Flashcard list for: OB/Peds NCLEX-PN Questions

Question Answer Side 3

A client that is 6 months' pregnant comes 2. Drink 8-10 cups of water and take a to the clinic for a routine visit. She asks daily walk. what she can do to relieve constipation. The nurse should teach the client that the RATIONALE most appropriate measures to alleviate this 1. Laxatives and enemas stimulate the problem include which of the following intestinal tract, but also can initiate uterine recommendations? contractions. 2. Intestinal motility is slowed in pregnancy 1. Take a mild laxative and use a Fleet due to the influence of progesterone. enema as needed. Increasing fluid intake and exercise 2. Drink 8-10 cups of water and take a daily stimulates peristalsis. walk. 3. High-fat and high-protein foods 3. Add more protein and fat to the daily contribute to constipation. diet. 4. Caffeine can cause tachycardia in the 4. Drink hot coffee or tea each morning at fetus and its use during pregnancy is breakfast. discouraged. A client at 26 weeks of gestation asks why 1. The muscle movement of the intestines she is having trouble with constipation slows down, which causes dry, hard stools. during her pregnancy. Which of the following explanations by the nurse would RATIONALE be most accurate? 1. Progesterone causes peristalsis to slow 1. The muscle movement of the intestines so more nutrients can be absorbed. slows down, which causes dry, hard stools. 2. An increase in intestinal motility causes 2. the muscl emovmeentn of the intestines diarrhea. speeds up, which ccauses dry, hard stools. 3. Compression of the intestines during 3. The intestines are compressed during pregnancy does not contribute to pregnancy, which causes stool stasis. constipation. 4. The intestines are expanded during 4. The intestines do not increase in pregnancy, which causes stool stasis. diameter due to pregnancy. A client was admitted to the obstetric unit 3. The client's LMP was 2/15/02. on 9/10/02 with c/o labor. The nurse palpated regular uterine contractions every RATIONALE 5 minutes with moderate intensity. A sterile 1. Blood type A with Rh+ does not present vaginal exam revealed a soft cervix that any problems in patient care. Maternal was 85% effaced and dilated to 2 cm. blood type O and/or Rh- blood types can Which of the following admission cause severe jaundice in the newborn due information is most important in planning to maternal antibodies that destroy fetal nursing care? RBCs. 1. The client's blood type and Rh were A+. 2. RBCs are diluted by the increase in 2. The client's hemoglobin was 11 g/dL. plasma volume in pregnancy. A 3. The client's LMP was 2/15/02. hemoglobin of 11 g/dL is phyiological 4. The client's blood pressure was 100/64 anemia, as opposed to true anemia. mm Hg. 3. Using Nagle's rule, and LMP of 2/15/02 would give an EDD of 11/29/02. This client is in preterm labor at 28 5/7 weeks' gestation. 4. During the first two trimesters of pregnancy, meternal blood pressure

normally decreases by 5-10 mmHg in both systolic and diastolic pressures. This decrease is due to peripheral vasodilation caused by pregnancy hormones. 4. "My craving are probably caused by iron deficiency." A 22-year-old client at 7 weeks' gestation attended the first trimester class on nutrition. Which of the following statements indicatea a need for further teaching? 1. "I should gain around 30 pounds by my due date." 2. "Planning meals around the food pyramid guide is best." 3. "Frozen foods are more nutritious than canned foods." 4. "My craving are probably caused by iron deficiency." RATIONALE 1. Appropriate weight gain for pregnancy is between 25 and 35 lbs. 2. Intrauterinie growth retardation can be caused by poor maternal diets. The U.S.F.D.A. recommends following the food pyramid recommendations for improving dietary intake. 3. Canned foods lose some nutrients in processing. Foods that are frozen are processed less and more nutritious. 4. Pica is more related to cultural values and beliefs than to dietary deficiencies. Pica is more likely to cause iron deficiency than to be caused by it. 1. Slow, deep breathing RATIONALE 1. This client is in the early phase of labor; slow, deep breathing and relaxation techniques are usually effective in relieving contraction pain during this phase. 2. Rapid, shallow breathing, or hyperventilation, is inappropriate for any phase of labor. 3. Local anesthesia is used for numbing of the perineum immediately before performance of an episiotomy and delivery of the fetus during the last phase of the first stage of labor. 4. Narcotic analgesia is not appropriate for use during early phases of labor. It can slow or stop labor if given before 5 cm dilation. In addition, minimizing use of narcotics is preferred when prepared childbirth techniques are used. 3. "The father's sperm determines if the baby is male or female."

