OB and Peds Test Bank Updated - Ob Peds HESI Test Bank

Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client? a. The client's readiness to learn. b. The client's educational background. c. The order in which the information is presented. d. The extent to which the pregnancy was planned. A When teaching any client, readiness to learn (A) is the most important criterion. For example, the client with severe morning sickness in the first trimester may not be "ready to learn" about labor and delivery but is probably very "ready to learn" about ways to relieve morning sickness. (B and C) are factors that may influence learning, but they are not as influential as (A). Even if a pregnancy is planned and very desirable (D), the client must be ready to learn the content presented. A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities? a. Wear support stockings. b. Reduce salt in her diet. c. Move about every hour. d. Avoid constrictive clothing. C Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the pelvic veins. Moving about every hour (C) will straighten out the pelvic veins and increase venous return. (A) increase venous return from varicose veins in the lower extremities but are little help with swelling. (B) might be helpful with generalized edema (which could be an indication of PIH) but is not specific for edematous lower extremities. (D) does not specifically address venous return in this particular case. During a prenatal visit, the nurse discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have a. lower Apgar scores. b. lower birth weights. c. respiratory distress. d. a higher rate of congenital anomalies. B Smoking is associated with low-birth-weight infants (B). Mothers are encouraged not to smoke during pregnancy. To date, significant relationships have not been found between smoking and options (A, C, or D). A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The nurse plans to monitor for which primary side effect of terbutaline sulfate? a. Drowsiness and bradycardia. b. Depressed reflexes and increased respirations. c. Tachycardia and a feeling of nervousness. d. A flushed, warm feeling and a dry mouth. C Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the drug may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of "nervousness" (C). Hypotension, hypertension, and/or drowsiness may occur, but tachycardia, not (A), is a primary side effect. (B and D) are side effects of magnesium sulfate. A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness? a. Wear a cotton bra. b. Increase nursing time gradually. c. Correctly place the infant on the breast. d. Manually express a small amount of milk before nursing. C The most common cause of nipple soreness is incorrect positioning (C) of the infant on the breast, e. g., grasping too little of the areola or grasping only the nipple. (A) helps prevent chafing. (B) is important but is not necessary for all women. (D) helps soften an engorged breast and encourages correct infant attachment but is not the BEST answer. A full term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn? a. Length of labor and method of delivery. b. Infant's condition at birth and treatment received. c. Feeding method chosen by the parents. d. History of drugs given to the mother during labor. B Immediate care is most dependent on the infant's current status (i. e., Apgar scores at 1 and 5 minutes) and any treatment or resuscitation that was indicated. The transitional care nurse needs the information listed in the choices (A, C, and D), but the priority is (B). In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The nurse bases the explanation on knowledge that for the normal newborn, the a. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week. b. anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week. c. anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month. d. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month. D In the normal infant the anterior fontanel closes at 12 to 18 months of age and the posterior fontanel by the end of the second month (D). These growth and development milestones should be memorized to prepare for the NCLEX. When assessing a client who is at 12-weeks' gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? a. At 16-weeks' gestation. b. At 20-weeks' gestation. c. At 24-weeks' gestation. d. At 30-weeks' gestation. D (D) is closest to the time parents would be ready for such classes. Learning is facilitated by an interested pupil! The couple is most interested in childbirth toward the end of the pregnancy when they are psychologically ready for the termination of the pregnancy, and the birth of their child is an immediate concern. (A, B, and C) are not the best times during a pregnancy for the couple to attend childbirth education classes--they will have other teaching needs The nurse should encourage the laboring client to begin pushing when a. there is only an anterior or posterior lip of cervix left. b. the client describes the need to have a bowel movement. c. the cervix is completely dilated. d. the