Exam 1: NU 160/NU160 V2 (2026–2027 Edition) Mental Health Concepts Review | Comprehensive Q&A | Verified Accurate Solutions | Grade A Guaranteed – Galen

…..DLDD Exam 1: NU 160/NU160 V2 (2026–2027 Edition) Mental Health Concepts Review | Comprehensive Q&A | Verified Accurate Solutions | Grade A Guaranteed – Galen Q. Of the skills listed below, which is of primary importance to a nurse working as a member of a community mental health team that is striving to use a seamless continuum of care? Select one: Patients' rights advocacy Physical assessment skills Case management Diagnostic ability ANSWER Case Management Q. The nurse perceives that a patient is experiencing emotional pain. The remark that would be most therapeutic is: Select one: "Please tell me what you would like me to do to help you through this." "I hear how painful this is for vou. I would like to help vou deal with the situation." "I don't think this is as serious as vou believe it is." "I'm so very sorry that this has happened to you, adding to your burdens." ANSWER "I hear how painful this is for vou. I would like to help vou deal with the situation." Q. Which patient should be considered for involuntary commitment for psychiatric treatment? The patient who: Select one: threatens to harm self and others. is noncompliant with the treatment regimen. who fraudulently files for bankruptcy. sold and distrubuted illegal drugs. ANSWER threatens to harm self and others. Q. A client hospitalized under emergency commitment is being treated for chronic depression with suicidal ideation. After 3 days, the client demands to be released. The nurse should intervene by: Select one: Restricting the client to her room Allowing the client to leave the unit Informing the client that she must stay 15 days Offering information that the client can speak to a lawyer ANSWER Offering information that the client can speak to a lawyer Q. Order: Biaxin 75 mg p.o. q12h Available: 125 mg per 5 ml Answer:______ml ANSWER 3ml Q. During the mental status examination, the patient tells the nurse, "I am God's special messenger sent to show the world the cure for cancer." The nurse should assess the patient's statement as indicating the presence of: Select one: hvpervigilance. a phobia. a delusion loose associations ANSWER a delusion Q. During the performance of the mental status examination, the data the nurse should examine as being most pertinent for determining the patient's mood is (are): Select one: degree of cooperation or resistance to the interview. facial expression and statements about feelings. answers to iudgment guestions. observations about sensorium. ANSWER facial expression and statements about feelings. Q. Which interventions should be selected for inclusion in the care plan of a patient being restrained or secluded? (Select All That Apply) a. Seclusion instituted when verbal intervention ineffective in stopping assaultive behavior. b. Constant observation in effect while patient secluded. c. Medication administered prn when patient's hallucinations noted. d. Written medical order obtained. ANSWER Written medical order obtained. Q. A 30-year-old male client has been admitted for substance abuse detoxification. The nurse receives a call from a person who says he is the client's co-worker and is inquiring about the client's condition. The nurse's response should: Select one: Suggest that the co-worker call the client directly on the client's phone Invite the caller to contact the client's phvsician for information Not acknowledge that the client has been admitted to the unit Give only the information that the client's condition is stable ANSWER Not acknowledge that the client has been admitted to the unit Q. When observing and interpreting a patient's nonverbal communication, an important nursing consideration to factor in is that: Select one: nonverbal cues have obvious meaning and are easily interpreted. verbal responses are more important than nonverbal cues. patients usually are very aware of their nonverbal cues. nonverbal cues provide significant information but must be validated. ANSWER nonverbal cues provide significant information but must be validated. Q. A client says, "I have something really important I need to share with you." The nurse stands at the door with her arms crossed and states, "Go ahead. I'm all ears." What positive behaviors can the nurse can display? Select all that apply. a. Incongruent communication b. Congruent communication c. Therapeutic communication d. Ineffective responses e. Setting limits ANSWER Therapeutic communication Congruent communication Setting limits A client is agitated, using profanity, and verbally threatening other clients. Based on these behaviors, the nurse should initially plan to: Select one: Speak to the physician about reevaluating the client's medications Initiate verbal intervention and take the client to his or her room Secure enough staff members to place the client in seclusion Speak with the other clients about their feelings Initiate verbal intervention and take the client to his or her room A patient tells the nurse in confidence that he still has suicidal thoughts, but doesn't want anyone to know because he is to be discharged that afternoon. The nurse's best course of action is to: Select one: maintain the patient's right to confidentiality. encourage the patient to call his outpatient counselor. keep in touch with the patient after discharge to monitor progress. inform the phvsician and other appropriate health team members. inform the physician and other appropriate health team members. A patient says, "I've done a lot of cheating and manipulating in my relationships." A nonjudgmental response by the nurse would be: Select one: a. "Have vou outgrown that type of behavior?" b. "It's good that you realize this." c. "That's not a good way to behave." d. "How do you feel about that?" "How do you feel about that?" A patient has a high level of non-goal-directed motor activity and runs from chair to chair crying,"They're coming! They're coming!" The patient neither follows staff direction nor responds to verbal interventions. The initial nursing intervention of highest priority is to: Select one: a. increase environmental stimuli. b. respect the patient's personal space. c. provide for patient safety. d. encourage clarification of feelings. provide for patient safety. The nurse caring for a newly admitted patient knows that effective use of the nursing process is dependent on communication that: Select one: a. meets the needs of both patient and nurse. b. fosters emotional distance between patient and nurse. c. is structured and goal-directed. d. is spontaneous and affords mutual self-disclosure. is structured and goal-directed. Which individual can the nurse assess as being at highest risk for becoming homeless? Select one: a. An adolescent with obsessive-compulsive disorder who has two parents b. An elderlv sinale woman with mild dementia who lives in an adult home c. A married alcoholic woman who has two grown children d. A man with serious mental illness who has no familv A man with serious mental illness who has no familv A patient discloses several concerns and associated feelings. If the nurse wishes to seek clarification, which comment would be appropriate? Select one: a. "What are the common elements here?' b. "Tell me again about vour experiences." c. "Tell me evervthing from the beginning." d. "Am I correct in understanding that ...?" "Am I correct in understanding that ...?" A client admitted on an involuntary basis is being treated for an acute exacerbation of paranoid schizophrenia. He refuses his morning dose of fluphenazine (Prolixin). The most