Test Bank For Essentials of Maternity, Newborn, and Women's
Health Nursing 4th Edition by Susan Ricci
A nurse is providing dietary counseling to a client at 14 weeks' gestation. The client is
a recent immigrant from Asia, and the nurse explores the foods that the client
usually eats. Which foods should the nurse counsel the client to avoid during
pregnancy? (Select all that apply.) - ANSWER: Raw shellfish
Herbal supplements
Soft-scrambled eggs
An expectant couple asks the nurse about the cause of low back pain during labor.
The nurse replies that this pain occurs most often when the fetus is positioned: -
ANSWER: Occiput posterior
How does the nurse know that a client at 40 weeks' gestation is experiencing true
labor? - ANSWER: Cervical dilation
A nurse is caring for a client who is receiving internal radiation for cancer of the
cervix. For which adverse reactions to the radiotherapy should the client be
monitored? (Select all that apply.) - ANSWER: Hemorrhage
Increased temperature
A client who has breast cancer had postlumpectomy chemotherapy and is now
scheduled for radiation on an outpatient basis. What is an important nursing
intervention while the client is receiving radiation? - ANSWER: Observing the
irradiated site daily for redness or irritation
A nurse is counseling a pregnant woman with type 1 diabetes. What is the most
important nursing consideration in the planning of care for this client? - ANSWER:
Requirement of intensive prenatal care
A 7-lb, 4-oz (3290-g) boy is admitted to the nursery and placed in a warm crib. The
neonate begins to choke on mucus. How should the nurse suction him with a bulb
syringe? - ANSWER: By suctioning the mouth before the nostrils
What should the nurse's initial discussion include to best help new parents
understand the unique characteristics of a newborn? - ANSWER: Expected
movements and behaviors
A parent of a preterm infant in the neonatal intensive care unit, asks a nurse why the
baby is in a bed with a radiant warmer. The nurse explains that preterm infants are
at increased risk for hypothermia because they: - ANSWER: Lack the subcutaneous
fat that usually provides insulation
,On a routine prenatal visit the sign or symptom that a healthy primigravida at 20
weeks' gestation will most likely report for the first time is: - ANSWER: Quickening
While caring for a client in labor, a nurse notes that during a contraction there is a
15-beat/min acceleration of the fetal heart rate above the baseline. What is the
nurse's next action? - ANSWER: Record the fetal response to contractions and
continue to monitor the heart rate
A nurse in the fertility clinic works with couples who have been trying to become
pregnant for more than 1 year. How can the nurse help ease the feeling of isolation
that infertile couples often experience? - ANSWER: Explore ways to promote
communication with family and friends
During a pelvic examination of a 24-year-old woman, the nurse suspects a vaginal
infection because of the presence of a white curdlike vaginal discharge. What other
assessment supports a fungal vaginal infection? - ANSWER: An itchy perineum
A client states that she wishes to use the calendar method of birth control. The nurse
concludes that the client understands how to calculate the beginning of the fertile
period when she states, "I will: - ANSWER: Subtract 18 days from the length of my
shortest cycle"
A client who has had a mastectomy asks what the term ERP-positive means. How
should the nurse explain this finding? - ANSWER: The tumor cells generally exhibit a
positive response to hormone therapy that reduces estrogen.
A newborn of 30 weeks' gestation has a heart rate of 86 beats/min and slow,
irregular respirations. The infant grimaces in response to suctioning, is cyanotic, and
has flaccid muscle tone. What Apgar score should the nurse assign to this neonate? -
ANSWER: 3
A nurse in the fertility clinic is instructing a client who will be using progesterone gel
vaginally in the treatment of luteal phase infertility. When discussing the side effects
of progesterone, what should the nurse tell the client to expect? - ANSWER:
Enlarged, tender breasts
A health care provider determines that a fetus is in a breech presentation. For which
complication should the nurse monitor the client? - ANSWER: Nonreassuring fetal
signs, indicating prolapse of the cord
Women who become pregnant for the first time at a later reproductive age (35 years
or older) are at risk for what complications? (Select all that apply.) - ANSWER:
Preterm labor
Multiple gestation
Chromosomal anomalies
Bleeding in the first trimester
,A client at term is admitted in active labor. She has tested positive for HIV. Which
intervention in the standard orders should the nurse question as a risk to the fetus? -
ANSWER: Internal fetal scalp electrode
A client who had a cesarean birth is unable to void 3 hours after the removal of an
indwelling catheter. How can the nurse evaluate whether the client's bladder is
distended? - ANSWER: By palpating the client's suprapubic area gently
What instruction should a nurse include when teaching about the correct use of a
female condom? - ANSWER: "Remove the condom before standing up."
