RECALLS 10 - NP2

What change does a nurse expect in a client's hematologic system during the second trimester of pregnancy?

A. An increase in hematocrit

B. An increase in blood volume

C. A decrease in sedimentation rate

D. A decrease in white blood cells

B. An increase in blood volume

A client in the active phase of the first stage of labor begins to tremble, becomes very tense during contractions, and is quite irritable. She frequently states, "I cannot stand this a minute longer." What does this behavior indicate to the nurse caring for her?

A. There was no preparation for labor.

B. She should receive an analgesic for pain.

C. She is entering the transition phase of labor.

D. Hypertonic uterine contractions are developing

C. She is entering the transition phase of labor.

A nurse is caring for a primigravida during labor. What does the nurse observe that indicates birth is about to take place?

A. Bloody discharge from the vagina increases.

B. Perineum begins to bulge with each contraction.

C. Client becomes irritable and stops following instructions.

D.Contractions occur more frequently, are stronger, and last longer

B. Perineum begins to bulge with each contraction.

fetal head is in the pelvic floor

A. Bloody discharge from the vagina increases.

beginning of 2nd phase

C. Client becomes irritable and stops following instructions.

transition phase

D.Contractions occur more frequently, are stronger, and last longer

progress of labor

For what complication should a nurse monitor a client when an oxytocin (Pitocin) infusion is used to induce labor?

A. Intense pain

B. Uterine tetany

C. Hypoglycemia

D. Umbilical cord prolapse

B. Uterine tetany

During the postpartum period it is expected for women to have an increased cardiac output with tachycardia. This knowledge should motivate a nurse who is caring for a client with cardiac problems to monitor for:

A. an irregular pulse.

B. respiratory distress.

C. hypovolemic shock.

D. an increase in vaginal bleeding.

B. respiratory distress.

A nurse anticipates that newborns of mothers who have diabetes often have tremors, periods of apnea, cyanosis, and poor sucking ability. With what complication are these signs associated?

A. Hypoglycemia

B. Hypercalcemia

C. Central nervous system edema

D. Congenital depression of the islets of Langerhans

A. Hypoglycemia

What is the most important factor for a nurse to consider when selecting nursing measures to help parent-child relationships during the immediate postpartum period?

A. Physical status of the infant

B. Duration and difficulty of the labor

C. Anesthesia during the labor process

D. Health and emotional status during the pregnancy

A. Physical status of the infant

A mother is concerned that her newborn may be exposed to communicable diseases when she goes home. When teaching the mother ways to decrease the risk of infection, what type of immunity should the nurse explain was transferred to her baby through the placenta?

A. Active natural

B. Passive natural

C. Active artificial

D. Passive artificial

B. Passive natural

A client is rooming-in with her newborn. A nurse observes the infant lying quietly in the bassinet with eyes opened wide. What action should the nurse take in response to the infant's behavior?

A. Brighten the lights in the room.

B. Wrap and then turn the infant to the side.

C. Encourage the mother to talk to her baby.

D. Begin the physical and behavioral assessments.

C. Encourage the mother to talk to her baby.

What is a nurse's primary critical observation when performing an assessment for determining an Apgar score?

Heart rate

Respiratory rate

Presence of meconium

Evaluation of Moro reflex

Heart rate

A parent and 3-month-old infant are visiting the well-baby clinic for a routine examination. What should the nurse include in the accident prevention teaching plan?

A. Remove small objects from the floor.

B. Cover electric outlets with safety plugs.

C. Remove toxic substances from low areas.

D. Test the temperature of water before bathing.

D. Test the temperature of water before bathing.

In a noisy room a sleeping newborn initially startles and has rapid movements but soon goes back to sleep. What is the most appropriate nursing action in response to this behavior?

A. Accept the infant's behavior.

B. Assess the infant's vital signs.

C. Test the infant's ability to hear.

D. Stimulate the infant's respirations.

A. Accept the infant's behavior.

The nurse is caring for a 7-year-old female on the school-age unit. Her mother is concerned that she may have some developmental delays. Which of the following statements would indicate to the nurse that the child is not developmentally on track for her age:

A. The child is able to follow a four-to-five-step command.

B. The child started wetting the bed on this admission to the hospital.

C. The child has an imaginary friend named Kelly.

D. The child enjoys playing board games with her sister.

C. The child has an imaginary friend named Kelly.

The nurse caring for an 8-year-old boy is trying to encourage developmental growth. What activity can the nurse provide for the child to encourage his sense of industry?

A. . Allow the child to choose what time to take his medication.

B. Provide the child with the homework his teacher has sent in.

C. Allow the child to assist with his bath.

D. Allow the child to help with his dressing change.

B. Provide the child with the homework his teacher has sent in.

The school nurse is preparing a discussion on nutrition with the fourth-grade class. Based on the childrens' developmental level, what information should she include in her presentation?

