancy-induced hypertension." Correct Answer: 1 Rationale 1: Cesarean birth is the greatest predictor of postpartum endometritis. The frequent cervical exams necessary to assess for arrest of dilation are another risk factor for postpartum infection. Rationale 2: Prolonged rupture of membranes (longer than 12 hours) is a risk factor for postpartum endometritis. Rationale 3: Internal fetal monitoring (both internal fetal scalp electrode and intrauterine pressure catheter) are risk factors for postpartum endometritis. Rationale 4: Pregnancy-induced hypertension is not a risk factor for postpartum endometritis. Question 26 The nurse suspects that a patient has developed a perineal hematoma. What assessment findings would the nurse have detected to lead to this conclusion?
1. Facial petechiae 2. Large, soft hemorrhoids 3. Tense tissues with severe pain 4. Elevated temperature Correct Answer: 3 Rationale 1: Facial petechiae do not indicate perineal hematoma. Rationale 2: Large, soft hemorrhoids are not indicative of perineal hematoma. Rationale 3: Tenseness of tissues that overlie the hematoma is characteristic of perineal hematomas. Rationale 4: An elevated temperature can be due to a variety of reasons, such as dehydration or mastitis. Question 27 The postpartum patient is suspected of having acute cystitis. Which symptoms would the nurse expect to see in this patient? Standard Text: select all that apply; 1. High fever 2. Frequency 3. Suprapubic pain 4. Chills 5. Nausea and vomiting Correct Answer: 2,3 Rationale 1: High fever is not usually present in acute cystitis, although it can appear if the cystitis progresses to pyelonephritis. Rationale 2: Frequency is characteristic of acute cystitis. Rationale 3: Suprapubic pain is characteristic of acute cystitis. Rationale 4: Chills are not usually present in acute cystitis, although they can appear if the cystitis progresses to pyelonephritis.
Rationale 5: Nausea and vomiting are not usually present in acute cystitis, although they can appear if the cystitis progresses to pyelonephritis. Question 28 The patient delivered vaginally 2 hours ago after receiving an epidural analgesia. She has a slight tingling sensation in both lower extremities, but normal movement. She sustained a second-degree perineal laceration. Her perineum is edematous and ecchymotic. What should the nurse include in the plan of care for this patient? 1. Assist the patient to the bathroom in 2 hours to void. 2. Place a Foley catheter now. 3. Apply warm packs to the perineum three times a day. 4. Allow the patient to rest for the next 8 hours. Correct Answer: 1 Rationale 1: This patient is at risk for urinary retention and bladder overdistention from both the perineal edema and the effects of the epidural. Assisting the patient to the bathroom is the most likely intervention that will prevent urinary retention. If the patient is unable to void soon, a straight in-and-out catheter may be used. Rationale 2: A Foley catheter is not indicated at this time. Rationale 3: Cold packs will help decrease the perineal edema; warm packs would increase the edema. Rationale 4: Waiting 8 hours to reassess the bladder is too long. Question 29 The nurse is preparing a community education class on healthy pregnancy. Which statements should be included? Standard Text: select all that apply; 1. Eating a well-balanced diet helps prevent pregnancy complications. 2. Stress management and support systems are important in pregnancy. 3. Prenatal care can be obtained at any point in the pregnancy. 4. Complications during a prior pregnancy do not recur. 5. Exercising regularly facilitates feeling better in pregnancy. Correct Answer: 1,2,5
Rationale 1: Good overall nutrition helps reduce the incidence of many pregnancy complications, including anemia, preterm labor, and delivery complications such as shoulder dystocia. Rationale 2: Patients with high stress levels and poor support systems are more likely to develop postpartum depression and have problems parenting. Rationale 3: Early and regular prenatal care is important to help prevent complications, and to detect complications if they develop. Rationale 4: Many complications of pregnancy have a tendency to recur, including postpartum hemorrhage, postpartum depression, preterm labor, and premature rupture of membranes. Rationale 5: Regular exercise during pregnancy helps prevent hypertension and gestational diabetes, helps reduce length of labor, and helps patients feel good. Question 30 A postpartum patient with endometritis is being discharged home on antibiotic therapy. The new mother plans to breastfeed her baby. What should the nurse’s discharge instruction include? 1. The patient can douche every other day. 2. Sexual intercourse can be resumed when the patient feels up to it. 3. Light housework will provide needed exercise. 4. The baby’s mouth should be examined for thrush. Correct Answer: 4 Rationale 1: Douching is contraindicated for this patient. Rationale 2: Pelvic rest is necessary for this patient, and sexual activity should be resumed only when the physician says it is safe. Rationale 3: This patient will need assistance at home. If the family cannot provide it, homecare services should be contacted. Rationale 4: A breastfeeding mother on antibiotics should check her baby’s mouth for signs of thrush, which should be reported to the physician. Question 31 The patient delivered by cesarean birth 3 days ago and is being discharged. Which statement should the nurse include in the discharge teaching? 1. "If your incision becomes increasingly painful, call the doctor."