A client admitted to the obstetric unit with contractions every 8-10 minutes, with cervical effacement of 100%, and dilation of 3 cm, reported that she and her support person planned to use prepared childbirth techniques. The nurse would expect the couple to utilize which of the following pain relief methods during this phase of labor? 1. Slow, deep breathing 2. Rapid, shallow breathing 3. Local anesthesia 4. Narcotic analgesia

A 30-year-old gravida 5, para 4 (all female) client at 12 weeks' gestation asks the nurse, "Do you think I'm having a boy? If I don't have a boy this time, my husband will RATIONALE probably divorce me." Which of the following explanations by the nurse would 1. The sex chromosome of males is XY; be most accurate? the sex chromosome for females is XX. The mother contributes one X 1. "Girls probably run in your family, there's chromosome to the fetus, the father nothing you can do about it." contributes either an X or a Y 2. "The heartbeat of the baby is fast, that chromosome.

2. The heart rate of the fetus is neither faster nor slower according to fetal gender. The range for the fetal heart rate is 110160 bpm regardless of gender. means it's a boy." 3. Meiosis results in the X and Y 3. "The father's sperm determines if the chromosomes of the male splitting so that baby is male or female." each sperm carries either an X or a Y 4. "Don't worry, you are carrying this baby chromosome, thus determining the gender low, that means it's a boy." of the fetus. 4. How a fetus is carried is related to meternal uterine and abdominal muscle tone. The gender of the fetus does not determine how high or low it is carried. 2. "The size of the breasts doesn't matter. All women have about the same amount of milk-producing tissue." A client at term states, "I would like to breastfeed, but my mother-in-law told me RATIONALE my breasts are too small and I won't have enough milk for my baby." The best 1. The volume of breast milk produced is response by the nurse would be which of related to how often the breasts are the following? emptied of milk. Formula supplementation decreases breast milk production since the 1. "Your breasts are small, but if you don't infant nurses less often. produce enough milk, you can give the 2. The amount of milk producing glandular baby some formula." tissue in all women is approximately the 2. "The size of the breasts doesn't matter. same. The size of large breasts is due to All women have about the same amount of increased fatty tissue. milk-producing tissue." 3. An infant is more efficient at emptying a 3. "You will produce more milk if you use a breast than a breast pump. In addition, oral breast pump and then give it to your baby stimulation of the nipples by the infant in a bottle." stimulates the release of oxytocin, which 4. "Milk production is increased by the triggers the let-down reflex. hormone estrogen. You can ask your 4. Estrogen does not stimulate milk doctor for a prescription to take." production. Oxytocin and prolactin are the hormones responsible for breast milk production and breastfeeding success. A 32-hour-old baby has yellowish skin 4. Encourage the mother to increase the undertones and a serum bilirubin level of frequency of breastfeeding sessions. 14 mg/100 mL. The blood type of the baby is B+. The mother's blood type os O+. The RATIONALE infant is being breast-fed. The nurse would include which of the following measures in 1. Bilirubin levels in excess of 12 mg/100 her plan of care? mL may indicate the presence of a pathological process. This jaundice is most 1. No special measures are necessary, likely due to an ABO incompatibility. newborns normally get a little jaundiced. 2. Breastfeeding jaundice occurs around 2. Tell the mother to stop breast-feeding the third day of age. Encouraging early and and give the baby formula instead. frequent feedings at the breast lowers 3. Place the infant under the bililights and neonatal bilirubin levels. prepare for an exchange transfusion. 3. Light therapy requires an order from the 4. Encourage the mother to increase the physician. Exchange transfusions for ABO frequency of breastfeeding sessions. incompatibilities are seldom necessary. 4. Early and frequent breastfeeding tends

