RECALLS 12 - NP 2

SITUATION

Erikson's psychosocial theory states that personalities develop in a series of stages, describing the impact of social experience across the whole lifespan. Erikson was interested in how social interaction and relationships played a role in the development and growth of human beings.

Renz and Richa, who just had their first baby a month ago, asked Nurse Rei on how they can meet the basic needs of Baby Eri. Based on an understanding of Erikson's stages of psychosocial development, Nurse Rei would tell them to?

A. Provide the infant with entertainment and stimulation for psychological growth

B. Talk with the infant during the times when the infant is awake

C. Hold the infant in a way the infant prefers

D. Attend to the infant's need for comfort, security, predictability, food, and warmth

After three years, Renz and Richa told Nurse Rei about how their daughter, Eri, has been rebelling constantly and having temper tantrums. Using Erikson's psychosocial development theory, which instructions should Nurse Rei provide Eri's parents? Select all that apply.

A. Set limits on the child's behavior.

B. Ignore the child when this behavior occurs.

C. Allow the behavior, because this is normal at this age period.

D. Provide a simple explanation of why the behavior is unacceptable.

E. Punish the child every time the child says "no" to change the behavior.

A. a & d

B. c & d

C. a, c & d

D. None of the above

A. a & d

Nurse Rei is assessing Eri's psychosocial developmental level using Erikson's eight stages. Which of the following behaviors would Nurse Rei most likely find if Eri were demonstrating being in shame and doubt instead of having mastered autonomy?

A. Dependency and constantly looking to others for approval

B. Sleep disturbance, crying, and vomiting

C. Always imitating others rather than using imagination

D. Frequent crying, emotional outbursts, and whining

A. Dependency and constantly looking to others for approval

The parent of an 8-year-old child tells the clinic nurse of a concern that the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse would plan to make which response?

A. "You need to be concerned."

B. "You need to monitor the child's behavior closely."

C. "At this age, children are developing their own personalities."

D. "You need to provide more praise to the child to stop this behavior."

C. "At this age, children are developing their own personalities."

In accordance with Erikson's theory, the main task associated with Nora, a 16 year-old female who refuses to do what her parents want her to do, who would be?

A. establishing intimate bonds of love and friendship

B. fulfilling life goals that involve family, career and society.

C. looking back over one's life and accepting its meaning

D. developing a sense of identity

D. developing a sense of identity

The nurse has noticed that her 5-year-old male patient does not recognize that his toy exists even when it is outside his visual field. Noting this, what action should the nurse perform?

A. Notify the physician about the observation.

B. Bring the toy within the child's field of vision.

C. Instruct the child to scan his environment carefully.

D. Provide the child with access to the lighting during playing.

A. Notify the physician about the observation.

age of object permanence: 8 MONTHS

Nurse Mara is observing the activity of a 5-year-old patient. Which of the following is the most common observation in the play activity of this age group?

A. Plays alongside but not with playmates, using a pounding bench and playing with a musical toy.

B. Plays with others, abiding by rules, making up fictitious friends, and engaging in fantasy play.

C. Plays with puppets and participates in team sports.

D. Plays by themselves in a corner, engaged in putting a puzzle together.

B. Plays with others, abiding by rules, making up fictitious friends, and engaging in fantasy play.

pre-school = pantasy

A. Plays alongside but not with playmates, using a pounding bench and playing with a musical toy.

PARALLEL PLAY = TODDLER

C. Plays with puppets and participates in team sports. COMPETITIVE PLAY = SCHOOL AGE

D. Plays by themselves in a corner, engaged in putting a puzzle together. SOLITARY PLAY = INFANT

The nurse cares for a toddler patient who must take medication every afternoon for five days. Which of the following is the most age-appropriate explanation for the toddler?

A. Your mama will give you the medicine between 1:00 and 2:00 in the afternoon. Each day until your cough is gone.

B. You will take your medicine every afternoon after your lunch, until your cough is gone.

C. For a week, you will be taking your medicine in the afternoon.

D. Every day at 1:00 p.m., your mama will give you your medicine until your cough is gone.

B. You will take your medicine every afternoon after your lunch, until your cough is gone.

CONCEPT OF TIME = SCHOOL AGE

Which of the following four infants does the nurse consider to have abnormal language development?

A. A 9-month-old who uses two-syllable sounds such as "mama."

B. A 7-month-old who is beginning to vocalize during play and pleasure.

C. A 2-month-old who begins singing in the presence of familiar sounds.

D. An 11-month-old who uses intentional gestures.

B. A 7-month-old who is beginning to vocalize during play and pleasure.

3-6 months

Which vehicle safety equipment is appropriate for an 8-year-old who is 4 feet tall?

A. Booster seat

B. Seat belt

C. Front-facing convertible seat

D. Rear-facing convertible seat

A. Booster seat

so they can use seatbelt

D. Rear-facing convertible seat = INFANT

The mother of a breastfed newborn reported that her infant's feces is golden in color, pasty rather than firm, and smells strongly of sour milk. What would be the best course of action for the nurse to take?