A nurse expects signs of respiratory distress syndrome (RDS) in a neonate whose
mother: - ANSWER: Has type 1 diabetes
A preterm infant with respiratory distress syndrome (RDS) has blood drawn for an
arterial blood gas analysis. What test result should the nurse anticipate for this
infant? - ANSWER: Decreased blood pH
After a spontaneous vaginal delivery the client expresses concern because the
newborn has a red rash with small papules on the face, chest, and back. What
condition does the nurse recognize? - ANSWER: Erythema toxicum
The nurse concludes that a couple with a newborn with Erb's palsy has an accurate
understanding of the infant's prognosis. Which statement confirms this conclusion? -
ANSWER: "Recovery usually occurs in about 3 months."
A new mother's laboratory results indicate the presence of cocaine and alcohol.
Which craniofacial characteristic indicates to the nurse that the newborn has fetal
alcohol syndrome (FAS)? (Select all that apply.) - ANSWER: Thin upper lip
Small upturned nose
Smooth vertical ridge in the upper lip
Which statement is true regarding caput succedaneum in newborns? - ANSWER: It is
swelling consisting of serum, blood, or both.
The nurse explains to a pregnant client undergoing a nonstress test that the test is a
way of evaluating the condition of the fetus by comparing the fetal heart rate with: -
ANSWER: Fetal movement
A client in the 38th week of gestation exhibits a slight increase in blood pressure. The
health care provider advises her to remain in bed at home in a side-lying position.
The client asks why this is important. What is the nurse's response regarding the
advantage of this position? - ANSWER: It increases blood flow to the fetus.
When reviewing the history of a client admitted in preterm labor during her 30th
week of gestation, the nurse suspects a risk factor associated with this client's
preterm labor. What is this risk factor? - ANSWER: Multiple urinary tract infections
, During a client's labor the fetal monitor reveals a fetal heart pattern that signifies
uteroplacental insufficiency. What is the nurse's first intervention? - ANSWER:
Helping the client turn to the side-lying position
A client with mild preeclampsia is being treated on an outpatient basis. Three days of
bedrest is prescribed. What position should the nurse encourage the client to
maintain while in bed? - ANSWER: Side-lying
A client at 35 weeks' gestation who has had no prenatal care arrives in labor and
delivery and is found to be 20 percent effaced and 2 cm dilated, with her
membranes intact and contractions 3 minutes apart. The nurse notices some
ruptured blisterlike vesicles in the genital area. What should the nurse's next action
be? - ANSWER: Contacting the health care provider about the need for a cesarean
birth
A client is admitted to the high-risk prenatal unit with the diagnosis of placenta
previa. What should the nurse instruct the client to do? - ANSWER: Lie on her side to
avoid putting pressure on the vena cava
A woman is being seen in the prenatal clinic at 36 weeks' gestation. The nurse is
reviewing signs and symptoms that should be reported to health care provider with
the mother. Which signs and symptoms require further evaluation by the health care
provider? (Select all that apply.) - ANSWER: Decreased urine output
Contractions that are regular and 5 minutes apart
During labor a client who has been receiving epidural anesthesia has a sudden
episode of severe nausea, and her skin becomes pale and clammy. What is the
nurse's immediate reaction? - ANSWER: Turning the client on her side
What actions are part of nursing care during the fourth stage of labor for the client
with a fourth-degree laceration? (Select all that apply.) - ANSWER: Pain management
with oral analgesics
Assessment of the site every 15 minutes
Application of an ice pack for 20-minute intervals
What findings occur with supine hypotensive syndrome? (Select all that apply.) -
ANSWER: Feeling of faintness
Increased venous pressure
Decreased systolic pressure
What is the most important parameter for the nurse to monitor during the first 24
hours after the birth of an infant at 36 weeks' gestation? - ANSWER: Respiratory
distress
Health Nursing 4th Edition by Susan Ricci
A nurse is providing dietary counseling to a client at 14 weeks' gestation. The client is
a recent immigrant from Asia, and the nurse explores the foods that the client
usually eats. Which foods should the nurse counsel the client to avoid during
pregnancy? (Select all that apply.) - ANSWER: Raw shellfish
Herbal supplements
Soft-scrambled eggs
An expectant couple asks the nurse about the cause of low back pain during labor.
