FAM 134 Family Nursing (Family Test 2 Q&A) | Obstetrics, Fetal heart rate | Download To Score A

Family Test 2 • A new mother asks the nurse for help with preparing for breastfeeding. She wishes to know how she can best prepare to nurse her baby. Which response by the nurse is the most correct ? o You should obtain a sports bra to give you the best support ▪ There is no special preparation required for breast feeding o Since you have small breast you are not likely to be successful at breastfeeding o Do not apply soap to the nipple area while bathing until after the baby is born • A mother refuses to have her child immunized because she is concerned about "problems related to immunizations." To identify the basis for the mother's concern, the nurse should ask which question? o Are you aware that your child could get sick and die if you refuse this immunization? o The injection will cause slight discomfort; do you feel your fears are unfounded?" o Thousands of children are immunized with no problems. Have you done any research on this recently? ▪ I can see that you are concerned. Can you tell me a little more about why you are concerned about this immunization? • A nurse provides suggestions to parents about the appropriate actions to take when the toddler has a temper tantrum. Which statement indicates an understanding of the best actions to take? ▪ I will ignore the tantrums as long as there is no physical danger o I will remind him that only bad boys have temper tantrums o I will put my child in time out for ten minutes after the temper tantrum o I will reward my child with candy at the end of the day if there are no tantrums • A woman just delivered her fourth baby, vaginally one hour ago. Which finding does the nurse find most concerning? o The mother complains of strong uterine cramping, that increases with breastfeeding. o The new mother asks that the nurse take the baby so that she can sleep. ▪ The fundus of the uterus is above the umbilicus and soft to palpation. o The new mother is shaking and complains of feeling cold and tired. • While inspecting a newborn's head, the nurse identifies a swelling of the scalp on the right posterior side of the head that does not cross the suture line. What term describes this finding? o caput succedaneum ▪ cephalohematoma o enlarged fontanelle o molding • A client who is 30 weeks pregnant delivers a stillborn child in the emergency department (ED). What should the ED nurse offer the client? Select all that apply. o Materials about support groups ▪ An opportunity to grieve o Advice about when to become pregnant again ▪ Privacy ▪ A memento (footprint or lock of hair) ▪ An opportunity to hold the infant • The nurse is caring for a woman who delivered vaginally, with forceps assistance one hour ago. The woman complains of perineal pain and pressure, not relieved by ibuprofen. Which sign should the nurse report promptly? ▪ Pulse rate 118 o Temperature of 99.6 F. o Blood pressure of 128/78 o WBC count 20,000 • A pregnant woman comes to the clinic and tells the nurse that she has three living children. Two of the children were full term, and one was premature. She had two miscarriages. Using TPAL, how will the nurse record the client's gravida and para status? o G 4 P 2 1 2 2 o G 5 P 2 1 2 3 ▪ G 6 P 2 1 2 3 o G 6 P 3 1 2 3 • The mother of an adolescent female is concerned because the child suddenly developed an aversion to eating meat products. The mother is concerned that her daughter will become deficient in nutrients such as iron and protein. Which response by the nurse is most appropriate for this mother? o This is just a phase, and will have no long term consequences. You should ignore the attention seeking behavior o People follow vegetarian lifestyles for many reasons. A carefully planned diet can be very healthful. o Your concerns are valid. I will arrange for your daughter to see the nutritionist, and psychologist. ▪ As long as your daughter is eating foods such as milk, eggs and cheese, a vegetarian diet is harmless. • Which term describes a client's status as being pregnant for the first time? o omnigravida o nulligravida ▪ primigravida o multigravida • While reviewing the nursing care plan of a child hospitalized who is immobilized because of skeletal traction, a licensed practical nurse notes that the registered nurse has documented a nursing diagnosis of Delayed growth and development related to immobilization and hospitalization. Which evaluative statement indicates a positive outcome for this child? o The fracture heals without complications