A. "You probably need to feed this baby some cereal to firm up the stool."

B. "Cut back on your fluid intake and be careful what you eat, as you pass this on to the baby."

C. "I need to check your temperature and your breasts to determine if you have a breast abscess."

D. "This is a normal stool for a newborn who is breast-fed."

D. "This is a normal stool for a newborn who is breast-fed."

When planning to educate a class of mothers about introducing new meals during the first year of their infants, which of the following should the nurse include?

A. Place up to three foods on the spoon at one time with an old favorite on the front of the spoon

B. Introduce fruits first; introduce one new fruit per day until all fruits are introduced

C. Alternate between offering one spoonful of fruits and one spoonful of vegetables

D. Introduce one new food at a time at 7-day intervals

D. Introduce one new food at a time at 7-day intervals

A mother is concerned about her 5-year-old occasionally peeing in his undies rather than using the restroom. Which of the following questions should the nurse ask in order to ascertain whether this is a typical occurrence?

A. "Do you remind your child to go to the bathroom every 2 hours?"

B. "Is this your firstborn child?"

C. "Has your child started school already?"

D. "Does this behavior occur when your child is engaged in some activity?"

D. "Does this behavior occur when your child is engaged in some activity?"

What information should the nurse tell to a mother when giving vitamins to a preschooler?

A. Give the vitamins with sips of milk.

B. Give preschoolers half a vitamin.

C. Store the vitamins in a locked cabinet that the child cannot access.

D. Allow the child to be independent by self-administering the vitamins.

C. Store the vitamins in a locked cabinet that the child cannot access.

SITUATION

The prenatal nurse monitors the health status of the mother and fetus, provides emotional support, and teaches the pregnant woman and her family about physiological and psychological changes during pregnancy, fetal development, labor and childbirth, and care for the newborn (International Council of Nurses).

Nurse Alvin is assessing a woman who thinks she may be pregnant. Which information from the client is most significant in confirming the diagnosis of pregnancy?

A. The client is experiencing nausea before bedtime and after meals.

B. The client says she has gained six pounds and her slacks are tight.

C. The client has noticed it is difficult to sleep on her "stomach" because her breasts are tender.

D. The client has a history of regular menstrual periods since age 13 and has a positive pregnancy test.

D. The client has a history of regular menstrual periods since age 13 and has a positive pregnancy test.

Nurse Alvin is performing an assessment on Patient Wayne who suspects that she is pregnant. Nurse Alvin should assess for which probable signs of pregnancy? Select all that apply.

A. Ballottement

B. Chadwick's sign

C. Uterine enlargement

D. Positive pregnancy test

E. Fetal heart rate detected by an electronic device

F. Outline of fetus via radiography or ultrasonography

A. A, B, C, & D

B. A, B, C,

C. A, B, C, D, & E

D. D, E & F

A. A, B, C, & D

When Patient Wayne returned on her 38 weeks gestation, Nurse Alvin notes that the fetal heart rate (FHR) is 180 beats/minute. On the basis of this finding, what is the priority nursing action?

A. Document the finding.

B. Check the mother's heart rate.

C. Notify the health care provider (HCP).

D. Tell the client that the fetal heart rate is normal.

C. Notify the health care provider (HCP).

FETAL DISTRESS

110-160 bpm

After a while, a nonstress test is performed on Patient Wayne, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should Nurse Alvin document this finding?

A. A normal test result

B. An abnormal test result

C. A high risk for fetal demise

D. The need for a cesarean section

A. A normal test result

nonstress test = normal = reactive

stress test = normal = negative

no late deceleration

While resting, Nurse Alvin decides to teach Patient Wayne on how to perform "kick counts." Which statement by Patient Wayne indicates a need for further instruction?

A. "I will record the number of movements or kicks."

B. "I need to lie flat on my back to perform the procedure."

C. "If I count fewer than 10 kicks in a 2-hour period, I should count the kicks again over the next 2 hours."

D. "I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks."

B. "I need to lie flat on my back to perform the procedure."

Which of the following is the appropriate pregnancy classification for Vilmawho has had her first pregnancy ended in a miscarriage at 9 weeks, second pregnancy delivered vaginally at 39 weeks of gestation and the child is 3 years old now, and is currently pregnant for the third time?

A. Gravida 3 para 1 1-0-1-1

B. Gravida 2 para 1 2-1-1-0

C. Gravida 3 para 2 3-2-0-1-0

D. Gravida 2 para 2 2-1-0-0

A. Gravida 3 para 1 1-0-1-1

Erma arrives at the clinic for the first prenatal assessment. She tells Nurse Justine that the first day of her last normal menstrual period was October 19, 2018. Using Naegele's rule, which expected date of delivery should the nurse document in the client's chart?

