RN Exam

A registered nurse (RN) who obtains histories, performs physical examinations, and manages care (in consultation with
a physician) throughout pregnancy and the postpartum period is called a: nurse practitioner (NP). clinical nurse specialist (CNS). pediatric nurse practitioner (PNP). certified nurse-midwife (CNW). RATIONALE: An NP performs in an expanded advanced practice role. She obtains histories, performs physical examinations, and manages care (in consultation with a physician) throughout pregnancy and the postpartum period. A CNS is an RN who has received education at a master's level and focuses on health promotion, client teaching, direct nursing care, and research activities. A PNP provides well-baby counseling and care, performs physical assessments, and obtains detailed client histories. A CNW is an RN with advanced education who cares for low-risk obstetric clients and is licensed to deliver a neonate. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Knowledge A group of people who have chosen to live together but aren't necessarily related by marriage or blood is known as: a cohabitation family. an extended family. a blended family. a communal family. RATIONALE: A communal family is a group of people who have chosen to live together but who aren't necessarily related by marriage or blood. A cohabitation family consists of an unmarried heterosexual couple who live together. A blended family results when two separate families join together because of remarriage. An extended or multigenerational family consists of the nuclear family as well as other family members, such as grandparents, aunts, uncles, cousins, and grandchildren. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis When a woman gives birth after carrying the fertilized ovum of another woman, it's called: in vitro fertilization. cesarean delivery. surrogate motherhood. gamete intrafallopian transfer. RATIONALE: Surrogate motherhood involves one woman giving birth after carrying the fertilized ovum of another woman or being inseminated with sperm from the biological father. In vitro fertilization is fertilization that takes place outside of the woman's body--usually in a test tube or petri dish. A cesarean delivery is a surgical procedure by which a fetus is delivered through an abdominal incision. In gamete intrafallopian transfer, ova and sperm are instilled and fertilized within the fallopian tubes. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Knowledge The science of improving a species through control of hereditary factors by manipulation of the gene pool is called: eugenics. in vitro fertilization. fetal tissue research. genealogy.
RATIONALE: Eugenics is the science of improving a species through control of hereditary factors by manipulation of the gene pool. In vitro fertilization refers to fertilization that takes place outside of the woman's body--usually in a test tube or petri dish. Fetal tissue research is the study of the use of fetal tissue in treating disease. Genealogy is the study of heredity. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Knowledge The intrapartum period starts: after delivery of the neonate and placenta. at the onset of contractions. at conception. during the second trimester. RATIONALE: The intrapartum period starts at the onset of contractions that cause cervical dilation and lasts until the after birth of the neonate and placenta (1 to 4 hours). The postpartum period begins after the intrapartum period. The prenatal period begins at conception and continues until the onset of contractions. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis Which term describes a pelvis with the widest anterior and posterior diameters as well as a pubic arch wide enough for childbirth? Android Anthropoid Gynecoid Platypelloid RATIONALE: A gynecoid pelvis is round, with straight side walls, widely separated ischial spines, and a deeply curved sacrum. An android pelvis is heart-shaped, with convergent side walls, prominent ischial spines with a narrow interspinous diameter, and a slightly curved sacrum that's beaked at the terminal portion. An anthropoid pelvis is oval, with straight side walls, prominent ischial spines with a narrow interspinous diameter, and a slightly curved sacrum. A platypelloid pelvis is flat, with straight side walls, widely separated ischial spines, and a slightly curved sacrum. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Knowledge In the male reproductive system, spermatogenesis occurs during which life stage? Infancy Toddlerhood Preadolescence Adolescence RATIONALE: During adolescence, when males go through puberty, sex cells present from birth undergo a maturing process and spermatogenesis occurs. The process of spermatogenesis normally continues throughout the man's lifetime. The male body isn't mature enough during infancy, toddlerhood, or preadolescence for spermatogenesis to occur. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis Spermatogenesis takes place in the male's: Leydig's cells. prostate gland.
bulbourethral glands. seminiferous tubules. RATIONALE: Spermatogenesis occurs in the seminiferous tubules. Leydig's cells are located near these structures in the testes and produce testosterone. The prostate gland encircles the urethra and contributes an alkaline fluid to semen that protects it against an acidic environment. The bulbourethral glands also secrete a fluid into semen that promotes lubrication and neutralizes acids, ultimately promoting sperm motility. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Knowledge A 13-year-old female visits the clinic for a routine examination. The nurse notes that she exhibits changes in her appearance that commonly occur during pregnancy, including an increase in breast size. Which hormone is partly responsible for the growth and increased vascularity of breast tissue during pregnancy? Follicle-stimulating hormone (FSH) Human chorionic gonadotropin (hCG) Lactoferrin Estrogen RATIONALE: The hormones responsible for the growth and vascularity of breast tissue during pregnancy include estrogen and progesterone. Estrogen and progesterone are also responsible for growth of the extensive ductile system of the breasts. Lactoferrin binds to iron and thwarts the growth of pathogenic bacteria in breast milk. hCG is secreted by the fertilized ovum; an elevation in hCG results in a positive pregnancy test. FSH is a pituitary hormone that stimulates growth of follicles in the ovary; FSH production is suppressed during pregnancy, causing amenorrhea (absence of menstruation). NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis Which phase is a part of the normal uterine cycle? Follicular Luteal Ovulation Proliferative RATIONALE: The proliferative phase is one of the four phases of the uterine cycle. The entire uterine cycle includes the menstrual phase (days 1 through 6), proliferative phase (days 7 through 14), secretory phase (days 14 through 26), and ischemic phase (days 26 through 28). The length of each phase may vary slightly based on the overall length of a woman's cycle. The luteal and follicular phases are part of the ovarian cycle, and ovulation is an event (the release of ovum) that occurs during the ovarian cycle. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application Which female hormone controls breast development during puberty? Estrogen Human chorionic gonadotropin (hCG) Luteinizing hormone (LH) Progesterone RATIONALE: Estrogen controls breast development during puberty. A fertilized ovum secretes hCG to maintain the corpus luteum. LH stimulates ovulation. Progesterone stimulates the growth of the endometrium and breasts during pregnancy. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis
Which male hormone is responsible for maintaining spermatogenesis, increasing sperm production, and producing seminal fluid? Human chorionic gonadotropin (hCG) Insulin Semen Testosterone RATIONALE: Testosterone is responsible for maintaining spermatogenesis, increasing sperm production, and producing seminal fluid. Males don't secrete hCG beyond gestation. Insulin isn't related to spermatogenesis. Semen is a fluid that contains sperm; it isn't a hormone. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis Which action occurs during the follicular phase of the ovarian cycle? Ovulation Maturation of an ovum Peak progesterone secretion Secretion of hormones by the corpus luteum RATIONALE: The follicular phase begins on the 1st day of the ovarian cycle and ends 14 days later (if the cycle is 28 days). During this phase, the ovum matures under the influence of luteinizing hormone and follicle-stimulating hormone secreted by the anterior pituitary gland. Ovulation occurs during the ovulatory phase. Hormones, including progesterone, are secreted by the corpus luteum during the luteal phase. Progesterone secretion peaks during the luteal phase. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Comprehension In a regular 32-day menstrual cycle, the client will probably ovulate: on day 11. on day 18. on day 22. 10 days after the start of the last menses. RATIONALE: Ovulation occurs at the onset of the luteal phase, about 14 days before the start of the next menses. When using the calendar method, the lengths of the previous 6 to 12 menstrual cycles are recorded; to calculate possible range of fertile days, the woman should subtract 18 days from the length of the shortest cycle and 11 days from the length of the longest cycle. If the menses are regular at 32 days, the client could be fertile between days 12 and 21. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis A nurse is teaching a group of 12-year-old boys about the male reproductive system. The nurse tells them that testosterone is produced by the: prostate gland. Cowper's glands. vas deferens. Leydig's cells.
RATIONALE: Leydig's cells in the testes produce testosterone. The prostate gland and Cowper's glands secrete seminal fluid. The vas deferens is a duct through which sperm travels from the epididymis to the urethra. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application Ovulation occurs at the end of which uterine phase? Menstrual Proliferative Secretory Ischemic RATIONALE: The ovum is released at the end of the proliferative phase, when the uterus has become a nutrientrich environment capable of supporting a developing embryo. During the menstrual phase, two-thirds of the endometrium sheds. During the secretory phase, the uterus prepares to receive the fertilized ovum by secreting substances to nourish the ovum. The endometrium becomes necrotic and ischemic during the ischemic phase. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis A nurse is teaching a client about menstruation. She explains that the predominant hormone produced by the ovaries in the secretory phase of the menstrual cycle is: estrogen. progesterone. oxytocin. prolactin. RATIONALE: Progesterone, the predominant hormone of the secretory phase of the menstrual cycle, is secreted by the corpus luteum. Estrogen is more predominant in the proliferative portion of the menstrual cycle when the uterine lining undergoes rapid growth. Oxytocin and prolactin, which are secreted by the pituitary gland, influence lactation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application Which hormone stimulates the development of the ovum? Human chorionic gonadotropin (hCG) Follicle-stimulating hormone (FSH) Gonadotropin-releasing hormone (GnRH) Luteinizing hormone (LH) RATIONALE: FSH is primarily responsible for development of the ovum. The hypothalamus secretes GnRH. In response to this secretion, the anterior pituitary secretes FSH and LH. LH is responsible for the ovum's final maturation. hCG, secreted by the fertilized ovum, acts as a fail-safe measure to ensure that the corpus luteum produces enough progesterone and estrogen to prevent endometrial sloughing in early pregnancy; it does this until the placenta can take over this function. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Knowledge Which statement best describes when fertilization occurs? When the embryo attaches to the uterine wall
When the spermatozoon passes into the ovum and the nuclei fuse into a single cell When the ovum is discharged from the ovary near the fimbriated end of the fallopian tube When the sperm and the ova undergo developmental changes resulting in a reduction in the number of chromosomes RATIONALE: Fertilization occurs when the spermatozoon passes into the ovum and their nuclei fuse into a single cell. Implantation occurs when the embryo attaches to the uterine wall. Release of the ovum from the ovary is ovulation. Meiosis is cell division in which the sperm and ova undergo developmental changes that reduce the number of chromosomes. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Comprehension A nurse is teaching a class about the reproductive system. She explains that fertilization most often takes place in the: uterus. vagina. ovary. fallopian tubes. RATIONALE: Fertilization usually takes place in one of the fallopian tubes (specifically, the outer third portion of the tube). When fertilization is complete, the zygote (fertilized ovum) migrates toward the body of the uterus and implants in the uterine wall. Fertilization doesn't occur in the vagina or the ovary. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application A pregnant client asks you about fetal development. At approximately what gestational age does the fetus's singlechambered heart begin to beat and pump its own blood cells through main blood vessels? 3 weeks 5 weeks 8 weeks 10 weeks RATIONALE: In the embryo's 3rd week, the heart is the most advanced organ. Around the 24th day, a singlechambered heart forms just outside the embryo's body cavity and begins beating a regular rhythm, pushing its own primitive blood cells through the main blood vessels. At 5 weeks, arm and leg buds are present. At 8 weeks, the body is fairly well-formed, with a flat nose, eyes that are far apart, and recognizable digits. At 10 to 12 weeks, the fetus begins to resemble a human, and the skin is pink and delicate. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Comprehension How many weeks is the gestational period of a full-term pregnancy? 33 to 35 35 to 37 38 to 42 More than 42 RATIONALE: A full-term pregnancy is one that lasts 38 to 42 weeks. A preterm pregnancy lasts 33 to 37 weeks. A postterm pregnancy lasts longer than 42 weeks. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis
A large number of neural tube defects may be prevented if a pregnant woman includes which supplement in her diet? Folic acid Vitamin A Vitamin D Vitamin E RATIONALE: A supplement of 0.4 mg of folic acid daily is recommended to prevent neural tube defects and is usually contained in the mother's daily prenatal vitamin. Deficiency of folic acid in the diet has been associated with spontaneous abortion, various bleeding complications of pregnancy, and such fetal malformations as neural tube defect. Vitamins A, D, and E are fat soluble; these vitamins increase the general nutrition of the client but don't protect against neural tube defects. Vitamin A is essential for cell development. Vitamin D is necessary for the absorption and action of calcium. Vitamin E is an antioxidant that's related to the body's ability to absorb fats. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Application An 18-year-old woman in her 8th week of pregnancy is being evaluated. Which positive sign of pregnancy should the nurse expect to be present? Fetal movement detectable by palpation Fetal heart tones detectable by Doppler stethoscope Fetal heart tones detectable by a fetoscope Visualization of the fetus by ultrasound examination RATIONALE: The fetus can be visualized by ultrasound examination at 5 to 6 weeks. Fetal heart tones may be detected by Doppler stethoscope at 10 to 12 weeks and by fetoscope at 17 to 19 weeks. Fetal movements may be palpated at 19 to 22 weeks. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Comprehension A 22-year-old client is at 20 weeks' gestation. She asks the nurse about the development of her fetus at this stage. Which of the following developments occurs at 20 weeks' gestation? Surfactant forms in the lungs. The pancreas starts producing insulin, and the kidneys produce urine. The swallowing reflex has been mastered, and the fetus sucks its thumb. The fetus follows a regular schedule of turning, sleeping, sucking, and kicking. RATIONALE: At 20 weeks' gestation, the fetus begins to follow a regular schedule of turning, sleeping, sucking, and kicking. At 11 weeks' gestation, the pancreas begins producing insulin and the kidneys produce urine. At 12 weeks' gestation, the swallowing reflex has been mastered and the fetus sucks its thumb. Surfactant begins to form in the lungs at about 27 weeks' gestation. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Comprehension During her prenatal visit, a 28-year-old client expresses concern about nutrition during pregnancy. She wants to know what foods she should be eating to ensure the proper growth and development of her baby. Which step should the nurse take? Instruct the client to continue to eat a normal diet. Give the client a sample diet plan for a 2,400-calorie diet. Emphasize the importance of avoiding salt and fatty foods. Assess the client's current nutritional status by taking a diet history.