A. A review of the number of calories that a fourth-grade child should consume in a day.

B. A review of a list of high-calorie foods that all fourth-graders should avoid.

C. A review of how to read food labels so children know which foods are good for them.

D. A review of nutritious foods with basic scientific information about how they affect the body organs and systems.

D. A review of nutritious foods with basic scientific information about how they affect the body organs and systems.

Situation:

Nurse Nico is assigned in the pediatric ward. There, he encountered pediatric cases and many curious mothers.

A 9-year-old boy has been hospitalized following a bicycle injury. What should the nurse recommend to the child's parents to prevent future injury?

A. Their son should wear safety equipment while riding bicycles.

B. Their son should read educational material on bicycle safety.

C. Their son should watch a video on bicycle safety.

D. Their son should ride his bike in the presence of adults.

A. Their son should wear safety equipment while riding bicycles.

The school nurse has seen several students in the health office. For which of the following students should the nurse suggest a follow-up exam?

a. A 14-year-old girl who has not experienced menarche

b. A 7-year-old boy who has grown 2 inches in a year

c. A 10-year-old girl who has gained 11 pounds in a year

d. An 8-year-old boy who has lost four deciduous teeth in the past year

c. A 10-year-old girl who has gained 11 pounds in a year

menarche = 11-15 y/o

normal weight gain in school age = 4.4-6.6 lbs/year

losing of deciduous teeth = 6-13 y/o

A child who has a BMI of 34 visits the school nurse. Which of the following factors does the nurse recognize that the child may be experiencing?

a. Increased bullying by peers

b. Increased self-esteem

c. Increased resiliency

d. Increased motivation to lose weight

a. Increased bullying by peers

Which is the first intervention that should be recommended to a pregnant woman complaining of hemorrhoid pain?

A. Steroid-based creams

B. Diet modifications

C. Surgery

D. Oral medications

B. Diet modifications

A pregnant client presents with vaginal bleeding and increasing cramping. Her exam reveals that the cervical os is open. Which term should the nurse expect to see in the client's chart notation to most accurately describe the client's condition?

A. Ectopic pregnancy

B. Complete abortion

C. Imminent abortion

D. Incomplete abortion

C. Imminent abortion

A nurse is caring for a pregnant woman who states she smokes two packs per day (PPD) of cigarettes. She states she has smoked in other pregnancies and has never had any problems. What is the nurse's best response?

A. "I am glad to hear your other pregnancies went well. Smoking can cause a variety of problems in pregnancies and it would be best if you could quit smoking with this pregnancy."

B. "You need to stop smoking for the baby's sake."

C. "Smoking can lead to having a large baby which can make it difficult for delivery. You may even need a cesarean section."

D. "Smoking less would eliminate the risk for your baby."

A. "I am glad to hear your other pregnancies went well. Smoking can cause a variety of problems in pregnancies and it would be best if you could quit smoking with this pregnancy."

A nurse is caring for a client who has been in the second stage of labor for the last 12 hours. The nurse should monitor for which cardiovascular change that occurs during labor?

A. An increase in maternal heart rate

B. A decrease in cardiac output

C. An increase in peripheral vascular resistance

D. A decrease in the uterine artery blood flow during contractions

A. An increase in maternal heart rate

NORMAL

B. A INCREASE in cardiac output

A nurse is assisting in the delivery of a term newborn. Immediately after delivery of the placenta, the nurse palpates the uterine fundus and finds that it is firm and located halfway between the client's umbilicus and symphysis pubis. Which action should the nurse take based on the assessment findings?

A. Immediately begin to massage the uterus

B. Document the findings

C. Assess for bladder distension

D. Monitor the client closely for increased vaginal bleeding

B. Document the findings

While assisting with the vaginal delivery of a fullterm newborn, a nurse observes that, in spite of the fact that the client did not have an episiotomy or a perineal laceration, her perineum and labia are edematous. To promote comfort and decrease the edema, which intervention is most appropriate?

A. Applying an ice pack to the perineum

B. Teaching the client to relax her buttocks before sitting in a chair

C. Applying a warm pack

D. Providing the client with a plastic donut cushion to be used when sitting

A. Applying an ice pack to the perineum

1st 24 hours

reduces edema and irritation

Teaching the client to TIGHTEN her buttocks before sitting in a chair

plastic donut cushion to be used when sitting is NOT RECOMMENDED

promotes separation of buttocks in postpartum

A postpartum client, who is 24 hours post-vaginal birth and breastfeeding, asks a nurse when she can begin exercising to regain her prepregnancy body shape. Which response by the nurse is correct?