2. "It is normal for the incision to ooze greenish discharge in a few days." 3. "Increasing redness around the incision is a part of the healing process." 4. "A fever is to be expected because you had a surgical delivery." Correct Answer: 1 Rationale 1: The patient should call the doctor if the incision becomes increasingly painful. Cesarean wound infections are characterized by fever, increased pain, increasing redness in the peri-wound area, and purulent drainage. Rationale 2: Green drainage is not an acceptable symptom. Rationale 3: The patient should call the doctor if the incision becomes increasingly painful. Cesarean wound infections are characterized by increasing redness in the peri-wound area. Rationale 4: A fever could be a symptom of infection. Question 32 The patient delivered her 2nd child yesterday, and is preparing to be discharged. She expresses concern to the nurse because she developed an upper urinary tract infection (UTI) after the birth of her first child. Which statement indicates that the patient needs additional teaching about this issue? 1. "If I start to have burning with urination, I need to call the doctor." 2. "Drinking 8 glasses of water each day will help prevent another UTI." 3. "I will remember to wipe from front to back after I move my bowels." 4. "Voiding two or three times per day will help prevent a recurrence." Correct Answer: 4 Rationale 1: Burning with urination is a common symptom of a UTI. Rationale 2: Drinking 8 or more glasses of water per day will help to prevent the development of a UTI. Rationale 3: Wiping from front to back after bowel movements will help to prevent the development of a UTI. Rationale 4: Voiding only two or three times per day is not sufficient to prevent recurrence of a urinary tract infection (UTI). Question 33
The postpartum patient who is being discharged from the hospital experienced severe postpartum depression after her last birth. What should the nurse include in the plan of follow-up care for this patient? 1. One visit from a homecare nurse, to take place in 2 days 2. Two visits from a public health nurse over the next month 3. An appointment with a mental health counselor 4. Follow-up with the obstetrician in 6 weeks Correct Answer: 3 Rationale 1: A home visit in 2 days will be helpful to assess feeding, but is too early to detect signs of postpartum depression. Rationale 2: Two home visits in a month are too sporadic to accurately pick up postpartum depression. Rationale 3: Postpartum depression has a high recurrence rate. Setting up an appointment with a mental health professional is the best option for a woman with a history of postpartum depression. Rationale 4: Following up with the obstetrician in 6 weeks is too long a wait. Question 34 Which interventions can the nurse utilize to provide continuity of care for the postpartal patient who experienced a complication and is now ready to return home? Standard Text: select all that apply; 1. Encourage the patient to take advantage of home visits. 2. Make telephone calls as a follow-up to check on the patient and newborn. 3. Provide information about postpartal support groups. 4. Refer to mental health professionals to help screen the patient for any mental health problems as a result of the complications experienced in the hospital. 5. Supply information about postpartal classes designed to meet the specific needs of a variety of families. Correct Answer: 1,2,3,5 Rationale 1: Home visits are effective measures for extending comprehensive care into the home setting. Rationale 2: Telephone calls are effective measures for extending comprehensive care into the home setting.
Rationale 3: Support groups in which child care is available can be an invaluable community service for the postpartum patient. Rationale 4: Referrals to mental health professions are not necessary unless there is a recognized concern or signal that further mental health evaluation is needed. Rationale 5: A series of structured classes might focus on such topics as parenting, postpartal exercise, or nutrition. Question 35 The childbirth educator revises the curriculum to include postpartum depression preventive measures. Topics will include: 1. Encouraging planning in the prenatal period for the postnatal period. 2. Reviewing historical cases of postpartum psychosis with parents. 3. The importance of counseling for all postpartum mothers. 4. Prophylactic administration of Paxil. Correct Answer: 1 Rationale 1: Offering realistic information and anticipatory guidance, and debunking myths about the perfect mother or perfect newborn, might help prevent postpartum depression. Rationale 2: Reviewing historical cases of postpartum psychosis will serve only to scare parents. Rationale 3: Postpartum depression affects 4.5% to 28% of all postpartum women in North America. It is not feasible or necessary to counsel all postpartum mothers. Rationale 4: Prophylactic administration of Paxil is not recommended. Treatment needs to be individualized.