o The caregivers verbalize safe and effective home care o The child maintains normal joint and muscle integrity ▪ The child displays age appropriate developmental behaviors • A nurse is discussing the function of the placenta with a pregnant client. Which response reflects an accurate response? o "It cushions and protects the baby" o "It helps to maintain a constant temperature." ▪ "It delivers nutrients and oxygen and removes waste." o "It prevents viruses and antibodies from passing to the fetus." • A first time mother is determining how she will feed her new baby. Which response by the nurse is the most appropriate response to the woman? o "Do you feel it would be easier for you to breast feed or bottle feed? ▪ "Breastfeeding has many benefits, would you like some more information?" o "How did your mother feed you? You should do the same." o "Breastfeeding is the preferred method; you want to do the right thing don't you?" • A woman who is in her seventh month of pregnancy complains of varicose veins. What is most important to teach this client? o Rest with your feet firmly on the floor three to five times per day o Avoid exercise until after you deliver your baby o Wear knee high support socks for the remainder of the pregnancy ▪ Avoid prolonged sitting or standing • A nurse is caring for a client who is diagnosed with placenta previa. Which symptoms are commonly associated with placenta previa? o urinary frequency and urgency ▪ painless bright red bleeding o rigid board-like abdomen o greenish discoloration of the amniotic fluid • A woman reports that her last normal menstrual period began on August 5, 2015. Using Nägele's rule, what would her expected date of delivery be in 2016? o April 30 o May 5 ▪ May 12 o May 26 • A nurse is assisting with monitoring a client during active labor. The nurse notes a V shaped deceleration, which drops quickly to 50 beats per minute, and returns within 15 seconds to the baseline. This most likely indicates which condition? o Early decelerations ▪ Variable decelerations o Late decelerations o Fetal heart rate accelerations • Which home care instructions should be included when teaching parents how to prevent infection in their infant after the surgical repair of an inguinal hernia? o Restrict all of the infant's physical activity ▪ Change the diapers as soon as they become damp o Soak the infant in a tub bath twice a day for the next five days o A mild fever is a normal finding for the next several days • A 24-year-old woman is two weeks late for her menstrual period and reports that she is also feeling very tired, and has been nauseated is showing what types of signs of pregnancy? o plausible signs ▪ presumptive signs o probable signs o positive signs • A nurse is caring for a woman who is six months pregnant. On the first visit, the nurse notes the following information. Gravida 4, Para 1111. The client is 5'6" and weighs 135 lbs. The mother verbalizes concerns about feeling tired at the end of the day. Which factor in the preceding data leads the nurse to be concerned about gestational diabetes? o obesity ▪ multiparity o maternal age o previous fetal demise. • A fetal non stress test results are documented as: "Two or more accelerations of 15 beats per minutes for 15 seconds or longer in association with fetal movement." How would this stress test results be reported. ▪ A Reactive Non stress test o A Nonreactive Non stress test o Equivical/ unable to interpret o Unsatisfactory • The nurse informs a class of expectant parents that the fetus is first considered viable (able to live outside the womb with support) at what age? o 12 - 14 weeks o 16 - 18 weeks ▪ 24 - 28 weeks o 37 - 40 weeks • A woman visits the clinic for initial prenatal care, and states that she is sure she is pregnant because she has missed her period for two weeks and has morning sickness. The nurse notes that these are what types of signs of pregnancy? o potential ▪ presumptive o probable o positive • The nurse is caring for a client who comes in for a non-stress test. The woman is lying on the bed when she suddenly complains of dizziness and nausea. The nurse determines that the woman may be experiencing supine postural hypotension. Which action is most appropriate for this client? o Offer the woman a snack and juice o Take a set of vital signs o Call the physician ▪ Turn the woman to her side • The nurse is caring for a newborn who just delivered vaginally. The new nurse is trying to prioritize her care. Which care is important for the nurse to accomplish within the first hour