appropriate initial nursing response would be: Select one: "If you do not take your medication, you will be placed in seclusion." "If you do not take your medication, I must give you an injection." "Let's discuss why you do not want to take vour medication." "Involuntarily committed clients cannot refuse medications." "Let's discuss why you do not want to take your medication." The nurse caring for a withdrawn, highly suspicious patient will plan interventions that give priority to tasks of the phase of the nurse-patient relationship known as the: Select one: orientation stage. identification and exploration stage. working stage. resolution or termination stage. orientation stage. When one considers the roles and functions of psychiatric nursing, the overlap of communication and management roles is seen in the function of: Select one: collaboration. teaching. direct care. delegation. collaboration. To help preserve the patient's rights to freedom from restraint and seclusion, the most important interventions that the nurse can use are based on principles of: Select one: therapeutic management. effective use of ancillary personnel. confidentiality of documentation. realitv-based communication. therapeutic management. A psychiatric nurse working as a case manager in a community mental health center receives a call asking for information about a patient at the center. Under which of the following conditions can the nurse release information to the caller? Select one: The patient has given written consent for release of information. The caller is a mental health professional. The attending psychiatrist approves the request. The caller is related to the patient. The patient has given written consent for release of information. Order: Epinephrine 0.5 mg subcut stat Available: Epinephrine 1 mg per ml a. How man milliliters will vou administer? b. Shade in the dosage on the svringe. 0.5mg To formulate an opinion about a patient's judgment, which question should the nurse ask during the mental status examination? Select one: a. "Do your thoughts ever seem to be all jumbled up?" b. "Do vou ever hear voices?" c. "On a scale of 1 to 50, how stressed are you?" d. "If you found a stamped, addressed envelope on the street, what would you do with it?" is: "If you found a stamped, addressed envelope on the street, what would you do with it?" A teenage client is hospitalized after a serious suicide attempt related to feelings of hopelessness. The client comes from an upper-middle-class home in the suburbs and has never had psychiatric care before. Two hours after admission, when the nurse asks about the client's reaction to hospitalization, the client is most likely to label the experience as Select one: a. frightening. b. necessary. c. enjoyable. d. exciting. frightening. The nurse performing a mental status examination for a patient wishes to determine whether the patient has experienced hallucinations. The nurse should ask: Select one: "Do vour moods shift more than those of other people?" "Can vou tell me where vou are now?" "What would vou do if vou found a stamped, addressed letter Iving on the street?" "Do vou hear or see things when others don't?' "Do vou hear or see things when others don't?' When asked by a mentee for hints about use of therapeutic listening, the nurse should mention: (Select all that apply) avoid questioning. assume an attending posture. maintain unbroken eye contact. use empathy sparingly. validate and clarify. give feedback appropriately. validate and clarify assume an attending posture give feedback appropriately. A 52-year-old woman is admitted involuntarily with a diagnosis of bipolar disorder. Lithium 300 mg PO tid is prescribed. The patient refuses to take her morning dose. The nurse should: Select one: assemble adequate help to force the patient to take the medication by the oral route. contact the physician to get the order changed to the IM route. allow the patient to refuse the medication; document and notify the physician. inform the patient that unit privileges are contingent on taking prescribed medication. allow the patient to refuse the medication; document and notify the physician. A common mistake that nurses make when beginning to develop therapeutic communication techniaues is: Select one: using too many different techniques during an interaction. allowing the patient to become too anxious before changing the subject. giving advice rather than encouraging the patient to solve problems. focusing on what the patient is saving rather than on communication techniques. giving advice rather than encouraging the patient to solve problems. A patient is admitted to an inpatient psychiatric unit for severe depression. Knowing that the patient will be discharged after a short stay, it is a priority for the nurse to: Select one: focus on milieu management and psychopharmacology. keep the relationship goal-directed and problem-centered. choose a specific theoretical model as a basis for care. immediately begin to explore serious patient issues. keep the relationship goal-directed and problem-centered. During the orientation portion of a psychiatric nursing course, which would the instructor be most likelv to tell students? Select one: "Psvchiatric nursing has vet to be recognized as a core mental health discipline." "There is one approved theoretical framework for psvchiatric nursing practice." "Contemporary practice of psychiatric nursing is primarily focused on inpatient care." "The psychiatric nursing patient may be an individual, a family, a group, an organization, or a community." "The psychiatric nursing patient may be an individual, a family, a group, an organization, or a community." The nurse determines that it would be helpful to give a patient an opportunity to try out new, more assertive behaviors. This can be accomplished if the nurse uses the technique of: Select one: giving feedback. encouraging evaluation. clarifving. role playing. role playing. The nurse tells a patient, " noticed that you seemed to become irritated when we discussed vour relationship with vour husband." The nurse is using the communication technique known as: Select one: making observations. giving information. interpreting. clarifying. making observations. A 23-year-old man has identified the need for better anger management. He tells the nurse he is afraid that someday he might "explode." The best strategy for reducing a patient's fear of losing control over his or her feelings is to: Select one: discuss feelings in general without reference to the patient. avoid talking about the feelings until the patient feels comfortable. reassure the patient that he or she will feel better if feelings are expressed. talk about feelings openly and directly. talk about feelings openly and directlv. A patient has been in the hospital 6 davs and has made little progress toward outcomes written at the time of admission. The nurse should make the determination that lack of progress toward goals indicates that: Select one: a. the chosen nursing interventions were inadequate. b. nursing diagnoses were incorrectly identified. c. a need for reassessment exists. a need for reassessment exists. Which nursing intervention will initially be most helpful for trust building with a suspicious patient? Select one: Keeping appointments and promises Agreeing not to share patient revelations Enforcing rules requiring participation Openly challenging questionable patient statements Keeping appointments and promises A nurse and a patient who have developed a therapeutic nurse-patient relationship are about to enter the termination phase of the relationship. An important nursing intervention for the termination