Old’s Maternal-Newborn Nursing and Women’s Health, 11e(Davidson/London/Ladewig) Chapter 36. Grief and Loss in the Childbearing Family 1) The nurse is planning an in-service presentation about perinatal loss. Which statements should the nurse include in this presentation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "Perinatal loss refers to third-trimester fetal death in utero." 2. "Perinatal loss occurs more frequently in assisted reproduction." 3. "Perinatal loss rates have declined in the United States over the past few years." 4. "Perinatal loss includes 25% of stillbirths occurring before the onset of labor." 5. "Perinatal loss rarely causes an emotional problem for the family." Answer: 2, 3 Explanation: 2. Pregnancies conceived by in vitro fertilization have higher rates of pregnancy loss and pregnancy complications. 3. Perinatal loss in industrialized countries has declined in recent years as early diagnosis of congenital anomalies and advances in genetic testing techniques have increased the use of elective termination. Page Ref: 943 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1 Discuss perinatal loss including etiology, diagnosis, and the nurse's role in facilitating the family's mourning process. MNL LO: 5.5.2 Determine the care of the family experiencing a perinatal loss.
2) The nurse has returned from working as a maternal-child nurse volunteer for a nongovernmental organization. After completing a community presentation about this experience, the nurse knows that learning has occurred when a participant states which of the following? 1. "Malaria is a chronic disease, and rarely causes fetal loss." 2. "Escherichia coli bacteria can cause diarrhea but not stillbirth." 3. "Group B streptococci can cause infection and the death of the fetus." 4. "Viral infections don't cause fetal death in developing nations." Answer: 3 Explanation: 3. Group B streptococci can cause ascending infections prior to or after rupture of membranes. Page Ref: 943 Cognitive Level: Applying Client Need/Sub: Safe Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1 Discuss perinatal loss including etiology, diagnosis, and the nurse's role in facilitating the family's mourning process. 3) The community nurse has identified that the mother who gave birth to a stillborn baby last week is an intuitive griever. Which behavior has the nurse encountered that would lead to this assessment? 1. The mother verbalized that her problem-solving skills have been helpful during this process. 2. The mother repeatedly talks about her thoughts, feelings, and emotions about losing her child. 3. The mother talks little about her experience, and appears detached and unaffected by the loss of her child. 4. The mother has asked close friends, co-workers, and relatives not to call or visit. Answer: 2 Explanation: 2. Intuitive grievers tend to feel their way through the loss and seek emotional and psychosocial support. Page Ref: 948 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2 Describe the physical, cognitive, emotional, behavioral, and spiritual responses experienced by parents during grieving associated with perinatal loss. MNL LO: 5.5.1 Compare theories related to the grieving process.
4) The nurse is anticipating the arrival of a couple in the labor unit. It has been determined that the 37-week fetus has died in utero from unknown causes. What should the nurse include in the plan of care for this couple? 1. Allow the couple to adjust to the labor unit in the waiting area. 2. Place the couple in a labor room at the end of the hall with an empty room next door. 3. Encourage the father to go home and rest for a few hours. 4. Contact the mother's emergency contact person and explain the situation. Answer: 2 Explanation: 2. Upon arrival to the facility, the couple with a known or suspected fetal demise should immediately be placed in a private room. When possible, the woman should be in a room that is farthest away from other laboring women. Page Ref: 955 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4 Identify nursing diagnoses and interventions to meet the special needs of parents and their families related to perinatal loss and grief. MNL LO: 5.5.3 Implement specific nursing interventions related to caring for families experiencing perinatal loss.
5) The client in the first trimester of pregnancy questions the nurse about the causes of fetal death. The nurse explains that factors associated with perinatal loss include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Maternal diabetes 2. Paternal hypertension 3. Fetal chromosomal disorders 4. Maternal infections 5. Placental abnormalities Answer: 1, 3, 4, 5 Explanation: 1. Fetal loss can be a result of a number of physiologic maladaptations, including maternal diabetes. 3. Chromosomal abnormalities can be associated with fetal loss. 4. Infections such as human parvovirus B19, syphilis, streptococcal infection, and Listeria can lead to fetal loss. 5. Placental abnormalities such as abruptio placentae and placenta previa can result in fetal death. Page Ref: 943, 944 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1 Discuss perinatal loss including etiology, diagnosis, and the nurse's role in facilitating the family's mourning process.
6) A woman has just delivered a stillborn child at 26 weeks' gestation. Which nursing action is appropriate at this time? 1. Remind the mother that she will be able to have another baby in the future. 2. Dress the infant in a gown and swaddle it in a receiving blanket. 3. Ask the woman whether she would like the doctor to prescribe a sedative for her. 4. Remove the baby from the delivery room as soon as possible. Answer: 2 Explanation: 2. After bathing, the infant should be placed in a suitable-sized gown and then wrapped in a blanket. Page Ref: 959 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4 Identify nursing diagnoses and interventions to meet the special needs of parents and their families related to perinatal loss and grief. MNL LO: 5.5.3 Implement specific nursing interventions related to caring for families experiencing perinatal loss.