RATIONALE: The nurse should first assess the client's current nutritional status. After a diet history is obtained, the nurse can help the client determine what nutrients might need to be added according to her likes and dislikes. This approach is more likely to ensure compliance. The client may not understand what a normal diet is; normal can be a vague term. Her caloric and protein intake should be increased over her prepregnancy diet. A 2,400-calorie diet wouldn't be appropriate for all clients, depending on their current weight and height. Salt isn't limited in a normal pregnancy. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Analysis At 17 weeks' gestation, a fetus isn't considered to be ballotable. Ballottement means that: the client feels fetal movement. the examiner feels fetal movement. the examiner feels rebound movement of the fetus. the client feels irregular, painless, uterine contractions. RATIONALE: Ballottement occurs when the examiner taps the fetus in the amniotic sac and it rebounds against the examiner's fingers. Fetal movements felt by the pregnant woman are known as quickening. Irregular, painless uterine contractions are Braxton Hicks contractions. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Comprehension The nurse is teaching a course on the anatomy and physiology of reproduction. In the illustration of the female reproductive organs, identify the area where fertilization occurs. RATIONALE: After ejaculation, the sperm travel by flagellar movement through the fluids of the cervical mucous into the Fallopian tube to meet the descending ovum in the ampulla. This is where fertilization occurs. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application Which of the following signs and symptoms is a presumptive (subjective) sign of pregnancy that may be present at 8 weeks' gestation? Quickening Abdominal enlargement Changes in skin pigmentation Breast enlargement and tenderness RATIONALE: Some women are aware of breast changes even before their first missed menstrual period. Skin changes such as chloasma and abdominal enlargement usually don't occur until the second trimester. Maternal perception of fetal movement (quickening) occurs between 16 and 22 weeks' gestation in women who have had previous pregnancies. A primigravida may not recognize fetal movement until between 18 and 22 weeks' gestation. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis At what time in pregnancy will a primigravid woman most likely feel fetal movement (quickening) for the first time? 14 weeks 16 weeks 20 weeks
24 weeks RATIONALE: Although the fetus is quite active before midpregnancy, the movements aren't usually perceived by a primigravid woman until 20 weeks (the range is 18 to 22 weeks). Women who have had previous pregnancies may recognize fetal movement as early as 16 weeks. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application A client at 6 weeks' gestation is making her first prenatal visit. Which prenatal screening test should be performed? Rh factor Triple screen 1-hour glucose challenge test Maternal serum alpha-fetoprotein level RATIONALE: An Rh factor test is one of the baseline laboratory studies done on the first prenatal visit in the first trimester. If the mother is Rh-negative, Rh immune globulin is given at 28 weeks' gestation and again after delivery if the newborn is Rh-positive. Maternal serum alpha-fetoprotein level is an optional screening test for open neural tube defects and is done at about 16 weeks' gestation. The triple screen is an optional test that measures three substances in maternal serum (alpha-fetoprotein, unconjugated estriol, and human chorionic gonadotropin) and is used to screen for open neural tube defects and Down syndrome; it's done at about 16 weeks' gestation. A 1-hour glucose challenge test is done at 24 to 28 weeks' gestation to determine the presence of maternal gestational diabetes. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Application A woman began her pregnancy at 125 lb (56.7 kg) and has gained 12 lb (5.4 kg) in the first 20 weeks of pregnancy. She tells the nurse that she feels she's gained too much weight. Which reply is most appropriate? "Some women gain 40 lb or more during pregnancy. Your weight gain thus far isn't excessive." "You should gain only about 20 lb during the entire pregnancy. You need to cut down on your caloric intake." "You haven't gained enough weight for your current stage of pregnancy. You need to increase your intake of calories." "Your weight gain thus far is appropriate. Most women gain 25 to 35 lb by the end of pregnancy." RATIONALE: For an average-weight woman, a weight gain of 25 to 35 lb (11.3 to 15.9 kg) is ideal by the end of pregnancy. At 20 weeks, this client has gained the appropriate amount of weight. A gain of 3 to 5 lb (1.4 to 2.3 kg) is typical for the first trimester, changing to at least 1 lb (0.45 kg) per week in the second and third trimesters. A total gain of 20 lb (9.1 kg) during pregnancy is too little, and 40 lb (18.1 kg) is too much. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Application At 20 weeks' gestation, where should the client's fundus be palpable? At the umbilicus At the xiphoid process Directly over the symphysis pubis Between the symphysis pubis and the ribs RATIONALE: At 20 weeks' gestation, the client's fundus is palpable at the umbilicus. It's palpable directly over the symphysis pubis at 12 weeks and at the xiphoid process at 36 weeks. Between the symphysis pubis and the ribs is too vague a description to be useful. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Comprehension
Which of Rubin's psychological tasks of pregnancy centers on the pregnant woman's efforts to build a maternal identity and provide appropriate care to the neonate? Binding in Ensuring safe passage Learning to give of self Seeking acceptance from others RATIONALE: During the phase of learning to give of self, the woman begins to develop the capacity for self-denial and learns to delay gratification of her own needs to meet the needs of the new baby, thus completing the development of her maternal identity. When the woman seeks prenatal care, she's attempting to ensure safe passage for herself and the fetus. She seeks acceptance of the baby from the significant persons in her life in anticipation of the changes birth will bring about. During the later part of pregnancy, she begins to develop a relationship with the fetus as quickening is felt and binding in begins. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: Psychosocial adaptation COGNITIVE LEVEL: Comprehension Several changes occur within the maternal renal system as a result of pregnancy. These changes include: increased bladder capacity and ureteral dilation. increased creatinine level and decreased renal plasma flow. decreased glomerular filtration rate (GFR) and decreased renal plasma flow. increased blood urea nitrogen (BUN) level and decreased bladder capacity. RATIONALE: The increased vascularity of the bladder decreases bladder tone, which permits the bladder to distend to approximately 1,500 ml. Bladder capacity is increased and ureters dilate. Glucose may be present in the urine, even in the absence of gestational diabetes, due to a lower tolerance for blood glucose levels above normal. BUN and creatinine levels decrease, and GFR and renal plasma flow increase. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis A 30-year-old client in her second trimester is complaining of constipation. To increase bowel motility, the nurse should recommend: limiting fluid intake. including roughage in the diet. taking laxatives or enemas as needed for constipation. performing Valsalva's maneuver when moving the bowels. RATIONALE: Roughage will increase bowel motility and help relieve constipation. Adequate fluid intake helps hydrate the fiber and increases the bulk of the stool. Laxatives and enemas shouldn't be taken unless prescribed by the physician. Valsalva's maneuver causes the amount of oxygen in the maternal bloodstream to diminish, resulting in fetal hypoxia. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application A pregnant woman comes to the clinic complaining of nasal stuffiness. Nasal stuffiness during pregnancy is caused by: estrogen. progesterone. increased cardiac output. human chorionic gonadotropin (hCG).
RATIONALE: Stuffiness results from nasal edema and vascular congestion of the nasal mucosa caused by high estrogen levels. Progesterone dilates and relaxes nasal mucosa. Increased cardiac output doesn't affect nasal stuffiness. Human chorionic gonadotropin, produced by the chorionic villi, doesn't result in nasal congestion. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis What significant cardiovascular change occurs during the second trimester of a normal pregnancy? Decreased pulse Decreased blood pressure Increased central venous pressure (CVP) Increased pulmonary artery wedge pressure (PAWP) RATIONALE: There is a slight decrease in blood pressure during pregnancy, with the lowest point occurring during the second trimester. This occurs because hormonal changes cause a decrease in peripheral vascular resistance. There isn't a significant change in PAWP or CVP during normal pregnancy. Pulse increases during pregnancy. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Comprehension Women may occasionally develop bizarre eating habits during pregnancy, eating such nonedible items as coal or laundry detergent. This type of behavior is referred to as: couvade. delusions. pica. prenatal psychosis. RATIONALE: Pica is the term for eating substances generally not considered edible. Usually, the client won't tell the nurse about cravings for nonfood substances unless directly asked. She may fear that others will find her behavior odd. Pica often accompanies iron deficiency anemia. Couvade refers to the unintentional development of pregnancy symptoms by the nonpregnant partner. Delusions occur when a person perceives objects or people that aren't present. Prenatal psychosis isn't usually related to bizarre eating habits. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Analysis An expectant mother asks about physiologic changes in the circulatory system during pregnancy. Which response is correct? "Pressure from the growing fetus causes blood clots to form in the legs." "You feel tired because your body makes so many extra red blood cells." "Blood pressure increases during pregnancy because cardiac output increases." "Pregnancy results in a lower hemoglobin level because of increased blood volume." RATIONALE: Physiologic anemia results from increased plasma in the blood that exceeds the increase in red blood cell (RBC) production. During pregnancy, cardiac volume increases by 25% to 45%, beginning in the first trimester. As a result, each milliliter of blood contains less hemoglobin because the blood is more dilute. There is a slight decrease, not increase, in blood pressure during pregnancy. Blood clots in the legs aren't related to pressure exerted by the growing fetus. The body does work to produce sufficient RBCs to carry oxygen to the mother and the fetus, but these efforts aren't related to the tiredness felt during the pregnancy. Such feelings are commonly the result of the ovarian hormone relaxin. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application
Research studies have linked neural tube defects in infants with low maternal levels of folic acid in early gestation. A good source of folic acid is: milk. pork. butter. green leafy vegetables. RATIONALE: The Centers for Disease Control and Prevention recommends that all women who can become pregnant consume at least 400 mcg of folic acid daily. Sources of folic acid include raw green leafy vegetables, oranges, whole grains and fortified cereals, liver, dried peas and beans, and yeast. Milk provides vitamin A, vitamin D, calcium, vitamin B12, thiamine, and riboflavin. Pork provides thiamine, vitamin B6, vitamin B12, and niacin. Butter provides vitamin D, vitamin A, and calcium. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Knowledge While reviewing laboratory results for a client at 20 weeks' gestation, the nurse notes her hemoglobin (Hb) level has decreased from 13 to 11 g/dl. The most likely explanation for this decrease is: internal bleeding. exacerbation of a hemolytic disease. irregular use of prenatal vitamins. hemodilution related to increased maternal blood volume. RATIONALE: As a protective mechanism and to meet maternal and fetal demands, a 40% increase in circulating blood volume occurs during pregnancy. The rate of plasma expansion is greater and occurs earlier than that of the cellular component, so Hb and hematocrit values decrease. Careful evaluation may be necessary to distinguish this physiologic anemia from true anemia; Hb levels less than 10.5 g/dl usually indicate true anemia. The information given about the client doesn't suggest a hemolytic disease, internal bleeding, or noncompliance with prenatal vitamin intake. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Comprehension During a routine prenatal visit, the nurse measures the height of a client's fundus. Which finding is cause for concern? Nonpalpable fundus at 10 weeks' gestation Measurement at 40 weeks' gestation 2 cm less than at 36 weeks' gestation Palpable fundus at the level of the umbilicus (about 20 cm) at 26 weeks' gestation Palpable fundus midway between the symphysis pubis and umbilicus at 16 weeks' gestation RATIONALE: Measuring the height of the fundus at regularly scheduled intervals and comparing measurements with norms helps determine whether the fetus is growing appropriately. The top of the fundus should reach the level of the umbilicus at 20 weeks' gestation. It should then continue upward and reach midway between the symphysis pubis and the xiphoid process by 26 weeks. Usually the fundus isn't felt above the symphysis pubis until about 12 weeks' gestation. At 16 weeks' gestation, the fundus is expected to be between the symphysis pubis and the umbilicus, which would be above the level of the umbilicus. With lightening, the fetal head descends into the pelvis, decreasing the height of the fundus at around 38 to 40 weeks' gestation. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Analysis Which statement regarding physiologic changes in the GI system during pregnancy is accurate?
Demineralization of teeth occurs when calcium intake is insufficient. Delayed emptying of the stomach contributes to many GI symptoms. Nausea is related to high levels of relaxin and estrogen early in pregnancy. Gums bleed easily because of high levels of human chorionic gonadotropin (hCG). RATIONALE: The effects of progesterone in pregnancy result in delayed emptying of the stomach; this can cause various GI symptoms. Insufficient calcium intake doesn't cause demineralization of teeth, but fetal needs may be met by demineralization of maternal bones. Gums may bleed during pregnancy as a result of high levels of estrogen. Nausea is related to high levels of hCG, which decrease after the 13th week of gestation, and to decreased gastric motility caused by increased progesterone levels. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Comprehension Vaginal or rectal cultures are done at 36 weeks' gestation to diagnose: hepatitis B. herpes simplex virus type II. human papilloma virus. group B beta-hemolytic streptococci RATIONALE: Group B beta-hemolytic streptococci infection, although asymptomatic in women, can cause devastating neonatal infections. Up to 30% of pregnant women are positive for group A beta-hemolytic streptococci, which is diagnosed through vaginal or rectal cultures. The condition must be treated with I.V. antibiotics at 28 weeks' gestation and during labor to reduce the possibility of the neonate being exposed. Hepatitis B is diagnosed by viral cultures of the amniotic fluid. Infection with herpes simplex virus type II or human papilloma virus would result in an abnormal Papanicolaou smear. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Application The lecithin-sphingomyelin (L/S) ratio is an antepartum assessment technique that: determines fetal lung maturity via amniocentesis. estimates the amount of estriol production of both fetus and mother. requires an invasive procedure with application of a spiral electrode to the fetal head. tests the intrauterine fetal-placental reserve in the last trimester. RATIONALE: The L/S ratio is done by amniocentesis to determine the ratio between two surfactants: lecithin and sphingomyelin. The amount of sphingomyelin remains constant in amniotic fluid during pregnancy, but the amount of lecithin increases after the 24th week. Therefore, an L/S ratio of 2:1 is used as a gauge of fetal lung maturity, which occurs at about 35 to 36 weeks' gestation. The triple screen, an analysis of three indicators (maternal serum for alpha-fetoprotein, unconjugated estriol, and human chorionic gonadotropin), is used to detect Down syndrome. Internal electronic fetal monitoring is an invasive procedure requiring application of a spiral electrode to the fetal head. Biophysical profiling can test intrauterine fetal-placental reserve in the last trimester. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Comprehension The nurse is caring for a pregnant client who is lactose intolerant. To ensure the appropriate level of calcium in the client's diet, the nurse should determine if the client can tolerate: liver. collard greens. carrot juice. vitamin-fortified cereal.
RATIONALE: Lactose intolerance is common in adults, particularly among Blacks, Asians, and Native Americans. One cup of collard greens has the equivalent amount of calcium as one cup of milk. Other good sources include fortified tofu, figs, sardines, and canned salmon with bones. Liver and ground beef are good sources of iron. Fortified cereals are good sources of vitamins but not calcium. Calcium can also be obtained by taking calcium supplements. Carrot juice is a good source of vitamin A and beta-carotene. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Application Fainting is common in pregnant clients during the first trimester due to: hyperglycemia. hypertension. hyperventilation. hypoglycemia. RATIONALE: Fainting is common in the pregnant client during the first trimester due to hypoglycemia from frequent nausea and vomiting. Fainting isn't caused by hyperglycemia, hypertension, or hyperventilation. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Knowledge Maternal physiologic changes during pregnancy include: increased cardiac output. decreased blood flow to the skin. increased uterine vascular resistance. higher carbon dioxide (CO2) threshold of the respiratory center. RATIONALE: Cardiac output increases to meet the increased demands for blood flow to the uterus and other body systems affected by pregnancy. Blood flow to the skin is increased, generally causing the client to feel warmer and appear flushed. The uterus allows more blood flow to accommodate uteroplacental exchanges, so uterine vascular resistance is lower. The body is more sensitive to CO2, and the CO2 threshold is lower. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Comprehension A 36-year-old multiparous woman in her first trimester is in the clinic for a routine prenatal visit. She complains of fatigue and nausea and says, "I can't believe I'm pregnant!" Which response from the nurse would be most appropriate? "Tell me about your husband. Is he angry or disappointed that you're having another child?" "Many women experience great difficulty becoming pregnant. I hope you realize how lucky you are." "Many women experience ambivalent feelings about being pregnant. In a few months when you hold your baby, you'll forget these ambivalent feelings ever existed." "Many women experience ambivalent feelings about being pregnant. Is this how you're feeling?" RATIONALE: Most women have some ambivalent feelings during pregnancy. Explaining that these feelings are common may help the client explore her own ambivalent feelings. Telling the client how lucky she is or that she will overcome her ambivalent feelings dismisses her feelings and closes the subject. Asking how the husband feels about the pregnancy is inappropriate based on the information provided. The client's feelings are of primary concern and need to be explored first, especially because the client hasn't indicated that she is married. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: Coping and adaptation COGNITIVE LEVEL: Analysis
A pregnant client at 26 weeks' gestation takes a 1-hour glucose tolerance test as part of a recommended screening for gestational diabetes. A result of greater than or equal to what number of mg/dl indicates the need for further testing? 140 RATIONALE: Screening for gestational diabetes using a 1-hour glucose test is recommended for all pregnant women between 24 and 28 weeks' gestation. An abnormal 1-hour glucose tolerance test is defined as a level of 140 mg/dl or greater. A 3-hour standard glucose tolerance test should be performed is results of the 1-hour test are abnormal. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application The nurse is palpating the uterus of a client who is 20 weeks pregnant to measure fundal height. Identify the area on the abdomen where the nurse should expect to feel the uterine fundus. RATIONALE: At 20 weeks, fundal height should be at approximately the umbilicus. Fundal height should be measured from the symphysis pubis to the top of the uterus. Serial measurements assess fetal growth over the course of the pregnancy. Between weeks 18 and 34, the centimeters measured correlate approximately with the week of gestation. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Comprehension In early pregnancy, some clients complain of abdominal pain or pulling. Identify the area most commonly associated with this pain. RATIONALE: As the uterus grows in early pregnancy, it deviates physically to the right. This shift, or dextrorotation, is due to the presence of the rectosigmoid colon in the left lower quadrant. As a result, many women complain of pain in the right lower quadrant. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis Which statement about an incompetent cervix is correct? A cerclage is a cervical suture that's cut before labor. Trendelenburg's position and tocolysis may help a client with an incompetent cervix. A client with an incompetent cervix usually has a history of several first-trimester spontaneous abortions. A cerclage always allow a client to give birth vaginally. RATIONALE: Trendelenburg's position and tocolysis (along with pelvic rest) are commonly useful in preventing further cervical dilation. The woman with an incompetent cervix usually has a history of second-trimester, not firsttrimester, pregnancy losses. A cerclage is a cervical suture that may be placed before the woman is pregnant, requiring future births to be cesarean. Alternatively, it may be placed after pregnancy begins to prevent premature dilation of the cervix; it's cut before delivery. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis A client is diagnosed with an early, unruptured ectopic pregnancy. Which medication may be used to treat this condition? Methotrexate Broad-spectrum antibiotics Follicle-stimulating hormone (FSH) Human chorionic gonadotropin (hCG)
RATIONALE: Methotrexate is a relatively new treatment for unruptured ectopic pregnancy. It's effective for the same reason that it's useful in treating cancer: It destroys human cells and is thus able to destroy the abnormally implanted blastocyst. Broad-spectrum antibiotics aren't used to treat ectopic pregnancy, but they may be prescribed to prevent a postabortion infection. Human chorionic gonadotropin is produced by the trophoblast, and FSH is produced by the anterior pituitary; they aren't related to treatment of ectopic pregnancy. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis Severe pregnancy-induced hypertension (PIH) causes which condition? Toxins in the bloodstream Uteroplacental insufficiency Development of heart disease Increased circulating blood volume RATIONALE: Severe PIH results in uteroplacental insufficiency, partly because of decreased circulating blood volume and vasospasm. Heart disease doesn't result from PIH nor does collection of toxins in the bloodstream. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Comprehension A client is admitted to the emergency department at 37 weeks' gestation after a motor vehicle accident and is diagnosed with a fractured femur that will need surgical repair. What efforts on the part of the operating room team will best avoid risk to the fetus during the procedure? Use general anesthesia to avoid vasodilatation. Hydrate with 5% dextrose in lactated Ringer's solution. Monitor the fetus with a scalp lead during the procedure. Position the client on her left side and prop her with a wedge. RATIONALE: Maternal hypotension causes the greatest risk to the fetus in maternal surgery during pregnancy. To avoid maternal hypotension, the mother should be placed on the operating room table tilted and propped on her left side to avoid vena caval compression. Hydration is best tolerated by using normal saline solution I.V. The fetus can't be monitored with a scalp lead unless the membranes are ruptured. General anesthesia won't avoid vasodilatation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Comprehension A pregnant client's blood tests show HELLP syndrome. Which abnormal blood component is found with these results? Low platelet count High hemoglobin (Hb) level Low white blood cell (WBC) count Low fibrin split product level RATIONALE: HELLP syndrome stands for hemolysis, elevated liver enzyme levels, and low platelet count. Hemoglobin levels are also low, fibrin split product levels are high, and WBC count may also be high. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: Comprehension A 22-year-old woman arrives at the emergency department with abdominal pain. Which signs and symptoms would lead the nurse to suspect ectopic pregnancy?