to lower serum bilirubin levels. 4. "Many babies are breech at this stage of pregnancy, most turn by term." A primiparous client at 18 weeks' gestation had an ultrasound examination done which RATIONALE showed the fetus in a breech position. The client asked the nurse, "Does this mean I 1. If the fetus remains in a breech position, will have to have a C-section?" Which of external version may be attempted at the following responses by the nurse would approximately 37 weeks' gestation to be most accurate? change position of the fetus. If version is unsuccessful in the nulliparous woman 1. "If a first baby is breech, it must always with a fetus in a breech position, cesarean be delivered by cesarean section." delivery is almost always certain. 2. "The baby will have more room to turn 2. The uterus becomes more crowded, not as your delivery date nears." less, as pregnancy progresses. 3. "You can probably deliver normally, most 3. Few fetuses (3%-4%) are in a breech babies are born breech." position by delivery; even fewer breech 4. "Many babies are breech at this stage of positions are delivered vaginally. pregnancy, most turn by term." 4. Approximately 96% of fetuses in a breech position will turn to a cephalic position by term. 1. Assist the client to a hands and knees position. RATIONALE A laboring client has been dilated 9-10 cm for 2 hours. The fetal head has remained at 1. Maternal position changes such as zero station for 45 minutes despite sitting, kneeling, lateral, or hands and adequate pushing efforts by the client. A knees, can assist fetal head rotation to an sterile vaginal exam reveals a position of occiput anterior position. occiput posterior. Which of the following 2. The gravid uterus compresses the pelvic actions by the nurse would be most blood vessels and compromises appropriate? uteroplacental blood flow. This position not only has no effect on rotation of the fetal 1. Assist the client to a hands and knees head, but can cause fetal compromise. position. 3. Use of forceps at zero station is 2. Assist the client to a supine position. considered to be a high forceps 3. Prepare the client for a forceps rotation. classification and is not acceptable 4. Prepare the client for a cesarean practice according to the American College delivery. of Obstetricians and Gynecologists. 4. Cesarean delivery should be considered only if adequate pushing efforts of 2 or more hours do not result in descent of the fetal head. A client with preterm contractions at 34 2. Phosphatidylgycerol (PG) weeks' gestation has had an amniocentesis for fetal lung maturity. RATIONALE Which of the following lab tests should the nurse monitor? 1. hCG is a hormone produced by the placenta that stimulates the corpus luteum 1. Human chorionic gonadotropin (hCG) to persist and secrete estrogen and 2. Phosphatidylgycerol (PG) progesterone, which maintains the 3. a-Fetoprotein (AFP) pregnancy for the first 20 weeks of 4. Partial thromboplastin time (PTT) gestation. It is found in maternal blood and

1. Monozygotic twins (identical) develop from one fertilized egg that splits into identical halves early in embryonic 1. "Monozygotic twins come from two development. different eggs and sperm." 2. Dizygotic twins develop from two 2. "Dizygotic twins come from one fertilized different ova fertilized by two different egg that split." sperm. 3. "Monozygotic twins come from one egg 3. Once an egg has been penetrated by a and two sperm." single sperm, chemical changes take place 4. "Dizygotic twins come from two different that prevent multiple sperm fertilization. eggs and sperm." 4. See rationale 2. 2. "Missed menses and breast tenderness are presumptive signs of pregnancy." A 20-year-old client has come to the obstetric clinic because her menstrual RATIONALE period is 7 days late. She tells the nurse, "I'm sure I'm pregnant because my period 1. The only positive signs of pregnancy are is late and my breasts are tender." Which auscultation of fetal heart tones, of the following responses by the nurse visualization of the fetus by ultrasound, would be most accurate? and fetal movement felt by the health-care provider. 1. "Missed menses and breast tenderness 2. Presumptive signs of pregnancy are are positive signs of pregnancy." amenorrhea, fatigue, breast tenderness 2. "Missed menses and breast tenderness and enlargement, morning sickness, and are presumptive signs of pregnancy." quickening. 3. "Missed menses and breast tenderness 3. Probable signs of pregnancy are are probable signs of pregnancy." Hegar's sign, ballottement, poristive 4. "Missed menses and breast tenderness pregnancy test, and Goodell's sign. are negative signs of pregnancy." 4. Amenorrhea and breast tenderness are presumptive signs of pregnancy. A client is seen in the emergency room at 3. Increasing heart rate 16 weeks' gestation with pelvic cramping and bright red vaginal bleeding. Which of RATIONALE the following signs and symptoms should the nurse observe the client for? 1. Increased temperature may be a sign of infection; however, the risk of infection is 1. Increased temperature greatest during the first 72 hours after

A client at 12 weeks' gestation has just been told that she is carrying dizygotic twins. She asks the nurse what the difference is between monozygotic and dizygotic twins. Which of the following explanations by the nurse would be most accurate?

urine. 2. PG is a major phospholipid of surfactant. The presence of PG in amniotic fluid indicates fetal lung maturity. 3. AFP is a plasma protein that is produced by the fetus. Abnormally high or low levels can indicate fetal anomalies. AFP levels are drawn from maternal blood. 4. PTT levels are drawn to determine if sodium warfarin levels are at a therapeutic level in women with thromboembolic disease. 4. "Dizygotic twins come from two different eggs and sperm." RATIONALE

2. Increased pulse pressure 3. Increasing heart rate 4. Increased blood pressure

spontaneous abortion or operative procedures. 2. The client is at risk for excess blood loss. The pulse pressure decreases with hemorrhage. 3. An increased pulse in the prescence of visible bleeding indicates excessive blood loss. 4. Increased blood pressure at this stage of pregnancy would be a symptom of a hydatidiform mole. 1. Hypotension RATIONALE