7) The nurse is teaching a class on perinatal loss to student nurses. What would the nurse explain about the relationship between attachment and the grief response? 1. The mother has no attachment to the fetus before it is born. 2. The severity of the grieving has nothing to do with attachment to the fetus. 3. The intensity of the grief response can be assessed by determining the level of attachment to the anticipated infant. 4. The mother would feel grief only if it were a planned pregnancy. Answer: 3 Explanation: 3. The intensity to which the grief will be experienced is best understood from the aspect of the level of attachment the grieving person had to the deceased and usually entails finding personal meaning in the loss for successful integration into the grieving person's life. Page Ref: 946 Cognitive Level: Understanding Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2 Describe the physical, cognitive, emotional, behavioral, and spiritual responses experienced by parents during grieving associated with perinatal loss. MNL LO: 5.5.1 Compare theories related to the grieving process.
8) A couple request to see their stillborn infant. How should the nurse prepare the infant? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Wrapping the infant in a blanket 2. Removing all blankets from the infant 3. Placing a hat on the infant 4. Removing any identification from the infant 5. Placing a diaper on the infant Answer: 1, 3 Explanation: 1. After bathing, the infant should be placed in a suitable-sized gown and then wrapped in a blanket. Many parents will eventually remove the covering to inspect the infant; however, applying a covering allows them time to adjust to the appearance at their own pace. 3. A hat can be applied to cover birth defects. This allows the parents an opportunity to view the infant before seeing the birth defect. Page Ref: 959 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4 Identify nursing diagnoses and interventions to meet the special needs of parents and their families related to perinatal loss and grief. MNL LO: 5.5.3 Implement specific nursing interventions related to caring for families experiencing perinatal loss.
9) Which of the following may lead to the development of disseminated intravascular coagulation (DIC), also called consumption coagulopathy, in the mother? 1. Hypertensive disorders 2. Abruptio placentae 3. Prolonged retention of the dead fetus 4. Heritable thrombophilias Answer: 3 Explanation: 3. Prolonged retention of the dead fetus may lead to the development of disseminated intravascular coagulation (DIC), also called consumption coagulopathy, in the mother. Page Ref: 944 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: VII. 1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations. | NLN Competencies: RelationshipCentered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1 Discuss perinatal loss including etiology, diagnosis, and the nurse's role in facilitating the family's mourning process. 10) How does the nurse consider the spiritual needs of a couple experiencing a fetal loss? 1. Explaining the fetal loss in terms of the nurse's own religious beliefs 2. Providing an atmosphere of acceptance regarding the couple's spiritual rites 3. Referring the couple to the hospital chaplain at discharge 4. Informing the couple of religious rituals that have helped other couples to cope with fetal loss Answer: 2 Explanation: 2. The nurse can facilitate the spiritual needs of the couple by providing an atmosphere of acceptance regarding spiritual rites and encouraging the couple's use of spiritual writings, prayers, and observances. Page Ref: 949 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Respect the patient's dignity, uniqueness, integrity, and self-determination, and his or her own power and self-healing process. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2 Describe the physical, cognitive, emotional, behavioral, and spiritual responses experienced by parents during grieving associated with perinatal loss. MNL LO: 5.5.2 Determine the care of the family experiencing a perinatal loss.
11) The nurse is caring for a client who has just been informed of the demise of her unborn fetus. Which common cognitive responses to loss would the nurse anticipate? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Denial and disbelief 2. Sense of unreality 3. Poor concentration 4. Palpitations 5. Loss of appetite Answer: 1, 2, 3 Explanation: 1. Denial and disbelief are common cognitive responses to fetal loss. 2. A sense of unreality is a common cognitive response to fetal loss. 3. Poor concentration is a common cognitive response to loss. Page Ref: 947 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. C. 8. Appreciate the role of the nurse in relief of all types and sources of pain or suffering. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Respect the patient's dignity, uniqueness, integrity, and self-determination, and his or her own power and self-healing process. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2 Describe the physical, cognitive, emotional, behavioral, and spiritual responses experienced by parents during grieving associated with perinatal loss. MNL LO: 5.5.1 Compare theories related to the grieving process.
12) The nurse is caring for a couple who are in the labor/delivery room immediately after the delivery of a stillborn baby with visible defects. Which of the following actions by the nurse is appropriate? 1. Discourage the parents from naming the baby. 2. Advise the parents that the baby's defects would be too upsetting for them to see. 3. Transport the baby to the morgue as soon as possible. 4. Offer the parents the choice to see and hold the baby. Answer: 4 Explanation: 4. The nurse should offer the couple the opportunity to see and hold the infant, and reassure the couple that any decision they make for themselves is the right one. Page Ref: 959 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Respect the patient's dignity, uniqueness, integrity, and self-determination, and his or her own power and self-healing process. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4 Identify nursing diagnoses and interventions to meet the special needs of parents and their families related to perinatal loss and grief. MNL LO: 5.5.3 Implement specific nursing interventions related to caring for families experiencing perinatal loss.