following birth? Select all that apply ▪ Vital signs every 15 minutes ▪ Identification of the baby and the mother o Bathe the infant in the warmer ▪ Dry the infant thoroughly ▪ Initiation of breastfeeding if desired o Infant metabolic screening tests (PKU) • A preschool age child is placed in traction for the treatment of a femur fracture. This child, who has been reportedly toilet trained for one year, begins wetting the bed. The nurse recognizes this behavior as a symptom of what problem? o Body image disturbance o Attention seeking behavior o Loss of developmental milestones ▪ Regression to earlier developmental behavior • A pregnant client calls the clinic with concerns about her health. Which symptom should be reported immediately? o "The fetus has not moved for half an hour" o "I had a small amount of bloody discharge." o "My mucous plug came out." o "I have had irregular contractions for two weeks." ▪ "I have a severe headache, and blurry vision." o "I have to go to the bathroom frequently." • The nurse is measuring the vital signs of a full-term newborn. What would be an abnormal finding? o Respiratory rate of 38 ▪ Apical heartbeat of 178 o Axillary temperature of 98.9 o Pulse oximeter reading of 95% • A nurse is assessing a newborn infant for congenital hip dysplasia. Which signs or symptoms should be brought to the attention of the health care provider for further evaluation? Select all that apply. o an infant who was in breech position still has the legs flexed onto the chest 2 hours after birth. ▪ an infant has one leg that appears longer than the other. o an infant whose right foot turns persistently inward. ▪ an infant who has extra skin folds on the inner thigh of one leg. ▪ an infant who has a click in the hip joint when one hip is maneuvered. • The nurse is caring for a macrosomic newborn whose mother has diabetes. The nurse should be sure to assess for what common complication? o intracranial hemorrhage ▪ hypoglycemia o erythroblastosis fetalis o pancreatic failure • A woman calls the clinic with complaint of nausea and vomiting. Which intervention will best help the mother? o You should take your iron tablets with milk to reduce gastric discomfort. ▪ You should eat small frequent meals that are bland and non-greasy. o You should try to eat foods that have a strong aroma to stimulate your appetite. o You should not complain. You are going to feel better in just a few weeks. • A nurse in a prenatal clinic is caring for a client who is diagnosed with gestational diabetes. Which piece of data is most essential for the nurse to check at each visit? o blood pressure and pulse o urine for amount and protein level o extremities for edema ▪ urine for glucose and ketones • A pregnant client is admitted to the perinatal unit for observation of symptoms of pre- eclampsia. In order to detect any early complications, the nurse should assess for what symptoms? o alternating periods of fetal movement ▪ complaints of a warm flushed feeling o petechiae and bleeding at the gum line o bilateral breast enlargement • How should a nurse measure the frequency of a laboring woman's contractions? o Measure the time between the beginning and the end of one contraction. o Measure the time between the end of one contraction and the beginning of the next. ▪ Measure the time between the beginning of one contraction and the beginning of the next. o Ask how long the client states the contractions last. • A woman two weeks past her expected delivery date who is receiving an oxytocin infusion to induce labor, begins to have contractions every 90 seconds, which last for 60 seconds. What should the nurse's initial action be? ▪ Stop the oxytocin infusion and report the findings to the health care provider. o Administer oxygen by face mask and report the findings to the health care provider. o Turn her on her left side and reassess the contractions. o Continue the infusion and report the findings to the health care provider. • The mother of a toddler who is hospitalized must leave for work. Which behavior will the nurse most likely observe in this child immediately after the mother's departure? o Playing quietly with a favorite toy ▪ Crying loudly, kicking both legs o Silently curled in bed with a blanket o Sucking the thumb, rocking back and forth • While talking to a prenatal client about her dietary and alcohol habits, the nurse notes that the client has difficulty concentrating and appears agitated. The nurse should proceed with the conversation and use which communication technique? ▪ A non-judgmental