The nurse replies that this pain occurs most often when the fetus is positioned: -
ANSWER: Occiput posterior
How does the nurse know that a client at 40 weeks' gestation is experiencing true
labor? - ANSWER: Cervical dilation
A nurse is caring for a client who is receiving internal radiation for cancer of the
cervix. For which adverse reactions to the radiotherapy should the client be
monitored? (Select all that apply.) - ANSWER: Hemorrhage
Increased temperature
A client who has breast cancer had postlumpectomy chemotherapy and is now
scheduled for radiation on an outpatient basis. What is an important nursing
intervention while the client is receiving radiation? - ANSWER: Observing the
irradiated site daily for redness or irritation
A nurse is counseling a pregnant woman with type 1 diabetes. What is the most
important nursing consideration in the planning of care for this client? - ANSWER:
Requirement of intensive prenatal care
A 7-lb, 4-oz (3290-g) boy is admitted to the nursery and placed in a warm crib. The
neonate begins to choke on mucus. How should the nurse suction him with a bulb
syringe? - ANSWER: By suctioning the mouth before the nostrils
What should the nurse's initial discussion include to best help new parents
understand the unique characteristics of a newborn? - ANSWER: Expected
movements and behaviors
A parent of a preterm infant in the neonatal intensive care unit, asks a nurse why the
baby is in a bed with a radiant warmer. The nurse explains that preterm infants are
at increased risk for hypothermia because they: - ANSWER: Lack the subcutaneous
fat that usually provides insulation
,On a routine prenatal visit the sign or symptom that a healthy primigravida at 20
weeks' gestation will most likely report for the first time is: - ANSWER: Quickening
While caring for a client in labor, a nurse notes that during a contraction there is a
15-beat/min acceleration of the fetal heart rate above the baseline. What is the
nurse's next action? - ANSWER: Record the fetal response to contractions and
continue to monitor the heart rate
A nurse in the fertility clinic works with couples who have been trying to become
pregnant for more than 1 year. How can the nurse help ease the feeling of isolation
that infertile couples often experience? - ANSWER: Explore ways to promote
communication with family and friends
During a pelvic examination of a 24-year-old woman, the nurse suspects a vaginal
infection because of the presence of a white curdlike vaginal discharge. What other
assessment supports a fungal vaginal infection? - ANSWER: An itchy perineum
A client states that she wishes to use the calendar method of birth control. The nurse
concludes that the client understands how to calculate the beginning of the fertile
period when she states, "I will: - ANSWER: Subtract 18 days from the length of my
shortest cycle"
A client who has had a mastectomy asks what the term ERP-positive means. How
should the nurse explain this finding? - ANSWER: The tumor cells generally exhibit a
positive response to hormone therapy that reduces estrogen.
A newborn of 30 weeks' gestation has a heart rate of 86 beats/min and slow,
irregular respirations. The infant grimaces in response to suctioning, is cyanotic, and
has flaccid muscle tone. What Apgar score should the nurse assign to this neonate? -
ANSWER: 3
A nurse in the fertility clinic is instructing a client who will be using progesterone gel
vaginally in the treatment of luteal phase infertility. When discussing the side effects
of progesterone, what should the nurse tell the client to expect? - ANSWER:
Enlarged, tender breasts
A health care provider determines that a fetus is in a breech presentation. For which
complication should the nurse monitor the client? - ANSWER: Nonreassuring fetal
signs, indicating prolapse of the cord
Women who become pregnant for the first time at a later reproductive age (35 years
or older) are at risk for what complications? (Select all that apply.) - ANSWER:
Preterm labor
Multiple gestation
Chromosomal anomalies
Bleeding in the first trimester
,A client at term is admitted in active labor. She has tested positive for HIV. Which
intervention in the standard orders should the nurse question as a risk to the fetus? -
ANSWER: Internal fetal scalp electrode
A client who had a cesarean birth is unable to void 3 hours after the removal of an
indwelling catheter. How can the nurse evaluate whether the client's bladder is
distended? - ANSWER: By palpating the client's suprapubic area gently
What instruction should a nurse include when teaching about the correct use of a
female condom? - ANSWER: "Remove the condom before standing up."