Unilateral cramps and tenderness, nausea and vomiting, and a missed menses Epigastric or periumbilical pain, tenderness at McBurney's point, and nausea and vomiting Mild to severe uterine cramping, amenorrhea followed by spotting, and slightly enlarged uterus Pain in both lower quadrants, bilateral tenderness on movement of the cervix, and infrequent nausea and vomiting RATIONALE: Signs and symptoms of an ectopic pregnancy may include unilateral cramps and tenderness, nausea and vomiting, and a missed menses. Mild to severe uterine cramping and amenorrhea followed by spotting, with a slightly enlarged uterus, may be a sign of a spontaneous uterine abortion. Epigastric or periumbilical pain and tenderness at McBurney's point accompanied by nausea and vomiting may indicate appendicitis. Pain in both lower quadrants, bilateral tenderness on movement of the cervix, and infrequent nausea and vomiting are signs of salpingitis. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Application A 38-year-old client in her 2nd month of pregnancy comes to the prenatal clinic reporting a rash, mild symptoms, and swollen suboccipital lymph nodes. The physician makes a diagnosis of rubella. Rubella exposure during the first 2 months of pregnancy may result in: fetal or neonatal hepatitis and preterm birth. malformations of the heart, eyes, ears, or brain and abnormal dermatoglyphics. systemic infection, hepatosplenomegaly, intrauterine growth retardation, and rash. hemolytic anemia, jaundice, hydrocephaly, pneumonitis, hepatosplenomegaly, and deafness. RATIONALE: Malformations of the heart, eyes, ears, or brain and abnormal dermatoglyphics are seen with rubella if it occurs in the first 2 months after conception. Dermatoglyphics refers to the pattern of ridges of the skin of the fingers, palms, toes, and soles. If a woman contracts rubella after the 4th month of conception, systemic infection, hepatosplenomegaly, intrauterine growth retardation, and rash may result. Fetal or neonatal hepatitis and preterm birth may occur in the presence of maternal hepatitis A infection. Cytomegalovirus during pregnancy may result in hemolytic anemia, jaundice, hydrocephaly, pneumonitis, hepatosplenomegaly, and deafness. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Knowledge A 22-year-old client has been admitted to the hospital with severe preeclampsia. An infusion of magnesium sulfate is started to decrease the incidence of seizure activity. The nurse assesses the client frequently to monitor for signs of magnesium toxicity. Which assessment finding is a sign of possible magnesium toxicity? Urine output of 30 to 40 ml/hour Blood pressure of 140/80 mm Hg Respiratory rate of 10 breaths/minute Uterine contractions every 3 to 5 minutes RATIONALE: Signs and symptoms of magnesium toxicity include respiratory depression, oliguria, respiratory arrest, cardiac arrest, and the loss of patellar reflexes. A respiratory rate less than 12 breaths/minute may indicate magnesium toxicity. Oliguria is defined by a urine output of less than 30 ml/hour. Blood pressure greater than 160/110 mm Hg should be reported to the physician. Magnesium is a tocolytic agent, so toxicity is likely to stop contractions. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Application A client positive for human immunodeficiency virus (HIV) is about to begin labor. The care plan includes: administering zidovudine (AZT) if the client has a T-cell count less than 400/mm3. using internal electronic fetal monitoring during labor for a better picture of fetal status. wiping away all body fluids right after delivery and bathing the neonate as soon as he's stable.
encouraging the mother to consider breast-feeding because of its benefits for the mother and baby. RATIONALE: Neonatal exposure to HIV can occur during labor or birth due to exposure to the mother's blood or other body fluids. To prevent accidental exposure of the neonate to the virus, the nurse should immediately wipe away all blood and body fluids. All personnel should also take infection control precautions. Zidovudine is given to all HIV-positive pregnant women regardless of their T-cell count. Internal electronic fetal monitoring isn't recommended because inoculation of the virus may occur when a scalp electrode is placed. Breast-feeding is discouraged for an HIV-positive mother because of the risk of HIV transmission in breast milk. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Comprehension A 23-year-old client is at 28 weeks' gestation. Physical assessment shows bruises on her abdomen and thighs and swollen labia. The nurse suspects physical abuse and understands that: battering typically occurs in lower-class families. the woman will leave the relationship if battering continues. battering occurs in only a small percentage of the population. 25% to 45% of all battering cases occur during pregnancy. RATIONALE: From 25% to 45% of all battering cases occur during pregnancy. Overall, the percentage of women in the population who have been battered is about 20% to 33%. Battering can occur in any family, regardless of social class. Many women don't leave a battering relationship, but stay with their partner because of fear and financial dependence. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Analysis Which pregnancy-related disorder is characterized by painless vaginal bleeding, most commonly occurring after 20 weeks' gestation? Placenta previa Abruptio placentae Threatened abortion Spontaneous abortion RATIONALE: With placenta previa, painless vaginal bleeding occurs when placental villi are torn from the cervical tissue as it begins to soften and efface. Spontaneous abortions, threatened abortions, and abruptio placentae are generally accompanied by pain. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Comprehension The nurse is caring for a woman with a fetus with a brow presentation. Which intervention is appropriate for this client? Schedule a cesarean delivery. Have the mother stand to push. Give a tocolytic to stop contractions. Put the mother in Trendelenburg's position to lessen pressure on the fetal head. RATIONALE: A woman with a fetus with a face or brow presentation should be placed in Trendelenburg's position, which will lessen pressure on the fetal head. The fetus may then be able to move its head around a bit, enhancing the likelihood of an occiput presentation and a normal delivery. It isn't appropriate to schedule a cesarean delivery or give a tocolytic to stop labor. Encouraging the mother to push wouldn't be appropriate with a face or brow presentation, and at this point the fetal head is probably too far engaged in the maternal pelvis to change position. A physician or nurse-midwife may decide to recommend a cesarean delivery. NURSING PROCESS STEP:
Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application The nurse is caring for a 15-year-old pregnant client. The client weighs 100 lb (45.4 kg) and has a history of pyelonephritis, which puts her at high risk for: polyhydramnios. chromosomal abnormalities. postterm labor. preterm labor. RATIONALE:This client has three risk factors for preterm labor: age younger than 16, pyelonephritis, and weight of less than 110 lb (50 kg). These risk factors aren't associated with polyhydramnios, chromosomal abnormalities, or postterm labor. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Analysis The nurse is assessing a primigravida at 34 weeks for signs of pregnancy-induced hypertension (PIH). In addition to her blood pressure of 140/92 mm Hg, what other assessment finding would make the nurse suspect PIH? Hematuria Proteinuria Fatigue Palpitations RATIONALE: Classic signs of PIH include elevated blood pressure, proteinuria, and edema. Hematuria, fatigue, and palpitations don't indicate PIH. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Comprehension Which pregnant client is at risk for delivering a neonate with ABO incompatibility? Type AB client with type O fetus Type AB client with type A fetus Type O client with type O fetus Type O client with type A fetus RATIONALE: Clients with type O blood have anti-A and anti-B antibodies, so they are most likely to have ABO incompatibility if they have either a type A or B fetus. Type AB clients have no anti-A or anti-B antibodies against A or B blood types so they're not at risk for ABO incompatibility. The type O client and type O fetus have compatible blood types. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Analysis A multigravida visits the clinic at 14 weeks' gestation. She has been experiencing dark brown vaginal bleeding, her fundal height is 18 cm, and her hands and face are somewhat edematous. You suspect that the client is experiencing a: threatened abortion. multifetal pregnancy. hydatidiform mole. missed abortion.
RATIONALE: Signs and symptoms of hydatidiform mole include dark brown or "prune juice"-colored bleeding, abdominal distention, a fundal height greater than gestational age, and signs and symptoms of pregnancy-induced hypertension (PIH) such as edema. Scant red vaginal bleeding and cramping indicate a threatened abortion. A missed abortion would reveal no fetal heart rate and no bleeding and would be detected via ultrasound. A normal multifetal pregnancy involves increased fundal height, but no bleeding or symptoms of PIH. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Comprehension The history of a 45-year-old primigravida client shows that she was exposed to diethylstilbestrol (DES) as a fetus. This client is at risk for which complication during her pregnancy? Placenta previa Incompetent cervix Postterm pregnancy Multiple gestation RATIONALE: DES causes structural defects of the reproductive tract, including the cervix, in exposed fetuses. When these women become pregnant, the congenitally weak cervix is prone to open prematurely. Placenta previa, multiple gestation, and postterm pregnancy aren't associated with DES exposure. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Analysis Which client is at risk for Rh sensitization and therefore should receive RhoGAM as soon as possible? An Rh-positive woman who delivers an Rh-negative neonate An Rh-positive woman who has a tubal pregnancy An Rh-negative woman who has a spontaneous abortion at 15 weeks An Rh-negative woman who delivers an Rh-negative neonate RATIONALE: Only Rh-negative women are at risk for Rh incompatibility when exposed to blood that's positive for the Rh factor. Because the blood type of the abortus is usually unknown at 15 weeks, the Rh-negative woman who aborts at 15 weeks should be prophylactically desensitized with an injection of RhoGAM. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis A diabetic client who currently takes oral antidiabetic agents to control her blood glucose level is planning to become pregnant. The nurse should advise her to: talk to her physician about beginning insulin. quit taking the oral antidiabetic agents. increase her morning dose of oral antidiabetic agent to ensure low blood glucose levels throughout the day. make no changes in her daily diabetes management. RATIONALE: The client will probably begin treatment with insulin because oral antidiabetic agents are associated with fetal anomalies and shouldn't be used during pregnancy. It's also advisable that her blood glucose levels be within normal limits at conception and early in the pregnancy, so the client shouldn't quit oral medications without medical supervision. Changes in her diabetic management routine are inevitable, and the client should be prepared for them. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Application A client with severe preeclampsia is receiving I.V. magnesium sulfate. Which antidote should be kept at the bedside to treat magnesium toxicity?
Naloxone (Narcan) Sodium bicarbonate Ephedrine Calcium gluconate RATIONALE: The nurse should keep calcium gluconate at the bedside of a client with severe preeclampsia who is receiving I.V. magnesium sulfate. Signs and symptoms of increasing magnesium sulfate levels include respirations less than 12 breaths/minute, urine output less than 25 ml/hour, and absent deep tendon reflexes with progression to respiratory paralysis and cardiac arrest. Naloxone is a narcotic antagonist used to reverse narcotic-induced respiratory depression. Sodium bicarbonate is used for treatment of metabolic acidosis. Ephedrine is a vasopressor used to treat hypotension. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Application A pregnant diabetic client hasn't been able to control her glucose in early pregnancy. Which fetal anomaly is most likely to occur? Neural tube defect Long bone damage Cleft lip and palate Skull deformity RATIONALE: Fetal anomalies such as neural tube defects occur in diabetic clients if their blood glucose isn't well controlled during early pregnancy. Early pregnancy is the time of organogenesis (when organ systems are developing), and poorly controlled diabetes puts many fetal organ systems at risk. Long bone damage, cleft lip and palate, and skull deformity aren't normally associated with poor diabetic control. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Comprehension A pregnant client who tests positive for human immunodeficiency virus (HIV) asks if anything can be done to prevent transmitting the virus to her child. The nurse tells her that prophylactic use of which of the following drugs has significantly lowered the transmission of HIV from mother to fetus? Zidovudine (AZT) Acyclovir (Zovirax) Ganciclovir (Cytovene) Trimetrexate (Neutrexin) RATIONALE: The use of zidovudine (a drug used to reduce symptoms of HIV infection) has lowered the transmission rate of HIV from mother to fetus to as low as 8%. Acyclovir and ganciclovir (both antiviral agents) aren't used to prevent HIV transmission. Trimetrexate (used to treat Pneumocystis carinii pneumonia in HIVinfected clients) is a category D drug and is contraindicated in pregnancy. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Comprehension A pregnant woman admits to using cocaine several times since becoming pregnant. What complication of pregnancy may occur with the use of cocaine? Ruptured uterus Abruptio placentae Placenta previa Postterm labor
RATIONALE: Because of its capacity to cause constriction of blood vessels and therefore hypertension, cocaine use puts a pregnant woman at increased risk for abruptio placentae (premature separation of the placenta from the uterine wall). Cocaine use isn't associated with a ruptured uterus, placenta previa, or postterm labor. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Comprehension A client's fetus is in the frank breech position. How is this fetus arranged? The buttocks and knees present, with the knees drawn up. The buttocks present, with the legs extended up. The occiput is directed diagonally and posterior. One or both feet are presenting. RATIONALE: In the frank breech position, the buttocks present with the legs extended up and pressed against the chest. Buttocks and knees presenting, with the knees drawn up describes the complete breech position. One or both feet presenting is the footling breech position. The occiput directed diagonally and posterior describes the occiput posterior position. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application A client in the 8th month of pregnancy comes to the emergency department with vaginal bleeding and severe pain. These signs and symptoms may indicate: placenta previa. abruptio placentae. Braxton Hicks contractions. disseminated intravascular coagulation. RATIONALE: Abruptio placentae is the premature separation of the placenta, characterized by bleeding and pain. Pain occurs as pressure builds behind the placenta and causes the uterus to become rigid. Clients with placenta previa have vaginal bleeding but no pain. Braxton Hicks contractions are normal, painless uterine contractions that occur throughout pregnancy. Disseminated intravascular coagulation is a life-threatening clotting disorder. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Analysis A woman in her first trimester of pregnancy comes to the prenatal clinic and states, "I feel nauseous and I'm vomiting all the time. I can't even keep down water." This client should be evaluated for what condition? Hyperemesis gravidarum RATIONALE: Hyperemesis gravidarum differs from the nausea and vomiting that normally occur during pregnancy. It's characterized by excessive vomiting that can lead to dehydration and starvation. Without treatment, metabolic changes can lead to severe complications, even death, of the fetus or mother. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application A pregnant client at 32 weeks' gestation has mild pre-eclampsia. She is discharged home with instructions to remain on bed rest. She should also be instructed to call her doctor if she experiences which of the following symptoms? Select all that apply: Headache Increased urine output Blurred vision Difficulty sleeping
Epigastric pain Severe nausea and vomiting RATIONALE: Headache, blurred vision, epigastric pain, and severe nausea and vomiting can indicate worsening maternal disease. Decreased, not increased, urine output is a concern because it could indicate renal impairment. Difficulty sleeping, a common complaint during the third trimester, is only a concern if it's caused by any of the other symptoms. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application A client who is 37 weeks pregnant comes to the office for a prenatal visit. The nurse performs Leopold's maneuvers to assess the position of the fetus. After performing the maneuvers, the nurse suspects that the physician will attempt external version. Where did the nurse palpate the head of the fetus? RATIONALE: If the fetal head is palpated at the top of the uterus, the fetus is in the breech position. That is, the head is not the presenting part and the physician may consider external version to convert the fetus to a vertex lie, or head-down position. This is accomplished by applying pressure on the maternal abdomen to turn the infant over, as in a somersault. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis Which term refers to the portion of the fetus that enters the pelvis first and covers the internal os of the cervix? Attitude Breech Fetal lie Presentation RATIONALE: Presentation is the term used to describe the portion of the fetus that enters the pelvis first. Attitude is the relationship of the fetal body parts to one another. Breech is an example of presentation. Fetal lie is the relationship of the long axis of the fetal spine to that of the mother. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Comprehension The first stage of labor lasts from: full dilation of the cervix to delivery of the fetus. onset of regular contractions to full dilation of the cervix. onset of regular contractions to 7-cm dilation of the cervix. onset of regular contractions to 3-cm dilation of the cervix. RATIONALE:The first stage of labor includes the latent phase (dilation of 0 to 3 cm), active phase (4 to 7 cm), and transition phase (8 to 10 cm). Thus, it lasts from the onset of regular contractions to full dilation of the cervix. The second stage lasts from full dilation of the cervix to delivery of the fetus. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis A pregnant woman has begun her third stage of labor. The third stage of labor lasts from: dilation of the cervix to delivery of the fetus. delivery of the fetus to delivery of the placenta. delivery of the placenta to 2 hours after delivery. the onset of contractions to full dilation of the cervix.