The anesthetist has just placed an epidural 1. Hypotension is common with epidural catheter dosed with bupivacaine anesthesia because the sympathetic hydrochloride (Marcaine) in a client at term nerves are also blocked by the medication, in active labor. The nurse should observe which results in vasodilation. the client for which of the following side 2. Hypertension is not a side effect of effects? epidural anesthesia. 3. Hyperventilation is not a side effect of 1. Hypotension epidural anesthesia. A client is more likely 2. Hypertension to hyperventilate during painful 3. Hyperventilation contractions. Epidural anesthesia relieves 4. Hypoventilation contraction pain. 4. Hypoventilation is possible if epidural narcotics are used. An epidural narcotic (such as fentanyl) was not used in this case. 2. Partial thromboplastin time RATIONALE A client at 12 weeks' gestation has a history of thromboembolitic disease. The client is placed on daily heparin therapy. The nurse should monitor the results of which of the following laboratory tests? 1. Prothrombin time 2. Partial thromboplastin time 3. Bleeding time 4. Clotting time 1. The PT is assessed to maintain correct dosages of warfarin (Coumadin). Coumadin crosses the placental barrier and is contraindicated in pregnancy. 2. The PTT is evaluated to determine the effectiveness of heparin therapy. 3. A bleeding time is obtained preoperatively to determine how quickly blood clots to maintain homeostasis. It is not routinely performed on pregnant women, and is unnecessary for a pregnant woman on heparin therapy. 4. A clotting time is a ficitonal test. 4. Elevating the affected extremity to promote venous blood flow.

A postpartum client complains of sharp pain in the calf of her right leg when walking. The nurse notes that the leg has a circumscribed area of redness, warmth, RATIONALE and tenderness. Which of the following nursing actions is most appropriate in this 1. These are symptoms of client's nursing care? thrombophlebitis; massage of the area can

break the thrombus from the venous wall and cause an embolus. 2. Local application of heat is one of the 1. Instructing the client to massage the treatments for superficial thrombosis. affected area to relieve the tenderness 3. The client with symptoms of 2. Applying cold packs to the affected area thrombophlebitis should be placed on bed to decrease inflammation rest. 3. Encourage the client to ambulate to 4. Administration of analgesics, local increase circulation. application of heat, bed rest for 5-7 days, 4. Elevating the affected extremity to and elevation of the affected extremity are promote venous blood flow. often all that is needed to treat superficial thrombophlebitis. 3. Physical assessment of the infant RATIONALE 1. The third stage of labor is the stage of delivery of the placenta. The placenta will spontaneously separate from the uterine A client has just started the third stage of wall and be expelled by uterine labor. Which of the following nursing contractions. Maternal pushing is actions have priority at this time? unnecessary. 2. Oxytocin should not be administered 1. Encouraging the client to push until after the placenta is delivered, which 2. Administration of an oxytocic medication usually occurs 5-7 minutes after delivery of 3. Physical assessment of the infant the infant. 4. Promotion of the bonding process 3. The infant's physical condition is a priority at on eand five minutes after delivery. The physical assessment done at this time is known as Apgar scoring. 4. Initiation of the bonding process as soon as possible after birth is important, bu the physical stability of the newborn is most important at this time. 2. "That is called molding. It usually lasts for a few days." A client who delivered 45 minutes ago RATIONALE comes into the transitional nursery to see her infant. She askss the nurse, "My baby's 1. Caput succedaneum is an area of head is shpaed like a cone? Will it stay like generalized edema of the scalp that was that?" Which of the following responses by present at birth. the nurse is most accurate? 2. Molding is an overlapping of the skull bones at the occiput of the skull. The infant 1. "That is called a caput. It usually lasts for skull has a cone shaped appearance. 3 or 4 days." 3. A cephalhematoma is a collection of 2. "That is called molding. It usually lasts blood between the skull bone and its for a few days." periosteum. It is one-sided(does not cross 3. "That is called a cephalhematoma. It suture lines), and appears within the first 2 usually lasts for a few weeks." days after delivery. 4. "That is called a nevi. It usually lasts 4. Nevi (also known as 'stork bites')are several months." pink areas on the upper eyelids, nose, upper lip, lower occiput, and the nape of the neck.

