NUR 318 Focus on Maternity Exam Questions & Answers

NUR 318 Focus on Maternity Exam Questions & Answers 1. The home care nurse is instructing a client with hyperemesis gravidarum about measures to ease the nausea and vomiting. What does the nurse tell the client to do? A. Eat foods high in calories and fat B. Lie down for at least 20 minutes after meals C. Eat carbohydrates such as cereals, rice, and pasta Correct D. Consume primarily soups and liquids at mealtimes Rationale: Low-fat foods and easily digested carbohydrates such as fruit, breads, cereals, rice, and pasta provide important nutrients and help prevent a low blood glucose level, which can cause nausea. Soups and other liquids should be taken between meals to avoid distending the stomach and triggering nausea. Sitting upright after meals reduces gastric reflux. Additionally, food portions should be small and foods with strong odors should be eliminated from the diet, because food smells often incite nausea. Test-Taking Strategy: Use the process of elimination and focus on the client’s diagnosis and the subject, ways to ease and prevent nausea and vomiting. Knowing that foods high in fat may be difficult to digest will assist you in eliminating this option. Next eliminate the option that involves consuming primarily soups and fluids at meals, recalling that liquids will cause distention of the stomach. To select from the remaining options, recall that lying down after meals can cause gastric reflux; this will direct you to the correct option. Review: preventing nausea and vomiting Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Maternity/Antepartum Giddens Concepts: Fluid and Electrolytes, Nutrition HESI Concepts: Fluids and Electrolytes, Nutrition Awarded 100.0 points out of 100.0 possible points. 2. The nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate infusion to prevent eclampsia. Which finding indicates to the nurse that the medication is effective? A. Clonus is present. B. Magnesium level is 10 mg/dL (4.11 mmol/L). C. Deep tendon reflexes are absent. D. The client experiences diuresis within 24 to 48 hours. Correct Rationale: Magnesium sulfate is effective in preventing seizures (eclampsia) if diuresis occurs within 24 to 48 hours of the start of the infusion. As part of the therapeutic response, renal perfusion is increased and the client is free of visual disturbances, headache, epigastric pain, clonus (the rapid rhythmic jerking motion of the foot that occurs when the client’s lower leg is supported and the foot is sharply dorsiflexed), and seizure activity. Hyperreflexia indicates cerebral irritability. Clonus is normally not present. The therapeutic magnesium level is 4 to 8 mg/dL (1.64 to 3.29 mmol/L). Reflexes range from 1+ to 2+ but should not be absent. Test-Taking Strategy: Focus on the subject, client with preeclampsia. Use the process of elimination and focus on the strategic word“effective”. This indicates that the action of the medication is appropriate. Recalling the actions of this medication and expected assessment findings after a client receives magnesium sulfate will direct you to this option. Review: magnesium sulfate infusion Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology Giddens Concepts: Evidence, Perfusion HESI Concepts: Evidence-Based Practice/Evidence, Perfusion/Clotting Awarded 100.0 points out of 100.0 possible points. 3. A client with preeclampsia who is receiving magnesium sulfate in an intravenous infusion exhibits signs of magnesium toxicity. The nurse immediately prepares for the administration of: A. Vitamin K B. Protamine sulfate C. Calcium gluconate Correct D. Naloxone hydrochloride Rationale: Calcium gluconate is the antidote to magnesium sulfate because it antagonizes the effects of magnesium at the neuromuscular junction. It should be readily available whenever magnesium is administered. Vitamin K is the antidote in cases of hemorrhage induced by the administration of oral anticoagulants such as warfarin sodium (Coumadin). Protamine sulfate is the antidote in cases of hemorrhage induced by the administration of heparin. Naloxone hydrochloride is administered to treat opioid-induced respiratory depression. Test-Taking Strategy: Focus on the subject of the question, the treatment for magnesium toxicity. Specific knowledge regarding antidotes and the process of elimination will assist in directing you to the correct option. Review: common antidotes if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Gahart, B., & Nazareno, A. (2015). 2015 Intravenous medications (31st ed., p. 773). St. Louis: Mosby. Awarded 100.0 points out of 100.0 possible points. 