A. July 12, 2019

B. July 26, 2019

C. August 12, 2019

D. August 26, 2019

B. July 26, 2019

During a prenatal visit, Nurse Justine evaluates the fundal height of the uterus to be at the umbilicus. Nurse Justine should estimate the gestation at

A. 16 weeks.

B. 20 weeks.

C. 24 weeks.

D. 28 weeks.

B. 20 weeks.

Nurse Justine is performing an assessment of a pregnant client who is at 28 weeks of gestation. Nurse Justine measures the fundal height in centimeters and notes that the fundal height is 30 cm. How should the nurse interpret this finding?

A. The client is measuring large for gestational age.

B. The client is measuring small for gestational age.

C. The client is measuring normal for gestational age.

D. More evidence is needed to determine size for gestational age

C. The client is measuring normal for gestational age.

2 cm variation = normal

A 17-year-old primigravida client at term is in active labor. Examination revealed cervical dilatation at 8cm with 100% cervical effacement. Which of the following should the nurse assess the client for?

a. Uterine inversion.

b. Cephalopelvic disproportion (CPD).

c. Rapid third stage of labor.

d. Decreased ability to push

b. Cephalopelvic disproportion (CPD).

A 23-year-old primigravida client at full term is in active labor. Which of the following should be incorporated into the plan of care for this patient?

a. Oxygen saturation monitoring every half hour.

b. Supine positioning on back

c. Anesthesia/pain level assessment every 30 minutes.

d. Vaginal bleeding, rupture of membrane (ROM) assessment every shift.

c. Anesthesia/pain level assessment every 30 minutes.

a. Oxygen saturation monitoring every half hour. ONLY NECESSARY IN PTS WITH HEART/RESPI PROBLEMS

d. Q 30 MINS / 1 HR

A primigravida client who is in active labor arrives at a birthing facility. Examination revealed that the client is at 1+ station, and the client's membranes are still intact. The doctor prepares for an amniotomy. What are the most likely outcomes of amniotomy?

I. Less pressure on the cervix

II. Decreased number of contractions

III. Increased efficiency of contractions

IV. The need for increased maternal blood pressure monitoring.

V. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord.

A. III, IV, V

B. I, III

C. I, II, III

D. III, V

D. III, V

more pressure on cervix

increased contractions

increased FETAL not maternal monitoring

A primigravida client in active labor is experiencing contractions that last 50 seconds every 3 minutes. The fetal heart rate in between contractions is 100 beats per minute. Which nursing intervention is best to perform?

A. Report to the primary health care provider (PHCP).

B. Continue to assess the contraction.

C. Encourage the client to continue pushing with each contraction.

D. Instruct the client's coach to continue to encourage breathing techniques.

A. Report to the primary health care provider (PHCP).

normal: 110-160 bpm

A primigravida patient in active labor is prescribed with scalp stimulation of the fetal head. What is the purpose of scalp stimulation?

A. Assessment of the fetal hematocrit level.

B. Increase in the strength of the contractions.

C. Increase in the fetal heart rate and variability.

D. Assessment of fetal position.

C. Increase in the fetal heart rate and variability.

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply.

A. The contractions are regular.

B. The membranes have ruptured.

C. The cervix is dilated completely.

D. The client begins to expel clear vaginal fluid.

E. The spontaneous urge to push is initiated from perineal pressure.

A. C & E

B. A & B

C. C & D

D. A B D

A. C & E

2nd stage

1st stage

A. The contractions are regular.

B. The membranes have ruptured.

D. The client begins to expel clear vaginal fluid.

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement?

A. "I won't be in labor until my baby drops."

B. "My contractions will be felt in my abdominal area."

C. "My contractions will not be as painful if I walk around."

D. "My contractions will increase in duration and intensity."

D. "My contractions will increase in duration and intensity."

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action?

A. Administer oxygen via face mask.

B. Place the mother in a supine position.

C. Increase the rate of the oxytocin intravenous infusion.

D. Document the findings and continue to monitor the fetal patterns.

A. Administer oxygen via face mask.

A Client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position?

A. Supine position with a wedge under the right hip

B. Trendelenburg's position with the legs in stirrups

C. Prone position with the legs separated and elevated

D. Semi-Fowler's position with a pillow under the knees

A. Supine position with a wedge under the right hip

A pregnant client asks the nurse when the stretch marks will disappear. The most appropriate response by the nurse is

A. "They will disappear with the birth of the infant."

B. "They will take up to 6 months to disappear."

C. "They will fade but do not totally disappear."

D. "They will disappear with a nutritionally balanced diet and exercise."

C. "They will fade but do not totally disappear."

SITUATION

Gestational diabetes greatly raises preeclampsia risks because the higher levels of sugar in the blood cause high blood pressure to develop (WFMC Health). Because preeclampsia and gestational diabetes may cause lots of complications, it is important for nurses to keep an eye out for the signs and symptoms and immediately refer findings to the physician.