2. "If my baby has at least two wet diapers and one bowel movement a day, he is getting enough to eat." A 20-year-old primiparous client, who is RATIONALE breastfeeding, is preparing to be discharged home with her newborn son. 1. The cord stump should be cleaned with The nusre has completed discharge the solution ordered by the health-care instructions on newborn care. Which of the provider daily until it falls off. Cord care following statements by the client would helps the cord to dry and prevents indicate a need for further teaching? infection. 2. A breastfeeding infant should have at 1. "I should clean the cord stump with least six wet diapers daily. Adequate alcohol or peroxide every day until it falls urinary output is a reliable indicator of off." adequate intake of breast milk. 2. "If my baby has at least two wet diapers 3. The infant should be dressed as parents and one bowel movement a day, he is would dress themselves. Overdressing can getting enough to eat." cause prickly heat rash. Wrapping the 3. "I should dress my baby in clothing I infant in a light blanket maintains body would be comfortable in, plus a light temperature and makes the infant feel blanket." secure. 4. "I should nurse my baby whenever he 4. Breast milk is more completely and acts hungry and for as long as he wants to quickly digested than formula. Breast-fed nurse." infants should be fed on deman. It is important for the infant to completely empty the breast, so infant sucking time at the breast should also not be limited. 4. The client will maintain physiological homeostasis. The nurse is planning care for a client who had a spontaneous vaginal delivery with epidural anesthesia over an intact perineum. She is currently in the fourth stage of labor. Which of the following nursing goals would be most appropriate for this client? RATIONALE

1. The fourth stage of labor is the immediate (approx. 1 hour) postpartum period. Epidural anesthesia takes approximately an hour to wear off. The client will be unable to ambulate during this time. In addition, all postpartum clients 1. The client will ambulate in the room should be assisted with ambulation the first without assistance. few times out of bed. 2. The client will turn, coudh, and deep 2. Pulmonary hygiene is important in breathe 10 times an hour. clients with a respiratory condition, or 3. The client's epsiotomy will remain clean, those who have undergone an operative dry, and intact. procedure. The client doesn't have an 4. The client will maintain physiological episiotomy. homeostasis. 3. The most common complication of the fourth stage of labor is uterine atony and hemorrhage. A client delivered a term infant 6 hours 2. Firm fundus 1-2 bingerfbreadths above ago. Which of the following assessment the umbilicus and midline with moderate findings indicate normal postpartum lochia rubra progression? RATIONALE 1. Firm fundus at the umbilicus and midline

with moderate lochia rubra 2. Firm fundus 1-2 bingerfbreadths above the umbilicus and midline with moderate lochia rubra 3. Firm fundus 1-2 fingerbreadths above the umbilicus and deviated to the right side with moderate lochia rubra 4. Firm fundus 3-4 fingerbreadths below the umbilicus and midline with moderate lochia rubra

1. The fundal height is approximately 2 fingerbreadths below the umbilicus immediately after delivery. The fundal height increases to 1 fingerbreadth above the umbilicus within 12 hours. The fundal height will decrease approximately 1-2 fingerbreadths a day afterward. Lochia rubra will be present for 3-4 days after delivery. 2. Fundal height increases to 1 fingerbreadth above the umbilicus within 12 hours after delivery. 3. Fundal deviation to one side or the other indicates a full bladder and risk for hemorrhage. 4. The fundal height is 3-4 fingerbreadths below the umbilicus by the fourth to fifth postpartum day. 3. Hemoglobin = 10 g/dL

RATIONALE A client is pregnant at 12 weeks' gestation. Which of the following lab tests would the 1. WBC counts indicate the presence or nurse need to interpret that would indicate absence of infection. The normal range for a need for change in the client's plan of WBCs in pregnancy is 9-15 mm3. There is care? no evidence of infection. 2. The normal hematocrit in pregnancy 1. White blood count = 14 mm3 ranges from 32%-45%. 2. Hematocrit = 32% 3. The normal hemoglobin in pregnancy 3. Hemoglobin = 10 g/dL ranges from 11-12 g/dL. This client is 4. Serum glucose = 105 g/dL slightly anemic. 4. The normal serum glucose in pregnancy ranges from 65-110 g/dL. 2. Assessing the client hourly for bladder A laboring client received epidural distention anesthesia with bupivacaine hydrochloride (Marcaine) for contraction pain 1 hour ago. RATIONALE Considering the effects of epidural anesthesia, which of the following nursing 1. Respiratory depression is associated measures are important her care? with epidural narcotics. Marcaine is an anesthetic agent. 1. Assessing the client hourly for 2. The woman may not sense the urge to respiratory depression void because of decreased sensation to 2. Assessing the client hourly for bladder the area. Pain caused by bladder distention distention can last for long periods of time. 3. Assessing the client hourly for uterine 3. Uterine atony is associated with atony administration of oxytoxic drugs. It is not 4. Assessing the client hourly for an effect of epidural anesthesia. hypertension 4. Maternal hypertension is not an effect of epidural anesthesia. A client arrived on the OB unit at term with 4. Send the client home and encourage mild irregular contractions. Findings from a her to ambulate. sterile vaginal exam were as follow: cervical dilation of 3 cm, membranes were RATIONALE