13) A pregnant couple have been notified that their 32-week fetus is dead. The father is yelling at the staff, and his wife is crying uncontrollably. Their 5-year-old daughter is banging the head of her doll on the floor. Which nursing action would be most helpful at this time? 1. Tell the father that his behavior is inappropriate. 2. Sit with the family and quietly communicate sorrow at their loss. 3. Help the couple to understand that their daughter is acting inappropriately. 4. Encourage the couple to send their daughter to her grandparents. Answer: 2 Explanation: 2. Sitting down for a moment with the woman and her partner and acknowledging the loss in the event of a known demise or impending death will go a long way toward establishing a relationship of trust between the nurse and the parents. Page Ref: 955 Cognitive Level: Understanding Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. C. 8. Appreciate the role of the nurse in relief of all types and sources of pain or suffering. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Respect the patient's dignity, uniqueness, integrity, and self-determination, and his or her own power and self-healing process. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4 Identify nursing diagnoses and interventions to meet the special needs of parents and their families related to perinatal loss and grief. MNL LO: 5.5.3 Implement specific nursing interventions related to caring for families experiencing perinatal loss.
14) The client at 37 weeks' gestation calls the clinic nurse to report that neither she nor her partner has felt fetal movement for the past 48 hours. The nurse anticipates that the physician will order which test to assess fetal viability? 1. Ultrasound 2. Serum progesterone levels 3. Computed tomography (CT) scan 4. Contraction stress test Answer: 1 Explanation: 1. Diagnosis of intrauterine fetal death (IUFD) is confirmed by visualization of the fetal heart with absence of heart action on ultrasound. Page Ref: 944 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1 Discuss perinatal loss including etiology, diagnosis, and the nurse's role in facilitating the family's mourning process. MNL LO: 5.5.2 Determine the care of the family experiencing a perinatal loss. 15) The postpartum unit nurse is caring for a client who delivered a term stillborn infant yesterday. The mother is heard screaming at the nutrition services worker, "This food is horrible! You people are incompetent and can't cook a simple edible meal!" The nurse understands this as which of the following? 1. An indication the mother is in the anger phase of grief. 2. An abnormal response to the loss of the child. 3. Reactive stress management techniques in use. 4. Denial of the death of the child she delivered yesterday. Answer: 1 Explanation: 1. Anger, resulting from feelings of loss, loneliness, and, perhaps, guilt, is a common reaction. Anger may be projected at significant others and/or healthcare team members. Page Ref: 946, 947 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. C. 9. Recognize that patient expectations influence outcomes in management of pain or suffering. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Respect the patient's dignity, uniqueness, integrity, and self-determination, and his or her own power and self-healing process. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2 Describe the physical, cognitive, emotional, behavioral, and spiritual responses experienced by parents during grieving associated with perinatal loss. MNL LO: 5.5.1 Compare theories related to the grieving process.
16) The nurse is caring for a client who experienced the birth of a stillborn son earlier in the day. The client is from a culture where a woman's status is dominated by themes of motherhood and childrearing. What behavior would the nurse expect in this client? 1. Crying inconsolably 2. Expressing feelings of failure as a woman 3. Requesting family members to be present 4. Showing little emotion Answer: 2 Explanation: 2. Mothers will often blame themselves, whether by commission or omission, particularly in cultures where a woman's status is dominated by themes of motherhood and childrearing. Page Ref: 952 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3 Delineate the personal, societal, and cultural issues that may complicate responses to perinatal loss. MNL LO: 5.5.1 Compare theories related to the grieving process.
17) The nurse is caring for a client who has just experienced a stillbirth. Which factors does the nurse recognize as potentially complicating the parents' response to this loss? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Unsupportive family 2. Adolescent mother 3. Strong religious faith 4. Open communication between the parents 5. Persistent denial of the situation Answer: 1, 2, 5 Explanation: 1. Features of bereaved individuals' circumstances that will put them at risk include an unsupportive or unavailable family. 2. With regard to age, adolescent parents probably pose the greatest challenge to nursing interventions. 5. Persistent denial hampers the grieving and healing processes. Page Ref: 947, 948 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3 Delineate the personal, societal, and cultural issues that may complicate responses to perinatal loss. MNL LO: 5.5.1 Compare theories related to the grieving process.