cervix is completely effaced. C Pushing begins with the second stage of labor, i.e., when the cervix is completely dilated at 10 cm (C). If pushing begins before the cervix is completely dilated (A, B, and D), the cervix can become edematous and may never completely dilate, necessitating an operative delivery. Many primigravidas begin active labor 100% effaced and then proceed to dilate. The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs a. two weeks before menstruation. b. immediately after menstruation. c. immediately before menstruation. d. three weeks before menstruation. A Ovulation occurs 14 days before the first day of the menstrual period (A). While ovulation can occur in the middle of the cycle, or 2 weeks after menstruation, this is only true for a woman who has a perfect 28-day cycle. For many women, the length of their menstrual cycle varies. The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take? a. Administer oxygen by face mask. b. Notify the healthcare provider of the client's symptoms. c. Have the client breathe into her cupped hands. d. Check the client's blood pressure and fetal heart rate. C Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper bag or cupped hands (C). (A) is inappropriate since the C02 level is low, not 02. (B and D) are not specific for this situation. When preparing a class on newborn care for expectant parents, what content should the nurse teach concerning the newborn infant born at term gestation? a. Milia are red marks made by forceps and will disappear within 7 to 10 days. b. Meconium is the first stool and is usually yellow gold in color. c. Vernix is a white, cheesy substance, predominantly located in the skin folds. d. Pseudostrabismus found in newborns is treated by minor surgery. C (C) is correct. Vernix, found in the folds of the skin, is a characteristic of term infants. (A) is white, pinpoint spots usually found over the nose and chin which represent blockage of the sebaceous glands. (B) is tarry-black. (D) (crossed eyes) is normal at birth but should be corrected if it persists after 6 to 9 months of age. Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The nurse knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as a. a cephalhematoma, caused by forceps trauma and may last up to 8 weeks. b. a subarachnoid hematoma, which requires immediate drainage to prevent further complications. c. molding, caused by pressure during labor and will disappear within 2 to 3 days. d. a subdural hematoma which can result in lifelong damage. A Cephalhematoma (A), a slight abnormal variation of the newborn, usually arises within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and the skull. (C) is a cranial distortion lasting 5 to 7 days and is caused by pressure on the cranium during vaginal delivery--it is a normal finding, or a common variation of the newborn. (B and D) both involve intracranial bleeding and could not be detected by physical assessment alone. An expectant father tells the nurse he fears that his wife "is losing her mind." He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father? a. Reassure him that these are normal reactions to pregnancy and suggest that he discuss his concerns with the childbirth education nurse. b. Help him to understand that his wife is experiencing normal symptoms of ambivalence about the pregnancy and no action is needed. c. Ask him to observe his wife's behavior carefully for the next few weeks and report any similar behavior to the nurse at the next prenatal visit. d. Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement. D These behaviors are positive signs of maternal/fetal bonding (D) and do not reflect ambivalence (B). No intervention is needed. Quickening, the first perception of fetal movement, occurs at 17 to 20 weeks’ gestation and begins a new phase of prenatal bonding during the second trimester. Although (A) is not wrong, it dismisses the father's concerns. (C) is not indicated. A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny looking head." Which response by the nurse is best? a. "This is not an unusual shaped head, especially for a first baby." b. "It may look funny to you, but newborn babies are often born with heads like your baby's." c. "That is normal; the head will return to a round shape within 7 to 10 days." d. "Your pelvis was too small, so the baby's head had to adjust to the birth canal." C. (C) reassures the mother that this is normal in the newborn and provides correct information regarding the return to a "normal" shape. Although (A) is correct, it implies that the client should "not worry." Any implied or spoken "don't worry" is usually the wrong answer! (B) is condescending and dismissing--the mother is seeking reassurance and information. (D) is a negative statement and implies that molding is the mother's "fault." A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation will the nurse provide? a. "Weigh the baby daily, and if she is gaining weight, she is eating enough." b. "Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day." c. "Offer the baby