RATIONALE: The third stage of labor lasts from delivery of the fetus to delivery of the placenta. The onset of contractions to full dilation of the cervix is the first stage of labor. Dilation of the cervix to delivery of the fetus is the second stage. Delivery of the placenta to 2 hours after delivery is the fourth stage of labor. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis Which pelvic measurement is the most critical for labor? True conjugate Direct conjugate Interspinous diameter Intertrochanteric diameter RATIONALE: The true conjugate is the measurement from the top of the symphysis pubis to the mother's spine. It's the smallest measurement through which the fetus must pass and thus the most critical. The direct conjugate is measured from the bottom of the symphysis pubis to the mother's spine and is the second most important measurement. The intertrochanteric and interspinous diameters were measured historically, but they have no actual contribution to delivering vaginally and are no longer considered necessary. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Comprehension A woman is in the second stage of labor. Her husband is with her and is becoming very tense. He asks the nurse, "Do you think I should leave? I feel like I'm in the way." Which response would be the most appropriate? "You may go sit in the father's waiting room if you want." "It isn't a good idea to run out on your wife at this time." "Why don't you go get a cup of coffee and relax? You can come back in later if you want." "I know this is hard for you. Let me try to help you coach your wife through this difficult phase." RATIONALE: The husband should remain to offer support to his wife at this time if possible. The nurse can help by providing instructions to the husband on how he can help his wife through this stage. The first and third options are encouraging the husband to leave. The second option is negative and judgmental and insinuates that the husband is failing his wife. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: Coping and adaptation COGNITIVE LEVEL: Application A couple attended childbirth classes to prepare for labor. The nurse reinforces what they learned about breathing techniques as the woman progresses through labor. During contractions in the latent phase of labor, the type of breathing generally called for is: panting breaths during contractions. slow paced breathing at a rate of 6 to 8 breaths/minute. modified paced breathing at a rate of 32 to 40 breaths/minute. patterned paced breathing at a rate of 32 to 40 breaths/minute. RATIONALE: During the latent phase (dilation of 0 to 3 cm), slow paced breathing is recommended. This type of breathing uses less energy and is less apt to result in fatigue early in the labor process. During the active stage (4 to 7 cm), as contractions become more painful, the woman may need to resort to faster paced breathing during contractions to maintain control. Panting generally isn't used until the transitional phase of labor (8 to 10 cm). NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis
A 30-year-old client is pregnant with her third child. She begins to have contractions and is told to come to the hospital for assessment. After examination, her physician tells her the contractions were false labor pains. In true labor, as opposed to false labor: contractions are more regular. contractions become quite uncomfortable. the cervix becomes progressively thinner and dilates. contractions may go away if the client lies down and relaxes. RATIONALE: True labor results in effacement and dilation of the cervix, so assessment of the cervix is necessary to differentiate between true labor and false labor. False labor doesn't impact the cervix even though the contractions may be regular and uncomfortable. Also, with true labor, the pains don't go away with rest, but lying down may make false labor pains stop. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Comprehension The way a fetus moves through the birth canal is determined by several factors, including fetal presentation, fetal lie, fetal attitude, and fetal position. Fetal position refers to: the part of the fetus that enters the pelvic inlet first. the relationship of the fetal body parts to one another. the relationship of the long axis (spine) of the fetus to the long axis of the mother. the relationship of the presenting part to the four quadrants of the mother's pelvis. RATIONALE: Position is defined as the relationship of the presenting part to the four quadrants of the mother's pelvis. For example, if the occiput is presenting in the left anterior quadrant of the mother's pelvis, the position is denoted as LOA (meaning left occiput anterior). The part of the fetus that enters the pelvic inlet first is the presenting part. The relationship of the fetal body parts to one another is called the attitude of the fetus. The relationship of the long axis (spine) of the fetus to the long axis of the mother is the fetal lie. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application A client is in labor, and the nurse is assessing the fetal heart pattern. The nurse notices variability in the fetal heart rate. Normal variability in fetal heart rate includes: a decrease in heart rate at the peak of the contraction. a decrease in heart rate at the beginning of each contraction. beat-to-beat fluctuations in the heart rate of 5 to 15 beats/minute. a decrease in fetal heart rate not reflective of the uterine contraction curve. RATIONALE: Beat-to-beat fluctuations of 5 to 15 beats/minute are normal variability. A decrease in fetal heart rate at the peak of the contraction may be a sign of late deceleration from uteroplacental insufficiency. A decrease in heart rate at the beginning of each contraction may be a sign of early deceleration from head compression. A decrease in fetal heart rate not reflective of the uterine contraction curve may be a sign of variable deceleration from cord compression. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis A woman has been in labor for about 20 hours, and the nurse notices a decrease in fetal heart rate at the beginning of each contraction. Early deceleration most commonly results from: placenta previa. cord compression. head compression.
uteroplacental insufficiency. RATIONALE: Early deceleration generally results from cephalopelvic disproportion (head compression). Placenta previa would cause vaginal bleeding. Variable decelerations are usually caused by cord compression. Uteroplacental insufficiency generally results in late decelerations. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Comprehension A 30-year-old client in labor has come to the hospital. She has discussed methods of pain control during the second stage of labor with her physician, and they have decided on a pudendal block. A pudendal block is: local anesthesia injected into the epidural space. local anesthesia injected through the third, fourth, or fifth lumbar interspace into the subarachnoid space. 10 to 20 ml of lidocaine (Xylocaine) or 2% chloroprocaine injected into the skin and subcutaneously (S.C.) into the perineal tissues. an anesthetic drug injected at or near the sacrosciatic notch just medial to the tip of the ischial spine on each side. RATIONALE: A pudendal block is an injection of an anesthetic drug at or near the sacrosciatic notch just medial to the tip of the ischial spine on each side. Local anesthesia injected through the third, fourth, or fifth lumbar interspace into the subarachnoid space is subarachnoid (spinal) anesthesia. Local anesthesia at the perineum involves 10 to 20 ml of lidocaine or 2% chloroprocaine injected into the skin and S.C. into the perineal tissues. Local anesthesia injected into the epidural space would produce epidural anesthesia. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Comprehension Which position increases the size of the pelvic outlet? Squatting Sims' position Hands and knees Sitting on a birthing chair RATIONALE: Squatting maximizes the pelvic outlet and facilitates birth because the fetus has more room in which to pass. The other positions are acceptable for delivery and may provide comfort for some women, but none increases the pelvic outlet to the same extent as the squatting position. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis Preterm labor may be precipitated by: maternal exercise. suboptimal hydration. increased maternal activity levels. increasing levels of maternal progesterone. RATIONALE: Dehydration is known to increase uterine irritability. Decreasing (not increasing) levels of progesterone are a risk factor for preterm labor. Exercise is encouraged during pregnancy, but heavy physical work could increase the risk of preterm labor. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Comprehension Fetal heart tones are monitored throughout labor. Reassuring tracings show: absence of beat-to-beat variability.
increased heart rate with increased fetal activity. fetal heart rate consistently less than 110 beats/minute. deceleration of fetal heart rate after the peak of the contraction. RATIONALE: Accelerations of fetal heart rate with fetal activity are a normal response. Normal fetal heart rate is 120 to 160 beats/minute. Late decelerations suggest placental insufficiency. Absence of beat-to-beat variability is a nonreassuring sign of potential fetal compromise resulting from fetal hypoxia and acidemia or from central nervous system drugs. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application When performing a pelvic examination on a labor client, which pelvic landmark does the nurse use to determine station? Pelvic brim Pelvic outlet Ischial spines Ischial tuberosities RATIONALE: Station is the measurement of the fetal descent in relation to the ischial spines in the maternal pelvis. It isn't measured using the ischial tuberosities, the pelvic brim, or the pelvic outlet. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Knowledge A fetus may be changed from a breech, shoulder, or oblique presentation to a cephalic presentation using an external version (manipulation of the fetus within the uterus). Which situation contraindicates using an external version? Previous vaginal delivery Reactive nonstress test Reassuring nonstress test Previous vertical uterine incision RATIONALE: Contraindications for version include a previous cesarean delivery with a vertical uterine incision, cephalopelvic disproportion, placenta previa, multifetal gestation, uteroplacental insufficiency, and ruptured membranes. A previous vaginal delivery, a reactive nonstress test, or a reassuring nonstress test wouldn't contraindicate external version. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Application While caring for a multigravida in active labor who has been lying in a supine position, the nurse detects a variable fetal heart rate deceleration. After contacting the client's physician, the nurse's first action is to: turn the client to her left side. decrease the I.V. fluid rate. prepare to perform a scalp pH on the fetus. administer an amnioinfusion solution. RATIONALE: When a variable deceleration is detected, the primary objective is to relieve pressure on the umbilical cord of the fetus. The nurse should turn the client to her left side and offer her reassurance. The I.V. fluid rate should only be decreased if oxytocin is being administered in the I.V. line. Otherwise, the I.V. fluid rate to the mother should be increased. A scalp pH is done to determine fetal acidosis, which may occur when variable decelerations have been prolonged or when late decelerations are present. Amnioinfusion solutions are used when thick meconium is present or when the variable decelerations have been profound and prolonged. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application
A primigravida in active labor has just received an epidural block anesthetic to relieve the pain of labor. The nurse's highest priority assessment immediately after administration of an epidural block anesthetic is: evaluation of the client's emotional status. intensity of the contractions. fetal heart rate. maternal bladder status. RATIONALE: A client receiving an epidural anesthetic should have continuous fetal monitoring to detect any significant fetal heart rate changes. Bradycardia and fetal decelerations may occur as a result of an epidural block anesthetic. The nurse should evaluate the client's mental status for evidence of confusion or lethargy. The intensity of the contractions isn't a priority at this time. Maternal bladder status should be evaluated after administration of an epidural anesthetic, because I.V. fluids and a lack of sensation can lead to a distended bladder, but this assessment doesn't take first priority. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Analysis The husband of a non-English-speaking client stays outside the door of the labor room with the other men in his family, but refuses to go into the room during labor or delivery. You should find a translator to: tell him that he should come in and be with his wife. encourage him to come in to support his wife periodically. assess his cultural beliefs about childbirth. ask the other men to leave. RATIONALE: Male participation in childbirth is taboo in some cultures; an accurate assessment of the family's belief in this area will determine which nursing interventions are most appropriate. Telling him that he should come in and be with his wife or asking the other men to leave might be offensive to his cultural beliefs. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: Psychosocial adaptation COGNITIVE LEVEL: Comprehension While performing a vaginal examination on a woman in labor, the nurse notes that the top of the fetal head is in line with the ischial spines of the maternal pelvis. What's the correct way to document this finding? 100% effacement 10 cm dilation 0 station Complete RATIONALE: The ischial spines are "0 station" in measuring the descent of the presenting part through the pelvis. Negative stations are higher and positive stations are lower. Dilation and effacement refer to the opening and thinning of the cervix. "Complete" refers to a 10-cm dilation of the cervix. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis When measuring the frequency of contractions, the nurse notes the time between: the number of contractions in 1 hour. the beginning of a contraction and the end of that contraction. the end of one contraction and the beginning of the next contraction. the beginning of one contraction and the beginning of the next contraction.
RATIONALE: Frequency is measured from the beginning of one contraction to the beginning of the next. Duration is measured from the beginning of one contraction to the end of that contraction. Interval is measured from the end of one contraction to the beginning of the next. The number of contractions in an hour isn't usually measured. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application A pregnant client has a small gush of clear fluid from the vagina. To positively differentiate this fluid as amniotic fluid, the nurse performs a nitrazine test. The test is positive if the fluid turns the paper: yellow. olive green. pink. blue. RATIONALE: Amniotic fluid, which is alkaline, turns the nitrazine paper blue. Mildly acidic urine turns the paper shades of yellow to olive green. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Comprehension The nurse is assisting with normal delivery, holding a neonate while a second nurse clamps the umbilical cord. Where should the nurse position the neonate? Above the level of the uterus Below the level of the uterus In whatever position is comfortable In his mother's arms RATIONALE: Holding the neonate below the level of the uterus prevents blood from the umbilical cord from draining into the placenta. The mother may hold her baby as soon as cord care is completed and the first assessment is done. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application While traveling on a city bus, the nurse is called upon to assist with emergency childbirth. The nurse observes that the neonate is preterm. What is the most important intervention after the neonate's airway is clear? Perform an assessment using the Apgar scale. Maintain normal body temperature. Stimulate the infant to cry. Allow the infant to try to suck. RATIONALE: Maintaining a normal body temperature is essential for a preterm neonate. The nurse should defer the Apgar assessment until a warm environment is available. The neonate should be stimulated to breathe by rubbing the back or the soles of the feet; stimulating the neonate to cry would make him use up valuable energy. Many preterm neonates have a poor sucking reflex, but this can be addressed later. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Application Crowning refers to the phase in the second stage of labor when a large segment of the fetal scalp is visible at the vaginal orifice. How can the nurse help a client resist the urge to push during crowning? Tell the client to take slow, deep breaths. Ask the client to squeeze your hand.
Encourage the client to take panting breaths. Remove the client's legs from the stirrups. RATIONALE: Short, panting breaths can help control the urge to push until the time is right. Slow, deep breaths are difficult to maintain during this period of labor, and the client's legs should remain in the stirrups if the lithotomy position is being used for delivery. Squeezing your hand may be painful for you and prevents the client from being able to relax between contractions. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application The nurse is evaluating a client who is 39 weeks pregnant for rupture of the amniotic membranes. Which findings indicate that this has occurred? Select all that apply: Fernlike pattern when vaginal fluid is placed on a glass slide and allowed to dry Acidic pH of fluid when tested with nitrazine paper Presence of amniotic fluid in the vagina Cervical dilation of 6 cm Alkaline pH of fluid when tested with nitrazine paper Contractions occurring every 5 minutes RATIONALE: The fernlike pattern that occurs when vaginal fluid is placed on a glass slide and allowed to dry, presence of amniotic fluid in the vagina, and alkaline pH of fluid are all signs of ruptured membranes. The fernlike pattern seen when the fluid is allowed to dry on a slide is a result of the high sodium and protein content of the amniotic fluid. The presence of amniotic fluid in the vagina results from the expulsion of the fluid from the amniotic sac. Cervical dilation and regular contractions are signs of progressing labor but do not indicate rupture of the membranes. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis A client in labor is 8 cm dilated. The fetus, which is in vertex presentation, is 75% effaced and is at 0 station. In the illustration below, identify the level of the fetus's head. RATIONALE: Station refers to the level of the presenting part in relation to the pelvic inlet and the ischial spines. A 0 station indicates that the presenting part lies at the level of the ischial spines. Other stations are defined by their distance in centimeters above or below the ischial spines. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application A fetus with severe variable decelerations will experience: increasing variability. a quick return to baseline heart rate. a heart rate less than 70 beats/minute. a heart rate less than 100 beats/minute, lasting less than 30 seconds. RATIONALE: A severe variable deceleration is defined as a fetal heart rate less than 60 to 70 beats/minute lasting longer than 60 seconds, with either increasing baseline fetal heart rate, decreasing beat-to-beat variability, or slow return to baseline heart rate. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Analysis A primigravid client arrives in the delivery area in early labor. Examination indicates the fetus is a single footling breech presentation. What should the nurse expect regarding delivery? Delivery will be by primary cesarean birth.