18) The nurse is caring for a client who finally conceived after several unsuccessful attempts at in vitro fertilization. The client has just been diagnosed with a perinatal loss. What should the nurse's plan of care include? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Giving accurate and honest information 2. Encouraging the couple to try right away to get pregnant again 3. Validating the many losses the client has experienced 4. Providing possible explanations for the fetal demise 5. Assessing where the client is in the grieving process, and communicating with compassion Answer: 1, 3, 5 Explanation: 1. Families can cope with extreme situations when they are properly informed in an honest and forthright manner. 3. The nurse should be compassionate, give accurate and honest information, and validate the many losses incurred. 5. The nurse caring for a couple who has had a previous loss needs to be kind, compassionate, and patient. Page Ref: 952, 963, 964 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 7. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5 Differentiate between helpful and nonhelpful responses in caring for families experiencing perinatal loss. MNL LO: 5.5.2 Determine the care of the family experiencing a perinatal loss.
19) A client has delivered a stillborn child at 26 weeks' gestation. She tells the nurse that none of her friends have called or visited, and that her husband's parents seem unwilling to talk about the loss. The nurse recognizes the mother's grief as which of the following? 1. Disenfranchised grief 2. Bereavement 3. An intuitive style of coping 4. Denial Answer: 1 Explanation: 1. Disenfranchised grief is not supported by the usual societal customs. People are uncomfortable discussing the loss with the parents and often pull away when their support is most needed. Page Ref: 945 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. C. 9. Recognize that patient expectations influence outcomes in management of pain or suffering. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2 Describe the physical, cognitive, emotional, behavioral, and spiritual responses experienced by parents during grieving associated with perinatal loss. MNL LO: 5.5.1 Compare theories related to the grieving process. 20) A client has just delivered her third child, who was stillborn and had obvious severe defects. Which statement by the nurse is most helpful? 1. "Thank goodness you have other children." 2. "I am so happy that your other children are healthy." 3. "These things happen. They are the will of God." 4. "It is all right for you to cry. I will stay here with you." Answer: 4 Explanation: 4. The nurse needs to let the client know that crying is a normal reaction to the loss event, and that the nurse will stay with her to offer support and understanding. Page Ref: 964 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. C. 8. Appreciate the role of the nurse in relief of all types and sources of pain or suffering. | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5 Differentiate between helpful and nonhelpful responses in caring for families experiencing perinatal loss. MNL LO: 5.5.2 Determine the care of the family experiencing a perinatal loss.
21) As the couple and their families begin to confront the pain of their loss, many normal manifestations of grief may be present. Which of the following would indicate an emotional response to the loss? 1. Lack of meaning or direction 2. Preoccupation 3. Flat affect 4. Dreams of the deceased Answer: 3 Explanation: 3. Flat affect would be an emotional response to loss. Page Ref: 947 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2 Describe the physical, cognitive, emotional, behavioral, and spiritual responses experienced by parents during grieving associated with perinatal loss. MNL LO: 5.5.1 Compare theories related to the grieving process. 22) The nurse is working with a family who experienced the stillbirth of a son 2 months ago. Which statement by the mother would be expected? 1. "I seem to keep crying for no reason." 2. "The death of my son hasn't changed my life." 3. "I have not visited my son's gravesite." 4. "I feel happy all the time." Answer: 1 Explanation: 1. Mourning may be manifested by certain behaviors and rituals, such as weeping, which help the person experience, accept, and adjust to the loss. Page Ref: 945 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2 Describe the physical, cognitive, emotional, behavioral, and spiritual responses experienced by parents during grieving associated with perinatal loss. MNL LO: 5.5.1 Compare theories related to the grieving process.
23) A 15-year-old client has delivered a 22-week stillborn fetus. What does the nurse understand? 1. Grieving a fetal loss manifests with very similar behaviors regardless of the age of the client. 2. Teens tend to withhold emotions and need older adults with the same type of loss to help process the experience. 3. Most teens have had a great deal of contact with death and loss and have an established method of coping. 4. Assisting the client might be difficult because of her mistrust of authority figures. Answer: 4 Explanation: 4. Adolescents rely heavily on peer support and have a natural mistrust of authority figures, which can make assisting them more difficult. Page Ref: 947 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3 Delineate the personal, societal, and cultural issues that may complicate responses to perinatal loss. MNL LO: 5.5.2 Determine the care of the family experiencing a perinatal loss.
24) The nurse is present when a mother and her partner are told that their 35-week fetus has died. Which nursing intervention should the nurse perform first? 1. Encourage open communication with the family and the healthcare team. 2. Ask the family to withhold questions until the next day. 3. Request that another nurse come and care for this family. 4. Contact a local funeral home to help the family with funeral plans. Answer: 1 Explanation: 1. The top priority for the nurse is to encourage open communications. The nurse functions as an advocate for the family in organizing interdisciplinary involvement, maintaining continuity of care, offering the opportunity for open communication, and ensuring that the family's wishes regarding their loss experience are honored. Page Ref: 965 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering. | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4 Identify nursing diagnoses and interventions to meet the special needs of parents and their families related to perinatal loss and grief. MNL LO: 5.5.3 Implement specific nursing interventions related to caring for families experiencing perinatal loss.