extra bottle milk after her feeding and see if she is still hungry." d. "If you're concerned, you might consider bottle feeding so that you can monitor her intake." B The urine will be dilute (straw-colored) and frequent (6 to 10 times/day) (B), if the infant is adequately hydrated. Although a weight gain (A) of 30 grams/day is indicative of adequate nutrition, most home scales do not measure this accurately and this suggestion is likely to make the mother very anxious! (C) causes nipple confusion and diminishes the mother's milk production. (D) does not answer the client's question. A client who gave birth to a healthy 8-pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant? a. Encourage the mother to provide total care for her infant. b. Provide privacy so the mother can develop a relationship with the infant. c. Encourage the father to provide most of the infant's care during hospitalization. d. Meet the mother's physical needs and demonstrate warmth toward the infant. D It is most important to meet the mother's requirement for attention to her needs so that she can begin infant care-taking (D). Nurse theorist Reva Rubin describes the initial postpartal period as the "taking-in phase," which is characterized by maternal reliance on others to satisfy the needs for comfort, rest, nourishment, and closeness to families and the newborn. (A) could impede development of maternal bonding. (B) is important but not the priority. (C) might encourage paternal bonding, but does not specifically encourage maternal bonding. A couple, concerned because the woman has not been able to conceive, is referred to a healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which complaint would indicate to the nurse that the woman's fallopian tubes are patent? a. Back pain. b. Abdominal pain. c. Shoulder pain. d. Leg cramps. C If the tubes are patent (open), pain is referred to the shoulder from a subdiaphragmatic collection of peritoneal dye/gas (C). (B) could be caused from uterine cramping, but might also be indicative of gas/dye collecting in the uterus due to occluded tubes. It should be further evaluated; it would not be normal after hysterosalpingography. (A and D) are not related to the procedure. Which nursing intervention would be most helpful in relieving postpartum uterine contractions or "afterpains?" a. Lying prone with a pillow on the abdomen. b. Using a breast pump. c. Massaging the abdomen. d. Giving oxytocic medications. A Lying prone (A) keeps the fundus contracted and is especially useful with multiparas, who commonly experience afterpains due to lack of uterine tone. (B and D) stimulate uterine contractions. (C) may contract the uterus temporarily and then encourage more afterpains later. Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time? a. She eagerly reaches for the infant, undresses the infant, and examines the infant completely. b. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. c. Her arms and hands receive the infant and she then cuddles the infant to her own body. She eagerly reaches for the infant and then holds the infant close to her own body. B Attachment/bonding theory indicates that most mothers will demonstrate behaviors described in (B) during the first visit with the newborn, which may be at delivery or later. After the first visit, the mother may exhibit greater affection such as eagerly reaching, hugging, etc. (A, C, and D). On admission to the prenatal clinic, a 23-year-old woman tells the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. This client's expected date of delivery (EDD) would be a. November 22. b. November 8. c. December 22. d. October 22. A (A) correctly applies Nagele's rule for estimating the due date by counting back 3 months from the first day of the last menstrual period (January, December, November) and adding 7 days (15+7=22). The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse correctly calculates that the woman's next fertile period will be a. January 14-15. b. January 22-23. c. January 30-31. d. February 6-7. C This woman can expect her next period to begin 36 days from the first day of her last menstrual period--the cycle begins at the first day of the cycle and continues to the first day of the next cycle. Her next period would, therefore, begin on February 13. Ovulation occurs 14 days before the first day of the menstrual period. Therefore, ovulation for this woman would occur January 31 (C). A client at 32-weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding would indicate that therapeutic drug level has been achieved? a. 4+ reflexes. b. Urinary output of 50 ml per hour. c. A decrease in respiratory rate from 24 to 16. d. A decreased body temperature. C Magnesium sulfate, a CNS depressant, helps prevent seizures. A decreased respiratory rate (C) indicates that the drug is effective. (Respiratory rate below 12 indicates toxic effects.) (A) indicates high CNS irritability. Urinary output must be monitored when administering magnesium sulfate and should be at least 30 ml per hour. (B) indicates that the magnesium sulfate is not at a toxic level, but does not indicate that a therapeutic level has been achieved. (D) is not specifically related to magnesium sulfate. (The therapeutic level of magnesium sulfate for a PIH client is 4.8 to 9.6 mg/dl.) Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action will the nurse take? a. Notify the healthcare provider or anesthesiologist immediately. b. Continue to assess the blood pressure q5 minutes. c. Place the woman in a lateral position. d. Turn off the continuous epidural. C The nurse should immediately turn the woman to a lateral position (C), place a pillow or wedge under the right hip to deflect the uterus, increase the rate of the main line IV infusion, and administer oxygen by face mask at 10-12 L/min. If the blood pressure remains low, especially if it further decreases, the anesthesiologist/healthcare provider should be notified immediately (A). Continued assessment of (B), without taking any further action would constitute malpractice. (D) may also be warranted, but such action is based on hospital protocol. A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? a. Come to the clinic today for an ultrasound. b. Go immediately to the emergency room. c. Lie on your left side for about one hour and see if the bleeding stops. d. Bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection. A Third trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first incidence life-threatening, nor cause for hypovolemic shock. Diagnosis is confirmed by transabdominal ultrasound (A). Bleeding that has a sudden onset and is accompanied by intense uterine pain indicates abruptio placenta, which IS life-threatening to the mother and fetus--then (B) would be appropriate. (C) does not take the symptoms seriously. The woman is not describing symptoms of a UTI (D). An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? a. Use a thread to tie off the umbilical cord. b. Provide as much privacy as possible for the woman. c. Reassure the husband and try to keep him calm. d. Put the newborn to breast. D Putting the newborn to breast (D) will help contract the uterus and prevent a postpartum hemorrhage--this intervention has the highest priority. It is not necessary to tie off the umbilical cord (A), the infant can be transported attached to the placenta. Providing privacy (B) is an important psychosocial need, but does not have the priority of (D). Although the husband is an important part of family-centered care, he is not the most important concern at this time (C). A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide this client? a. "Complete bedrest decreases oxygen needs and demands on the heart muscle tissue." b. "We want your baby to be healthy, and this is the only way we can make sure that will happen." c. "I know you're upset. Would you like to talk about some things you could do while in bed?" d. "Labor is difficult and you need to use this time to rest before you have to assume all child-caring duties." A To help preserve cardiac reserves, the woman may need to restrict her activities and complete bedrest is often prescribed (A). (B) offers false reassurance. (C) does not answer the woman's question. While (D) may be true, it is not the most important reason for bedrest. The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn. Which infectious organism will this treatment prevent from harming the infant? a. Herpes. b. Staphylococcus. c. Gonorrhea. d. Syphilis. C Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmica neonatorum, an infection caused by gonorrhea, and inclusion conjunctivitis, an infection caused by chlamydia (C). The infant may be exposed to these bacteria when passing through the birth canal. Ophthalmic ointment is not effective against (A, B, and D). A newborn infant is brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. What action should the nurse take first? a. Notify the pediatrician immediately. b. Suction the infant's nares, then the oral cavity. c. Check the infant's oxygen saturation rate. d. Position the infant on the right side. C When possible, the nurse should first obtain measurable objective data; an oxygen saturation rate provides such information (C). The pediatrician should be notified if the oxygen saturation rate is below 90% (A). The infant is not demonstrating signs of an obstructed airway, but if suctioning was required, the oral cavity should be suctioned first to prevent the infant from aspirating pharyngeal secretions (B). (D) facilitates drainage from the mouth and promotes emptying into the small intestine, but at this time, this intervention is not as high a priority as (C). Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention is best for the nurse to implement first? a. Assess the husband's feelings about his wife's decision to breastfeed their baby. b. Ask the client to describe why she was unsuccessful with breastfeeding her last child. c. Encourage the client to develop a positive attitude about breastfeeding to help ensure success. d. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery. A Infants respond to breastfeeding best when feeding is initiated in the active phase soon after delivery (D). (A and B) might provide interesting data, but gathering this information is not as important as providing support and instructions to the new mother. While (C) is also true, this response by the nurse might seem judgmental to a new mother. The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception? a. Between the time the temperature falls and rises. b. Between 36 and 48 hours after the temperature rises. c. When the temperature falls and remains low for 36 hours. d. Within 72 hours before the temperature falls. A In most women, the BBT drops slightly 24 to 36 hours before ovulation and rises 24 to 72 hours after ovulation, when the corpus luteum of the ruptured ovary produces progesterone. Therefore, intercourse between the time of the temperature fall and rise (A) is the best time for conception. The human ovum can be fertilized 16 to 24 hours after ovulation, so (B) is beyond the fertile period. (C) indicates that ovulation has not occurred. (D) would occur before ovulation. A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important for the nurse to provide this client? a. Elevate lower legs while resting. b. Increase caloric intake by 200 to 300 calories per day. c. Increase water intake to 8 full glasses per day. d. Take prescribed multivitamin and mineral supplements. D A client who has had a spontaneous abortion or still birth in the last 1 years should take multivitamin and mineral supplements (D) and maintain a balanced diet because the previous pregnancy may have left her nutritionally depleted. (A, B, and C) are sound instructions to provide any pregnant client, but do not have the priority of (D) for this particular client who had a miscarriage 6 months ago. A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most likely presenting symptom for a pediatric client with AIDS is a. shortness of breath. b. joint pain. c. a persistent cold. d. organomegaly. C Respiratory tract infections commonly occur in the pediatric population. However, the child with AIDS has a decreased ability to defend the body against these infections and often the presenting symptom of a child with AIDS is a persistent cold (C). (A, B, and D) are symptoms of complications which may occur later in the disease process. The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern? a. Edema, basilar rales, and an irregular pulse. b. Increased urinary output and tachycardia. c. Shortness of breath, bradycardia, and hypertension. d. Regular heart rate and hypertension. A Edema, basilar rales, and an irregular pulse (A) indicate cardiac decompensation and require immediate intervention. Though (B, C, and D) are cardiac symptoms, they require less emergency intervention than (A). A woman with Type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement? a. Describe diet changes that can improve the management of her diabetes. b. Inform the client that oral hypoglycemic agents are teratogenic during pregnancy. c. Demonstrate self-administration of insulin. d. Evaluate the client's ability to do glucose monitoring. A Diet modifications (A) are effective in managing Type 2 diabetes during pregnancy, and describing the necessary diet changes is the most important intervention for the nurse to implement with this client. (B, C, and D) are interventions that should also be implemented, but do not have the priority of (A). A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first? a. Raise the foot of the bed. b. Assess for vaginal bleeding. c. Evaluate the fetal heart rate. d. Take the client's blood pressure. A These symptoms are suggestive of hypotension which is a side effect of epidural anesthesia. Raising the foot of the bed (A) will increase venous return and provide blood to the vital areas. Increasing the IV fluid rate using a balanced non-dextrose solution and ensuring that the client is in a lateral position are also appropriate interventions. (B and C) will not raise the maternal blood pressure. Since the symptoms are common side effects of epidural anesthesia and suggest hypotension, (D) can wait until (A) is implemented. The total bilirubin level of a 36-hour, breastfeeding newborn is 14 mg/dl. Based on this finding, which intervention should the nurse implement? a. Provide phototherapy for 30 minutes q8h. b. Feed the newborn sterile water hourly. c. Encourage the mother to breastfeed frequently. d. Assess the newborn's blood glucose level. C The normal total bilirubin level is 6 to 12 mg/dl after Day 1 of life. This infant's bilirubin is beginning to climb and the infant should be monitored to prevent further complications. Breast milk provides calories and enhances GI motility, which will assist the bowel in eliminating bilirubin (C). (A) is not indicated at this level. (B) would limit caloric intake, which is essential in preventing jaundice. (D) is not related to bilirubin levels. A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data would indicate to the nurse that the client is experiencing magnesium sulfate toxicity?