Nurse Mimay is caring for Jolina who is at 30 weeks gestation, has gained 17 pounds during the pregnancy, and has a blood pressure of 110/70. Jolina states that she feels warmer than everyone around her. Which interpretation of these findings is most correct?

A. All of these findings are normal.

B. Her weight gain is excessive for this point in pregnancy.

C. The blood pressure is abnormal.

D. She should be evaluated for a serious infection because pregnant women are usually cooler than other people.

A. All of these findings are normal.

1st tri: 2-4 lbs

2nd-3rd tri: 1 lb/week

should be 19 lbs

Consequently, Nurse Mimay takes Patient Jolina's vital signs. Her blood pressure reads 160/94; pulse rate of 88 bpm; respiration rate of 24 cpm; and temperature of 98°F. Additionally, Jolina complains of epigastric pain and headache. What should Nurse Mimay do initially?

A. Insert an indwelling catheter.

B. Give Maalox 30 cc now.

C. Contact the doctor stat with findings.

D. Provide supportive care for impending convulsion

D. Provide supportive care for impending convulsion

Magnesium sulfate is ordered for Patient Jolina for her pregnancy-induced hypertension (PIH). What effects would Nurse Mimay expect to see as a result of this medication?

A. CNS depression

B. Decreased gastric acidity

C. Onset of contractions

D. Decrease in number of bowel movements

A. CNS depression

If Nurse Mimay were assessing a patient with severe preeclampsia, which assessment findings would be most closely associated with a complication of this diagnosis?

A. Enlargement of the breasts

B. Complaints of feeling hot when the room is cool

C. Periods of fetal movement followed by quiet periods

D. Evidence of bleeding, such as in the gums, petechiae, and purpura

D. Evidence of bleeding, such as in the gums, petechiae, and purpura

severe pre-eclampsia

widespread vascular damage

DIC

SITUATION

Prenatal nurses are empowered to promote healthy habits among prospective mothers and assist primary care providers in promoting healthy outcomes (Regis College Master of Science in Nursing)

Which of the following should the nurse assess for a newborn infant whose mother has type 2 diabetes?

A. Hypoglycemia

B. Rh sensitization

C. ABO incompatibility

D. Hypothermia

A. Hypoglycemia

Hypoglycemia may occur in a large-for-gestational-age newborn as a result of which of the following:

A. Limited glycogen stores.

B. Hyperinsulinemia.

C. Large ratio of body surface to weight.

D. Excessive brown fat stores.

B. Hyperinsulinemia.

Based on the knowledge about gestational diabetes. Which of the following should the nurse assess in the newborn?

A.Heart abnormalities

B.Group B beta-hemolytic strep pneumonia

C.Group B beta-hemolytic strep meningitis

D.Inborn errors of metabolism

A.Heart abnormalities

more viscous blood

high cardiac workload

hypertrophic cardiomyopathy

When admitting a newborn to the nursery, the nurse prepares to administer erythromycin ointment to the newborn's eyes to prevent blindness caused by which of the following? Select all that apply:

I.Gonorrhea

II.Syphilis

III.Herpes simplex virus

IV.Hepatitis

V.Chlamydia

VI.Human immunodeficiency virus (HIV)

A.I, II, V

B.I, II, III, IV, V, VI

C.II, III, V

D.I, V

D.I, V

A multigravida client with HIV who has recently delivered a newborn infant asks the nurse about the proper way to feed her newborn. Which of the following is the correct response by the nurse:

A."You will need to bottle-feed your newborn."

B."You will need to feed your newborn by nasogastric tube feeding."

C."You will be able to breast/chest-feed for 6 months and then will need to switch to bottle-feeding."

D."You will be able to breast/chest-feed for 9 months and then will need to switch to bottle-feeding."

A."You will need to bottle-feed your newborn."

Maria, a 40-year-old woman who is 28 weeks pregnant, comes to the emergency room with painless, bright red bleeding of 1.5 hours duration. What condition does the nurse suspect Maria has?

A.Abruptio placenta

B.Placenta previa

C.Hydatidiform mole

D.Prolapsed cord

B.Placenta previa

Maria who is 28 weeks gestation comes to the emergency room with painless, bright red bleeding of 1.5 hours in duration. Which of the following would the nurse expect during assessment of Maria?

A.Alterations in fetal heart rate

B.Board-like uterus

C.Severe abdominal pain

D.Elevated temperature

A.Alterations in fetal heart rate

The common normal site of nidation/implantation in the uterus is:

A.Upper uterine portion

B.Mid-uterine area

C.Lower uterine segment

D.Lower cervical segment

A.Upper uterine portion

The maternity nurse is preparing for the admission of Leila who is in her third trimester of pregnancy and is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription?

A.Prepare the client for an ultrasound.

B.Obtain equipment for a manual pelvic examination.

C.Prepare to draw a hemoglobin and hematocrit blood sample.

D.Obtain equipment for external electronic fetal heart rate monitoring.