approach may help to gain maternal trust o Provoking feelings of guilt may help the mother seek support for her habits. o Discussion of the possible risks of alcohol use during pregnancy should be avoided o Women tend to respond negatively to a message about risk related to alcohol use. • The nurse caring for a newborn delivered with the use of forceps should be sure to assess for what complication? o The loss of hair from contact with the forceps. ▪ Facial asymmetry o Shoulder dislocation o Sacral hematoma • A nurse is monitoring a pregnant woman in labor, and notes the presence of fetal heart rate accelerations which are 15 - 20 beats per minute above the baseline, and last for 15 - 20 seconds. What is the most appropriate action for the nurse to take? o Turn the woman on her side and administer oxygen ▪ Record the findings as normal. o Report the findings to the physician at once o Take the mother's vital signs and report the finding. • 40)A nurse, working in a prenatal clinic measures the fundal height of a woman who is in her second trimester of pregnancy. What should the nurse expect the fundal height to be? o Fewer centimeters than the gestational age ▪ Correlate in centimeters to the gestational age o Greater centimeters than the gestational age o Have no relationship in centimeters to the gestational age. • What is part of the normal umbilical cord? ▪ 2 arteries carrying blood away from the fetus and 1 vein carrying blood to the fetus. o 2 arteries carrying blood to the fetus and 2 veins carrying blood away from the fetus. o 1 artery carrying blood to the fetus and 2 veins carrying blood away from the fetus. o 1 artery carrying blood to the fetus and 1 vein carrying blood away from the fetus. • A nurse is caring for a client newly diagnosed with gestational diabetes. Which teaching topic should be given the highest priority for teaching? o How to test for proteinuria ▪ Symptoms of hypo and hyperglycemia o Management of discomforts of pregnancy o Symptoms of preterm labor • The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. What should be the nurse's next assessment? o level of pain o blood pressure o amount of lochia ▪ fullness of the bladder • A nurse is caring for a woman who is 36 weeks pregnant, and has frequent symptom of heartburn. The nurse should recommend which strategy to reduce heartburn? o Avoid tea and coffee ▪ Take frequent sips of milk o Take antacids that contain sodium o Eat fatty meals only in the morning • A new mother is known to be anemic. Her health care provider decided that she should eat an iron rich diet and take supplemental iron. The new mother tells the nurse that she is a vegetarian, and will not eat meat, but does eat dairy and egg products. Which foods should the nurse recommend to the client? SELECT ALL THAT APPLY o Cottage cheese ▪ Dried fruit o Organ meats such as liver ▪ Green leafy vegetables ▪ Dried beans and lentils • What would the nursing care of a woman with a third-degree laceration immediately after delivery include? o warm compresses to the perineum o elevation of hips to prevent edema. ▪ cold pack to the perineum. o warm sitz bath. • A woman who is 9 weeks pregnant is experiencing heavy bleeding and cramping. She reports passing some tissue. Cervical dilation is noted on examination. This woman most likely had what type of abortion? o missed ▪ inevitable o complete o incomplete • A nurse is caring for a client on a Pitocin infusion for induction of labor. The LPN notifies the RN when she notes which assessment? o contractions every three minutes ▪ fetal tachycardia and late decelerations o soft uterus palpated between contractions o presence of three contractions in ten minutes • A nurse is assisting with the care of a child who underwent surgical repair of cleft lip 24 hours previously. The nurse should implement which safety precaution when caring for the surgical incision? o Clean the incision only if serious exudate forms o Remove the Logan bar carefully to clean the incision o Rub the incision briskly, but carefully with a cotton tipped swab ▪ Rinse the incision with water and diluted hydrogen peroxide if prescribed • The nurse observes on the fetal monitor a baseline fetal heart rate of 140 beats per minute with a pattern of a 15-beat increase in the fetal heart rate that lasts 15 to 20 seconds. The nurse knows that this pattern is indicative of what situation? o Compression of the fetal head o Compression of the umbilical cord ▪ A well oxygenated fetus o Uteroplacental insufficiency. • Following an amniotomy (rupture of