4. The maternity nurse is caring for a pregnant client with no history of preeclampsia who is receiving a magnesium sulfate infusion. Why is this client receiving this infusion? A. To contract the uterus Correct B. To treat hypotension C. To reverse extreme muscle weakness D. To halt preterm labor contractions respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels Test-Taking Strategy: Focus on the subject, pregnant client receiving magnesium sulfate infusion. Know that magnesium sulfate is used to relax smooth muscle, not contract the muscle. Note the options that are comparable or alike in that they are related to treating hypotension and reverse extreme muscle weakness because these conditions are adverse effects of this medication. Review: Magnesium sulfate infusion Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Awarded 100.0 points out of 100.0 possible points. 5. The nurse instructs a pregnant client about foods that are high in folic acid. Which item does the nurse tell the client is the best source of folic acid? A. Milk B. Steak C. Chicken D. Lima beans Correct Rationale: The best sources of folic acid are liver; kidney, pinto, lima, and black beans; and fresh dark-green leafy vegetables. Other good sources of folic acid are orange juice, peanuts, refried beans, and peas. Milk is high in calcium. Chicken and steak are high in protein. Test-Taking Strategy: Use the process of elimination and focus on the subject, source of folic acid. Note the strategic word “best”. This indicates the most appropriate source of folic acid. Eliminate the options that are comparable or alike in that they are high in protein. Next eliminate milk, recalling that milk is high in calcium. Review: foods high in folic acid Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Nutrition Giddens Concepts: Nutrition, Reproduction HESI Concepts: Metabolism – Nutrition, Sexuality, Reproduction Awarded 100.0 points out of 100.0 possible points. 6. The nurse is providing instructions to a mother of an infant with seborrheic dermatitis (cradle cap) about treatment of the condition. What does the nurse tell the mother to do? A. Avoid the use of shampoo on the infant’s scalp B. Apply oil to the affected area on the infant’s scalp Correct C. Wash the infant’s scalp daily, using only tepid water D. Shampoo the infant’s scalp, avoiding the anterior fontanel area Rationale: Treatment includes the application of oil (e.g., mineral oil) to the area to help soften the lesions followed by gentle removal of the scaly lesions with a comb before the head is shampooed. Seborrheic dermatitis, a chronic inflammation of the scalp or other areas of the skin, is characterized by yellow, scaly, oily lesions. It sometimes results when parents do not wash over the anterior fontanel carefully for fear that they will hurt the infant. The nurse should teach the mother how to shampoo the scalp and explain that she will not damage the fontanel with normal gentle shampooing. The scalp should be rinsed well to remove all soap, which could cause irritation. Test-Taking Strategy: Focus on the subject, infant with seborrheic dermatitis. Use the process of elimination. Eliminate the option containing theclosed-ended word “only.” To select from the remaining options, recall that this condition is characterized by the presence of scaly lesions; this will direct you to the correct option. Review: seborrheic dermatitis (cradle cap) Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Newborn Giddens Concepts: Client Education, Tissue Integrity HESI Concepts: Teaching and Learning/Patient Education, Tissue Integrity Awarded 100.0 points out of 100.0 possible points. 7. The nurse is monitoring a client who was given an epidural opioid for a cesarean birth. The nurse notes that the client’s oxygen saturation on pulse oximetry (Spo2) is 92%. What should the nurse do first? A. Documents the findings B. Contacts the primary health care provider C. Administers 100% oxygen by way of face mask D. Instructs the client to take several deep breaths Correct Rationale: If the client has been given an epidural opioid, the nurse should monitor the client’s respiratory status closely. If the Spo2 falls below 95%, the nurse instructs the client to take several deep breaths to increase the level. Although the finding would be documented, action is required to increase the oxygen saturation level. It is not necessary to contact the primary health care provider. If the deep breaths fail to increase the oxygen saturation level, the primary health care provider is notified and may prescribe oxygen. eliminating this option. Noting the strategic word “first” will direct you to the correct option. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Giddens Concepts: Clinical Judgment, Gas Exchange HESI Concepts: Clinical Decision-Making/Clinical Judgment, Oxygenation/Gas Exchange Awarded 100.0 points out of 100.0 possible points. 8. A client who delivered a healthy newborn 11 days ago calls the clinic and tells the nurse that she is experiencing a white vaginal discharge. What does the nurse tell the client? A. To perform a vaginal douche B. To come to the clinic for a checkup C. That this is an indication of an infection D. That this is a normal postpartum occurrence Correct Rationale: For the first 3 days following childbirth, lochia consists almost entirely of blood, with small particles of decidua and mucus, and is called lochia rubra because of its red color. The amount of blood decreases by about the fourth day, at which time the lochia changes from red to pink or brown-tinged; this stage is called lochia serosa. By about the 11th day, the erythrocyte component of lochia has decreased and the discharge becomes white or cream- colored. This final stage is known as lochia alba. Lochia alba contains leukocytes, decidual cells, epithelial cells, fat, cervical mucus, and bacteria. It is present in most women until the third week after childbirth but may persist for as long as 6 weeks. Lochia alba is a normal finding during the postpartum course, and no intervention is required, so the other options are incorrect. Test-Taking Strategy: Focus on the subject, client with white vaginal discharge 11 days after normal delivery. Use your knowledge of expected postpartum findings to answer the question. Recalling the normal expected occurrences in regard to vaginal discharge will direct you to the correct option. Also, noting that the incorrect options are comparable or alike will direct you to the correct option. Review: normal postpartum findings Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Giddens Concepts: Clinical Judgment, Reproduction HESI Concepts: Clinical Decision-Making/Clinical Judgment, Sexuality/Reproduction Awarded 100.0 points out of 100.0 possible points. 9. A rubella antibody screen is performed on a pregnant client, and the results indicate that the client is not immune to rubella. What does the nurse tell the client to do? A. A rubella vaccine must be administered immediately B. A rubella vaccine must be administered after childbirth Correct C. She will not contract rubella if she is exposed to the disease D. She does not need to be concerned about being exposed to rubella determine whether she is immune to rubella, which can cause serious fetal anomalies. If she is not immune, rubella vaccine is offered after childbirth to keep her from contracting rubella during subsequent pregnancies. The vaccine is a live virus, and defects might occur in the fetus if the vaccine were administered during pregnancy or if the mother were to become pregnant soon after it was administered. Administering a rubella vaccine immediately places the fetus at risk. Telling the client that she does not need to be concerned about being exposed to rubella is incorrect, because the possibility of exposure, which could be harmful to the fetus, does exist. Test-Taking Strategy: Focus on the subject, pregnant women who is not immune to rubella. Use the process of elimination. Eliminate first the options that are comparable or alike (i.e., the client will not acquire rubella and does not need to be concerned about exposure). To select from the remaining options, recall that rubella vaccine is a live virus; this will direct you to the correct option. Review: rubella vaccine during pregnancy Level of Cognitive Ability: Applying Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum Giddens Concepts: Immunity, Safety HESI Concepts: Immunity, Safety Awarded 100.0 points out of 100.0 possible points. 