B.Obtain equipment for a manual pelvic examination.

A nurse in the postpartum unit is caring for Leila who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa?

A.Disseminated intravascular coagulation

B.Chronic hypertension

C.Infection

D.Hemorrhage

D.Hemorrhage

Leila, who is a pregnant client, was diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells the client that the usual treatment for partial placenta previa is which of the following?

A.Bed rest

B.Platelet infusion

C.Immediate cesarean delivery

D.Oxytocin-induced labor

A.Bed rest

Nurse Mitch is assessing Lei in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present?

A.Soft abdomen

B.Uterine tenderness

C.Absence of abdominal pain

D.Bright red vaginal bleeding

B.Uterine tenderness

In abruption placenta, the blood sits behind the placenta for some time before exiting the body. During this time, clotting factors come into play. Clots turn the blood a darker red or even a brownish color.

To separate placenta previa from abruptio placenta, Nurse Mitch knows that which of the following findings are included in abruptio placenta? SATA

a.Uterine pain

b.Bright red vaginal bleeding

c.Uterine rigidity.

d.Soft uterus

e.Dark red vaginal bleeding

f.Painless uterus

A.A, E, F

B.A, D, E

C.A, C, E

D.C, E, F

C.A, C, E

In abruption placenta, the blood sits behind the placenta for some time before exiting the body. During this time, clotting factors come into play. Clots turn the blood a darker red or even a brownish color.

Lei is hospitalized for vaginal bleeding from suspected abruptio placentae. Nurse Mitch bases the appropriate interventions on which understanding of the pathology?

A.Placenta tears away from the cervical os during dilation and results in fetal hemorrhage

B.Placental abruption is umbilical cord hemorrhage from trauma

C.Placental abruption is premature separation of the normally implanted placenta from the uterine wall

D.Abruptio placentae is the rupturing of membranes along the uterine wall and the resulting loss of fetal blood and amniotic fluid

C.Placental abruption is premature separation of the normally implanted placenta from the uterine wall

The nursing care plan for patient Lei who has placenta abruptio should include careful assessment for signs and symptoms of which of the following?

A.Jaundice

B.Hypovolemic shock

C.Impending convulsions

D.Hypertension

B.Hypovolemic shock

Since Nurse Mitch is busy, she decides to delegate client assignments in a maternity unit. Which of the following assignments should Nurse Mitch delegate to a licensed practical nurse?

A.Provide the care to a client suspected of having abruptio placentae

B.Provide the care to a woman in her 37th week of gestation experiencing dyspnea

C.Teach a pregnancy class to a group of women

D.Document the characteristics of a woman's lochia

D.Document the characteristics of a woman's lochia

A & B = COMPLICATED PREGNANCY

D = HT = NURSE

The nurse is explaining to a preeclamptic client how to keep track of her fetus' movements to assess fetal well-being. Which of the client's statements suggests that she needs further guidance on when to contact the healthcare provider concerning fetal movement?

A.If the fetus is less active than it was previously.

B.If it takes longer each day for the fetus to move ten times.

C.When the fetus did not move for 12 hours.

D.If the fetal movement exceeds three times per hour.

D.If the fetal movement exceeds three times per hour.

no need to contact HCP

A 16-year-old primigravid client who is 5 feet, 1 inches tall, and 30 weeks pregnant has gained 20 lbs, with a gain of 1 lb in the last two weeks. Glucose levels in the urine are negative, but a trace of protein was seen. Which of the following factors increases the client's risk for preeclampsia?

A.Total weight gain.

B.Short stature.

C.Adolescent age group.

D.Proteinuria.

C.Adolescent age group.

reproductive organs not yet fully developed

The nurse knows that the client needs further education when she states that preeclampsia can result in which of the following?

A.Hydrocephalic infant.

B.Abruptio placentae.

C.Intrauterine growth retardation.

D.Poor placental perfusion.

A.Hydrocephalic infant.

The nurse determines that instruction was effective when the multigravid client says she will count the number of times the baby moves during which of the following time periods?

A.30-minute period three times a day.

B.45-minute period after lunch each day.

C.1-hour period each day.

D.12-hour period each week.

C.1-hour period each day.

Which of the following assessment results for the patient receiving intravenous magnesium sulfate for severe preeclampsia would alert the nurse to suspect hypermagnesemia?

A.Hypoactive deep tendon reflexes.

B.Decreased skin temperature.

C.Rapid pulse rate.

D.Tingling in the toes.

A.Hypoactive deep tendon reflexes.

Hyper Mg = Hyper Ca

MaluwanG = low BP

MahinanG mahina = weakness and dec. reflex

A 33-week-old client with severe preeclampsia is receiving intravenous magnesium sulfate. Which of the following are the desired objectives for this treatment?

I.T = 98 F, PR = 72, RR = 14.

II.Urinary output less than 30 mL/h.

III.Fetal heart rate with late decelerations.

IV.DTR 2+.