A. "Simple abdominal and pelvic exercises can begin right now."

B. "You will need to wait until after your 6-week postpartum checkup."

C. "Once your lochia has stopped you can begin exercising."

D. "You should not exercise while you are breastfeeding."

A. "Simple abdominal and pelvic exercises can begin right now."

A primiparous client, who is bottle feeding her infant, asks a nurse when she can expect to start having her menstrual cycle again. Which response by the nurse is most accurate?

A. "Most women who bottle feed their infants can expect their periods to return within 6 to 10 weeks after birth."

B. "Your period should return a few days after your lochial discharge stops."

C. "You will notice a change in your vaginal discharge from pink to white; once that happens your period should return within a week."

D. "Bottle feeding will delay the return of a normal menstrual cycle until 6 months post-birth."

A. "Most women who bottle feed their infants can expect their periods to return within 6 to 10 weeks after birth."

While working in a perinatal clinic, a nurse receives a phone call from a client who is 20 days postpartum. The client tells the nurse she has been having heavy, bright red bleeding since leaving the hospital 18 days ago. She is concerned and wonders what she should do. Which instruction to the client is correct?

A. Come to the clinic immediately

B. Decrease physical activity until the bleeding stops

C. Stop being concerned because this is expected after birth

D. Call again next week if the bleeding has not stopped by then

A. Come to the clinic immediately

The husband of a postpartum client, who has been diagnosed with postpartum depression (PPD), is concerned and asks a nurse what kind of treatment his wife will require. The nurse's response should be based on the knowledge that the collaborative plan of care for PPD includes which of the following?

A. Antidepressant medications and psychotherapy

B. Psychotherapy alone

C. Removal of the infant from the home

D. Hypnotic agents and psychotherapy

A. Antidepressant medications and psychotherapy

The father of a 12-hour-old newborn calls a nurse into his wife's hospital room. He is agitated and reports to the nurse that his baby's hands and feet are blue. The nurse confirms acrocyanosis and intervenes by:

A. immediately stimulating the infant to cry.

B. explaining to the father that this is an expected finding in a newborn.

C. assessing the newborn's temperature

D. assessing the newborn's cardiac status.

B. explaining to the father that this is an expected finding in a newborn.

While assessing a full-term newborn, a nurse notes molding on the infant's head. Considering this assessment finding, which information should the nurse expect to see on the mother's labor and delivery documentation?

A. Vaginal breech birth

B. Planned cesarean section, no labor

C. 16-hour labor

D. Precipitous delivery after a 30-minute labor

C. 16-hour labor

The nurse evaluates that a mother understands information provided about her newborn's milia when the mother says:

A. "I will put lotion on my infant's nose twice a day."

B. "I understand these raised white spots will clear up without treatment."

C. "I realize the baby will need surgery to remove these skin lesions."

D. "I will apply alcohol twice a day to the lesions until they disappear."

B. "I understand these raised white spots will clear up without treatment."

normal exposed sebaceous glands

While caring for a 30-year-old, single female who delivered a term newborn, a nurse determines that the best way to assess the impact of the newborn on the client's lifestyle would be to:

A. observe how the client interacts with her hospital visitors

B. review the client's prenatal record.

C. ask the client what plans she has made for newborn care at home.

D. observe the relationship between the client and her newborn's father.

C. ask the client what plans she has made for newborn care at home.

While caring for a small for gestational age newborn (SGA), a nurse notes slight tremors of the extremities, a high-pitched cry, and an exaggerated Moro reflex. In response to these assessment findings, what should be the nurse's first action?

A. Assess the infant's blood sugar level

B. Document the findings in the infant's medical record

C. Immediately inform the health-care provider of the symptoms

D. Assess the infant's temperature.

A. Assess the infant's blood sugar level

signs of HYPOGLYCEMIA

A nurse is planning the care of a 2-hour-old infant at 38 weeks gestation whose mother has type 1 diabetes mellitus. The nurse writes the following NANDA diagnosis: "Altered Nutrition: less than body requirements" and appropriately adds which "related to" statement?

A. Decreased amounts of red blood cells secondary to low erythropoietin levels

B. Decreased amounts of total body fat secondary to decreased growth hormone

C. Increased glucose metabolism secondary to hyperinsulinemia

D. Increased amounts of body water

C. Increased glucose metabolism secondary to hyperinsulinemia

When assessing an infant undergoing phototherapy for hyperbilirubinemia, a nurse notes a maculopapular rash over the infant's buttocks and back. In response to this assessment finding, what action should the nurse take next?

A. Document the results in the newborn's medical record.

B. Call the health-care provider immediately to report this finding.

C. Discontinue the phototherapy immediately.

D. Assess the infant's temperature

A. Document the results in the newborn's medical record.

temporary = maculopapular rashes

PHOTOTHERAPY

1. remove clothes

2. cover eyes and gonads

3. provide extra fluids to excrete bilirubin

4. remove from phototherapy for human contact

Situation:

As a nurse, it is very important to be knowledgeable not only on what are the normal signs, but also on the abnormal signs. A meticulous eye and quick decision making skills makes the difference especially in handling difficult cases.