intact, and the presenting part at -1 station. An external fetal monitor was placed and the fetal heart tracing revealed a baseline 1. This is a reassuring fetal heart pattern; of 130 with accelerations to the 150s no immediate nursin gactions othe rthan during contractions. Which of the following comfort measures are necessary. nursing acitons would be most appropriate 2. There ais no fetal distresss. considering the client's situation? 3. The client is in no need for fluid volume expansion; neither she nor the fetus is in 1. Prepare the client for an immediate distress. operative delivery. 4. This client is in very early labor. The 2. Turn the client to her left side and fetal heart pattern is reassuring. adminster oxygen. Ambulation at home would stimulate labor 3. Notify the registered nurse to start an and descent of the presenting part and intravenous infusion stat. decrease hospitalization time. 4. Send the client home and encourage her to ambulate. 3. "Breastfeeding itself is effective at preventing pregnancy." RATIONALE A 6-week postpartum client, who is breastfeeding, asks for information on birth 1. Condoms are a mechanical barrier control methods that do not affect breast method of contraception with an milk production. Which of the following effectiveness rate of 88%. Condom usage statements would indicate the client needs does not interfere with breast feeding. further instruction? 2. Depo-Provera is an injectable form of progestin with an effectiveness rate of 1. "Using condoms would be a good choice 99.7%. Pregnancy is prevented for 3 for me." months. It is safe for use during lactation 2. "I can use Dep-Provera and breastfeed once the milk supply is established. without problems." 3. High prolactin levels with exclusive 3. "Breastfeeding itself is effective at breastfeeding can delay ovulation for up to preventing pregnancy." 6 months. However, it is an unpredictable 4. "I can use contraceptive foam for birth method of birth control. control." 4. The effectiveness of the contraceptive foams range from 72%-82%. It has no hormones to affect lactation, and is safe for use during the postpartum period. 1. Client drug allergies An antepartum client at 16 weeks' gestation has tested positive for gonorrhea. RATIONALE All tests for other sexually transmitted infections were negative. Which fo the 1. Gonorrhea is usually treated with following information is most important in penicillin. Drug allergies to penicillin are planning her nursing care? ocmmon and can result in an anaphylactic reaction. 1. Client drug allergies 2. A malodorous vaginal discharge is 2. Fishy-smelling discharge cause by Gardnerella vaginalis. 3. The presence of a chancre 3. A chancre is seen with syphilis. 4. The presence of vesicles 4. Vesicles are seen with herpes. A non-insulin-dependent diabetic has just 2. "You can control your blood sugar with found out she is pregnant. She asks th insulin injectons." eclinic nurse what she shoudl do about her diabetes. The most appropriate response RATIONALE

by the nurse would be which of the following? 1. Oral hypoglycemic agents cross the 1. "You can control your blood sugar with placenta and cna cause fetal anomalies. oral hypoglycemic agents." 2. Insulin does not cross the placenta and 2. "You can control your blood sugar with is safe for use in pregnancy. insulin injectons." 3. Only gestational diabetes can be treated 3. "You can control your blood sugar with with diet during pregnancy. dietary changes." 4. Only gestation diabetes can be treated 4. "You can control your blood sugar by with exercise during pregnancy. exercising more." 3. "This test is for neural tube defects." An insulin-dependent diabetic at 18 weeks' RATIONALE gestation has arrived for a-fetoprotein testing. She asks the nurse why this test is 1. Analysis of amniotic fluid from being performed. Which of the following amniocentesis allows determination of fetal explanations by the nurse would be most gender. accurate? 2. The presence of phosphatidylglycerol and the L/S ratio determine fetal lung 1. "This test is to determine the sex of your maturity. It is obtained from amniotic fluid. baby." 3. AFP is a mternal blood test that can 2. "This test is for fetal lung maturity." detect neural tube defects (The most 3. "This test is for neural tube defects." common anomaly) in fetuses of diabetic 4. "This test is to determine glycemic women. It can also indicate the presence control." of Down's syndrome. 4. Glycemic control is determined by hemoglobin A1c, A meternal blood test. 2. Call the health-care provider A postpartum client had a spontaneous vaginal delivery 30 minutes ago. During the postpartum assessment, the nurse notes that there is constant tricling of bright red vaginal bleeding in the presence of a contracted uterus at midline. Which action by the nurse would be most appropriate in this situation? RATIONALE