10. The nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The nurse takes the client’s temperature and notes that it is 38° C (100.4° F). What is the most appropriate nursing action? A. Contact the primary health care provider B. Recheck the temperature in 1 hour C. Encourage the intake of oral fluids Correct D. Tell the client that antibiotics will be prescribed Rationale: Because the client delivered her baby just 12 hours ago, the most appropriate nursing action is to encourage the intake of oral fluids. A temperature of 38° C (100.4° F) is common during the 24 hours after childbirth. It may be the result of dehydration or normal postpartum leukocytosis. If the increased temperature persists for longer than 24 hours or exceeds 38° C, infection is a possibility, and the fever is reported to the primary health care provider or nurse midwife. Test-Taking Strategy: Focus on the subject, post-partum client with temperature of 38° C (100.4° F.). Note the strategic words “most appropriate”. This indicates the best action the nurse should take in this situation. Use the process of elimination. Also, note the words “12 hours ago” and recall that a low-grade temperature is a common postpartum assessment finding. This will direct you to the correct option. Review: normal post-partum vital signs Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Giddens Concepts: Reproduction, Thermoregulation HESI Concepts: Sexuality/Reproduction, Thermoregulation Awarded 100.0 points out of 100.0 possible points. 11. The nurse is assessing the uterine fundus of a client who has just delivered a baby and notes that the fundus is boggy. The nurse massages the fundus, and then presses to expel clots from the uterus. To prevent uterine inversion during this procedure, what should the nurse do? A. Have the client void before the uterine assessment B. Tell the woman to bear down during fundal message C. Simultaneously provide pressure over the lower uterine segment Correct D. Ask the client to take slow, deep breaths during fundal assessment Rationale: After massaging a boggy fundus until it is firm, the nurse presses the fundus to expel clots from the uterus. The nurse must also keep one hand pressed firmly just above the symphysis (over the lower uterine segment) the entire time. Removing the clots allows the uterus to contract properly. Providing pressure over the lower uterine segment prevents uterine inversion. Having the client void before uterine assessment will not prevent uterine inversion. Telling the woman to bear down while the nurse performs fundal message and asking the client to take slow, deep breaths during fundal assessment also will not prevent uterine inversion. Test-Taking Strategy: Use the process of elimination, focusing on the subject, prevention of uterine inversion. Visualizing each of the actions in the options and relating the action to the subject of the question will direct you to the correct option. Review: fundal assessment and massage Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Giddens Concepts: Reproduction, Safety HESI Concepts: Sexuality/Reproduction, Safety Awarded 100.0 points out of 100.0 possible points. 12. A nonstress test is performed, and the primary health care provider documents “accelerations lasting less than 15 seconds throughout fetal movement.” How does the nurse interpret these findings? A. Normal B. Reactive C. Nonreactive Correct D. Inconclusive Rationale: A reactive nonstress test is a normal, or negative, result and indicates a healthy fetus. The result requires two or more fetal heart rate accelerations of at least 15 beats/min lasting at least 15 seconds from the beginning of the acceleration to the end, in association with fetal movement, during a 20-minute period. A nonreactive test is an abnormal test, showing no accelerations or accelerations of less than 15 beats/min or lasting less than 15 seconds during a 40- minute observation. An inconclusive result is one that cannot be interpreted because of the poor quality of the fetal heart rate recording. Test-Taking Strategy: Focus on the subject, nonstress test performed on a pregnant client. Use the process of elimination. Eliminate a reactive nonstress test and a normal nonstress test first because they are comparable or alike. To select from the remaining options, note the relationship between “less than 15 seconds” in the question and “nonreactive” in the correct option. Review: interpretation of nonstress test results Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Maternity/Antepartum Giddens Concepts: Clinical Judgment, Reproduction HESI Concepts: Clinical Decision-Making/Clinical Judgment, Sexuality/Reproduction Awarded 100.0 points out of 100.0 possible points. 