stage is for the nurse to: Select one: encourage the patient to describe his or her goals for change. discuss feelings about termination with the patient. provide structure and intensive support. inform the patient of the progress the she or he has made. discuss feelings about termination with the patient. Following the admission interview, a spouse asks the nurse, "Why did you ask my partner all those questions? Some of them had nothing to do with current problems." The best response for the nurse would be that "Those questions help us understand: Select one: the patient's past experiences." the patient's current status." what the patient's prognosis will be." the complete family history." the patient's current status." Nurse K. states, "I plan ways for patients assigned to me to participate in their own care and to be actively involved in all of the activities on the unit." Her approach demonstrates the concept of: Select one: social accountability. nurse-patient relationship. therapeutic community. multidisciplinary mental health team. therapeutic community. A patient tells the nurse, "When I get out, I'm going to get even with a lot of people." With respect to the nurse's duty to warn, the nurse should: Select one: take no action on a general threat. document and discuss the threat with the clinical team. warn onlv close relatives. warn all relatives and friends of the patient. document and discuss the threat with the clinical team. A 27-year-old patient with schizophrenia says to the nurse, "I feel really close to you. You're the only true friend I have." The most therapeutic response for the nurse to make is: Select one: "Because ours is a professional relationship, let's explore other opportunities for friendship in vour life." "I feel good that you trust me. Trust is important for the work we are doing together." "I'm sure that there are others in vour life who are vour friends." "We're really not friends. Our relationship is professional." "Because ours is a professional relationship, let's explore other opportunities for friendship in vour life." A mental health crisis team lead by a psychiatric nurse is called to a residence because a man with a history of chronic schizophrenia is standing on the front lawn shouting that the neighbors are poisoning his water. The nurse should advise the police officer member of the crisis team to institute procedures for: Select one: a probable cause hearina. short-term observation and treatment. emergency care. long-term commitment. emergency care. Planning for clients with mental illness is facilitated by understanding that under behavioral health managed care, inpatient hospitalization is generally reserved for clients who Select one: develop new symptoms during the course of the illness. present a clear danger to self or others. have no support systems in the community. are noncompliant with medication at home. present a clear danger to self or others. Upon voluntary admission, the nurse will inform the client about his or her rights. Select all rights that should be discussed. Select all that apply. Right to vote Right to enter into a contract Right to receive visitors Right to a private room Right to treatment Right to vote Right to enter into a contract Right to receive visitors Right to treatment During a nurse-patient interaction the patient stands up and shouts at the nurse, "You are a controlling bitch! You want me to do everything your way." In reality, the nurse had just invited the patient to consider what step he wished to take next in resolving an issue. What assessment can be made about the patient's behavior? It is probable that it is rooted in: Select one: emotional catharsis. projection. transference. dissociation. transference. Clinical rotations for nursing students include a psychiatric mental health rotation to give the student an opportunitv to: Select one: learn to care for patients who have emotional disorders. work with patients who have psychiatric as well as physical health issues. learn to work with patients with osvchiatric mental health issues and to become familiar become familiar with patients who have chronic psychiatric mental health issues. learn to work with patients with schiatric mental health issues and to become familiar with new information in the behavioral and psychiatric fields. A patient begins shouting at the nurse, "Stay away from me." He is waving his arms in the air and backing into the corner of the room. The initial nursing intervention in this situation should be to: Select one: administer a prn iniection of haloperidol. obtain an order for seclusion. call for assistance to restrain the patient physically. talk to the patient in a calm, nonthreatening manner. The nurse is assessing a client at 30 weeks' gestation who reports increased constipation. Which suggestion should the nurse prioritize for this client? 1. Increase intake of meat 2. Reduce iron supplements 2. Take mineral oil 4. Increase fluid intake 4. Increase fluid intake Explanation: Increasing fluid content by drinking at least 8 glasses of noncaffeinated beverages helps relieve constipation in both pregnant and nonpregnant women. Reducing an iron supplement could lead to anemia; mineral oil can reduce absorption of fat-soluble vitamins. The client should add foods rich in fiber, which would include grains, vegetables, and fruits (instead of meat). The nurse is caring for a client who had consistent exposure to lead while pregnant. When the neonate is born, which focused assessment is essential? 1. Muscle tone 2. Hearing 3. Reflexes 4. Swallowing ability 3. Reflexes Explanation: A factor determining the effects of a teratogen is the teratogen's affinity for specific body tissues. Lead and mercury attack and disable nervous tissue. Assessment of reflexes and cognitive alertness is a priority. A hearing assessment is completed on most neonates in the nursery before discharge. Screening does not indicate lead poisoning. Muscle tone and the ability to swallow are not related to lead poisoning. A pregnant client in the second trimester is diagnosed with hyperemesis gravidarum with a 10% weight loss. The nurse is gathering data to form the foundation of a nutritional nursing care plan. Which way is best to obtain a nutritional assessment? 1. Outline the meals eaten over the past 7 days 2. Have the client complete an intake and output sheet 3. Complete a 24-hour food and fluid nutritional recall 4. Document food intake over the past 3 days 3. Complete a 24-hour food and fluid nutritional recall Explanation: Hyperemesis gravidarum causes dangerous health effects such as weight loss, dehydration, electrolyte imbalance, ketonuria, and ketonemia. It is important to complete a nutritional assessment, including everything that was ingested over the past 24 hours. The assessment includes both foods and fluids ingested. It is important to understand what was eaten in addition to what is recorded on the intake and output chart. It is most accurate to have the client recall the intake from the past 24 hours. It is unlikely that the client would recall all food and fluids ingested over the past 3 or 7 days. The nurse is concerned that a client is not obtaining enough folic acid. Which test would the nurse anticipate being used to evaluate the fetus for potential neural tube defects? 