1. Uteirne atony would reveal a constant trickle of bright red blood in the prexence of a boggy uterus. 2. Excessive lochia in the presence of a contracted uterus suggests lacerations of the birth canal. The HCP must be notified so the laceration can be repaired. 1. Massage the fundus 3. Excessive bleeding caused by a full 2. Call the health-care provider bladder would reveal a uterus that was 3. Have the client empty her bladder high and deviated to one side. 4. Increase the oxytocin (Pitocin) infusion 4. Increasing the rate of an infusion of oxytocin would not correct the problem of a lacerated birth canal. The nurse enters the room of a 4. Knowledge deficit related to breastfeeding client who delivered 3 hours breastfeeding techniques ago and who is in tears. "I just don't know what I'm doing wrong!" she sobs. "I can't RATIONALE get my baby to take the nipple!" Which of the following nursing diagnoses would be 1. One session of breastfeeding problems most appropriate in this case? does not result in altered parenting. 2. The difficulty is in infant latch-on, not 1. Altered parenting related to difficulty in sore nipples.

breastfeeding 3. Success in breastfeeding has little to do 2. Altered comfort related to sore nipples with bonding/attachment. 3. Altered bonding process related to 4. Instruction and assistance from the maternal frustration nurse would most likely result in successful 4. Knowledge deficit related to latch-on and breastfeeding. breastfeeding techniques 4. Give the baby to his mother and point out his features. RATIONALE A client delivered her first infant 1 day ago 1. Giving the mother pictures of her baby is at term. Which of the following actions by appropriate only when an infant is too ill for the nurse would most likely promote the physical contact. attachment process? 2. Descriptions of the infant do not replace physical contact between mother an 1. Take pictures of the baby for the mother dbaby. to see. 3. Direct physical contact between mother 2. Tell the mother what her baby looks like. and baby is most likely to promote 3. Take the mother to the nursery window attachment. to see her baby. 4. The combination of direct physical 4. Give the baby to his mother and point contact between mother and baby and out his features. discussion of the child's physical and personality attributes assists the mother in recognizing her infant as a distinct individual who is yet a part of her. This process is the beginnings of attachment. 1. "Eat a serving of live culture yogurt daily." A 20-year-old multipara at 18 weeks gestation reports symptoms of thick white RATIONALE vaginal dishcarge and intense itching. A wet mount specimen reveals budding yeast 1. Evidence indicates that ingestion of livecells with a diagnosis of Candida albicans. culture yogurt decreases the incidence of The client asks how to prevent future vaginal yeast infections. infections. Which of the following 2. Vinegar and water douches decrease responses by the nurse is most accurate? vaginal pH and inhibit the growth of yeast cells. However, douching is not 1. "Eat a serving of live culture yogurt recommended in pregnancy. daily." 3. Douching with live-culture yogurt 2. "Douche after intercourse with vinegar decreases vaginal pH. However douching and water." is not recommended in pregnancy. 3. "Douche with live culture yogurt daily." 4. All antimicrobials cross the placenta; 4. "Take antibiotics as ordered until all are many can cause fetal organ damage. In gone." addition, antibiotic therapy can increase the incidence of vaginal yeast infections. A 24-year-old primipara at 32 weeks' 2. "These symptoms are common in gestation comes into the clinic with pregnancy because pregnancy hormones complaints of nasal stuffiness, nosebleeds, cause increased blood flow, which causes and bilateral hearing loss. She asks why head congestion." she is having these symptoms. Which of the following explanations by the nurse is RATIONALE most accurate? 1. Increased estrogen levels cause

1. "This sounds like a bad cold, you need to take a decongestant." 2. "These symptoms are common in pregnancy because pregnancy hormones cause increased blood flow, which causes head congestion." 3. "These are symptoms of a major problem. You need to be referred to a specialist." 4. "This sounds like a sinus infection. It is caused by exposure to allergens, such as cat dander or plant pollen. You need to take antibiotics and antihistamines."

congestion, swelling, an dhyperemia of the capillaries in the upper respiratory tract. These symptoms will not be relieved by antihistamines. 2. The elevated levels of estrogen during pregnancy cause increased blood blow in the upper respiratory tract. Nasal stuffiness, ear aches, hearing loss, and nose bleeds are common. 3. Referral to a specialist is not necessary because these are normal pregnancy symptoms. 4. These are normal pregnancy symptoms. Many antibiotics cross the placenta and are contraindicated in pregnancy. Antihistamines are also generallly not recommended in pregnancy. 1. Hemoglobin of 11 g/mL