An epidural will be used to make the labor more comfortable. The woman will need augmentation with oxytocin (Pitocin). The birth will require use of Piper forceps for the aftercoming head. RATIONALE: A primigravida has an "untried pelvis," and it's unknown whether she can deliver vaginally in this situation. A cesarean birth is typically used for a primigravid woman when the fetus presents as a breech. Oxytocin augmentation is contraindicated. An epidural may be used for cesarean anesthesia, not to make labor more comfortable. Piper forceps would only be used in a woman who has previously given birth. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Comprehension A woman is admitted to the hospital with a second episode of bleeding from a placenta previa. Which intervention is indicated? Use a scalp electrode to record fetal heart rate. Get the client out of bed to empty her bladder before surgery. Perform frequent vaginal examinations to record cervical changes. Obtain a complete blood count (CBC) and an order for packed red blood cells (RBCs). RATIONALE: A client with a second episode of bleeding from a placenta previa usually needs to undergo cesarean delivery, and a CBC is necessary to determine hemoglobin level before surgery; an order for packed RBCs will ensure replacement blood is available in case it's needed. A scalp electrode can't be used because the placenta blocks access to the fetus. Vaginal examinations could promote vaginal bleeding by disturbing the placenta. The client should remain on bed rest, and the bladder will be emptied when an indwelling urinary catheter is inserted before surgery. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Application Which assessment finding would the nurse expect in a client experiencing hidden abruptio placentae? Severe abdominal pain Bright red, painless vaginal bleeding Variable fetal heart rate decelerations A history of heroin use in the past 24 hours RATIONALE: Hidden abruptio placentae occurs when blood is trapped between the placenta and the uterus as the placenta separates prematurely from the uterine wall. A client with abruptio placentae has severe abdominal pains and frequent, strong uterine contractions because trapped blood irritates the uterus. There is often no visible blood if the separation is hidden between the wall of the uterus and the placenta. The fetus usually shows late decelerations because of diminished placental perfusion from frequent strong contractions. Heroin use isn't related to abruptio placentae, although cocaine use is. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Analysis Which condition, drug, or treatment can cause uterine dystocia? Oxytocin (Pitocin) Gestational diabetes Uterine overdistention Artificial rupture of membranes RATIONALE: An overdistended uterus doesn't seem to contract normally, resulting in uterine dystocia. Gestational diabetes may cause overdistention due to macrosomia, but the disorder itself doesn't cause dystocia. Oxytocin and artificial rupture of the membranes don't cause dystocia. NURSING PROCESS STEP: Analysis CLIENT
NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Comprehension A 23-year-old woman is in the active phase of labor. The nurse notes variable decelerations on the fetal monitor and observes the cord protruding out of the vagina. Which intervention should the nurse perform immediately? Instruct the client to push. Stimulate the fetal scalp or use acoustic stimulation. Help the woman to roll over and assume a side-lying position. Insert two fingers into the vagina to the cervix and press upward on the presenting part. RATIONALE: The goal here is to relieve pressure on the cord from the presenting part. This can be accomplished by manually holding the presenting part off the cord through exerting upward pressure on the presenting part. With many complications, it helps to have the woman assume the side-lying position. In this case, however, that may not be enough to relieve pressure on the cord. She should be put in a deep Trendelenburg's or a modified Sims' position. Stimulating the fetal scalp or using acoustic stimulation is sometimes called for when a nonreassuring fetal heart rate pattern is seen on the monitor. The client shouldn't push because that would result in pressure on the cord. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application The nurse is monitoring for signs of placental abnormalities in a client in labor. One type of placental abnormality is abruptio placentae, which is: the placenta delivered with the shiny side up. the placenta implanted in the lower uterine segment. placental pieces retained after delivery of the placenta. the placenta separated from the uterine wall before delivery of the infant. RATIONALE: Abruptio placentae is a placenta that separates from the uterine wall before delivery of the infant. A placenta delivered shiny side (fetal side) up is referred to as Schultze mechanism; dull side (maternal side) up is referred to as Duncan mechanism. A placenta implanted in the lower uterine segment is called placenta previa. Retained placental pieces may cause postpartum bleeding, but this wouldn't be a concern during labor. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Knowledge Preterm labor is the onset of regular uterine contractions that cause cervical changes between 20 and 37 weeks' gestation. Risk factors associated with preterm labor include: diabetes mellitus, fetal congenital anomalies, and isoimmunization. prolonged rupture of the membranes, intrauterine growth retardation, and intrauterine fetal death. maternal cyanotic heart disease, pregnancy-induced hypertension (PIH), and recurrent antepartum hemorrhage. maternal age younger than 16 or older than 35, poor nutrition, incompetent cervix, and maternal weight less than 110 lb (50 kg). RATIONALE: Many risk factors are associated with preterm labor, including maternal age younger than 16 or older than 35, poor nutrition, incompetent cervix, and maternal weight less than 110 lb. Diabetes mellitus, fetal congenital anomalies, and isoimmunization are risk factors associated with polyhydramnios. Prolonged rupture of the membranes, intrauterine growth retardation, and intrauterine fetal death are risk factors associated with oligohydramnios. Intrauterine growth retardation can be caused by maternal cyanotic heart disease, PIH, and recurrent antepartum hemorrhage. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis
Which condition can increase the risk of postterm pregnancy (beyond 42 weeks)? Anencephalic fetus Low serum estrogen level Low maternal weight gain Early threatened miscarriage RATIONALE: Although the exact trigger for labor is unknown, both the maternal and fetal systems are thought to contribute to its initiation. An anencephalic fetus is unlikely to help initiate labor as effectively as a normal fetus. Low maternal weight gain, early threatened miscarriage, and low serum estrogen levels aren't conclusively related to postterm pregnancy. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis A woman in preterm labor is receiving terbutaline (Brethine) subcutaneously to try and halt her contractions. The nurse should monitor this client for: tachycardia. hypoglycemia. fever. bradycardia. RATIONALE: Adverse reactions to terbutaline include hypotension, jitteriness, tachycardia, palpitations, tremors, hyperglycemia, hypokalemia, and feelings of anxiety. There is no indication that this drug causes a fever. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Comprehension Which medication is used to promote fetal lung maturity when a client has preterm labor? Terbutaline Betamethasone Magnesium sulfate Clarithromycin RATIONALE: Betamethasone, a glucocorticoid, is used to stimulate the development of surfactant in the fetal lung. It's given when the fetus is less than 34 weeks' gestation and is most effective if birth occurs at least 24 hours after beginning the drug. Terbutaline is a beta-adrenergic agonist used to treat preterm labor. Magnesium sulfate is a central nervous system depressant used to prevent seizures of preeclampsia and preterm labor. Clarithromycin is an antibiotic often used to treat upper respiratory tract infections. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Analysis A client in labor has a fetus in breech presentation. What should the nurse assess for first? Meconium in the amniotic fluid A prolapsed cord if membranes are ruptured An increase in intensity and duration of contractions Presence of early decelerations RATIONALE: When the fetus is in a breech presentation and the membranes rupture, the umbilical cord may be swept downward through the cervix and may prolapse into the vagina. Pressure from the presenting part of the fetus may cause diminished blood flow through the umbilical cord because it's trapped in the cervix. It's critical to observe fetal heart rate (FHR) pattern at this time because variable or late decelerations are danger signals. Meconium in the
amniotic fluid is often seen in this situation and is acceptable as long as the FHR pattern is normal. An increase in intensity and duration of contractions or the presence of early decelerations isn't a result of rupture of membranes. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application A woman in labor has had a positive group B beta-hemolytic streptococcal culture during her 36th week of pregnancy. Which medication should the nurse be prepared to administer to this client? 80 mg gentamicin 5 million U penicillin G 1 g streptomycin 500 mg tetracycline RATIONALE: The group B beta-hemolytic streptococcal colonization of the vagina during pregnancy requires treatment with 5 million U penicillin G when the woman goes into labor. From 15% to 35% of all women are carriers of this organism and may transmit it to their neonates at birth. Gentamicin, streptomycin, and tetracycline aren't used for this purpose. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Application The nurse is caring for a mildly hypertensive multigravida in active labor whose cervix is dilated to 7 cm. The client tells the nurse that she frequently smoked crack cocaine during her pregnancy. The nurse should assess the client for symptoms of: abruptio placentae. placenta accreta. placenta previa. placental infarction. RATIONALE: The exact cause of abruptio placentae is unknown, but hypertension, multiparity, crack cocaine use, abdominal trauma, increasing maternal age, cigarette smoking, and pregnancy-induced hypertension have all been associated with the disorder. Placenta accreta occurs when placental tissue has grown into the myometrium and can't be diagnosed until delivery. Placenta previa isn't associated with hypertension or crack cocaine use. Placental infarction can't be diagnosed until delivery. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Analysis The nurse is caring for a gravida VII, para V, Ab I client whose labor is being induced with oxytocin (Pitocin). While assessing the client, the nurse observes that the client is having difficulty breathing, is anxious, and that her lips and fingernails have become cyanotic. The client's blood pressure is 80/50 mm Hg and her pulse rate is 130 beats/minute. The nurse suspects that the client is experiencing: an amniotic fluid embolism. a pulmonary embolism. supine hypotension syndrome. septic shock. RATIONALE: The client's high parity, induction of labor, dyspnea with cyanosis, anxiety, and shock indicate amniotic fluid embolism, which carries an extremely high maternal mortality rate. If the mother survives the initial shock, bleeding secondary to disseminated intravascular coagulation is likely. Clients with pulmonary embolism also have symptoms of shock, difficulty breathing, and cyanosis, but these symptoms are most often accompanied by sharp or crushing chest pain. Pulmonary embolism also occurs in the postpartum period more often than during labor. In supine hypotension syndrome, the large uterus compresses the vena cava when the mother is supine. The client experiences hypotension, tachycardia, pallor, and faintness but not cyanosis. Respiratory failure is common
with septic shock, but evidence of underlying infection usually exists. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Analysis The nurse is caring for a nullipara in active labor whose cervix is dilated to 6 cm with complete effacement. The client hasn't received any analgesia or anesthesia, and her contractions continue at 3 to 5 minutes apart. After 2 hours, the client's cervix remains at 6 cm and the baby's head is at 0 station. You suspect that this client may be experiencing: prolonged latent phase of labor. myometrial dysfunction. cephalopelvic disproportion. cervical anomalies. RATIONALE: When a nulliparous client has made no progress in cervical dilation for 2 hours without any analgesia or anesthesia to slow the progress of labor, the nurse should suspect cephalopelvic disproportion. A client whose cervix is at 6 cm is in the active phase of labor, not latent. Myometrial dysfunction would include poor contractions. A client with cervical anomalies wouldn't have a cervix dilating or effacing to this point. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application A client in labor is experiencing severe variable decelerations. Nursing interventions should concentrate on: reducing umbilical cord compression. enhancing placental perfusion. maintaining maternal comfort. decreasing maternal blood pressure. RATIONALE: Variable decelerations result from sudden "crimping" or compression of the umbilical cord. Repositioning the client or performing an amnioinfusion can reduce cord compression. Uteroplacental deficiencies result in late decelerations, not variable decelerations. Maintaining maternal comfort isn't the primary concern in this situation. Variable decelerations aren't associated with maternal blood pressure. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Application A client is admitted in active labor. The nurse auscultates fetal heart tones above the umbilicus. This should lead the nurse to alert the physician to the possibility of: placenta previa. abruptio placentae. breech presentation. face presentation. RATIONALE: When the fetus is in the breech presentation--with the head "up" (but usually tucked) and the fetal buttocks down--the nurse can hear fetal heart tones in the upper quadrants of the maternal abdomen. Placenta previa presents with a sudden onset of painless uterine bleeding. Signs of abruptio placentae are vaginal bleeding, abdominal pain, and uterine hyperactivity and tenderness. In a face presentation, the fetal heart tones would be auscultated below the umbilicus. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis A client at 32 weeks' gestation is experiencing premature labor. The client receives an I.V. magnesium sulfate drip to:
relieve nausea and vomiting. relax smooth muscle. reduce the risk of seizures. maintain normal blood pressure. RATIONALE: Magnesium sulfate relaxes smooth muscles such as the uterus, stopping contractions. Magnesium sulfate can worsen nausea and vomiting. It can be used to control seizure activity and blood pressure in a client with pregnancy-induced hypertension, but that isn't its indication for this client. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Comprehension A client at 43 weeks' gestation is scheduled for an induction of labor. The client asks why induction must be done. Which response is most appropriate? "Your prenatal care policy will only cover pregnancy through 42 weeks." "Induction is much better for the neonate than a cesarean delivery." "The baby needs a healthy placenta to receive the oxygen and nutrients it needs; yours is getting too old to supply those needs." "Women who experience pregnancies longer than 43 weeks have a significantly higher rate of postpartum depression and mood disorders." RATIONALE: The placenta begins to calcify at term and deteriorates postterm; at 43 weeks, the placenta may not be able to supply all the fetus's needs. The length of insurance coverage for prenatal care, the benefits of this type of delivery, and the mother's postpartum psychological condition aren't the reasons for induction. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: Coping and adaptation COGNITIVE LEVEL: Application Immediately after an amniotomy, the nurse should assess: maternal pulse. maternal temperature. fetal heart tones. fundal height. RATIONALE: Fetal heart tones between 120 to 160 beats/minutes indicate that cord prolapse didn't occur during the amniotomy. Assessing maternal temperature and maternal pulse is relevant later in labor due to increased risk for infection, but it isn't relevant immediately after the procedure. Fundal height is irrelevant after an amniotomy. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Application A client in labor needs assistance with delivery, and the physician prepares to use forceps. Which condition must apply for a successful forceps delivery? Cervical dilation of at least 50% Strong uterine contractions A breech presentation A fully dilated cervix RATIONALE: A fully dilated cervix is necessary for safe delivery with forceps. Severe lacerations and hemorrhage may occur if a rim of cervical tissue remains. Strong contractions aren't required. A breech presentation isn't the only indication for forceps delivery, but forceps may be used to deliver the head (which presents last) in a breech presentation. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application
A woman develops postepidural hypotension during labor. Which action should the nurse take first? Increase the I.V. infusion rate. Administer oxygen. Call the attending physician. Turn the woman onto her left side. RATIONALE: Increasing the rate of the I.V. infusion will help fill the vascular system and offset the client's vasodilation. Administering oxygen and turning the client on her left side are helpful steps, but they don't provide immediate treatment for the hypotension. Increasing the I.V. infusion rate is more immediately important than calling the physician. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Comprehension The nurse is treating a client who is pregnant with twins. The client goes into labor. Which delivery method will the nurse most likely prepare her for? Spontaneous vaginal delivery Low forceps extraction Vacuum extraction Cesarean delivery RATIONALE: A cesarean delivery is commonly chosen with twins because there is an increased mortality rate associated with twins who are delivered vaginally. Low forceps extraction and vacuum extraction are options during a vaginal delivery. In this case, however, a cesarean birth is a more likely choice than any type of vaginal delivery. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis A grand multipara is undergoing induction of labor. The client is at increased risk for which complication? Long, painful contractions Rupture Placenta previa Bicornuate uterus RATIONALE: A grand multipara is a client who has had five or more births. This causes stretching and weakening of her uterus, putting her at risk for a ruptured uterus during induction of labor. Long, painful, and intense contractions may occur as a result of oxytocin administration, but they aren't directly related to multiparity. The risk of placenta previa increases with multiple gestations, not multiparity. A bicornuate uterus is a genetic abnormality of the uterus. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Comprehension The nurse is evaluating the external fetal monitoring strip of a client who is in labor. She notes decreases in the fetal heart rate (FHR) that coincide with the client's contractions. What term does the nurse use to document this finding? Early decelerations RATIONALE: A deceleration is a decrease in the FHR below the baseline. When decelerations occur at the same time as uterine contractions, they're called early decelerations. Early decelerations result from head compression during normal labor and do not indicate fetal distress. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application
On the waveform below, identify the area that indicates possible umbilical cord compression. RATIONALE: Variable decelerations are decreases in fetal heart rate that aren't related to the timing of contractions. Characteristic of umbilical cord compression, variable decelerations generally occur as drops of 10 to 60 beats/minute below the baseline. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis A client who is 29 weeks pregnant presents comes to the to the labor and delivery unit. She states that she's having contractions every 8 minutes. The client is also 3 cm dilated. Which of the following can the nurse expect to administer? Select all that apply: Folic acid (Folvite) Terbutaline (Brethine) Betamethasone Rho (D) immune globulin (Rhogam) I.V. fluids Meperidine (Demerol) RATIONALE: The client is at risk for preterm delivery. The nurse can expect that terbutaline, a beta-2 agonist that relaxes smooth muscle, will be administered to halt contractions. The nurse can also expect that betamethasone, a corticosteroid, will be administered to decrease the risk of respiratory distress in the infant if preterm delivery occurs and I.V. fluids will be used to expand the intravascular volume and decrease contractions, if dehydration is the cause. Folic acid is a mineral recommended throughout pregnancy (especially in the first trimester) to decrease the risk of neural tube defects. It isn't used to address preterm delivery. Rho (D) immune globulin is administered to Rh-negative clients who have been or are suspected of having been exposed to Rh-positive fetal blood. Meperidine is a narcotic used during labor and delivery to manage pain. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Analysis You're trying to prevent heat loss in the neonate by providing a warm environment. Heat loss by convection refers to: evaporation of moisture on the skin. transfer of heat to the cool air in the room. radiation to solid objects at a greater distance. transfer of heat to cooler objects touching the skin. RATIONALE: Convection is the loss of heat to cooler air in the surroundings. Transfer of heat to cooler objects touching the skin is referred to as heat loss by conduction. When objects, such as the walls of the room and windows, are cold, heat can be lost by radiation. Heat can also be lost by evaporation of moisture on the skin. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Comprehension You're assessing a neonate and find a boggy, edematous swelling on the fetal skull and consider the possibility of caput succedaneum. Caput succedaneum is swelling that: generally resolves in 3 to 6 weeks. extends across suture lines of the fetal skull. doesn't pulsate or bulge when the infant cries. usually peaks in size on the 2nd or 3rd day.