membranes), what nursing assessment should be reported immediately? o amniotic fluid is clear with flecks of vernix. o fetal heart rate is regular at 154 beats/min ▪ amniotic fluid is watery and pale green o maternal temperature is 98.8° F • A woman presents to the labor and delivery unit in active labor. It is noted that she has a history of previous Cesarean Section. The client complains of a burning and tearing sensation in her lower abdomen. Which is the most therapeutic response? o "Don't worry, we have the surgical crew on the way." o "I don't have time to focus on that right now, I have to get you ready for surgery." o "The doctor will be in to discuss this with you as soon as possible." ▪ "I know you are concerned. We are doing everything possible for you and your baby." • At a prenatal visit, a primigravida asks the nurse how she will know her labor has started. The nurse instructs the woman that the beginning of true labor is indicated by what symptom? o Discomfort in the abdomen and groin that becomes worse with walking. ▪ Regular contractions which become more painful and closer together. o Contractions that are made better by walking. o Contractions that are irregular, but continue for more than 30 minutes. • A client calls the labor and delivery unit stating she thinks she is in true labor. Which client complaint leads the nurse to believe that the client is in true labor? o The contractions ease up when she walks ▪ The contractions are getting stronger and closer together o The discomfort is only in the abdomen o The client also has nausea. • A 15 year old client calls the clinic concerned that she may be pregnant. Her last period was two weeks ago. Her periods are normally every 27 - 29 days apart. She had intercourse one week ago. What information should the nurse give the client? o "There is a good chance that you may have become pregnant. You should come in for testing as soon as possible." o "It is difficult to determine from this information if you are pregnant. Why aren't you on some form of birth control?" o "There is no chance that you are pregnant, but you should be using birth control, let's get you some condoms." ▪ "There is little chance that you are pregnant, but you are at risk. Let's get you scheduled with the healthcare provider." • A nurse caring for a newly delivered infant delays the instillation of antibiotic ointment into the neonate's eyes. Which best describes the rationale for the time sequence used? o The ointment may diminish the infant's vision, interfering with the bonding process o The delay allows the nurse to discuss the importance of health promotion with the family. ▪ The ointment prevents infection from Neisseria Gonorrhea infection and should be delayed for one hour. o The ointment protects the infant from environmental pollutants and should be given within the first hour. • A 26-year-old woman is pregnant with her second child. She reveals that she has to travel to a relative's home which is about 1000 miles from her home. Which instructions should be given to this client? SELECT ALL THAT APPLY o It is safest to travel during the third trimester. ▪ You need to take breaks to walk and stretch every couple of hours. ▪ You should obtain copies of your prenatal records before travel. ▪ You should drink enough water to prevent dehydration. ▪ You should always wear your seatbelt. • Which measure is most appropriate for relief of back pain in pregnancy? o Wear supportive shoes with a 3 inch or higher heel o Fully relax the abdominal muscles when standing for long times o Wear a tightly fitted abdominal support garment ▪ Do pelvic tilt exercise several times daily. • The nurse is discussing kick counts with a group of pregnant women at a prenatal class. What should be included in the teaching plan? ▪ Decreased fetal movement may indicate that the fetus is asleep. o Fetal movements should be assessed following a meal o Count the fetal movements for 30 - 60 minutes 8 times per day. o If the fetus moves fewer than 25 times per day, notify the physician. • When the nurse observes the client bearing down with contractions and crying out, "The baby is coming!" What is the nurse's best response? ▪ Put on the call light and stay with the woman. o Go immediately to the nurse's station to call the health care provider. o Ask the woman's partner to go for help. o Calm the woman and assist her with breathing. • A client is admitted to the labor and delivery unit for fetal demise. The nurse caring for parents of the demised infant best determines the discussion with