25) The labor and delivery nurse is caring for a client whose labor is being induced due to fetal death in utero at 35 weeks' gestation. In planning intrapartum care for this client, which nursing diagnosis is most likely to be applied? 1. Powerlessness 2. Urinary Elimination, Impaired 3. Coping: Family, Readiness for Enhanced 4. Skin Integrity, Impaired Answer: 1 Explanation: 1. Powerlessness is commonly experienced by families who face fetal loss. Powerlessness is related to lack of control in current situational crisis. Page Ref: 954 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 4 Identify nursing diagnoses and interventions to meet the special needs of parents and their families related to perinatal loss and grief. MNL LO: 5.5.2 Determine the care of the family experiencing a perinatal loss.
26) The nurse is supervising care by a new graduate nurse who is working with a couple who have experienced a stillbirth. Which statement made by the new nurse indicates that further instruction is necessary? 1. "I should stay out of their room as much as possible." 2. "The parents might express their grief differently from each other." 3. "My role is to help the family communicate and cope." 4. "Hopelessness might be expressed by this family." Answer: 1 Explanation: 1. Families experiencing perinatal loss need support. The nurse should stay with the couple so they do not feel alone and isolated; however, cues that the couple wants to be alone should be assessed continuously. Page Ref: 956 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2 Describe the physical, cognitive, emotional, behavioral, and spiritual responses experienced by parents during grieving associated with perinatal loss. MNL LO: 5.5.2 Determine the care of the family experiencing a perinatal loss.
27) Which nursing diagnoses can apply to the couple experiencing a perinatal loss? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Grieving related to the imminent loss of a child 2. Fear related to discomfort of labor and unknown outcome 3. Knowledge, Deficient related to lack of information about involution 4. Powerlessness related to lack of control in current situational crisis 5. Spiritual Distress, Risk for related to intense suffering secondary to unexpected fetal loss Answer: 1, 4, 5 Explanation: 1. The nurse should anticipate that the family will experience the grieving process for the lost fetus. 4. The parents are faced with the sudden and unanticipated death of the unborn child, which occurred without any input or control on their part. 5. Spiritual distress is a common reaction of parents who experience an unanticipated loss. Page Ref: 954 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 4 Identify nursing diagnoses and interventions to meet the special needs of parents and their families related to perinatal loss and grief. MNL LO: 5.5.2 Determine the care of the family experiencing a perinatal loss.
28) Which nursing interventions would be included in the plan of care for a family that has just been informed of a perinatal loss? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Provide the parents with a private place and time to express their grief. 2. Offer reassurance that parents can have a subsequent successful pregnancy. 3. Allow the parents to participate in personal grief rituals. 4. Encourage interaction with other families. 5. Offer to give the family mementos of the infant such as footprints, crib card, and lock of hair. Answer: 1, 3, 5 Explanation: 1. The couple with a known or suspected fetal demise should immediately be placed in a private room. When possible, the woman should be in a room that is farthest away from other laboring women. 3. The nurse should assist the couple in exploring their feelings and help them to make decisions about who will be present and what rituals will occur during and following the birth. 5. In a fetal demise, mementos are some of the few memories the parents have to provide them comfort after the death of their baby. Every effort should be made to offer as many quality mementos as possible, such as pictures and hand- or footprint molds and cards. Page Ref: 955, 957, 960 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4 Identify nursing diagnoses and interventions to meet the special needs of parents and their families related to perinatal loss and grief. MNL LO: 5.5.3 Implement specific nursing interventions related to caring for families experiencing perinatal loss.
29) What of the following nursing interventions are appropriate when caring for the family experiencing a stillbirth? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Use active listening techniques. 2. Avoid the use of clichés. 3. Avoid periods of silence. 4. Wrap the infant in a blanket before the parents see the infant. 5. Do not permit the parents of an infant with birth defects to hold the infant. Answer: 1, 2, 4 Explanation: 1. It is important to allow the parents to verbalize their concerns. 2. The nurse can facilitate a healthy mourning process for the family by using active listening techniques and avoiding the use of clichés and platitudes. 4. The infant should be wrapped in a blanket to allow parents to see the infant before viewing any deformities. Page Ref: 954, 959, 962 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4 Identify nursing diagnoses and interventions to meet the special needs of parents and their families related to perinatal loss and grief. MNL LO: 5.5.3 Implement specific nursing interventions related to caring for families experiencing perinatal loss.