RATIONALE: Caput succedaneum extends across suture lines of the fetal skull; unlike a subdural hematoma, a caput succedaneum may pulsate. With a subdural hematoma, the size of the swelling usually peaks on the 2nd or 3rd day and resolves in 3 to 6 weeks. A caput succedaneum is largest at birth and resolves in 3 to 4 days. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis While evaluating a neonate in the nursery, you check his hips for signs of dislocation. Which of the following signs indicates that the hips are in the normal position? Both legs abduct easily. Skin folds are asymmetrical. A click is heard when hip integrity is assessed. The femur head is felt to slip forward in the acetabulum. RATIONALE: Inspection of a neonate's hips during assessment should reveal symmetrical skin folds, easy abduction of both legs, and absence of a click or sense that the femur is moving within the acetabulum. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Analysis Assessing a neonate's primitive reflexes helps to rule out neurologic deficits. When the tonic neck reflex is elicited, you should see: the trunk flex and the pelvis swing toward the stimulated side. the arms abduct with flexion of the elbows while the hands stay clenched. the neonate turn his head toward the stimulus, open his mouth, take hold, and suck. the neonate extend the arm and leg on one side and flex the arm and leg on the other side. RATIONALE: The tonic neck reflex is characterized by extension of the arm and leg on one side with flexion of the arm and leg on the other side. The Galant, or trunk incurvation, reflex is characterized by flexion of the trunk while the pelvis is swung toward the stimulated side. In the startle reflex (also known as Moro's reflex), the neonate abducts his arms and flexes his elbows while clenching his hands. In the rooting reflex, the neonate turns his head toward the stimulus, opens his mouth, takes hold, and sucks. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Comprehension Instillation of a prophylactic agent in the eyes of all neonates is mandatory in the United States as a precaution against ophthalmia neonatorum. Eye inflammation may be contracted as the neonate passes through the maternal birth canal. One sexually transmitted disease associated with ophthalmia neonatorum is: gonorrhea. herpes virus. human papillomavirus. syphilis. RATIONALE: Either gonorrhea or a chlamydial infection can cause ophthalmia neonatorum. Herpes and human papillomavirus are viral (not bacterial) infections. Syphilis can result in many birth defects or fetal death if contracted before the seventh month of pregnancy, but it doesn't cause ophthalmia neonatorum. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Analysis You're assessing a neonate. Normal assessment findings include: absent Babinski's reflex and pale skin.
heart rate of 130 to 140 beats/minute and acrocyanosis. absence of head control and a relaxed posture while awake. respiratory rate of 60 breaths/minute and expiratory grunting. RATIONALE: Heart rate of 130 to 140 beats/minute is within normal range, and acrocyanosis (cyanosis of the extremities) is normal in the neonate. Acrocyanosis generally lasts 7 to 10 days. If Babinski's reflex is absent and the skin is pale, the neonate may have central nervous system damage. Absence of head control and a relaxed posture while awake are signs of prematurity. A respiratory rate of 60 breaths/minute and expiratory grunting may indicate a respiratory disorder. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis Which of the following cardiac changes occurs in the fetus during the transition to extrauterine life? Decreased partial pressure of arterial oxygen (Pao2) levels Decreased left atrial pressure Decreased right atrial pressure Decreased pulmonary blood flow RATIONALE: Decreased right atrial pressure occurs because of the decrease in blood returning through the inferior vena cava after clamping of the umbilical cord and increased systemic blood pressure. Pressure in the left atrium, pulmonary blood flow, and Pao2 levels increase after birth. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Comprehension What is the normal white blood cell (WBC) count for a full-term neonate? 10,000 to 30,000/ml 30,000 to 50,000/ml 50,000 to 70,000/ml 70,000 to 90,000/ml RATIONALE: Normal values for WBCs in a full-term neonate are 10,000 to 30,000/ml. Higher values would indicate infection. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Knowledge When assessing a neonate, you note that one side of his body has a deep pink color and the other side appears pale. This condition is known as: jaundice. stork bites. harlequin sign. erythema toxicum. RATIONALE: The harlequin sign results from immature circulation in which blood pools on one side of the body close to the surface, causing redness. This sign doesn't necessarily indicate a problem. Jaundice is a yellow discoloration of the skin that results from the breakdown of red blood cells during the conversion to adult hemoglobin. Stork bites are small birthmarks that appear around the neck area. Erythema toxicum consists of small lesions; it's commonly referred to as the newborn rash. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis
You're assessing a neonate who has blackish blue marks around his buttocks. What are these marks called? Milia Vernix caseosa Mongolian spots Nevus flammeus RATIONALE: Mongolian spots typically appear on or near the buttocks and resemble bruises. They're especially common in Asian and Black neonates. Milia are small white spots on the face that are caused by unopened sebaceous glands. They usually disappear in the first few weeks of life. Vernix caseosa is a white, cheeselike substance that covers a neonate at birth. Nevus flammeus (port wine stain) is a capillary angioma located directly below the epidermis that appears as a reddened area on the skin. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis A neonate's ability to focus and follow indicates: well-developed neonatal reflexes. neuromuscular control. precocious social adaptation. neurologic integrity. RATIONALE: Focusing and following are signs of neurologic integrity. Neonatal reflexes include swallowing, sucking, and grasping. The ability to focus and follow isn't related to precocious social adaptation. Although neuromuscular control is one aspect of ability to focus and follow, neurologic integrity is the more precise answer. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Comprehension Vitamin K is administered to all neonates immediately after birth because: their fetal blood cells are prone to coagulation problems. their immature livers predispose them to low vitamin K levels. they lack intestinal organisms to synthesize vitamin K. they all experience avitaminosis. RATIONALE: Neonates have sterile GI tracts at birth and, therefore, are incapable of synthesizing vitamin K until about 8 days after birth. At 8 days, the intestinal tract becomes colonized with organisms. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Comprehension A new mother asks you why her neonate is voiding so often. Your best reply is that the: kidneys of the neonate can't concentrate urine well. intestines of a neonate aren't yet absorbing fluid. fluid retained during fetal life is being excreted. neonate's fluid intake is too great for his age. RATIONALE: The neonate's kidneys are immature at birth and, therefore, unable to properly concentrate urine. This causes the neonate to void frequently. A neonate's intestines don't regulate the amount of fluid excreted. Fluid isn't retained during fetal life; it's excreted after the kidneys form. Frequent voiding in neonates isn't a sign of excess fluid intake. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis
Which characteristic best describes a breast-fed neonate's stools, as compared with a formula-fed neonate's stools? Soft and seedy Dry Light yellow in color Less frequent RATIONALE: A breast-fed infant passes soft, seedy stools that have a sweet-and-sour odor and are mustard yellow. Breast milk is easier to digest than formula, so a breast-fed neonate also has more frequent stools. A formula-fed neonate has less frequent, dry, light yellow stools. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis The best protection against infection for a neonate during hospitalization is provided by: a daily bath with soap. gowns and masks worn by all staff members. hand washing by staff and parents. limitation of visitors to the maternity unit. RATIONALE: Thorough hand washing by everyone who handles the neonate is the best protection against infection. A daily bath won't prevent infection. It isn't necessary for all staff to wear gowns and masks. Limiting visitors isn't necessary because neonates have a natural immunity to some organisms. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Analysis Which statement is accurate regarding neonatal respirations? The neonate should grunt on expiration. The neonate has minimal amounts of surfactant at term. The neonate's respirations are commonly irregular. The neonate's respiratory rate is less than 28 breaths/minute. RATIONALE: A neonate has irregular respirations that range from 30 to 60 breaths/minute. A neonate may seem to hold his breath from time to time, but several rapid breaths in succession follow these occurrences. Grunting is a common sign of respiratory distress. A neonate has adequate amounts of surfactant in his lungs to promote the opening of alveoli. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Comprehension At 1 minute after birth, you assess a neonate as follows: heart rate, 150 beats/minute; respiratory rate, 48 breaths/minute with a vigorous cry; active flexing and extending of all extremities; Moro's, suck, and grasp reflexes present; and color pale with acrocyanosis of all extremities. Based on these findings, the neonate's 1-minute Apgar score is: 7. 8. 9. 10. RATIONALE: Apgar scores are calculated at 1 minute and 5 minutes after birth. A value of 0 or 2 points is given for each of the parameters of heart rate, respiratory rate, muscle tone, reflex irritability, and color. In this case, the neonate receives 2 points for heart rate, 2 points for respiratory rate, 2 points for muscle tone, 2 points for reflex irritability, and no points for color, resulting in a score of 8. NURSING PROCESS STEP:
Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application The complement of blood vessels in the umbilical cord includes: two arteries and two veins. one artery and one vein. one artery, two veins, and one capillary vessel. two arteries and one vein. RATIONALE: The umbilical cord contains two arteries and one vein. Two arteries carry blood from the fetus to the placenta, and one vein returns blood to the fetus. The presence of only one artery may indicate congenital malformation. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Knowledge The first temperature of a neonate is sometimes taken rectally rather than axillary to assess for: hyperthermia. Moro's reflex. imperforate anus. Babinski's reflex. RATIONALE: Temperature can be assessed using the rectal or axillary method. The rectal method may be chosen because insertion of a rectal thermometer confirms rectal patency. In the past, this was common practice; however, currently, passage of meconium is considered sufficient evidence of patency. Reflex assessments aren't associated with temperature assessment. Hyperthermia, not hypothermia, is common after delivery. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application Which of the following reactions occurs after clamping of the umbilical cord? Systemic resistance increases. Pulmonary vascular resistance increases. The foramen ovale opens. The ductus arteriosus opens. RATIONALE: With the removal of the placental vasculature, neonatal circulation is restricted to the neonate. This increases systemic vascular resistance, causing the ductus arteriosus to close. Resulting decreased pulmonary vascular resistance causes the foramen ovale to close. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis What information should the nurse include when teaching post circumcision care to parents of a neonate prior to discharge from the hospital? Select all that apply: The infant must void before being discharged home. Petroleum jelly should be applied to the glans of the penis with each diaper change. The infant can take tub baths while the circumcision heals. Any blood noted on the front of the diaper should be reported. The circumcision will require care for 2 to 4 days after discharge. RATIONALE: It's necessary for the infant to void prior to discharge to ensure that the urethra isn't obstructed. A lubricating ointment is appropriate and is applied with each diaper change. Typically, the penis heals within 2 to 4
days, and circumcision care is needed for that period only. To prevent infection, avoid giving the infant tub baths until the circumcision is healed; sponge baths are appropriate. A small amount of bleeding is expected following a circumcision; parents should report only a large amount of bleeding. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: Application A nurse is eliciting reflexes in a neonate during a physical examination. Identify the area the nurse would touch to elicit a plantar grasp reflex. RATIONALE: To elicit a plantar grasp reflex, the nurse should touch the sole of the foot near the base of the digits, causing flexion or grasping. This reflex disappears around age 9 months. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application At 5 minutes of age, a neonate is pink with acrocyanosis, has his knees flexed and fists clinched, has a whimpering cry, has a heart rate of 128, and withdraws his foot when slapped on the sole. What 5-minute Apgar score would the nurse record for this neonate? 8 RATIONALE: Apgar consists of a 0 to 2 point scoring system for a neonate immediately following birth and at 5 minutes of age. The nurse evaluates the neonate for heart rate, respiratory effort, muscle tone, reflex irritability, and color. This neonate has a heart rate above 100, which equals 2; pink color with acrocyanosis, which equals 1; is well-flexed, which equals 2; has a weak cry, which equals 1; and has a good response to slapping the soles of the feet, which equals 2. Therefore, the nurse should record a total Apgar score of 8. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis The presence of respiratory distress in a full-term neonate is best determined: at delivery. 3 to 4 hours after delivery. 6 to 8 hours after delivery. 10 to 12 hours after delivery. RATIONALE: Most full-term neonates with respiratory distress show characteristic signs of rapid respirations, grunting, and flaring of the nares within 3 to 4 hours of delivery. If the neonate is preterm, symptoms may be noticeable before 3 to 4 hours after delivery. If respiratory distress occurs more than 12 hours after birth, the origin is usually pneumonia, sepsis, or hypoglycemia. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Application Which of the following findings is characteristic of a neonate whose mother is addicted to crack cocaine? Gaze aversion Absent Moro's reflex Cardiac arrhythmias Unstable core temperature RATIONALE: The neonate of a mother addicted to crack cocaine shows gaze aversion (he turns his head away when you pick him up and look into his face). He doesn't have cardiac arrhythmias, an unstable core temperature, or an absent Moro's reflex. He's hyperactive and difficult to soothe. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Comprehension
At age 6 days, a preterm neonate has developed abdominal distention, vomiting, and bloody stools. Which of the following disorders should you suspect? Pneumothorax Neonatal sepsis Diaphragmatic hernia Necrotizing enterocolitis RATIONALE: Abdominal distention, vomiting, and bloody stools indicate necrotizing enterocolitis, a condition characterized by intestinal necrosis and accompanied by sepsis in one-third of cases. Necrotizing enterocolitis occurs most commonly in premature neonates. A neonate with a pneumothorax has diminished breath sounds, barrel chest, tachypnea, and a low oxygen saturation level. A neonate with sepsis is lethargic with an increased heart rate but not always an increased temperature. A neonate with a diaphragmatic hernia has compromised respiratory effort because the intestinal contents slip through the diaphragm into the chest cavity, compressing lung tissue. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Analysis Patent ductus arteriosus in a neonate exists when there's a shunt: between the right and left atria of the heart. between the superior vena cava and the aortic arch. in the heart between the aorta and the pulmonary artery. between the umbilical vein from the liver and the inferior vena cava. RATIONALE: Patent ductus arteriosus is an opening in the heart between the aorta and the pulmonary artery. This opening causes blood from the aorta (oxygenated blood) to combine with blood from the pulmonary artery (deoxygenated blood). If the patent ductus arteriosus is large, the neonate may incur heart failure and respiratory distress. An opening between the right and left atria of the heart is known as patent foramen ovale. There shouldn't be any shunts between the superior vena cava and the aortic arch. The shunt between the liver and the inferior vena cava is called the ductus venosus. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Comprehension Which of the following complications isn't related to the presence of maternal diabetes mellitus? Macrosomia Birth trauma Breech presentation Congenital anomalies RATIONALE: Fetal position is unrelated to the presence of maternal diabetes. Congenital anomalies, macrosomia, and birth trauma are all associated with maternal diabetes mellitus. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Analysis A neonate has been diagnosed with phenylketonuria (PKU). When teaching the mother about this disease, you should include which of the following information? Diet restrictions should be started within the first 2 to 3 weeks of life. Regular formula or breast milk can be used with no ill effects on the neonate. When the child starts to eat solid food, a diet low in phenylalanine should be provided. A diet low in phenylalanine includes milk, milk products, meat, fish, and other high-protein foods. RATIONALE: PKU results from an enzyme deficiency that decreases the body's ability to metabolize phenylalanine. Severe mental retardation can result from this disorder if a diet low in phenylalanine isn't provided