the parents was effective when the parents respond in which way? o State they have no questions o Are surprised by the infant's appearance o Refuse to take the footprint and photo of the infant ▪ Ask to hold the infant and name him • A nurse is caring for a 16-year-old client who is pregnant for the first time. While taking a nutritional history, which statement by the client suggests a potential problem? o I need to eat more nutrient dense foods than I am used to eating. o I don't like milk, but do eat other dairy products, and green leafy vegetables. ▪ I want a small petite baby, so I will try not to gain more than 10 pounds. o I will continue eating my afternoon snack of popcorn. • Which statement by a parent indicates understanding of how to feed their infant who had surgical repair of a cleft lip? o "We resumed bottle feeding after discharge." ▪ "We are feeding the baby with a dropper for two weeks." o "The baby is drinking well from a straw." o "We started the baby on solid food yesterday." • A woman asks the nurse about the frequency of prenatal visits. In an uncomplicated pregnancy, the nurse would tell her that appointments are scheduled how often? o Every 3 weeks until the 6th month, then every 2 weeks until delivery. o Every 2 - 3 weeks throughout the pregnancy o Every month until the eighth month, then every week until delivery. ▪ Every 4 weeks until the 7th month, after which appointments become more frequent. • The nurse is caring for an infant born at 43 weeks. What would you expect on physical assessment? o short, rough nails. o abundant lanugo on the body. o minimal hair on the head. ▪ dry, peeling skin • When assessing a preterm infant, the nurse observes nasal flaring, sternal retractions, and expiratory grunting. What condition are these findings indicative? o Postmaturity syndrome o Apneic episode ▪ Respiratory Distress Syndrome o Cold stress syndrome • The LPN is assigned to assist the RN in caring for a client who is on a magnesium sulfate infusion. The LPN assesses the client every 30 minutes. Which finding should be reported to the RN immediately? o The client reports fatigue and a warm flush o Urinary output of 20 since the last assessment o Fetal heart rate of 118 ▪ Respirations of less than 10 • A pregnant client tells the nurse "I just found out that I am having twins instead of one baby!" Which response is the most therapeutic? o Oh, you poor thing, you must be feeling overwhelmed ▪ This sounds like a surprise to you; how are you feeling about this? o You will definitely need a vacation before you have the babies. o How exciting! You and your husband must be thrilled! • A nurse is caring for a woman who is diagnosed with gestational diabetes. The nurse recognizes that the client is able to identify symptoms of hypoglycemia when she lists which as a symptom of hypoglycemia? o Increased urination o increased thirst ▪ shaking and tremor o Decreased appetite • When the client asks when her infant's heart will begin to pump blood, the nurse replies that blood circulation begins at what gestational age? ▪ By the end of week 3. o By the end of week 14 o By the end of week 24 o By the beginning of week 40 • What is an appropriate nursing action while caring for an infant having phototherapy? o Reposition at least every 4 to 8 hours. o Cover the infant's head with a hat. ▪ Keep the infant's eyes covered. o Dress the infant lightly in a T-shirt. • A seven-year-old girl is being discharged from the hospital following emergency surgery for appendicitis. What should the RN teach the family? SELECT ALL THAT APPLY o Keep the child on clear liquids for the next few weeks ▪ Monitor for signs of infection such as fever ▪ Keep the incision clean and dry o Encourage outdoor activities ▪ Manage the child’s pain with medications • During a routine prenatal visit, a pregnant client complains that she has been unable to get her wedding ring off. She states that "The heat is making my fingers swell." Which symptom is most important for the nurse to assess? ▪ blood pressure and protein in the urine o fundal height and maternal heart rate o glucose in the urine blood glucose o changes in vaginal discharge. • A nurse is caring for a 19 year old woman who is six weeks pregnant with her first child. The woman tells the nurse that she smokes one pack of cigarettes a day. The nurse should explain that newborns of women who smoke are at particular risk for which problem? o hearing loss ▪ intrauterine growth restriction o gestational diabetes o congenital heart defects • A 15 year old client