13. A stillborn infant was delivered a few hours ago. After the birth, the family remains together, holding and touching the baby. Which statement by the nurse is appropriate? A. “I know how you feel.” B. “This must be hard for you.” Correct C. “Now you have an angel in heaven.” D. “You’re young. You can have other children.” Rationale: Therapeutic communication helps the mother, father, and other family members express their feelings and emotions. “This must be hard for you” is a caring and empathetic response, focused on feelings and encouraging communication. The other options are nontherapeutic and may devalue the family members' feelings. Test-Taking Strategy: Focus on the subject, comments to family after stillborn infant is delivered. Note the strategic word “appropriate”. This indicates the best statement the nurse can give in this situation. Use your knowledge of therapeutic communication techniques. The correct option is the only option that is focused on the family members’ feelings. Review: therapeutic communication Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Maternity/Postpartum Giddens Concepts: Communication, Coping HESI Concepts: Communication, Grief and Loss Awarded 100.0 points out of 100.0 possible points. 14. The nurse is providing nutritional counseling to pregnant client with a history of cardiac disease. What does the nurse advise the client to eat? A. Water and pretzels B. Low-fat cheese omelet C. Nachos and fried chicken D. Apple and whole-grain toast Correct woman needs a well-balanced diet high in iron and protein and adequate in calories for weight gain. Iron supplements that are taken during pregnancy tend to cause constipation. Constipation causes the client to strain during defecation, inadvertently performing the Valsalva maneuver, which causes blood to rush to the heart and overload the cardiac system. The pregnant woman, then, should increase her intake of fluids and fiber. An unlimited intake of sodium (pretzels, cheese, nachos) could cause overload of the circulating blood volume and contribute to the cardiac condition. Test-Taking Strategy: Focus on the subject, nutritional counseling to a pregnant client. Use the process of elimination and note that the client has a history of cardiac disease. Recalling the concepts of care of the client with cardiac disease and noting that the question involves a client who is pregnant will direct you to the correct option. Review: dietary requirements for pregnant client with heart diesase Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Maternity/Antepartum Giddens Concepts: Nutrition, Reproduction HESI Concepts: Metabolism – Nutrition, Sexuality, Reproduction Awarded 100.0 points out of 100.0 possible points. 15. The nurse is reviewing the records of the clients admitted to the maternity unit during the past 24 hours. Which clients does the nurse recognize as being at risk for the development of disseminated intravascular coagulation (DIC)? Select all that apply. A. A client with septicemia Correct B. A client with mild preeclampsia C. A client with diabetes mellitus who delivered a 10-lb (4.5 kg) baby D. A client who had a cesarean section because of abruptio placentae Correct E. A client who delivered 12 hours ago and has lost 475 mL of blood Rationale: DIC is a pathologic form of clotting that is diffuse and consumes large amounts of clotting factors, including platelets, fibrinogen, prothrombin, and factors V and VII. In the obstetric population, DIC occurs as a result of septicemia, abruptio placentae, amniotic fluid embolism, dead fetus syndrome (in which the fetus has died but is retained in utero for at least 6 weeks), severe preeclampsia, cardiopulmonary arrest, or hemorrhage. A loss of 475 mL is not considered hemorrhage. A mild case of preeclampsia is not a risk factor for DIC. It is not unusual for a client with diabetes mellitus to deliver a large baby, and this condition is unrelated to DIC. Test-Taking Strategy: Use the process of elimination and focus on the subject, the client at risk for DIC. Thinking about the pathophysiology of DIC and the conditions listed in the options will assist in answering correctly. Review: risk factors associated with DIC Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Maternity/Intrapartum Giddens Concepts: Reproduction, Perfusion HESI Concepts: Sexuality/Reproduction, Perfusion/Clotting Awarded 100.0 points out of 100.0 possible points. 16. The delivery room nurse is preparing a client for a cesarean delivery. The client is placed on the delivery room table. How does the nurse position the client? A. Prone B. In a semi-Fowler position C. In the Trendelenburg position D. Supine with a wedge under the right hip Correct Rationale: The pregnant client is positioned so that the uterus is displaced laterally to prevent compression of the inferior vena cava, which causes decreased placental perfusion. This is accomplished by placing a wedge under the hip. Positioning for abdominal surgery necessitates a supine position. The Trendelenburg position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler or prone position is not practical for this type of abdominal surgery.