If a nurse is concerned that a newborn may have congenital hydrocephalus, which assessment finding is noted?

A. Bulging anterior fontanel

B. Head circumference equal to the chest circumference

C. A narrowed posterior fontanel

D. Low-set ears

A. Bulging anterior fontanel

D. Low-set ears

trisomy 21

While caring for a client with severe preeclampsia who has been receiving intravenous magnesium sulfate for 24 hours, a nurse evaluates that the medication is effective when noting:

A. an increase in blood pressure.

B. an increase in urine output.

C. a decrease in platelet count.

D. an increase in hematocrit.

B. an increase in urine output.

L. After teaching a group of parents of preschoolers attending a well-child clinic about oral hygiene and tooth brushing, the nurse determines that the teaching has been successful when the parents state that children can begin to brush their teeth without help at which of the following ages?

A. 3 years.

B. 5 years.

C. 7 years.

D. 9 years

C. 7 years.

After having a blood sample drawn, a 5-year old child insists that the site be covered with a bandage. When the parent tries to remove the bandage before leaving the office, the child screams that all the blood will come out. The nurse encourages the parent to leave the bandage in place and tells the parent that the child:

A. Fears another procedure.

B. Does not understand body integrity.

C. Is expressing pain.

D. Is attempting to regain control.

B. Does not understand body integrity.

The mother of a 4-year-old expresses concern that her child may be hyperactive. She describes the child as always in motion, constantly dropping and spilling things. Which of the following actions would be appropriate at this time?

A. Determine whether there have been any changes at home.

B. Explain that this is not unusual behavior.

C. Explore the possibility that the child is being abused.

D. Suggest that the child be seen by a pediatric neurologist.

B. Explain that this is not unusual behavior.

PRESCHOOL

POWERHOUSE OF GROSS MOTOR SKILLS

LOW FINE MOTOR SKILLS

A nurse is assessing the growth and development of a 10-year-old. What is the expected behavior of this child?

A. Enjoys physical demonstrations of affection.

B. Is selfish and insensitive to the welfare of others.

C. Is uncooperative in play and school.

D. Has a strong sense of justice and fair play.

D. Has a strong sense of justice and fair play.

A. Enjoys physical demonstrations of affection. NOT APPLICABLE TO LATENCY

B. Is selfish and insensitive to the welfare of others. TODDLER

C. Is uncooperative in play and school. TODDLER

The mother asks the nurse about her 9-year old child's apparent need for between-meal snacks, especially after school. When developing a sound nutritional plan for the child with the mother, the nurse should advise the mother:

A. The child does not need to eat between-meal snacks.

B. The child should eat the snacks the mother thinks are appropriate.

C. The child should help with preparing his or her own snacks.

D. The child will instinctively select nutritional snacks.

C. The child should help with preparing his or her own snacks.

Which of the following actions initiated by the parents of an 8-month-old indicates they need further teaching about preventing childhood accidents?

Placing a fire screen in front of the fireplace.

Placing a car seat in a front-seat, front-facing position.

Inspecting toys for loose parts.

Placing toxic substances out of reach or in a locked cabinet

Placing a car seat in a front-seat, front-facing position.

A nurse is assessing the growth and development of a 14-year-old boy. He reports that his 13-year-old sister is 2 inches taller than he is. The nurse should advise the boy that the growth spurt in adolescent boys, compared with the growth spurt of adolescent girls:

A. Occurs at the same time.

B. Occurs 2 years earlier.

C. Occurs 2 years later.

D. Occurs 1 year earlier.

C. Occurs 2 years later.

Parents of a 15-year-old state that he is moody and rude. The nurse should advise his parents to:

A. Restrict his activities.

B. Discuss their feelings with their child.

C. Obtain family counseling.

D. Talk to other parents of adolescent

B. Discuss their feelings with their child.

A mother tells the nurse that one of her children has chickenpox and asks what she should do to care for that child. When teaching the mother, the nurse should instruct the mother to help her child prevent:

A. Acid-base imbalance.

B. Malnutrition.

C. Skin infection.

D. Respiratory infection.

C. Skin infection.

The school nurse develops a plan with an adolescent to provide relief of dysmenorrhea to aid in her development of which of the following?

A. Positive peer relations.

B. Positive self-identity.

C. A sense of autonomy.

D. A sense of independence

B. Positive self-identity.

The mother asks the nurse for advice about discipline for her 18-month-old. Which of the following should the nurse suggest that the mother use?