V.Magnesium level = 5.6 mg/dL (2.8 mmol/L).

A.I, II, IV

B.III, IV, V

C.I, IV, V

D.I, II, V

C.I, IV, V

After having an eclamptic seizure, a 35-weeks pregnant client starts to show signs of labor. The client should be assessed by the nurse for:

A.Abruptio placentae.

B.Transverse lie.

C.Placenta accreta.

D.Uterine atony

A.Abruptio placentae.

The nurse is looking over the records of a multigravida client who is 39 weeks pregnant and may have HELLP syndrome. Which of the following test results should the nurse inform the doctor about?

A.Platelets 200,000 mm3 (200 × 10 9 /L).

B.Lactate dehydrogenase (LDH) greater than 200 U/L (3.34 μkat/L).

C.Uric acid 3 mg/dL (178.4 μmol/L).

D.Aspartate aminotransferase (AST) 15 U/L (0.25 μkat/L)

B.Lactate dehydrogenase (LDH) greater than 200 U/L (3.34 μkat/L).

Platelets = 150k-400k

UA = 2-6.6 mg/dL

AST = 4-20 U/L

Which of the following would warn the nurse that placenta previa is present while examining a multigravida client at 33 weeks gestation who is having significant vaginal bleeding?

A.Painless vaginal bleeding.

B.Uterine tetany.

C.Intermittent pain with spotting.

D.Dull lower back pain

A.Painless vaginal bleeding.

A multigravida client at 33 weeks of gestation was admitted because of vaginal bleeding. After interviewing the client, which of the following factors might lead the nurse to suspect abruptio placentae?

A.Several hypotensive episodes.

B.Previous low transverse cesarean birth.

C.One induced abortion.

D.History of cocaine use.

D.History of cocaine use.

A multigravida client at 34 weeks of gestation with abruptio placentae was prescribed to receive whole blood replacement. Which of the following should the nurse perform first before administering the intravenous blood product?

A.Validate client information and the blood product with another nurse.

B.Check the vital signs before transfusing over 5 hours.

C.Ask the client if she has ever had any allergies.

D.Administer 100 mL of 5% dextrose solution intravenously.

A.Validate client information and the blood product with another nurse.

Which of the following would the nurse expect to deliver intravenously when caring for a multigravida client admitted to the hospital with vaginal bleeding at 38 weeks' gestation if the client develops disseminated intravascular coagulation (DIC)?

A.Ringer's lactate solution.

B.Fresh frozen platelets.

C.5% dextrose solution.

D.Warfarin sodium (Coumadin).

B.Fresh frozen platelets.

The nurse is caring for a 22-year-old G 2, P 2 client who has disseminated intravascular coagulation after delivering a dead fetus. Which finding is the highest priority to report to the health care provider?

A.Activated partial thromboplastin time (APTT) of 30 seconds.

B.Hemoglobin of 11.5 g/dL (115 g/L).

C.Urinary output of 25 mL in the past hour.

D.Platelets at 149,000/mm3 (149 × 10 9 /L).

C.Urinary output of 25 mL in the past hour.

kidney injury

The nurse would put the ultrasound transducer to monitor fetal heart rate in which of the following maternal positions if a fetus at 35 weeks of gestation is in the left occiput anterior position?

A.Near the symphysis pubis

B.Two inches (5.1 cm) above the umbilicus.

C.Below the umbilicus on the left side.

D.At the level of the umbilicus.

C.Below the umbilicus on the left side.

A.Near the symphysis pubis = TRANSVERSE

B.Two inches (5.1 cm) above the umbilicus.

BREECH

D.At the level of the umbilicus.

BREECH

A primigravida client at 35 weeks of gestation went to the hospital because she believed her water had been broken. After testing the leaking fluid with nitrazine paper, which color confirms that the client's membrane has ruptured?

A.Yellow.

B.Green.

C.Blue.

D.Red.

C.Blue.

At 30 weeks gestation, a primigravid client was taken to the hospital due to an early rupture of the membranes without contractions. Her cervix is 50% effaced, and 2 cm dilated. The nurse needs to assess next:

A.Red blood cell count.

B.Degree of discomfort.

C.Urinary output.

D.Temperature.

D.Temperature.

early ROM = infxn = chorioamnitis

At 34 weeks gestation, a primigravid client has 35-second contractions every three to four minutes. Her cervix is 50% effaced, and 2 cm dilated. Which of the following would the nurse do first if the client said, "I think my bag of water just broke"?

A.Check the status of the fetal heart rate.

B.Turn the client to her right side.

C.Test the leaking fluid with nitrazine paper.

D.Perform a sterile vaginal examination.

A.Check the status of the fetal heart rate.

at risk for prolapsed cord

A 38-year-old multigravida patient was admitted to the hospital due to ruptured ectopic pregnancy. Which of the following would be crucial for determining a predisposing factor when learning the client's history?

A.Recurrent urinary tract infection.

B.Use of Marijuana during pregnancy.