1. Triple-marker screen 2. Amniocentesis 3. Doppler flow study 4. Maternal serum alpha-fetoprotein analysis 4. Maternal serum alpha-fetoprotein analysis Explanation: Alpha-fetoprotein is a substance produced by the fetus. AFP enters the maternal circulation by crossing the placenta. If there is a developmental defect, more AFP escapes into amniotic fluid from the fetus. The optimal time for AFP screening is 16 to 18 weeks. The triple marker screens for AFP, hCG, and unconjugated estriol. This screens for neural defects and Down syndrome. The Doppler flow study evaluates the blood flow, and amniocentesis evaluates the contents of the amniotic fluid looking for chromosomal defects. A client at 29 weeks' gestation tells the nurse she is experiencing aches in her hips and joints. What would the nurse do next? 1. Have the primary healthcare provider see the client 2. Ask the client if there is a family history of arthritis 3. Tell the client these are normal findings during pregnancy 4. Document these findings in the clients chart 3. Tell the client these are normal findings during pregnancy Explanation: The hormone relaxin causes the smooth muscles, joints, and ligaments of the body to relax. Because of the production of relaxin during pregnancy, women often experience aches in the pelvic area. The nurse would explain to the client this is a normal finding of pregnancy and will resolve. The nurse should document this in the chart, but it is not priority over educating the client. The nurse discovers a soft systolic murmur when auscultating the heart of a client at 32 weeks' gestation. Which action would be most appropriate? 1. Ask another nurse to assess the heart 2. Inquire if the patient has chest pain 3. Document this and continue to monitor the murmur at future visits 4. Refer her for cardiac catheterization 3. Document this and continue to monitor the murmur at future visits Explanation: Due to the increased blood volume that occurs with pregnancy, soft systolic murmurs may be heard and are considered normal To prevent exposure to hepatitis A virus, the nurse teaches the pregnant client to avoid which food? 1. Grilled tuna 2. Raw fish 3. Undercooked chicken 4. Raw eggs 2. Raw fish Explanation: The hepatitis A virus is found in raw fish. Raw eggs and undercooked chicken can transmit salmonella, and swordfish can contain high levels of mercury. The nurse provides instructions to a client with hyperemesis gravidarum. Which outcome indicates that teaching has been effective? 1. The client is able to ingest clear liquids between episodes of vomiting. 2. The client has vomiting episodes only in the morning. 3. The client is able to tolerate soft foods after episodes of vomiting. 4. The client is able to ingest a regular diet after progressing through clear liquids and soft foods. 4. The client is able to ingest a regular diet after progressing through clear liquids and soft foods. Explanation: The pregnant client with hyperemesis gravidarum may be hospitalized and treated with intravenous fluids. If there is no vomiting after the first 24 hours of oral restriction, small amounts of clear fluid can be started, and the woman discharged home. If able to take clear fluid without vomiting, small quantities of dry toast, crackers, or cereal can be added every 2 or 3 hours, then the woman may be gradually advanced to a soft diet and then to a regular diet. If vomiting returns at any point, enteral or total parenteral nutrition may be prescribed to ensure she receives adequate nutrition. Vomiting episodes in the morning or tolerating clear liquids or soft foods between vomiting episodes indicates that teaching has not been effective. A maternal serum alpha-fetoprotein (MSAFP) test reveals a human chorionic gonadotropin (hCG) level of 2.5 MoM (multiple of median). Which teaching does the nurse prepare when the client and support person attend the next prenatal visit? 1. Information on delivering and caring for a multifetal pregnancy 2. Information on caring for a child with Tay-Sachs disease 3. Information on bleeding tendencies and hemophilia A 4. Information on further testing due to the risk for down syndrome 4. Information on further testing due to the risk for down syndrome Explanation: The nurse should inform the client that since the human chorionic gonadotropin (hCG) level is significantly elevated above 2 MoM, there is a significant risk for Down syndrome. Further information on what that means and further testing should be discussed at the next appointment. Also, misinformation should be clarified about having a child with Down syndrome. The MSAFP test does provide information about the risk for Tay-Sachs disease or hemophilia A. While hCG base levels may be slightly higher, the increases in levels (doubling pattern) remain the same as singleton pregnancies A nurse is caring for a client in her second trimester of pregnancy. During a regular follow-up visit, the client reports varicosities of the legs. Which instruction should the nurse provide to help the client alleviate varicosities of the legs? 1. Refrain from crossing legs when sitting down for long periods 2. Avoid sitting in one position for long periods of time 3. Applying heating pads on extremities 4. Refrain from wearing any kind of stockings 1. Refrain from crossing legs when sitting down for long periods Explanation: To help the client alleviate varicosities of the legs, the nurse should instruct the client to refrain from crossing her legs when sitting for long periods. The nurse should instruct the client to avoid standing, not sitting, in one position for long periods of time. The nurse should instruct the client to wear support stockings to promote better circulation, though the client should stay away from constrictive stockings and socks. Applying heating pads on the extremities is not reported to alleviate varicosities of the legs. A pregnant woman at her first prenatal visit asks the nurse if it is safe to have sex during her pregnancy. Which client statement alerts the nurse to the need for further teaching? 1."I will avoid having intercourse following the rupture of the membranes." 2. "I should substitute intercourse with nonsexual touch to avoid harming the fetus." 3. "I will experience a heightened need for touch throughout my pregnancy." 4. "If I experience bleeding, I will abstain from vaginal intercourse." 2. "I should substitute intercourse with nonsexual touch to avoid harming the fetus." Explanation: Sexual needs may be met through sexual intercourse with a partner as long as the pregnancy is healthy and there are no other risk factors, such as bleeding or rupture of membranes. Pregnancy is a time of a heightened need for touch, which may be met partially by sexual expression, but which can also be met through nonsexual touch, such as massage, caressing, or holding. During pregnancy most nutritional needs can be consumed in adequate amounts through the diet. Which nutrient is the exception to this statement? 1. Sodium 2. Iron 3. Vitamin D 4. Calcium 2. Iron Explanation: Although most nutrients are needed in greater amounts during pregnancy, most women who are at low nutritional risk can meet their nutrient needs throughout pregnancy from food alone. A notable exception is iron. Folic acid is another possible exception. As previously noted, fortified foods or supplements containing 600 micrograms of folic acid are recommended during pregnancy. A woman at low nutritional risk can meet the needs for calcium, sodium, and vitamin D in her diet. Which of these cardiac variations, if found in the client who is pregnant, should the nurse recognize as a normal finding in pregnancy? 1. Premature Ventricular contractions 2. S4 (atrial gallop) 3. Split S1S2 4. Soft systolic murmur 4. Soft systolic murmur Explanation: A soft systolic murmur is common in pregnancy secondary to the increased blood volume. The other findings are not normal and require further assessment by the nurse. A client in her second trimester arrives at a health care facility for a follow-up visit. During the exam, the client reports constipation. Which instruction should the nurse offer to help alleviate constipation? 