A. Structured interactions.

B. Spanking.

C. Reasoning

D. Time out.

D. Time out.

To assess the development of a 1-month-old, the nurse asks the parent if the infant is able to:

A. Smile and laugh out loud.

B. Roll from back to side.

C. Hold a rattle briefly.

D. Turn the head from side to side

D. Turn the head from side to side

While assessing a neonate weighing 3,175 g (7 lb) who was born at 39 weeks' gestation to a primiparous client who admits to cocaine use during pregnancy, which of the following would alert the nurse to possible cocaine withdrawal?

A. Bradycardia.

B. High-pitched cry.

C. Sluggishness.

D. Hypocalcemia

B. High-pitched cry.

Situation: There is a rotation in the hospital for trainee nurses where Nurse Betty is working. Nurse Betty is assigned in the labor and delivery unit.

The amniotic fluid of a client has a greenish tint. The nurse interprets this to be the result of which of the following?

a. Lanugo

b. Hydramnio

c. Meconium

d. Vernix

c. Meconium

A client has delivered a child at 28 weeks gestation. The nurse would expect the newborn to exhibit which of the findings?

A. Bones are fully developed

B. Eyes are developed and open

C. Lanugo is beginning to disappear

D. Lungs are completely mature

B. Eyes are developed and open

A. Bones are fully developed

32 weeks

C. Lanugo is beginning to disappear

26 weeks

D. Lungs are completely mature

37 weeks

A client in labor at 38 weeks gestation was admitted to the labor and delivery unit. As the client was walking around the hallway, she told the nurse that her water broke. Which of the following should the nurse do first?

a. Check the color of the amniotic fluid.

b. Escort the client to the labor room and assess FHR.

c. Have the client lie on the bed and check vital signs.

d. Escort the client to the labor room and notify the physician.

b. Escort the client to the labor room and assess FHR.

ROM can cause umbilical cord prolapse = uteroplacental insufficiency

A nurse is teaching a postpartum client about cord care for the newborn. Which statement by the client indicates a need for further teaching?

a. "I will secure the diaper over the cord to protect it."

b. "I can expect the cord to turn black in a few days."

c. "I will give my newborn sponge baths until the cord falls off."

d. "I should let the cord fall by itself."

a. "I will secure the diaper over the cord to protect it."

The nurse should make which statement to a pregnant client found to have gynecoid pelvis?

a. "Your type of pelvis has a narrow pubic arch."

b. "Your type of pelvis is the most favorable for labor and birth."

c. "Your type of pelvis is a wide pelvis, but it has a short diameter."

d. "You will need a cesarean section because this type of pelvis is not favorable for a vaginal delivery."

b. "Your type of pelvis is the most favorable for labor and birth."

a. "Your type of pelvis has a narrow pubic arch."

NADROID

c. "Your type of pelvis is a wide pelvis, but it has a short diameter."

PLATYPELOID

Situation 2: Nurse Augustine is handling patients who are high-risk during their pregnancy.

The nurse is assisting with a vaginal delivery of a full-term infant. Which assessment finding of the newborn is most important for the nurse to follow-up?

a. Flat bluish discolored area on the buttocks

b. Localized soft tissue edema of the scalp

c. Small amount whitish substance in axilla

d. Tuft of hair at the base of the spine

d. Tuft of hair at the base of the spine

spina bifida

A nurse is caring for a client who is about to undergo an emergency cesarean birth for severe preeclampsia at 26.3 weeks gestation. The client is admitted after 3 days of a severe headache and a 10-pound weight gain. Her blood pressure is 180/110 mm Hg, and she has a moderate abruption. The woman states, "It's my fault! If I would have called earlier, they could have stopped it and I wouldn't be having my baby delivered now!" What is the nurse's best response?

a. "This is not your fault. You are here now, and we are going to take care of you."

b. "Earlier intervention might have deemed a better outcome, but you can't think of that now."

c. "Your baby is going to be fine."

d. "Your health and well-being are what is important, you need to think of yourself and not the baby right now.

a. "This is not your fault. You are here now, and we are going to take care of you."

A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate?

a. Contact the primary health care provider.

b. Instruct the client to maintain bed rest for the remainder of the pregnancy.

c. Inform the client that these contractions are common and may occur throughout the pregnancy.

d. Call the maternity unit and inform them that the client will be admitted in a preterm labor condition.

c. Inform the client that these contractions are common and may occur throughout the pregnancy.

The nurse is performing a postpartum assessment 12 hours after the prolonged vaginal delivery of a term infant. Which assessment findings should be reported to the health care provider?

a. Complaints of discomfort during fundal palpation

b. Foul-smelling lochia

c. Oral temperature of 37.7 C

d. White blood cell of 20,000/mm3

b. Foul-smelling lochia

When assessing a client at 12 weeks of 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 of gestation

B. At 20 weeks of gestation

C. At 24 weeks of gestation

D. At 30 weeks of gestation

D. At 30 weeks of gestation

In developing a teaching plan for expectant parents, the nurse decides to include information about when the parents can expect the infant's fontanels to close. Which statement is accurate regarding the timing of closure of an infant's fontanels that should be included in this teaching plan?