C.History of pelvic inflammatory disease.

D.Use of estrogen-progestin contraceptives.

C.History of pelvic inflammatory disease.

A primigravida client was diagnosed with ectopic pregnancy. Which of the following medications should the nurse anticipate to be administered to the patient?

A.Progestin contraceptives.

B.Medroxyprogesterone.

C.Methotrexate.

D.Dyphylline.

C.Methotrexate.

A multigravida client at 15 weeks of gestation was admitted to the hospital with a diagnosis of hydatidiform mole. Which of the following would the nurse assess?

A.Pregnancy-induced hypertension.

B.Gestational diabetes.

C.Hypothyroidism.

D.Polycythemia.

A.Pregnancy-induced hypertension.

ANEMIA

HYPERthyroidism

Which of the following would be the most crucial to assess for in the client following dilatation and curettage (D&C) to remove a molar pregnancy?

A.Urinary tract infection.

B.Hemorrhage.

C.Abdominal distention.

D.Chorioamnionitis.

B.Hemorrhage.

A multigravida client asks the nurse as to when she can conceive after treatment with molar pregnancy. The nurse should answer by not getting pregnant for how long?

A.6 months.

B.12 months.

C.18 months.

D.24 months

B.12 months.

1. pelvic exam

2. Hcg blood test

1st 6 months = q month = 6x

2nd 6 months = q 2 months = 3x

TOTAL= 9x check ups

Nurse Tammy is monitoring Patient Jocelyn in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss?

A.A temperature of 100.4 °F (38 °C)

B.An increase in the pulse rate from 88 to 102 beats/minute

C.A blood pressure change from 130/88 to 124/80 mm Hg

D.An increase in the respiratory rate from 18 to 22 breaths/minute

B.An increase in the pulse rate from 88 to 102 beats/minute

Nurse Tammy is preparing a list of self-care instructions for Jocelyn who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply.

A. Wear a supportive bra.

B.Rest during the acute phase.

C.Maintain a fluid intake of at least 3000 mL/day.

D.Continue to breast-feed if the breasts are not too sore.

E.Take the prescribed antibiotics until the soreness subsides.

F.Avoid decompression of the breasts by breast-feeding or breast pump.

A.A, B, C, & D

B.C, D, E, F

C.A, D, F

D.All of the above

D.All of the above

Nurse Tammy, then, provides instructions about measures to prevent postpartum mastitis in the future for Jocelyn. Which response by Jocelyn would indicate a need for further instruction?

A."I should breast-feed every 2 to 3 hours."

B."I should change the breast pads frequently."

C."I should wash my hands well before breastfeeding."

D."I should wash my nipples daily with soap and water."

D."I should wash my nipples daily with soap and water."

WATER ONLY

Meanwhile, Nurse Tammy is assessing Tina, who is in the fourth stage of labor, and notes that the fundus is firm but that bleeding is excessive. Which should be Nurse Tammy's initial action?

A.Record the findings.

B.Massage the fundus.

C.Notify the health care provider (HCP).

D.Place the client in Trendelenburg's position.

C.Notify the health care provider (HCP).

fundus is already firm, no need to massage

might be laceration of cervix

On the other hand, Nurse Tammy notes that Patient Susmita's uterus feels soft and boggy. Which action should Nurse Tammy take?

A.Document the findings.

B.Elevate the client's legs.

C.Massage the fundus until it is firm.

D.Push on the uterus to assist in expressing clots.

C.Massage the fundus until it is firm.

Nurse Claire assisted with the birth of Patient Gloria's newborn, Fulgencio. Which nursing action is most effective in preventing heat loss by evaporation?

A.Warming the crib pad

B.Closing the doors to the room

C.Drying the infant with a warm blanket

D.Turning on the overhead radiant warmer

C.Drying the infant with a warm blanket

Nurse Claire proceeds to administer erythromycin ointment (0.5%) to the eyes of Fulgencio and Patient Gloria asks her why this is performed. Which explanation is best for Nurse Claire to provide about neonatal eye prophylaxis?

A.Protects the newborn's eyes from possible infections acquired while hospitalized.

B.Prevents cataracts in the newborn born to a woman who is susceptible to rubella.

C.Minimizes the spread of microorganisms to the newborn from invasive procedures during labor.

D.Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection

D.Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection

Nurse Claire prepares to administer a phytonadione (vitamin K) injection to a newborn. Being the curious mother that she is, Gloria asks her why Fulgencio needs the injection. What's Nurse Claire's best response?

A."Your newborn needs the medicine to develop immunity."

B."The medicine will protect your newborn from being jaundiced."

C."Newborns have sterile bowels, and the medicine promotes the growth of bacteria in the bowel."

D."Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."

D."Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."

After giving the essential newborn care, Nurse Claire assesses Fulgencio after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate?

A.Apply gentle pressure.

B.Reinforce the dressing.

C.Document the findings.