1. Practice Kegel exercises 2. Avoid spicy or greasy foods in meals 3. Ensure adequate hydration and bulk in the diet 4. Avoid lying down for 2 hours after meals 3. Ensure adequate hydration and bulk in the diet Explanation: To help alleviate constipation, the nurse should instruct the client to ensure adequate hydration and bulk in the diet. The nurse should instruct the client to avoid spicy or greasy foods when a client complains of heartburn or indigestion. The nurse also should instruct the client to avoid lying down for 2 hours after meals if the client experiences heartburn or indigestion. The nurse should instruct the client to practice Kegel exercises when the client experiences urinary frequency. A nursing student is explaining to a newly pregnant woman what happens during each stage of fetal development. At which stage does the nurse inform the woman that the lungs are fully shaped? 1. End of 16 weeks 2. End of 8 weeks 3. End of 4 weeks 4. End of 12 weeks 1. End of 16 weeks Explanation: At the end of 16 weeks, the lungs are fully shaped, fetus swallows amniotic fluid, skeletal structure is identifiable, downy lanugo hair is present on the body, and sex can be determined using ultrasound. A primigravida client has come to the clinic for a prenatal checkup. What teaching topics would help to promote a healthy pregnancy for this client? 1. Swimming in a pool is recommended exercise during pregnancy 2. More frequent tooth brushing is recommended to prevent caries related to ptyalism 4. Applying lanolin ointment to the breasts is recommended to prevent cracked nipples 1. Swimming in a pool is recommended exercise during pregnancy Explanation: Swimming in a pool is good exercise for a pregnant woman. However, swimming in a lake can be harmful because of the danger of infection, especially in the latter months. Douching can increase the risk of vaginal infections. Increased salivation or ptyalism, seen in some women during pregnancy, does not cause tooth decay and necessitate more frequent brushing. Lanolin ointments may damage the areola and nipple and have not been shown to be effective in preventing sore and cracked nipples. A client presents at the emergency department. During the assessment, the nurse notes the following: Client is a 22-week primipara, age 25, pulse 82, BP 110/76, temp 38.3°C (100.9°F). The client is diagnosed with pyelonephritis. What would be the treatment of choice? 1. Hospitalization and intravenous antibiotics 2. Oral antibiotics and bed rest at home 3. Hospitalization and intravenous hydration 4. Home care and oral hydration and antibiotics 1. Hospitalization and intravenous antibiotics Explanation: Pyelonephritis can develop when a urinary tract infection (UTI) is not treated promptly. Because the immune system does not fight infections as well during pregnancy, a bladder infection can quickly become a kidney infection, characterized by severe flank pain and a fever above 100.4°F (38°C). While pyelonephritis is often treated on an outpatient basis for nonpregnant clients, during pregnancy, pyelonephritis requires intravenous antibiotics immediately to prevent generalized sepsis, which is potentially fatal. A nurse is providing care to a woman who has just found out that she is pregnant. The nurse is describing the events that have occurred and the structures that are forming. When describing the trophoblast to the client, the nurse would explain that this structure forms: 1. Zygote 2. Placental 3. Morula 4. Fetal membrane 2. Placenta Explanation: The trophoblast forms the placenta and chorion. The blastocyst forms the embryo and amnion. The zygote is formed from the union of the sperm and ovum. The morula is a mass of 16 cells that develop as cleavage cell division continues after fertilization. The nurse is instructing on maternal hormones which may impact the onset of labor. Which hormones are included in the discussion? Select all that apply. 1. Insulin 2. Testosterone 3. Thyroxine 4. Progesterone 5. Prostaglandins 6. Oxytocin 4. Progesterone 5. Prostaglandins 6. Oxytocin Explanation: There are several hypotheses regarding what triggers labor to begin. Progesterone is the hormone of pregnancy and elimination may cause the uterus to contract. Oxytocin also causes the uterus to contract. Prostaglandins cause the cervix to soften and also cause the uterus to contract. Testosterone, thyroxine, and insulin are not one of the main factors in the onset of labor theories. The nurse is assessing a pregnant woman on a routine prenatal visit. Which breast assessment finding will the nurse document as a normal and expected finding? 1. Disappearance of superficial veins 2. Tingling sensations and tenderness 3. Expression of colostrum in the first trimester 4. Hypopigmentation of the areola and nipples 2. Tingling sensations and tenderness Explanation: Normal changes in the breasts associated with pregnancy include tingling sensations and tenderness, enlargement of the breast and nipples, hyperpigmentation of the areola and nipples, enlargement of Montgomery glands (tubercles), prominence of superficial veins, development of striae (stretch marks), and expression of colostrum in the second and third trimesters. The nursing instructor is illustrating the circulatory flow between the mother and fetus. The instructor determines the session is successful when the class correctly chooses which structure with which route? 1. The two umbilical veins carry waste products from the fetus to the placenta. 2. The one umbilical vein carries oxygen-rich blood to the fetus from the placenta. 3. The two umbilical arteries carry waste products from the placenta to the fetus. 4. The one umbilical artery carries oxygen-rich blood to the fetus from the placenta. 2. The one umbilical vein carries oxygen-rich blood to the fetus from the placenta. Explanation: There are two umbilical arteries and one umbilical vein. The arteries carry waste from the fetus to the placenta; the vein carries oxygenated blood to the fetus from the placenta. Which hormone(s) is secreted by the placenta during the pregnancy? Select all that apply. 1. Prolactin 2. Estrogen 3. Testosterone 4. Progesterone 5. Human Chorionic Gonadotropin 2. Estrogen 4. Progesterone 5. Human Chorionic Gonadotropin Explanation: The placenta secretes hormones that help to sustain the pregnancy. These include progesterone, estrogen, human placental lactogen, and human chorionic gonadotropin. Testosterone is secreted by the male testes. Prolactin is secreted by the anterior pituitary gland. Which would be a normal finding by the nurse during a physical exam of a woman in her third trimester? 1. Kyphosis 2. Dyspnea 3. Increased hematocrit 4. Ptyalism 2. Dyspnea Explanation: In the third trimester, a women experiences dyspnea from the uterus pushing up into the diaphragm. A pregnant woman will experience lordosis, not kyphosis. Ptyalism is excessive saliva production and is often seen in the first trimester of pregnancy. The hematocrit of a pregnant woman will decrease in the third trimester, not increase. A nursing instructor identifies a need for further instruction in regards to the three stages of fetal development when a nursing student makes which statement? 1. "The embryonic stage begins approximately 2 weeks after fertilization." 