30) The nurse is caring for a 15-year-old who just delivered a 32-weeks'-gestation stillborn infant with numerous defects. In caring for this client, the nurse knows which of the following? 1. The client will likely do no grieving, as she is so young and the pregnancy was probably a mistake in any case. 2. Adolescents have a sense of invulnerability, an "It can't happen to me" mentality. 3. The client's mother will handle her daughter's grief, so the nurse doesn't need to be concerned. 4. The nurse will remove the baby before the client sees it. Answer: 2 Explanation: 2. Though adolescents have a mature concept of death, it is often clouded by their sense of invulnerability, an "It can't happen to me" mentality. Page Ref: 947 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3 Delineate the personal, societal, and cultural issues that may complicate responses to perinatal loss. MNL LO: 5.5.3 Implement specific nursing interventions related to caring for families experiencing perinatal loss.
31) The nurse is working with a laboring woman who has a known intrauterine fetal demise. To facilitate the family's acceptance of the fetal loss, after delivery the nurse should do which of the following? 1. Encourage the parents to look at the infant from across the room. 2. Offer the parents the choice of holding the infant in their arms. 3. Take the infant to the morgue immediately. 4. Call family members and inform them of the birth. Answer: 2 Explanation: 2. The nurse should offer the couple the opportunity to see and hold the infant and reassure the couple that any decision they make for themselves is the right one. Page Ref: 959 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4 Identify nursing diagnoses and interventions to meet the special needs of parents and their families related to perinatal loss and grief. MNL LO: 5.5.3 Implement specific nursing interventions related to caring for families experiencing perinatal loss.
32) The mother of a client who has experienced a term stillbirth arrives at the hospital and goes to the nurses' desk. The mother asks what she should say to her daughter in this difficult time. What is the nurse's best response? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "Use clichés; your daughter will find the repetition comforting." 2. "Remind her that she is young and can have more children." 3. "Keep talking about other things to keep her mind off the loss." 4. "Express your sadness, and sit silently with her if she doesn't respond." 5. "Encourage her to talk about the baby whenever she wants to." Answer: 4, 5 Explanation: 4. Silence is commonly what is needed most, and simply saying "I'm sorry for your loss" might help to facilitate communication. 5. Talking is a way for the client experiencing grief and begin to come to terms with what has happened, and is important for resolution of grief. Intuitive grievers will need to talk about the event. Page Ref: 948, 954, 955 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering. | AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5 Differentiate between helpful and nonhelpful responses in caring for families experiencing perinatal loss. MNL LO: 5.5.1 Compare theories related to the grieving process.
33) The community nurse is planning care for a family that experienced the loss of twins at 20 weeks. Which of these steps should be part of the nurse's care of this family? 1. Base care on the reactions of previous clients who experienced stillbirth. 2. Express the belief that the family will be able to get through this experience. 3. Encourage the couple to keep their feelings to themselves. 4. Honor the birth by reminding the couple that their babies are happy in heaven. Answer: 2 Explanation: 2. Maintaining belief is defined as believing in the parents' capacity to get through the event and face a future with meaning and it is one of the attributes of caring theory. Page Ref: 955 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering. | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3 Delineate the personal, societal, and cultural issues that may complicate responses to perinatal loss. MNL LO: 5.5.1 Compare theories related to the grieving process. 34) A client has experienced a stillbirth. Which statement by the nurse would be appropriate? 1. "You are young. You can try again." 2. "At least you have your other children." 3. "I'm sure you had many dreams and hopes for the future." 4. "It's a blessing in disguise." Answer: 3 Explanation: 3. Perinatal loss is unique in that the parents have not had experiences with the child that was to be, and attachment is based mostly upon hopes and dreams for the future relationship. Page Ref: 945 Cognitive Level: Understanding Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering. | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5 Differentiate between helpful and nonhelpful responses in caring for families experiencing perinatal loss. MNL LO: 5.5.2 Determine the care of the family experiencing a perinatal loss.
35) A client has delivered a stillborn infant at 28 weeks' gestation. Which nursing action is appropriate? 1. Discuss funeral options for the baby. 2. Encourage the couple to try to get pregnant again soon. 3. Ask the couple whether or not they would like to hold the baby. 4. Advise the couple that the baby's death was probably for the best. Answer: 3 Explanation: 3. Some parents will hold their infant for a short time before returning him or her to the nurse, whereas others will wish to spend a great deal of time with their infant. Allow the infant to remain with the parents for as long as they desire. Page Ref: 959 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I. B. 6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering. | AACN Essentials Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4 Identify nursing diagnoses and interventions to meet the special needs of parents and their families related to perinatal loss and grief. MNL LO: 5.5.3 Implement specific nursing interventions related to caring for families experiencing perinatal loss.