A. The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the end of the first week.

B. The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the end of the second week.

C. The anterior fontanel closes at 8 to 11 months and the posterior fontanel by the end of the first month.

D. The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month.

D. The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month.

When preparing a class on newborn care for expectant parents, which is correct for the nurse to 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. Vernix is a white cheesy substance, predominantly located in the skin folds.

Pseudostrabismus refers to the appearance of eye misalignment in the absence of true misalignment of the visual axes

A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In developing a plan of care, the nurse should give the highest priority to which finding?

*

A. Cyanosis of the hands and feet

B. Skin color that is slightly jaundiced

C. Tiny white papules on the nose or chin

D. Red patches on the cheeks and trunk

B. Skin color that is slightly jaundiced

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 unusually shaped head, especially for a first baby."

B. "It may look odd, but newborn babies are often born with heads like that."

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 head had to adjust to the birth canal."

C. "That is normal. The head will return to a round shape within 7 to 10 days."

An expectant father tells the nurse he fears that his wife "is losing her mind." He states that she is constantly rubbing her abdomen and talking to the baby and that she actually talks to the baby as if it can understand her. Which recommendation should the nurse make to this expectant father?

A. Suggest that his wife seek professional counseling to deal with her symptoms.

B. Explain that his wife is exhibiting ambivalence about the pregnancy.

C. Ask him to report similar abnormal behaviors at the next prenatal visit.

D. Reassure him that normal maternal-fetal bonding is occurring.

D. Reassure him that normal maternal-fetal bonding is occurring.

Situation 3: Nurse Tyler is a newly-hired nurse. He has always been very interested in taking care of newborn babies.

Prior to discharging a 24-hour-old newborn, the nurse assesses her respiratory status. Which of the following would the nurse expect to assess?

A) Respiratory rate 45, irregular

B) Costal breathing pattern

C) Nasal flaring, rate 65

D) Crackles on auscultation

A) Respiratory rate 45, irregular

NORMAL: 40-60

When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes?

A) Gastrointestinal and hepatic

B) Urinary and hematologic

C) Respiratory and cardiovascular

D) Neurological and integumentary

C) Respiratory and cardiovascular

Which anticipatory guidance action by the nurse makes the role transition to parenthood easier?

a. Helps the new parents identify resources

b. Recommends employing babysitters frequently

c. Tells the parents about the realities of parenthood

d. Offers a home phone number and tells parents to call if they have a question

a. Helps the new parents identify resources

Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as:

A) A good time to initiate breast-feeding

B) The period of decreased responsiveness preceding sleep

C) The need to be alert for gagging and vomiting

D) Evidence that the newborn is becoming chilled

A) A good time to initiate breast-feeding

A new mother is changing the diaper of her 20-hour-old newborn and asks why the stool is almost black. Which response by the nurse would be most appropriate?

A) "It must be something you ate during your pregnancy."

B) "This is meconium stool, normal for a newborn."

C) "I'll take a sample and check it for possible bleeding."

D) "This is unusual and I need to report this."

B) "This is meconium stool, normal for a newborn."

Which of the following would alert the nurse to the possibility of respiratory distress in a newborn?

A) Symmetrical chest movements

B) Periodic breathing

C) Respirations of 40 breaths/minute

D) Sternal retractions

D) Sternal retractions

B) Periodic breathing: Newborns can sometimes exhibit brief pauses in their breathing patterns, known as periodic breathing. While it can be a cause for concern if it's frequent or prolonged, it's not necessarily a sign of respiratory distress on its own.

When counseling a mother about the immunologic properties of breast milk, the nurse would emphasize breast milk as a major source of which immunoglobulin?

A) IgA

B) IgG

C) IgM

D) IgE

A) IgA

A postpartum adolescent mother confides to the nurse that she hopes her baby will be good and sleep through the night. What should the nurse plan to teach the client to do?

a. Talk softly and cuddle her baby when crying occurs

b. Keep her baby awake for longer periods during the day

c. Ensure sleep by adding cereal to her baby's bedtime bottle

d. Put a soft and brightly colored toy next to her baby at bedtime

a. Talk softly and cuddle her baby when crying occurs

A pregnant client is making her first Antepartum visit. She has a two year old son born at 40 weeks, a 5 year old daughter born at 38 weeks, and 7 year old twin daughters born at 35 weeks. She had a spontaneous abortion 3 years ago at 10 weeks. Using the GTPAL format, the nurse should identify that the client is:

A) G4 T3 P2 A1 L4

B) G5 T2 P2 A1 L4

c) G5 T2 P1 A1 L4

D) G4 T3 P1 A1 L4

c) G5 T2 P1 A1 L4

The client tells the nurse that her last menstrual period started on May 8 and ended on May 13. Using Nagele's rule, the nurse determines her EDD to be which of the following?