2. "The fetal stage begins at 9 weeks after fertilization" 3. "The fetal stage ends at birth" 4. "The pre-embryonic stage begins approximately 2 weeks after fertilization" 4. "The pre-embryonic stage begins approximately 2 weeks after fertilization" Explanation: The three stages of human development are the pre-embryonic stage, which begins at fertilization and lasts through the end of the second week after fertilization; the embryonic stage, which begins approximately 2 weeks after fertilization and ends at the conclusion of the 8th week after fertilization; and the fetal stage, which begins approximately 9 weeks after fertilization and ends at birth. A nurse is providing care to several pregnant women at different weeks of gestation. The nurse would expect to screen for group B streptococcus (GBS) infection in the client who is at: 1. 28 weeks' gestation 2. 36 weeks' gestation 3. 32 weeks' gestation 4. 16 weeks gestation 2. 36 weeks' gestation Explanation: Pregnant women between 36 and 37 weeks' gestation should be universally screened for GBS infection during a prenatal visit and, if positive, receive appropriate intrapartum antibiotic prophylaxis. A nurse is completing the assessment of a woman admitted to the labor and birth suite. Which information would the nurse expect to include as part of the physical assessment? Select all that apply. 1. Membrane status 2. Current pregnancy history 3. Support system 4. Estimated date of birth 5. Fundal height measurement 6. Contraction pattern 1. Membrane status 5. Fundal height measurement 6. Contraction pattern Explanation: As part of the admission physical assessment, the nurse would assess fundal height, membrane status, and contractions. Current pregnancy history, support systems, and estimated date of birth would be obtained when collecting the maternal health history. When stimulating the fetus via an acoustic vibrator, which action indicates fetal well-being? 1. The fetus descends further into the birth canal 2. There is an increase in fetal movement 3. Fetal heart rate acceleration occurs 4. Fetal heart rate deceleration occurs 3. Fetal heart rate acceleration occurs Explanation: The fetus is stimulated via an acoustic vibrator. From the stimulation, the fetal heart rate accelerates. If the acceleration occurs, fetal acidosis is not present. Fetal movement is limited in the birth canal. Decelerations do not indicate well-being. Acoustic vibrations do not descend the fetus into the birth canal. A new dad is alarmed at the shape of his newborn's head. When responding to the dad, the nurse reminds him this is due to: 1. A congenital defect 2. Prolonged labor 3. Cranial bones overlapping at the suture line 4. Extreme pressure in the vaginal vault 3. Cranial bones overlapping at the suture line Explanation: This is due to molding, which is the result of overlapping of the cranial bones at the suture lines. It is a temporary situation that will correct itself. It is due to the fetus passing through the pelvis. Molding is not the result of extreme pressure, a congenital defect, or prolonged labor. A client is in the first stage of labor and asks the nurse what type of pain she should expect at this stage. What is the nurse's most appropriate response? 1. Distention of the vagina and perineum 2. Pressure on the lower back, buttocks, and thighs 3. Pain from the dilation or stretching of the cervix 4. Hypoxia of the contracting uterine muscles 3. Pain from the dilation or stretching of the cervix Explanation: In the first stage of labor, the primary source of pain is the dilation (dilatation) of the cervix. Hypoxia of the contracting uterine muscles, distension of the vagina and perineum, and pressure on the lower back, buttocks, and thighs may occur in the first stage but are more significantly associated with the second stage of labor. A client is scheduled for a cesarean section under spinal anesthesia. After instruction is given by the anesthesiologist, the nurse determines the client has understood the instructions when the client states: 1. "I will need to lie on my right side to reduce vena cava compression." 2. "I can continue sitting up after the spinal is given." 3. "I may end up with a severe headache from the spinal anesthesia." 4. "The anesthesia will numb both of my legs to a level above my breasts." 3. "I may end up with a severe headache from the spinal anesthesia." Explanation: Cerebrospinal fluid (CSF) leakage from the needle insertion site and irritation caused by a small amount of air that enters at the injection site and shifts the pressure of the CSF causes strain on the cerebral meninges, initiating pain from a postdural puncture (spinal) headache. The nurse is reviewing the medical record of a woman in labor and notes that the fetal position is documented as LSA. The nurse interprets this information as indicating which part as the presenting part? 1. Face 2. Shoulder 3. Buttocks 4. Occiput 3. Buttocks Explanation: The second letter denotes the presenting part which in this case is "S" or the sacrum or buttocks. The letter "O" would denote the occiput or vertex presentation. The letter "M" would denote the mentum (chin) or face presentation. The letter "A" would denote the acromion or shoulder presentation. A nurse is explaining the fetus's position to a female client whose baby is in the frank breech position. Which statement by the client would indicate that the teaching was understood? 1."My baby's hips are extended, and the knees are flexed." 2. "My baby's hips are flexed, and the knees are extended." 3. "My baby's hips and knees are extended." 4. "My baby's hips and the knees are flexed." 2. "My baby's hips are flexed, and the knees are extended." The frank breech position of the fetus indicates that the sacrum is the presenting part. The hips are flexed, and the knees are extended. Complete breech is when both the hips and knees are flexed and the sacrum is presenting. Kneeling breech is when the hips are extended, and the knees are flexed. Footling breech is when both the hips and knees are extended so that the fetus presents feet first. The nurse is caring for a client in labor whose fetus is in an occiput posterior position. Which intervention should the nurse use to reduce this client's discomfort? 1. Place in a prone position 2. Place in the Trendelenburg position 3. Apply ice packs to the lower back 4. Massage the lower back 4. Massage the lower back Because the fetal head rotates against the sacrum in the occiput posterior position, the client may experience pressure and pain in the lower back because of sacral nerve compression. Applying counter pressure on the sacrum by a back rub may be helpful in relieving a portion of the pain. The client does not need to be placed in the prone or Trendelenburg positions. Ice packs are not indicated to reduce this pain. A nursing instructor is conducting a class on the various types of pelvic shapes to a group of nursing students. The instructor determines the class is successful when the students correctly choose which factor is specific for an anthropoid pelvis? 1. Has weaker bones than normal 2. Is "male" shaped 3. Is narrow transversely 4. Is ideal for birth 3. Is narrow transversely A gynecoid pelvis is the best shape for birth. An anthropoid pelvis is usually narrow. A "male" pelvis is termed an "android pelvis." The condition of the bones is not a determining factor for the shape of the pelvis. ROA was documented in the babys chart. Which position was the baby born in? 1. Rear facing with the occiput facing the posterior quadrant of the pelvis 2. With the brow facing the right anterior quadrant of the pelvis 3. With the right side presenting, and the occiput facing the anterior quadrant 4. With the occiput facing the right anterior quadrant of the pelvis 4. With the occiput facing the right anterior quadrant of the pelvis A fetus in the vertex presentation has the occiput as the reference point. If the occiput is facing the anterior quadrant of the pelvis, the nurse is correct to record the position as ROA. Proper notation does not include a rear or right facing position. The vertex presentation is associated with the fetal occiput, not brow. The nurse is preparing materials to instruct a pregnant client about the use of a local anesthetic to block specific nerve pathways. About which type of pain reduction technique will the nurse instruct the client? 