RATIONALE A client in the second trimester of pregnancy has blood drawn for routine 12- 1. Blood volume increases by 30%-50% in week lab work. Which of the following pregnancy. This causes hemodilution of results would be considered normal for this RBCs and physiological anemia. Normal stage of pregnancy? hemoglobin levels in pregnancy range from 11-12 g/dL. 1. Hemoglobin of 11 g/mL 2. Plethora is not a normal finding in 2. Hemoglobin of 18 g/mL pregnancy. 3. Serum glucose of 80 3. Normal serum glucose in pregnancy is 4. RBC count of 4 65. 4. This is a normal RBC count for nonpregnant individuals. Normal RBCs in pregnancy range from 11-12. 1. "My areolas will get smaller and lighter in color." A nurse educator teaching a prenatal class asked for feedback from the class on the RATIONALE topic "Breast Changes During Pregnancy." Which of the following statements from on 1. Pregnancy causes the areolas to darken eo fthe attendees would indicate further and enlarge. instruction is needed? 2. Breast tenderness and swelling ar almost universal findings in pregnancy. 1. "My areolas will get smaller and lighter in 3. Pregnancy causes darkening of the color." pigment in the nipples and causes them to 2. "My breasts will be tender and swollen." become more erectile. 3. "The nipples will get darker and more 4. Breast enlargement is caused by the erect." influence of progesterone and estrogen. 4. "My breasts will enlarge and may feel Nodularity is caused by an increase in the lumpy." size of the mammary glands during the second trimester. A 36-year-old professional woman who is 4. "Many women have mixed emotions pregnant for the first time at 10 weeks' when they are first pregnant." gestation tells the nurse that her pregnancy was planned, bu that "I'm feeling like RATIONALE

1. Ambivalent feelings about pregnancy are common in all women. In addition, this maybe this wasn't such a good idea." response is a block to therapeutic Which of the following responses by the communication. The nurse is telling the nurse would be most appropriate? client how she "should" feel. 2. Even women with a desired pregnancy 1. "These are unnatural feelings. You have ambivalent feelings. Such feelings do should be happy to be pregnant." not necessarily mean the woman desires 2. "Maybe you should consider abortion an abortion. since you feel this way." 3. "Mother love" does not necessarily 3. "Don't worry, you'll feel differently once appear right after birth, especially in a first the baby is born." pregnancy. It may take time for such 4. "Many women have mixed emotions feelings to grow. when they are first pregnant." 4. Ambivalence is a normal response experienced by any individual preparing for a new role. 2. B-, antibody+ RATIONALE 1. AFP is drawn in the second trimester A 20-year-old client came in fo rher first around 18 weeks' gestation. Low AFP may prenatal appointment at 10 weeks' indicate Down's syndrome. gestation. Blood is drawn for routine 2. Antibodies formed by a mother because prenatal screening. Which of the following of an ABO or Rh incompatibility cause lab results would indicate a risk to the fetus erythroblastosis fetalis. Blood and Rh for erythroblastosis fetalis? typing an dantibody screening can alert the HCP to the possible development of this 1. Low a-fetoprotein condition. 2. B-, antibody+ 3. The L/S ratio is obtained from amniotic 3. L:S ratio of 2:1 fluid analysis and indicates fetal lung 4. O+, antibodymaturity.. 4. There is a possibility of ABO incompatibility that could result in erythroblastosis fetalis; however the antibody screen is negative. A client is in active labor at term with 3. Turn the client to her left side. cervical findings of 5 cm dilated, effacement of 90% station -1. The FHR RATIONALE baseline is in the 120s with long-term variability. Three late decelerations were 1. Compression of the major vessels of the noted within the last hour with a quick pelvis occurs with a supine position. This return to the 150s and then baseline. will compromise placental perfusion and Which of the following nursing actions contribute to fetal distress. would be most appropriate? 2. Fetal reserves are still present as evidenced by long-term variability, 1. Position the client on her back so the "shoulders," and a return to baseline. An monitor strip is more accurate. operative delivery is not yet required. 2. Prepare for a stat cesarean section. 3. Late decelerations are caused by 3. Turn the client to her left side. decreased uteroplacental perfusion. 4. Encourage the client to ambulate. Positioning a woman on her left side promotes fetal well-being by increasing placental perfusion and subsequent fetal

oxygenation. This position change may stop the late decelerations. 4. Ambulation will stimulate uterine contractions and promote fetal descent. Increased frequency and/or intensity of contractions will impair uterine perfusion. 1. Epigastric discomfort RATIONALE A client in the 26th week of gestation has been admitted to the OB unit with a 1. Epigastric pain/discomfort is a sign of diagnosis of PIH. Which of the following impending seizure in the client with severe symptoms would indicate worsening of the PIH. disease? 2. A blood pressure reading of 140/90 mm Hg indicates hypertension. Hypertension is 1. Epigastric discomfort considered severe when diastolic blood 2. BP of 140/90 mm Hg pressures exceed 110 mm Hg. 3. 2+ deep tendon reflexes 3. Normal deep tendon reflexes are 2+. 4. 2+ dependent edema 4. Dependent edema is a normal finding of pregnancy. Edema of the hands or face or pitting edema indicate a worsening of the disease.