a. February 20

b. February 1

c. January 20

d. February 15

d. February 15

A multigravida at 37 weeks' gestation arrives at the emergency room with painless, bright red bleeding and mild contractions every 7 to 10 minutes. Which of the following assessments should be avoided?

a. Maternal vital sign

b. Fetal heart rate

c. Contraction monitoring

d. Cervical dilation

d. Cervical dilation

may cause hemorrhage

A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client?

a. "Come to the clinic immediately."

b. "The vaginal discharge may be bothersome, but is a normal occurrence."

c. "Report to the emergency department at the maternity center immediately."

d. "Use tampons if the discharge is bothersome, but be sure to change the tampons every 2 hours."

b. "The vaginal discharge may be bothersome, but is a normal occurrence."

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?

a. Turn the client on her side.

b. Notify the health care provider.

c. Check the vaginal area for bleeding.

d. Monitor the fetal heart rate every three minutes.

a. Turn the client on her side.

A nurse observes a laboring client's amniotic fluid and decides that it is the expected color. What description of amniotic fluid supports this conclusion?

a. Clear, dark amber, and contains shreds of mucus

b. Straw-colored, clear, and contains little white specks

c. Milky, greenish yellow, and contains shreds of mucus

d. Greenish yellow, cloudy, and contains little white specks

b. Straw-colored, clear, and contains little white specks

A nurse is assigned to an adolescent who gave birth 12 hours ago. She continually talks on the phone to her friends and does not respond when her new baby cries. What is the best immediate intervention?

a. Calling social service for a consult

b. Calling the psychiatric team for an intervention

c. Calling her mother and having her speak with the client

d. Modeling appropriate behaviors that encourage infant bonding

d. Modeling appropriate behaviors that encourage infant bonding

What is the best nursing intervention to minimize perineal edema after an episiotomy?

a. Applying ice packs

b. Offering warm sitz baths

c. Administering aspirin prn

d. Elevating the hips on a pillow

a. Applying ice packs

A nurse teaches a postpartum client how to care for her episiotomy to prevent infection. Which behavior indicates that the teaching was effective?

a. The perineal pad is changed twice daily.

b. She washes her hands whenever a perineal pad is changed.

c. She rinses her perineum with water after using an analgesic spray.

d. The perineum is cleansed from the anus toward the symphysis pubis

b. She washes her hands whenever a perineal pad is changed.

A client in labor begins to experience contractions 2 to 3 minutes apart that last about 45 seconds. Between contractions the nurse identifies a fetal heart rate of 90 beats/min on the internal fetal monitor. What is the next nursing action?

a. Notify the health care provider.

b. Resume continuous fetal heart monitoring.

c. Continue to monitor the maternal vital signs.

d. Document the fetal heart rate as an expected response to contractions.

a. Notify the health care provider.

NORMAL: 110-160 bpm

A nurse examines a client who had a cesarean birth. It is 3 days since the birth and the client is about to be discharged. Where does the nurse expect the fundus to be located?

a. 1 fingerbreadth below the umbilicus

b. 2 fingerbreadths below the umbilicus

c. 3 fingerbreadths below the umbilicus

d. 4 fingerbreadths below the umbilicus

c. 3 fingerbreadths below the umbilicus

A client on the postpartum unit asks the nurse why the nurses are always encouraging her to walk. What should the nurse consider when forming a response in language the client will understand?

a. Respirations are enhanced.

b. Bladder tonicity is increased.

c. Abdominal muscles are strengthened.

d. Peripheral vasomotor activity is promoted.

d. Peripheral vasomotor activity is promoted

to prevent DVT

Situation 5: Despite numerous ehealth teachings, high-risk pregnancies are inevitable. Different cases of high-risk pregnancies always keep the Labor and Delivery Unit of JTA Hospital.

A client is receiving magnesium sulfate therapy for severe preeclampsia. What initial sign of toxicity should alert the nurse to intervene?

a. Hyperactive sensorium

b. Increase in respiratory rate

c. Lack of the knee-jerk reflex

d. Development of a cardiac dysrhythmia

c. Lack of the knee-jerk reflex

MgSO4

RESPIRATORY AND NEURLOGIC DEPRESSANT

A client at 9 weeks' gestation asks the nurse in the prenatal clinic if she can have her chorionic villi sampling (CVS) done at this visit. At what week gestation should the nurse respond is the best time for this test?

a. 8 weeks and less than 10 weeks

b. 10 weeks and less than 12 weeks

c. 12 weeks and less than 14 weeks

d. 14 weeks and less than 16 weeks

b. 10 weeks and less than 12 weeks

CVS

AMNIOCENTESIS

d. 14 weeks and less than 16 weeks

A nurse is assessing a client with a tentative diagnosis of hydatidiform mole. Which clinical finding should the nurse anticipate?