D.Contact the health care provider (HCP).

C.Document the findings.

Which statement by Patient Gloria reflects a new mother's understanding of the teaching about the prevention of newborn abduction?

A."I will place my baby's crib close to the door."

B."Some health care personnel won't have name badges."

C."I will ask the nurse to attend to my infant if I am napping and my husband is not here."

D."It's okay to allow the nurse assistant to carry my newborn to the nursery."

C."I will ask the nurse to attend to my infant if I am napping and my husband is not here."

After a while, Nurse Claire receives a telephone call to prepare for the admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority?

A.Turn on the apnea and cardiorespiratory monitors.

B.Connect the resuscitation bag to the oxygen outlet.

C.Set up the intravenous line with 5% dextrose in water.

D.Set the radiant warmer control temperature at 36.5 °C (97.6 °F)

B.Connect the resuscitation bag to the oxygen outlet.

After admission, Nurse Clairehas been monitoring the newborn for respiratory distress syndrome. Which assessment findings should alert Nurse Claire to the possibility of this syndrome? Select all that apply.

A.Cyanosis

B.Tachypnea

C.Hypotension

D.Retractions

E.Audible grunts

F.Presence of a barrel chest

A.A, B, D, & E

B.B & F

C.A, B, D, E & F

D.None of the above

A.A, B, D, & E

barrel chest = chronic respiratory condition

After being discharged, Gloria calls the clinic and reports that when cleaning the umbilical cord, she noticed that Fulgencio's cord was moist and that discharge was present. What is the most appropriate nursing instruction should Nurse Claire relay?

A.Bring the infant to the clinic.

B.This is a normal occurrence and no further action is needed.

C.Increase the number of times that the cord is cleaned per day.

D.Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues.

A.Bring the infant to the clinic.

Meanwhile, Nurse Claire is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn?*

A.Developmental delays because of excessive size

B.Maintaining safety because of low blood glucose levels

C.Choking because of impaired suck and swallow reflexes

D.Elevated body temperature because of excess fat and glycogen

B.Maintaining safety because of low blood glucose levels

Additionally, Nurse Claire creates a plan of care for a woman with human immunodeficiency virus (HIV) infection and her newborn. The nurse should include which intervention in the plan of care?

A.Monitoring the newborn's vital signs routinely

B.Maintaining standard precautions at all times while caring for the newborn

C.Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems

D.Instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment

B.Maintaining standard precautions at all times while caring for the newborn

Nurse Claire is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. Which of the following should she instruct the mother?

A.Feed the newborn less frequently.

B.Continue to breast-feed every 2 to 4 hours.

C.Switch to bottle-feeding the infant for 2 weeks.

D.Stop breast-feeding and switch to bottle-feeding permanently.

B.Continue to breast-feed every 2 to 4 hours.

The nurse examines a collection of blood beneath the newborn's scalp that does not cross suture lines. The nurse notes this as:

A.caput succedaneum.

B.cephalohematoma.

C.occiput.

D.sinciput.

B.cephalohematoma.

blood

A.caput succedaneum. = edema

A newborn is evaluated by the nurse after birth. Which assessment findings reveal a problem and indicate the need for more evaluation?

A.Rosy skin color

B.Heart rate of 138 beats per minute

C.Noisy breath sounds

D.An axillary temperature of 36.5°C, or 97.7°F

C.Noisy breath sounds

Which of the following reflexes is being evaluated by the nurse by elevating the infant's body slightly over the crib, lowering it abruptly, and then observing for bilateral arm extension and leg flexion?

A.Moro reflex

B.Galant reflex

C.Palmar grasp

D.Babinski reflex

A.Moro reflex

present till 6 months

B.Galant reflex

curve hip outward if lower back is stroked next to spine

C.Palmar grasp

infant wraps fingers around objects

D.Babinski reflex

stroking plantar surface

The nurse is questioned by the parents of an infant about the need to test their child for phenylketonuria. The nurse should respond appropriately by saying:

A.Prevent mental retardation.

B.Prevent chronic lung infections.

C.Treat conductive deafness effectively.

D.Treat hematuria and proteinuria before complications develop.

A.Prevent mental retardation.

B.Prevent chronic lung infections. CYSTIC FIBROSIS

C.Treat conductive deafness effectively. OSTEOGENESIS IMPERFECTA TYPE 1

D.Treat hematuria and proteinuria before complications develop.

POLYCYSTIC KIDNEY DSE

The nurse is discussing the characteristics of newborn and toddler stools with a group of pregnant clients. Which of the following is the correct statement by the nurse:

A.Infants who are breastfed have dark yellow or tan, formed feces.

B.During the first week of life, the feces of the newborn are brown, formed, and firm.

C.For the first 24 hours, the feces passed by the newborn are black, tarry, and sticky.

D.Infants who are formula-fed have bright yellow or golden-colored feces.

C.For the first 24 hours, the feces passed by the newborn are black, tarry, and sticky.