is pregnant for the first time wants to know how much weight gain is normal. Which responses is most accurate? o You should be careful not to gain too much o You should gain about 15 - 20 pounds. ▪ You should gain between 25 - 35 pounds. o You should gain between 35 - 50 pounds. • The nurse is caring for a newborn who weighed 7 lbs, 8 oz. at birth (7.5 lbs). The nurse needs to determine the infant's weight in kilograms. What is the infant's weight in kilograms (round to the nearest tenth place)? ▪ 3.4 kg o 3.54 kg o 3.55 kg o 7.5 kg • A nurse is caring for a woman who is in labor with her first child. The client states that she feels wet. The nurse notes that the amniotic fluid sac has ruptured. Which is most important for the nurse to note at this time? o The reaction of the client to the ruptured membranes ▪ The time, amount, color and odor of the fluid o The fetal heart rate and maternal vital signs o The cervical dilation and station • A nurse is caring for a pre-eclamptic client, when the client suddenly progresses to an eclampsia state. What is the initial action the nurse should take? o Obtain fetal heart rate o Check the maternal blood pressure ▪ Maintain a patent airway o Administer oxygen via face mask • A pregnant client in the third trimester of pregnancy complains of urinary frequency. Which strategy can help manage this discomfort associated with pregnancy? o Avoid drinking fluid after 7:00 pm. o Avoid completely emptying the bladder o Drink a minimum of 2,000 mL daily ▪ Empty the bladder regularly • A woman in active labor has an epidural infusion in place. She is currently 5 cm dilated. What is the top nursing priority at this time? ▪ Assess the bladder at regular intervals o Assess for hypertension every 15 minutes o Encourage the woman to walk to facilitate labor o Assist the woman to a supine position • What statement by a nurse demonstrates understanding of cultural beliefs and practices of a childbearing woman during pregnancy o All women are comfortable discussing sexual practices with her healthcare provider. ▪ Many women find it difficult to discuss sexual practices because of traditional beliefs and practices. o Most males in all cultures are informed about information related to the spread of sexually transmitted infections o Safe sex practices are common in most cultural groups, and should be fully supported. • The nurse is caring for an infant who delivered by cesarean section four hours ago. Which finding should be reported to the health care provider at once? o Respiratory rate of 56 o Heart rate persistently 150 - 160 beats per min o Bruising of the face, head, and extremities ▪ Jaundice of the skin • A pregnant client complains that she is having swelling in her ankles at the end of the day. Which statement by the client indicates the need for further teaching? ▪ "I should avoid frequent rest periods." o "I should elevate my feet during the day." o "I should wear supportive stockings or hose." o "I should avoid standing in one position for long periods." • A woman is pregnant with her first child at eight weeks of pregnancy, and is complaining of morning sickness. Which strategy might the nurse suggest to reduce the feeling of nausea? o Eat high protein foods in the morning, such as eggs, peanut butter and protein shakes ▪ Eat dry carbohydrates before getting out of bed in the morning, such as crackers o Eat three well balanced meals per day, and eliminate snacks between meals. o Eat your spicy and fatty foods at the noon meal, and avoid spicy foods between meals. • A first time mother is admitted to the labor room, and is complaining of "back labor". The nurse assists the woman to the hands and knees position because this position can help to do what? o distract the woman from the pain of labor o determine the position of the fetus in the pelvis ▪ rotate the fetus from posterior to anterior o prevent fetal distress syndrome. • The nurse recognizes it is important to assess the laboring woman's bladder for fullness and distention during labor, because a full bladder during labor can contribute to what problem? o postpartum urinary tract infection ▪ slow progress during labor o increased sensation of pain o proteinuria • A nurse in a prenatal clinic overhears a student practical nurse discussing conception with a client. Which statement by the student practical nurse requires intervention by the nurse? o Fertilization takes place in the outer third of the fallopian tube ▪ Implantation occurs between three to four weeks after conception o Sperm remain viable in