A nurse expects signs of respiratory distress syndrome (RDS) in a neonate whose
mother: - ANSWER: Has type 1 diabetes
A preterm infant with respiratory distress syndrome (RDS) has blood drawn for an
arterial blood gas analysis. What test result should the nurse anticipate for this
infant? - ANSWER: Decreased blood pH
After a spontaneous vaginal delivery the client expresses concern because the
newborn has a red rash with small papules on the face, chest, and back. What
condition does the nurse recognize? - ANSWER: Erythema toxicum
The nurse concludes that a couple with a newborn with Erb's palsy has an accurate
understanding of the infant's prognosis. Which statement confirms this conclusion? -
ANSWER: "Recovery usually occurs in about 3 months."
A new mother's laboratory results indicate the presence of cocaine and alcohol.
Which craniofacial characteristic indicates to the nurse that the newborn has fetal
alcohol syndrome (FAS)? (Select all that apply.) - ANSWER: Thin upper lip
Small upturned nose
Smooth vertical ridge in the upper lip
Which statement is true regarding caput succedaneum in newborns? - ANSWER: It is
swelling consisting of serum, blood, or both.
The nurse explains to a pregnant client undergoing a nonstress test that the test is a
way of evaluating the condition of the fetus by comparing the fetal heart rate with: -
ANSWER: Fetal movement
A client in the 38th week of gestation exhibits a slight increase in blood pressure. The
health care provider advises her to remain in bed at home in a side-lying position.
The client asks why this is important. What is the nurse's response regarding the
advantage of this position? - ANSWER: It increases blood flow to the fetus.
When reviewing the history of a client admitted in preterm labor during her 30th
week of gestation, the nurse suspects a risk factor associated with this client's
preterm labor. What is this risk factor? - ANSWER: Multiple urinary tract infections
, During a client's labor the fetal monitor reveals a fetal heart pattern that signifies
uteroplacental insufficiency. What is the nurse's first intervention? - ANSWER:
Helping the client turn to the side-lying position
A client with mild preeclampsia is being treated on an outpatient basis. Three days of
bedrest is prescribed. What position should the nurse encourage the client to
maintain while in bed? - ANSWER: Side-lying
A client at 35 weeks' gestation who has had no prenatal care arrives in labor and
delivery and is found to be 20 percent effaced and 2 cm dilated, with her
membranes intact and contractions 3 minutes apart. The nurse notices some
ruptured blisterlike vesicles in the genital area. What should the nurse's next action
be? - ANSWER: Contacting the health care provider about the need for a cesarean
birth
A client is admitted to the high-risk prenatal unit with the diagnosis of placenta
previa. What should the nurse instruct the client to do? - ANSWER: Lie on her side to
avoid putting pressure on the vena cava
A woman is being seen in the prenatal clinic at 36 weeks' gestation. The nurse is
reviewing signs and symptoms that should be reported to health care provider with
the mother. Which signs and symptoms require further evaluation by the health care
provider? (Select all that apply.) - ANSWER: Decreased urine output
Contractions that are regular and 5 minutes apart
During labor a client who has been receiving epidural anesthesia has a sudden
episode of severe nausea, and her skin becomes pale and clammy. What is the
nurse's immediate reaction? - ANSWER: Turning the client on her side
What actions are part of nursing care during the fourth stage of labor for the client
with a fourth-degree laceration? (Select all that apply.) - ANSWER: Pain management
with oral analgesics
Assessment of the site every 15 minutes
Application of an ice pack for 20-minute intervals
What findings occur with supine hypotensive syndrome? (Select all that apply.) -
ANSWER: Feeling of faintness
Increased venous pressure
Decreased systolic pressure
What is the most important parameter for the nurse to monitor during the first 24
hours after the birth of an infant at 36 weeks' gestation? - ANSWER: Respiratory
distress