1. General anesthesia 2. Regional anesthesia 3. Pressure anesthesia 4. Pudendal nerve blok 2. Regional anesthesia Regional anesthesia is the injection of a local anesthetic to block specific nerve pathways. This achieves pain relief by blocking sodium and potassium transport in the nerve membrane so the nerve is unable to conduct sensations. General anesthesia is rarely used and is not referred to as being general anesthesia. Pressure anesthesia results from the fetal head pressing against the stretched perineum. A pudendal nerve block is the injection of a local anesthetic through the vagina to anesthetize the pudendal nerve. The client presents in the early stage of labor with mild contractions 7 to 9 minutes apart and blood pressure 130/80 mm Hg. The client changes from happy, excited, and confident to introverted and restless. Assessment reveals heart rate 100, blood pressure 137/85 mm Hg, and hyperventilation. EFM reveals no variability for almost 20 minutes, then evident variability with no late decelerations. Which action should the nurse prioritize? 1. Assist the client into a hands-and-knees position. 2. Help the client regain control of her breathing technique. 3. Notify the RN that client's blood pressure has increased. 4. Notify the RN about the lack of FHR variability. 2. Help the client regain control of her breathing technique. The primary focus is to regain her breathing to a normal rhythm; focus her on breathing and relaxation and relief from the hyperventilation. If there is no improvement, notify the RN. Putting the client in the hands-and-knees position should be avoided until later in labor. A primigravida client admitted with signs of labor is evaluated with external electronic fetal monitoring that shows baseline FHR of 136 to 150 and two instances of FHR at 165 for 15 to 20 seconds. Which response should the nurse prioritize? 1. Before reporting to the RN, determine the short term variability (STV). 2. Before reporting to the RN, determine the uterine contraction pattern. 3. Immediately report to the RN that the FHR shows no variability. 4. Immediately report to the RN that the FHR shows tachycardia. 2. Before reporting to the RN, determine the uterine contraction pattern. The nurse needs to assess and determine if the changes are related to accelerations secondary to contractions. Assess the contraction pattern with the fetal heart rate and provide information to the RN. If the accelerations are not due to uterine contractions, notify the RN immediately. Until then, the nurse should do the assessment before reacting. A 33-year-old client has been progressing slowly through an unusually long labor. The nurse assesses the fetal scalp pH and determines it is 7.26. How should the nurse explain this result to the client when asked what it means? 1. Worrisome; it may be associated with metabolic acidosis. 2. Reassuring; it is associated with normal acid-base balance. 3. Damaging; it is frequently associated with fetal neurological damage. 4. Critical; it represents metabolic acidosis. 2. Reassuring; it is associated with normal acid-base balance. The fetal pH slowly decreases during labor as a result of the normal stress of labor. Although 7.26 is low for an adult, it is not problematic during labor for an emerging fetus. Which positions would be most appropriate for the nurse to suggest as a comfort measure to a woman who is in the first stage of labor? Select all that apply. 1. straddling with forward-leaning over a chair 2. walking with partner support 3. rocking back and forth with foot on chair 4. closed knee-chest position 5. supine with legs raised at a 90-degree angle 1. straddling with forward leaning over a chair 2. walking with partner support 3. rocking back and forth with foot on chair Positioning during the first stage of labor includes walking with support from the partner; side-lying with pillows between the knees; leaning forward by straddling a chair, table, or bed; kneeling over a birthing ball; lunging by rocking weight back and forth with a foot up on a chair or birthing ball; or an open knee-chest position. Patterned breathing techniques used in labor provide which benefits? Select all that apply. 1. pain relief without special tools 2. conscious relaxation 3. distraction 4. spirituality 1. pain relief without special tools 2. conscious relaxation 3. distraction Patterned breathing can be very effective when the woman has practiced before labor and has an attentive coach. It can provide distraction, conscious relaxation, and pain relief without any special tools. The basic breathing patterns can be taught by the nurse and are easy to learn and simple to perform. During which phase of labor would the nurse anticipate providing the most emotional support for the mother? 1. Final phase of labor 2. Latent phase of labor 3. Active phase of labor 4. Transition phase of labor 4. Transition phase of labor The transition phase of labor is the most difficult. This phase of the first stage of labor starts when the cervix is dilated at 8 cm and ends with full cervical dilation (dilatation). The contractions at this point are strong and lasting 60 to 90 seconds. It is important for the nurse to help the woman through this stage and encourage her to rest between contractions. The nurse is preparing to assess the duration of contractions for a client in labor. Which process should the nurse use to time the contractions? 1. the interval between the beginning and the end of one contraction 2. the interval between the acmes of two consecutive contractions 3. the end of one contraction to the beginning of the next 4. number of contractions that occur in 5 minutes 1. the interval between the beginning and the end of one contraction To determine the beginning of a contraction without a monitor, rest a hand on a woman's abdomen at the fundus of the uterus very gently until you sense the gradual tensing and upward rising of the fundus that accompanies a contraction. Time the duration of the contraction from the moment the uterus first tenses until it has relaxed again. This is the duration. Contractions are not timed by measuring the number of contractions in 5 minutes, the end of one contraction to the beginning of the next, or by using the interval between the acmes of two consecutive contractions. The nurse is preparing an injection of an opioid to relieve a pregnant woman's pain. As the nurse is about to give it, the client asks for a bedpan because she has to move her bowels. The nurse's best action would be to: 1. give the injection, then offer the bedpan; abdominal comfort will help her move her bowels. 2. give the injection first, then offer the bedpan to complete a clean procedure before a contaminated one. 3. hold the injection until you evaluate her labor progress. 4. give the bedpan before you give the injection because the opioid is constipating. 3. hold the injection until you evaluate her labor progress. A feeling of having to move bowels or push with contractions could mean the woman is entering the second stage of labor. Abdominal discomfort does not affect a pregnant woman's urge to move her bowels. The nurse should hold off on the injection as it may be too late to be effective. The constipating effects of the opioid are not immediate. The labor and delivery charge nurse is making assignments for the day. Which client should the charge nurse assign to a nurse with 6 months experience in labor and delivery? 