from age 2 to 3 weeks. By age 8 months, irreversible mental retardation occurs, so treatment must be started long before solid foods are introduced into the diet. Foods high in phenylalanine include milk, milk products, meat, fish, and other high-protein foods. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Application A 25-year-old woman gave birth to a neonate with a cleft lip. Which of the following information should you give the mother? Cleft lip primarily affects appearance. Chronic ear infections can result from cleft lip. Speech defects are common in children with cleft lip. Orthodontia may be needed to correct the angle of the teeth. RATIONALE: Cleft lip is a congenital fissure, or split, of the lip. When occurring by itself, it's primarily a defect in appearance. Cleft palate is a fissure of the roof of the mouth or palate. Cleft palate can result in speech defects, chronic ear infections, and the need for orthodontia. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application A neonate has been born with a neural tube defect. The diagnosis is spina bifida occulta. In this condition: the spinal cord and cauda equina are encased in a protective sheath of bone and meninges. a saclike cyst of meninges filled with spinal fluid is protruding through a defect in the bony spine. a saclike cyst of meninges, spinal fluid, and a part of the spinal cord is protruding through a defect in the vertebral column. fusion failure of the posterior vertebral arches has occurred without accompanying herniation of the spinal cord or meninges. RATIONALE: Spina bifida occulta is the failure of the posterior vertebral arches to fuse, without the presence of a meningocele or myelomeningocele. Normal development of the spinal structures includes encasement of the spinal cord and cauda equina in a protective sheath of bone and meninges. A saclike cyst of meninges filled with spinal fluid protruding through a defect in the bony spine is called a meningocele. When a meningocele includes a portion of the spinal cord, it's called a myelomeningocele. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Analysis On the postpartum unit, a new mother expresses concern about her family's history of cystic fibrosis. You instruct the client to observe her neonate for which of the following signs and symptoms? Joint pain and anemia Progressive weakening of the muscles Steatorrhea, poor weight gain, and salty perspiration Difficulty swallowing, chronic ear infections, and speech defects RATIONALE: Symptoms of cystic fibrosis include steatorrhea (fatty stools), poor weight gain due to malabsorption syndrome, salty perspiration due to an increased electrolyte concentration in the sweat, and repeated episodes of bronchitis. Sickle cell anemia may cause joint pain and anemia. Muscular dystrophy results in progressive weakening of the muscles. Difficulty swallowing, chronic ear infections, and speech defects are seen in clients with cleft palates. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Application
You're assessing a neonate who has a persistent low body temperature. You should evaluate the neonate for which of the following conditions? Infection Thyroid disorder Ocular hemorrhage Developmental delay RATIONALE: A neonate with an infection can't maintain thermoregulation. An inability to maintain temperature may be the first sign of infection. However, unlike an adult's temperature, an infant's temperature doesn't always increase with infection; therefore, the infant may have a low body temperature. Infants with infection may also eat poorly and seem lethargic. Ocular hemorrhage, thyroid disorder, and developmental delay aren't related to temperature stability. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Comprehension You suspect that a neonate has a fractured clavicle. What sign may indicate a fractured clavicle? Bruising near the fracture site Denting of skin at the break site Reddened area around the break site Asymmetrical body response to Moro's reflex RATIONALE: In Moro's reflex, when the neonate is lifted above the crib and suddenly lowered, the arms and legs symmetrically extend and then abduct while the fingers spread to form a "C." Asymmetry of Moro's reflex is common in neonates with fractured clavicles because pain results when the arms are moved. A neonate may also wince or pull away if the clavicle is touched, and the examiner may feel crepitus at the break site. The affected arm usually hangs limply at the neonate's side, rather than being pulled close. Reddening, denting of the skin, and bruising aren't common findings with a fractured clavicle. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Comprehension Unequal length of the legs in a neonate is most indicative of: talipes deformity. dislocated hips. calcium deficiency. physical abuse of the mother during pregnancy. RATIONALE: Dislocated hips are commonly manifested by one leg being shorter than the other. Physical abuse of the mother during pregnancy may cause dislocation of the hips, but unequal length of the legs doesn't conclusively point to physical abuse. Talipes deformity is a condition that affects the feet. Calcium deficiency doesn't cause hip dislocation. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Analysis You're assessing a neonate with trisomy 21 (Down syndrome). You should closely observe for signs of what commonly associated anomaly? Congenital renal agenesis Cleft palate Rocker-bottom feet Congenital heart defect
RATIONALE: Congenital heart defects occur in 40% of neonates born with trisomy 21. Congenital renal agenesis, cleft palate, and rocker-bottom feet aren't associated with trisomy 21. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis Which maternal factor is most commonly the cause of a neonate being small for gestational age? Diabetes Excessive weight gain Exercise Smoking RATIONALE: Smoking causes vasoconstriction, and pregnant clients who smoke are most likely to deliver smallfor-gestational-age neonates. Diabetes mellitus contributes to the development of large-for-gestational-age neonates, not small-for-gestational-age neonates. Excessive weight gain and exercise don't cause small-for-gestational-age neonates. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis You're caring for a 28-week preterm infant. You carefully monitor the infant's oxygen levels to prevent which complication of oxygen therapy? Pulmonary hypertension Respiratory distress syndrome Retinopathy of prematurity Patent ductus arteriosus RATIONALE: Excessive oxygen administered to the preterm infant can cause retinal detachment and blindness (known as retinopathy of prematurity). Oxygen therapy doesn't cause pulmonary hypertension, respiratory distress syndrome, or patent ductus arteriosus. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Application The physician has ordered indomethacin (Indocin) to be administered to a preterm neonate with patent ductus arteriosus. You explain to the parents that this drug is used to: slow the heart rate. maintain peripheral oxygenation. close the ductus. increase cardiac output. RATIONALE: Patent ductus arteriosus is persistence of the opening between the pulmonary artery and the aorta. Indomethacin is a prostaglandin inhibitor that's commonly prescribed for preterm neonates to close a patent ductus. This drug doesn't slow the neonate's heart rate, maintain oxygenation, or increase cardiac output. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Application You observe that the neonate of a mother with diabetes is jittery 6 hours after delivery. Which nursing action should you carry out first? Offer the neonate formula. Feed the neonate glucose water. Take the neonate out to nurse. Check the neonate's blood glucose level.
RATIONALE: You should check the neonate's serum glucose level before trying other interventions. If the level indicates that the neonate is hypoglycemic, you may need to follow up by feeding the neonate formula, glucose water, or breast milk. You should also observe for additional signs and symptoms of hypoglycemia, including poor muscle tone, sweating, tachypnea, dyspnea, and cyanosis. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Application When is the appearance of neonatal jaundice of greatest concern? When the mother breast-feeds exclusively If the neonate refuses to take water from a bottle In the first 24 hours of life When a family history of neonatal jaundice exists RATIONALE: Neonatal jaundice in the first 24 hours of life indicates a pathologic event. Neonates may develop "breast-milk jaundice" that extends beyond the first week of life, but this isn't a troublesome concern. It isn't essential for the neonate to take water from a bottle. A family history of neonatal jaundice isn't a concern unless the mother is Rh negative. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Comprehension You're caring for a 30-week-gestation preterm neonate who weighed 1,021 g (2 lb, 4 oz) at birth. The neonate is receiving nasogastric tube feedings. You monitor the neonate for early symptoms of necrotizing enterocolitis, which include: decreased respiratory rate. increased residual stomach contents. decreased abdominal girth. increased or hyperactive bowel sounds. RATIONALE: Early symptoms of necrotizing enterocolitis include increased residuals during feedings, increased abdominal girth, decreased or absent bowel sounds, and bloody mucus discharge from the intestinal tract. A decreased respiratory rate doesn't indicate necrotizing enterocolitis. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Analysis A preterm neonate at 35 weeks' gestation is admitted to the neonatal intensive care unit. You observe that the neonate has frequent periods of apnea and you notify the neonatologist. You anticipate that the neonatologist will order which of the following medications? Theophylline (Slo-Phyllin) Surfactant (Survanta) Vancomycin (Vancocin) Indomethacin (Indocin) RATIONALE: Theophylline is a respiratory stimulant that has been used successfully to treat apnea. Surfactant is useful in treating respiratory distress syndrome in preterm neonates. Vancomycin is an antibiotic and isn't useful for stimulating respirations. Indomethacin is used to treat patent ductus arteriosus. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Analysis When assessing a neonate, you note a high red blood cell (RBC) count (polycythemia). Which of the following explanations probably accounts for this finding?
The neonate is in the early stages of leukemia. The neonate is hyperglycemic. The neonate was chronically hypoxic before birth. The neonate is large for gestational age. RATIONALE: As a defense for the absence of an adequate oxygen supply, the body speeds up production of RBCs to enhance the transportation of available oxygen to cells. Although hypoxia is sometimes found in large-forgestational-age neonates, it's more common in small-for-gestational-age neonates. Infants with polycythemia are generally hypoglycemic after delivery. There's no reason to suspect leukemia. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Comprehension The care plan for a neonate with fetal alcohol syndrome should include: increased sensory stimulation to promote cerebral function. maintenance of a quiet, dimly lit environment. assessment of the mother's readiness to care for the infant and, if necessary, restrictions on contact with the infant. fluid restrictions. RATIONALE: Decreasing sensory stimulation by maintaining a quiet, dimly lit environment may reduce irritability and seizure risks in neonates with fetal alcohol syndrome. Maternal bonding should be facilitated to reduce inherent psychological risks. Fluids should be promoted because the infant may be a poor feeder. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application Successful family adaptation to an infant with health problems typically follows which predictable pattern? Anger, abandonment, reconciliation Denial, acceptance, chronic depression Blaming, bargaining, denial, disillusionment, resignation Shock, denial, depression, acceptance, reorganization RATIONALE: In successful adaptation, the family structure is ultimately reorganized to meet the needs of the infant. Family relationships change as a result. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: Coping and adaptation COGNITIVE LEVEL: Analysis You're assessing the neonate of a mother with diabetes. The neonate has a serum glucose level of 60 mg/dl. What other laboratory data do you anticipate the physician to order? Serum chloride Complete blood count Serum magnesium Serum calcium RATIONALE: A neonate born to a mother with diabetes is at risk for calcium imbalance because he may have an immature parathyroid gland. Apnea, seizures, irritability, and nervousness are common symptoms of both hypocalcemia and hypoglycemia. You should anticipate that the physician would order a calcium level measurement because the neonate's serum glucose level is within the normal range. Neonates with asphyxia, sepsis, or respiratory distress syndrome and preterm neonates are also at risk for calcium imbalance. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: Analysis
A neonate is suspected of having a tracheoesophageal fistula. Priority nursing care until the diagnosis is confirmed includes: monitoring the neonate carefully during and after feedings. elevating the neonate's head after feedings. feeding only glucose. feeding nothing by mouth. RATIONALE: Because of the connection between the esophagus and the trachea, a neonate with tracheoesophageal fistula is at risk for aspiration of stomach contents and its complications. Therefore, the neonate should be fed nothing by mouth. Signs and symptoms of tracheoesophageal fistula include excessive oral secretions; progressive respiratory distress (due to excessive secretions); choking, coughing, and cyanosis after fluid intake by mouth; regurgitation after the first feeding; and abdominal distention soon after birth. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Comprehension A preterm neonate develops bradycardia, apnea, and blood-tinged oral secretions. You should further assess the neonate for: bronchopulmonary dysplasia. pulmonary hemorrhage. necrotizing enterocolitis. respiratory distress syndrome. RATIONALE: Suspect pulmonary hemorrhage in a preterm neonate who develops bradycardia, apnea, and bloodtinged oral secretions. Bronchopulmonary dysplasia is a complication of mechanical ventilation in which the neonate requires more oxygen. Necrotizing enterocolitis causes increased abdominal girth, decreased or absent bowel sounds, vomiting, and visible loops of bowel in the abdominal wall. Respiratory distress syndrome produces subtle signs, such as low body temperature, nasal flaring, tachypnea, and sternal and subcostal retractions. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Analysis The nurse is doing a neurologic assessment on a 1-day-old neonate in the nursery. Which of the following findings would indicate possible asphyxia in utero? Select all that apply: The neonate grasps the nurse's finger when she puts it in the palm of his hand. The neonate does stepping movements when held upright with sole of foot touching a surface. The neonate's toes don't curl downward when soles of feet are stroked. The neonate doesn't respond when the nurse claps her hands above him. The neonate turns toward the nurse's finger when she touches his cheek. The neonate displays weak, ineffective sucking. RATIONALE: If the neonate's toes don't curl downward when the soles of his feet are stroked and he doesn't respond to a loud sound, it may be evidence that neurologic damage from asphyxia has occurred. A normal neurologic response would be the toes curling downward with stroking and extending arms and legs with a loud noise. Weak, ineffective sucking is another sign of neurologic damage. A neonate should grasp a person's finger when it's placed in the palm of his hand, do stepping movements when held upright with the sole of foot touching a surface, and turn toward the nurse's finger when she touches his cheek. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application A nurse is conducting a physical examination on a neonate. At which pulse point on an infant would the absence of a palpable pulse indicate a possible coarctation of the aorta? Femoral
RATIONALE: With coarctation of the aorta, the nurse should note bounding pulses and increased blood pressure in the upper extremities, as well as decreased or absent pulses and lower blood pressure in the lower extremities. This is due to the narrowing of the aortic arch. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application The period of immediate recovery after the birth of a neonate during which homeostasis is reestablished is called: attitude. power of labor. third stage of labor. fourth stage of labor. RATIONALE: The fourth stage of labor lasts about 2 hours after the birth of the placenta, when homeostasis is reestablished. It's also a time to observe for complications. Attitude is the relation of fetal body parts to one another. Power of labor refers to uterine contractions. The third stage of labor lasts from delivery of the fetus to delivery of the placenta. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis Which of the following findings is normal 24 hours after a circumcision has been performed? Foul odor Excessive bleeding Retractable foreskin Yellow exudate over penis glans RATIONALE: Yellow exudate from the penis after circumcision is a normal part of the healing process. It may last for 2 to 3 days. A foul odor may indicate infection. Excessive bleeding is a sign of hemorrhage and requires immediate attention. The foreskin is removed when circumcision is performed. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis To relieve discomfort from breast engorgement, it isn't uncommon for a breast-feeding mother to: take aspirin. express milk by hand. give the infant formula at night. decrease the infant's feeding frequency. RATIONALE: Breast engorgement is relieved by manually expressing the milk. It's performed using the thumb and forefinger just outside the areola, squeezing together and downward. Certain over-the-counter medications, such as aspirin, are contraindicated in breast-feeding mothers. Decreasing feedings by giving the infant formula at night or decreasing feeding frequency increases breast engorgement. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application Which of the following statements about breast-feeding is correct? Breast-fed babies are more likely to be overfed. Breast milk is nutritionally superior to an alternative. Breast-feeding interferes with good jaw development. Breast-feeding can be more expensive than formula feeding.