the woman's reproductive tract for 2 - 3 days o Bleeding or spotting can accompany implantation. • When a labor dysfunction due to decreased uterine muscle tone occurs in a client who is dilated to 5 cm with membranes intact, the nurse informs the client that the most likely the health care provider will do what? o an emergency cesarean section. ▪ an amniotomy. o initiate tocolytic drugs. o order a sedative for the client. • A nurse is planning to teach an adolescent client about sexuality. The nurse should begin the teaching session by doing which action? ▪ Determining the client's knowledge about sexuality o Informing the client about the dangers of pregnancy o Advising the client to maintain sexual abstinence until marriage o Providing the client with written information about sexually transmitted infections. • What special precaution should the nurse caring for an infant with hydrocephalus take? ▪ Support the head. o Keep the head elevated on a pillow o Monitor intake and output o Align the limbs • The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. The panicked woman asks the nurse, "Please give me something." After calling for assistance, what is the most appropriate pain relief intervention for a woman in precipitate labor? ▪ Stay and breathe with her during contractions. o Get an order for an intravenous narcotic. o Notify the anesthesiologist for an epidural block. o Tell her to bear with it because she is close to delivery. • During the initial examination of a newborn, the nurse discovers cryptorchidism and these findings are shared with the parents. The nurse understands that if this condition is not corrected, which of the following could have a psychosocial impact? o atrophy ▪ infertility o malignancy o feminization • The parents of a male infant who will have an inguinal hernia repair make the following comments. Which comment requires follow up by the nurse? o I understand that surgery will repair the hernia ▪ I don't know if he will be able to father a child o We will sponge bathe him for a few days after surgery o I bought extra diapers because we will change him frequently after surgery • Which description best describes cryptorchidism to a new mother? ▪ It occurs when one or both testes fail to descend into the scrotal sac. o It is a congenital anomaly which involves the urethral opening being on the underside of the penis o It is a congenital anomaly which involves the urethral opening being on the dorsal side of the penis o It is a congenital anomaly which involves the urinary bladder being on the outside of the body through an opening in the lower abdominal wall • The client who is 40 weeks pregnant complains of a sense of weakness and dizziness when she lies on her back. The nurse assesses this as an indication of what condition? o gestational hypertension o pseudoanemia ▪ supine hypotension o orthostatic hypotension • For security purposes, when the nurse brings the infant from the nursery to the mother the nurse should do what? o Ask, "Is this your band number?" ▪ Check the band number of the infant to that of the mother. o Confirm room number of mother. o Ask the mother to identify herself verbally. o Ask the mom if this is her baby? • Where is the usual location for implantation of the zygote during insemination? o lateral aspect of the uterine wall. o lower portion of the uterus near the cervical os. o inner third of the fallopian tube near the uterus. ▪ upper section of the posterior uterine wall. • A nurse at a well-baby clinic is collecting data about the language and communication patterns of a seven month old infant. The nurse understands that what occurs at this stage of development? o Cooing sounds ▪ Use of gestures o Use of one to three word sentences o Increased interest in sounds • A client in labor is observed changing body positions, bearing down, and making expiratory vocalizations. The nurse knows that this client is most likely in which stage of labor? ▪ First stage, transition phase o Second stage, latent phase o Third stage, transition phase o Second stage, descent phase • A first time mother asks if she should deliver at the hospital, or if she could deliver at a birthing center. Which responses are appropriate for the nurse? Select all that apply o You should deliver at the hospital since it is safer ▪ Have you done any research on your options? ▪ Which option do you think would best suit your needs? o You will not be able to have any pain management at a birthing center. ▪ There are risks and benefits to each of your options. Show Less