1. A gravida 5 para 2 mother in active labor 2. A gravida 3 para 0 mother at 36 weeks' gestation 3. A gravida 1 para 0 mother with mild preeclampsia 4. A gravida 2 para 1 mother for TOLAC 1. A gravida 5 para 2 mother in active labor The gravida 5 para 2 mother is in active labor, is in no apparent distress, and is expected to deliver without complications. The other 3 clients all have documented medical problems and may require more experience and critical thinking than the new nurse with only 6 months experience. A client in labor is anxious about having an intravenous infusion. Following insertion of the intravenous line, which nursing action is best? 1. Maintain the client in the supine position. 2. Use distraction therapy. 3. Wrap the intravenous line with a cling wrap. 4. Instruct the client to lie still so not to dislodge the catheter. 2. Use distraction therapy. Many women in labor may receive intravenous fluid to maintain hydration. Distraction therapy helps the client to focus her attention on the birthing process. The woman can be out of bed with this in place. She should lie on her side as should all women in labor. Pediatric clients are upset by the site of the intravenous infusion site so the site is wrapped with a cling wrap or gauze. Immediately following an epidural block, a pregnant client's blood pressure suddenly falls to 86/44 mm Hg. What action should the nurse take first? 1. Ask the client to take deep breaths. 2. Administer an angiotensin-converting enzyme (ACE) inhibitor. 3. Raise the client's legs. 4. Place the client supine. 3. Raise the client's legs To help prevent supine hypotension syndrome, the nurse will place the pregnant client on the left side after an epidural block. If hypotension should occur, the client's legs should be raised in addition to providing oxygen, intravenous fluids, and medication such as an antihypotensive agent like ephedrine. The supine position encourages hypotension syndrome. Deep breathing would not nhelp with hypotension syndrome. An ACE inhibitor is an anti-hypertensive agent that would cause the client's blood pressure to decrease. Which nursing intervention offered in labor would probably be the most effective in applying the gate control theory for relief of labor pain? 1. Massage the woman's back. 2. Encourage the woman to rest between contractions. 3. Change the woman's position. 4. Give the prescribed medication. 1. Massage the woman's back. Gate-control is based on the idea of distraction or redirection of the conduction of impulses up the neural pathways. Massage redirects the paths of sensation away from the pain to the other area. Encouragement is a form of psychological support. Position change will only distract the client. Medication should be withheld until all nonpharmacologic treatments have been exhausted. A woman received morphine during labor to help with pain control. Which finding would the nurse need to monitor the newborn for after birth? 1. increased agitation 2. decreased alertness 3. low Apgar 4. increased crying 2. decreased alertness Morphine is a commonly used opioid for the management of pain during labor. It is associated with newborn respiratory depression, decreased alertness, inhibited sucking, and a delay in effective feeding. A gravida 3 para 2 client has been in labor for 4 hours and is experiencing severe back pain with each contraction. She is extremely uncomfortable and distressed because she never had this type of pain with her other labors. Which intervention can the nurse point out is best for this client to try to address her pain? 1. imagery 2. oral pain medication 3. effleurage 4. lying still 3. effleurage Effleurage or massage would be an appropriate technique to use at this point. It is used as a distraction and relaxation technique. It increases the production of endorphins which reduce the transmission of signals between nerve cells and thus lowers the perception of pain. Imagery is another technique but may not be as effective for relieving the pain if it is intense. A change of position may help with the pain as the woman finds a position of comfort; lying still may not be effective. The use of oral pain medication presents a danger to the fetus depending on what is used, as it can pass through the placenta and adversely affect the heart and lungs of the fetus. When documenting the fetus is at 0 station, the nurse knows this is where in relation to the pelvic structure? 1. ischial spines 2. pelvic inlet 3. pelvic outlet 4. pelvic crest 1. ischial spines During the cervical check for fetal station, 0 station is the engagement of the fetus at the level of the ischial spines of the pelvis. The ischial spines are a landmark that is used mark the passage of the fetus. The pelvic crest is a landmark location on the pelvis for documenting fetal station. The pelvic inlet must be shaped accordingly to allow for passage of the fetus. The pelvic outlet is associated with internal rotation of the fetal head. The nurse is caring for a laboring client. The nurse observes that there are early decelerations. The fetal heart rate remains within normal limits with adequate variability. What is the nurse's best action? 1. Promptly inform the primary care provider. 2. Advocate for the client to have a vaginal examination. 3. Continue to monitor the client and the fetal heart rate.. 4. Reposition the client. 3. Continue to monitor the client and the fetal heart rate.. As long as baseline remains within normal limits and the variability is good, early decelerations are benign and no further action is necessary. A pregnant client with a history of spinal injury is being prepared for a cesarean birth. Which method of anesthesia is to be administered to the client? 1. regional anesthesia 2. local infiltration 3. General anesthesia 4. epidural block 3. General anesthesia General anesthesia is administered in emergency cesarean births. Local anesthetic is injected into the superficial perineal nerves to numb the perineal area generally before an episiotomy. Although an epidural block is used in cesarean births, it is contraindicated in clients with spinal injury. Regional anesthesia is contraindicated in cesarean births. A nurse is assisting a client who is in the first stage of labor. Which principle should the nurse keep in mind to help make this client's labor and birth as natural as possible? 1. Routine intravenous fluid should be implemented. 2. Women should be able to move about freely throughout labor. 3. A woman should be allowed to assume a supine position. 4. The support person's access to the client should be limited to prevent the client from becoming overwhelmed. 2. Women should be able to move about freely throughout labor. Six major concepts that make labor and birth as natural as possible are as follows: 1) labor should begin on its own, not be artificially induced; 2) women should be able to move about freely throughout labor, not be confined to bed; 3) women should receive continuous support from a caring other during labor; 4) no interventions such as intravenous fluid should be used routinely; 5) women should be allowed to assume a nonsupine position such as upright and side-lying for birth; and 6) mother and baby should be housed together after the birth, with unlimited opportunity for breastfeeding. Which is the most important factor on how much admission data is obtained when a client reports to the hospital in labor? 1. participation