a. Hypotension

b. Decreased fetal heart rate

c. Unusual uterine enlargement

d. Painless, heavy vaginal bleeding

c. Unusual uterine enlargement

Sonography of a primigravida who is at 15 weeks' gestation reveals a twin pregnancy. The nurse reviews with the client the risks of a multiple pregnancy that were explained by the health care provider. Which condition does the client identify that indicates the need for further instruction about complications associated with a multiple gestation?

a. Preterm birth

b. Down syndrome

c. Twin to twin transfusion

d. Gestational hypertension

b. Down syndrome

A nurse is reviewing the obstetric history of a client who had an abruptio placentae. What prenatal condition does the nurse expect the client to have had?

a. Cardiac disease

b. Hyperthyroidism

c. Gestational hypertension

d. Cephalopelvic disproportion

c. Gestational hypertension

A client arrives at the hospital at 38 weeks' gestation with profuse vaginal bleeding. She states that it occurred suddenly without any contractions. Which condition may the client be experiencing that requires immediate notification of the health care provider?

a. Placenta previa

b. Placenta accreta

c. Ruptured uterus

d. Concealed abruptio

a. Placenta previa

PAINLESS VAGINAL BLEEDING

When is it most important for a female client to know that a fetus may be structurally damaged by the ingestion of drugs?

a. During early adolescence

b. Throughout the entire pregnancy

c. When planning to become pregnant

d. At the beginning of the first trimester

c. When planning to become pregnant

A client at 10 weeks' gestation calls the clinic and tells a nurse that she has morning sickness and cannot control it. What should the nurse suggest to promote relief?

a. "Eat dry crackers before arising."

b. "Increase fat intake before bedtime."

c. "Drink high-carbohydrate fluids with meals."

d. "Have two small meals a day with a snack at noon."

a. "Eat dry crackers before arising."

A client tells a nurse in the prenatal clinic that she has vaginal staining but no pain. Her history reveals amenorrhea for the last 2 months and pregnancy confirmation after her first missed period. She is admitted to the high-risk unit because she may be having a spontaneous abortion. What type of abortion is suspected?

a. Missed

b. Inevitable

c. Threatened

d. Incomplete

c. Threatened

A nurse is assessing a pregnant client during the third trimester. What clinical finding is an expected response to the pregnancy?

a. Tachycardia

b. Dyspnea at rest

c. Progressive dependent edema

d. Shortness of breath on exertion

d. Shortness of breath on exertion

During a client's first visit to the prenatal clinic, a nurse discusses a pregnancy diet. The client states that her mother told her she should restrict her salt intake. What is the nurse's best response?

a. "Your mother is correct. You should use less salt to prevent swelling.

b. "Because you need salt to maintain body water balance, it is not restricted. Just eat a well-balanced diet."

c. "Salt is an essential nutrient that is naturally reduced by the body's estrogen. There is no reason to restrict salt in your diet."

d. "We no longer recommend that salt intake be as restricted as much as in the past. However, you shouldn't add salt to your food."

b. "Because you need salt to maintain body water balance, it is not restricted. Just eat a well-balanced diet."

A pregnant client uses a computer continuously during her working hours. This has implications for her plan of care during pregnancy. What should a nurse recommend?

a. "Try to walk around every few hours during the workday."

b. "Ask for time in the morning and afternoon to elevate your legs."

c. "Tell your boss that you cannot work beyond the second trimester."

d. "Ask for time in the morning and afternoon to get something to eat."

a. "Try to walk around every few hours during the workday."

A pregnant client is being prepared for a pelvic examination. She states that she is always tired and feels sick to her stomach, especially in the morning. What is the nurse's best response?

a. "Tell me about how you feel the rest of the day."

b. "Let's discuss ways to resolve these common problems."

c. "Perhaps you should ask your health care provider about it."

d. "There is no need to worry about these expected problems."

b. "Let's discuss ways to resolve these common problems."

What is the best advice a nurse can give to a pregnant woman in her first trimester?

a. "Cut down on drugs, alcohol, and cigarettes."

b. "Avoid drugs, and refrain from smoking and ingesting alcohol."

c. "Avoid smoking, limit alcohol consumption, and do not take aspirin."

d. "Take only prescription drugs, especially in the second and third trimesters."

b. "Avoid drugs, and refrain from smoking and ingesting alcohol."

What information concerning the childbearing process should the nurse teach a client during the first trimester of pregnancy?

a. Labor and birth

b. Signs and symptoms of complications

c. Role transition into parenthood and its acceptance

d. Physical and emotional changes resulting from pregnancy

d. Physical and emotional changes resulting from pregnancy