RATIONALE: Breast milk can't be matched in nutritional value by formula. It's easily digested, is unlikely to be contraindicated, has immunologic properties, and doesn't cause allergic reactions. Breast-fed babies are less likely to be overfed. Breast-feeding promotes good jaw development and generally costs less than formula feeding. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Comprehension A client received morphine (Duramorph) spinal anesthesia for a cesarean birth. Which of the following interventions should you perform in the first 24 hours after surgery? Check reflexes every hour. Monitor respirations frequently. Determine pulse pressure every hour. Monitor body temperature every 2 hours. RATIONALE: After morphine spinal anesthesia, you should check pulse oximetry, respiratory rate, and blood pressure frequently. There's no reason to monitor body temperature or reflexes for this client. Pulse pressure isn't relevant in this situation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Application Which of the following hormones stimulates the uterus to contract in the postpartum period? Estrogen Oxytocin Prolactin Relaxin RATIONALE: Oxytocin, released from the posterior pituitary gland, stimulates the uterus to contract postpartum. It's also responsible for the release (let-down) of milk from the breasts. Prolactin, an anterior pituitary hormone, acts to promote growth of breast tissue and lactation. Relaxin is an ovarian hormone that promotes general relaxation of body tissues. Estrogen, the major hormone of pregnancy, is produced by the ovaries and placenta. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Knowledge Where should a client's uterine fundus be located 12 hours after delivery? At 2 cm below the umbilicus At 3 cm above the umbilicus To the right of the umbilicus At or slightly above the umbilicus RATIONALE: The uterus decreases in size (involution) at a predictable rate. In the first 24 hours after birth, it's located at or slightly above the umbilicus. It isn't likely to be 3 cm above the umbilicus 12 hours after delivery. If it has deviated to the right, the client's bladder is usually full and efforts should be made to promote emptying it. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Analysis A client who has just given birth would most likely be in which of Rubin's stages of maternal development? Taking in Letting go Taking hold
Role transition RATIONALE: In the early postpartum period, the mother is in the taking in phase. In this stage, the mother wants to be cared for by the staff rather than show independence. As she moves into the taking hold phase, she prefers to do more of her own care and is now interested in learning how to care for herself and her neonate. The letting go phase arrives when she's faced with reassessing and reformulating relationships with others in her life, usually at the time of discharge from the hospital. Role transition is experienced by an expectant mother a few weeks before birth as she tires of being pregnant and wants the birth experience to occur. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: Coping and adaptation COGNITIVE LEVEL: Comprehension Which of the following interventions may help a client who has just given birth avoid constipation in the postpartum period? Give a Fleet enema the day after delivery. Encourage her to rest rather than to ambulate. Give mineral oil or milk of magnesia at bedtime. Stress the need to include fruits and vegetables in her diet. RATIONALE: The client can best prevent constipation by eating a healthy diet, including fruits, vegetables, grains, and fluids. A Fleet enema may treat constipation after it occurs, but it doesn't prevent it. Walking promotes bowel activity. Laxatives are best avoided so the body doesn't rely on them for bowel function. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application You locate a new mother's uterus in the midline, but it's boggy. Which step should you take first? Gently massage the uterus until it feels firm. Put the neonate to the breast to facilitate involution. Obtain an order to add oxytocin (Pitocin) to the I.V. line. Massage the uterus vigorously to prevent hemorrhage. RATIONALE: If the uterus is boggy, gentle massage should be performed first because it usually results in rapid uterine contractions. Putting the neonate to the breast can be done next, resulting in the release of oxytocin and, eventually, uterine contractions. I.V. oxytocin can also help the uterus contract but usually isn't needed if the uterus is gently massaged. Vigorous massage of muscle tissue causes overstimulation, resulting in failure to contract. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application A 25-year-old woman undergoes a second cesarean delivery. When you assess her 2 hours postoperatively, you can expect to find which of the following conditions? The client tolerates clear liquids. Active bowel sounds can be heard. The client is ambulating with assistance. An indwelling urinary catheter is in place draining more than 30 ml/hour. RATIONALE: An indwelling urinary catheter is placed before the cesarean delivery and remains in place until 25 to 48 hours after the cesarean delivery. The client isn't usually allowed to have anything by mouth until at least 4 hours postoperatively. Bowel sounds are usually absent until 4 hours postoperatively, when hypoactive bowel sounds may be auscultated. Bed rest is generally maintained for the first 4 hours postoperatively. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Comprehension
You're writing a care plan for a 25-year-old client who has decided to breast-feed her neonate. Which of the following expected outcomes is appropriate? At day 4, the neonate has four wet diapers in 24 hours. The mother's breasts remain hard and heavy even after feedings. The neonate has bursts of at least 10 sucks with audible swallows. The mother doesn't have an increased lochia flow or uterine cramping during feedings. RATIONALE: A burst of 10 sucks with audible swallows through several bursts of sucking indicates proper positioning and latching on. Some of the signs of potential problems related to breast-feeding include lochia flow that doesn't increase, lack of uterine cramping during feeding, and breasts that remain hard and heavy even after feedings. The neonate should have at least six wet diapers in 24 hours by day 4. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis A breast-feeding mother should increase her daily caloric intake by how much above the intake recommended during pregnancy? No added calories 200 added calories 500 added calories 1,000 added calories RATIONALE: The recommendation for women during lactation is an additional 500 calories per day over the pregnancy recommendation (2,500 calories per day). Adding calories is necessary to provide adequate nutrition to the breast-feeding mother. A caloric intake greater than 500 calories over pregnancy values is unnecessary. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Knowledge How long after delivery does the fundus completely descend into the pelvis, making it no longer palpable through the abdomen? 10 days 2 weeks 4 weeks 6 weeks RATIONALE: By 10 days postpartum, the fundus should no longer be palpable through the abdomen. By 6 weeks, the uterus should be relatively close to its prepregnancy size. Infection, retained placental fragments, and other complications can interfere with the normal process of uterine involution. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Comprehension A client who has just given birth asks how long she should wait before becoming pregnant again. The nurse responds that the minimum length of time a woman should wait between pregnancies is: 6 weeks. 3 months. 6 months. 2 years. RATIONALE: The recommended wait time between pregnancies is 6 months. It's highly unlikely that a woman would become pregnant within 6 weeks of giving birth because many women haven't reestablished ovulation by that
time. Two years is considered the ideal time to wait before becoming pregnant again. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Comprehension Which of the following nursing interventions is appropriate for a new postpartum mother? Bathe the neonate in the nursery. Teach her to wipe from front to back. Assist her to change her perineal pad. Give her ice as soon as she arrives at the unit. RATIONALE: Giving the new mother ice provides immediate pain relief and greatly reduces swelling, ensuring a rapid recovery. Helping the mother change her perineal pad is generally unnecessary because most women prefer to do this themselves. Teaching the woman to wipe from front to back is helpful but won't significantly alter her immediate postpartum recovery. Bathing the neonate in the nursery is also helpful, but most mothers prefer to have the neonate bathe in their rooms. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application Which of the following postpartum findings would indicate infection during the first 24 hours after delivery? Leg cramps Tender abdomen Temperature of 100.4% F (38% C) Reddened area on the breast RATIONALE: A reddened area on the breast is a sign of infection. A temperature of 100.4% F, resulting from dehydration and exertion during the labor process, is considered normal in the first 24 hours. A tender abdomen may result from the birth process; however, it doesn't always indicate infection. Leg cramps may result from muscle strain, being positioned in one place for too long, or electrolyte imbalance--not infection. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Analysis The nurse is assessing a postpartum client during the first 24 hours after a cesarean delivery. She should expect to find: large clots. absence of vaginal bleeding. lighter lochia flow than after a vaginal birth. heavier lochia flow than after a vaginal birth. RATIONALE: During a cesarean delivery, the placenta is removed manually and the uterus is cleaned out, so lochia flow is lighter than it would be after a vaginal delivery. There wouldn't be large clots, but there would be some vaginal drainage. Cesarean delivery is a risk factor for postpartum hemorrhage. If large clots or a large amount of vaginal bleeding is present, the nurse should suspect uterine atony. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Comprehension A client who has just had a cesarean birth client tells you that she "feels like a failure" because she couldn't deliver vaginally. What is the most appropriate nursing diagnosis for this client? Disturbed sleep pattern Ineffective sexuality pattern
Ineffective role performance Situational low self-esteem RATIONALE: Many clients who intend to deliver vaginally but are forced to undergo cesarean birth experience situational low self-esteem. If these feelings aren't resolved, the client may also experience a disturbed sleep pattern, an alteration in sexuality, and an alteration in role performance. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: Coping and adaptation COGNITIVE LEVEL: Application Early breast-feeding promotes release of which of the following hormones responsible for milk production? Oxytocin Prolactin Estrogen Progesterone RATIONALE: Prolactin, which is released from the anterior pituitary gland in response to neonatal sucking, is responsible for milk production. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Knowledge The nurse is caring for a 1-day postpartum mother who's very talkative but isn't confident in her decision-making skills. The nurse is aware that this is a normal phase for the mother. What is this phase called? Taking-in RATIONALE: The taking-in phase is a normal first phase for a mother when she's feeling overwhelmed by the responsibilities of newborn care, while still fatigued from delivery. Taking hold is the next phase, when the mother has rested and she can think and learn mothering skills with confidence. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: Psychosocial adaptation COGNITIVE LEVEL: Analysis The nurse observes several interactions between a mother and her neonate son. Which of the following behaviors of the mother would the nurse identify as evidence of mother-infant attachment? Select all that apply: Talks and coos to her son. Cuddles her son close to her. Doesn't make eye contact with her son. Requests that the nurse take the baby to the nursery for feedings. Encourages the father to hold the baby. Takes a nap when the baby is sleeping. RATIONALE: Talking, cooing, and cuddling with her son are positive signs that the mother is adapting to her new role as mother. Avoiding eye contact is a nonbonding behavior. Eye contact, touching, and speaking help establish attachment with a neonate. Feeding a neonate is an important role of a new mother and facilitates attachment. Encouraging the father to hold the neonate will facilitate attachment between the neonate and his father. Resting while the neonate is sleeping will conserve needed energy and allow the mother to be alert and awake when her infant is awake; however it isn't evidence of bonding. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: Psychosocial adaptation COGNITIVE LEVEL: Analysis The nurse is palpating the uterine fundus of a client who delivered a baby 8 hours ago. At what level in the abdomen would the nurse expect to feel the fundus? RATIONALE: The uterus should be felt at the level of the umbilicus from 1 hour after birth and for approximately the next 24 hours. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological
integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Comprehension On a client's first postpartum day, the nurse assesses the client's vaginal discharge as dark red and containing shreds of decidua and mucus. What term should the nurse use in her nurse's notes to describe the discharge? Lochia rubra RATIONALE: For the first 3 days after birth, a lochia discharge consists almost entirely of blood with only small particles of decidua and mucus. Because of its red color, it's called lochia rubra. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Knowledge A new mother has a temperature of 100.8% F (38.2 % C) 8 hours after giving birth. This is probably related to: dehydration after labor. a developing uterine infection. the beginning of the lactation cycle. a response to her epidural anesthesia. RATIONALE: In the early postpartum period, it's common for a new mother to have a slightly elevated body temperature as a result of dehydration that occurs during labor. When a uterine infection develops, the client's temperature is much higher and is uterine tenderness is also present. An increase in temperature isn't related to epidural anesthesia or the beginning of the lactation cycle because they aren't infectious processes. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Comprehension A new mother's episiotomy is edematous, red, and painful 8 hours after delivery. Which of the following interventions should you plan initially? Apply an ice bag to the perineum. Teach the client how to take a sitz bath. Call the physician for additional pain medication. Suggest a warm shower with water directed at the perineum. RATIONALE: In the early postpartum period, an episiotomy is typically uncomfortable and swollen. An ice bag applied to the area reduces edema and promotes comfort. Warmth in the form of a shower or a sitz bath are appropriate interventions after the first 24 hours, when edema has resolved. A strong pain medication isn't usually required, but a mild analgesic is typically useful to promote comfort. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application An 18-year-old client has given birth to a 2,948 g (6-lb 8-oz) boy. On postpartum day 1, she says to the nurse, "I wish I had a girl. Boys are so messy. Would you please take it back to the nursery." Which of the following responses would be appropriate? "Why do you think boys are messy? Did you have to care for your younger brothers?" "Boys are fun. Once you get used to him, you'll learn to love him." "Having a baby is a big responsibility. How are you coping with this now that the baby is here?" "Yes, I'll take him back to the nursery. You get some rest and let the nursery know if you want him back again later." RATIONALE: Generally, by 24 hours postpartum, mothers are ready to begin to take hold and assume more responsibility for the neonate. If a client is having difficulty with this, you should encourage her to talk about her feelings. Opening up lines of communication facilitates bonding with the neonate. Offering to take him back to the
nursery doesn't reinforce the importance of maternal bonding with the neonate. The first two responses don't provide the client with the opportunity to express her feelings. The focus needs to be on the client's feelings regarding the current situation. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: Coping and adaptation COGNITIVE LEVEL: Application Your postpartum client experienced periods of overwhelming sadness that resolved after a few days. What's this condition called? Postpartum blues Postpartum psychosis Postpartum depression Postpartum hallucinations RATIONALE: Postpartum blues--periods of overwhelming sadness--are a common occurrence for most women and are usually transient. Postpartum depression, psychosis, and hallucinations don't resolve on their own, and evaluation by a trained health care provider is necessary. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: Psychosocial adaptation COGNITIVE LEVEL: Analysis You're caring for a client who reports severe burning pain in one or both breasts during breast-feeding. The client should be evaluated for: mastitis. a plugged duct. candidal infection. overproduction of breast milk. RATIONALE: A characteristic symptom of a candidal infection is burning during let-down or breast-feeding. Mastitis most commonly manifests as a reddened area on the breast, followed by extreme malaise and flulike symptoms. A plugged duct usually appears as a hardened area on the breast; it may become mastitis if left untreated. Overproduction of milk would be characterized by fullness or engorgement and leaking. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Comprehension As part of a routine postpartum assessment, Homans' sign is checked to: determine whether the cervix has healed properly. assess pain in the calf, possibly indicating thrombosis. make sure the neonate's clavicle wasn't broken during delivery. make sure the vaginal muscles haven't stretched too extensively. RATIONALE: Homans' sign is calf pain on passive dorsiflexion of the foot. A positive Homans' sign may indicate thrombosis. However, redness and warmth in the calf should also be assessed because thrombophlebitis may be present with a negative Homans' sign. The extent of muscle tone in the vaginal muscles is usually assessed at the 6week checkup. The cervix is checked for healing during the visit in which a postpartum Papanicolaou test is performed. The neonate's clavicle is assessed as part of the neonate assessment. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Comprehension A woman who tested seronegative for a condition when pregnant was given a vaccine postpartum and told to delay her next pregnancy for 3 months. For which condition did she test seronegative? Chickenpox Hepatitis B
Rh factor Rubella RATIONALE: A woman who is seronegative for rubella would receive the vaccine during the postpartum period. Because rubella is self-limiting to mothers but can have devastating effects on developing fetuses, all women are vaccinated to prevent contracting the disease during pregnancy. A woman at risk for contracting hepatitis B would be offered the hepatitis B vaccine; however, it isn't necessary for all women. Rh factor isn't a vaccine. Rho(D) immune globulin (RhoGAM) would be given to an Rh-negative mother who has an Rh-positive fetus. Most pregnant women have already had chickenpox, but those who are seronegative could be offered the vaccine. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Analysis A client has suffered a pregnancy loss complicated by the presence of a hydatidiform mole. This client should avoid pregnancy for at least 1 year to allow for: psychological healing. replenishment of maternal iron stores. regrowth of healthy endometrial tissue. monitoring of human chorionic gonadotropin hormone (hCG) levels. RATIONALE: One complication of trophoblastic disease is choriocarcinoma, for which an elevated hCG level is a marker. Because pregnancy also increases hCG levels, the patient should avoid getting pregnant to make monitoring levels to detect cancer possible and accurate. Psychological healing and replenishment of maternal iron stores may occur over the next year, but this isn't the reason the woman is told to avoid pregnancy. Regrowth of healthy endometrial tissue is important but not as important as monitoring for cancer. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis Three weeks after delivery, a client is readmitted to the hospital with postpartum hemorrhage. What's the most likely cause of her hemorrhage? Long, induced labor Macrosomia of the neonate General anesthesia for delivery Retained placental fragments RATIONALE: Retained placental fragments are the major cause of late postpartum hemorrhage. Macrosomia, general anesthesia, and long, induced labor are associated with early hemorrhage. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis Which of the following physiological responses is typical for the early postpartum period? A feeling of urinary urgency and dysuria Rapid diuresis of 2,000 to 3,000 ml/day Decrease in blood pressure Increased motility of the GI system RATIONALE: In the early postpartum period, glomerular filtration rate increases and progesterone levels drop. Together these two events result in rapid, marked diuresis. The woman should not experience urinary urgency or dysuria, although she may be anxious and fear that voiding will be uncomfortable. Minimal change in blood pressure and a residual decrease in GI motility occur after birth. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Comprehension
Your client is human immunodeficiency virus (HIV) positive. Which of the following supplies will you need to conduct a postpartum assessment on this client? Gloves and a mask Gown and gloves Gloves, a gown, and a mask Gloves and a labeled trash container RATIONALE: To conduct a postpartum assessment on a woman who is HIV positive, you need only gloves and a labeled trash container. Standard precautions require that you protect yourself with gloves and a designated site for their disposal. A mask and gown are unnecessary to conduct this assessment. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Application Which of the following strategies is most important for preventing infections in the maternity department? Using hospital-supplied scrub clothing Frequent monitoring of the unit by the occupational health department Careful hand washing with soap, warm water, and friction Using only sterile supplies in providing care to mother and neonate RATIONALE: Careful hand washing with soap, warm water, and friction is the most important measure to prevent infection in the maternity department. Using hospital-supplied scrub clothing doesn't help to prevent infection. Although a healthy nursing staff is important, occupational health departments are responsible for monitoring specific parameters, such as tuberculin testing and providing vaccinations (such as hepatitis B). There's no evidence that using sterile supplies when caring for mother and neonate reduces the incidence of infection in the maternity department. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: Analysis When assessing a client who gave birth 2 hours earlier, you palpate an indefinite fundus two fingerbreadths above and to the right of the umbilicus. The client is bleeding heavily. You should: increase the I.V. flow rate or encourage oral fluid intake. encourage the client to ambulate. assist the client to urinate. take no action; these findings are normal. RATIONALE: A full bladder displaces the uterus, which can prevent it from contracting adequately, causing excessive bleeding. Increasing fluid intake at this point would increase the urine volume; however, it may become necessary to replace blood volume lost by vaginal bleeding. Ambulation is contraindicated until the bladder is emptied and bleeding has slowed. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Application Which behavior may indicate malattachment (poor bonding) between a mother and her neonate? En face positioning Antepartum decision to bottle-feed References to "it" or "that baby" Touching the baby with only the fingertips RATIONALE: Calling a neonate by name indicates attachment and pleasure with the sex and appearance of the infant. Avoiding references to the infant's sex and name could indicate malattachment. En face positioning in the
early postpartum period is characteristic of adequate bonding. Bottle-feeding isn't indicative of malattachment unless the decision to switch from breast to bottle was made for no apparent reason after delivery. Fingertip touching is typically the first way that a mother explores her infant. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: Coping and adaptation COGNITIVE LEVEL: Analysis A client who delivers a premature neonate wants to begin breast-feeding as soon as possible. You encourage her to: begin suppressing lactation because small neonates expend too many calories trying to suck. consider bottle-feeding because after discharge the neonate may have difficulty adapting to breast-feeding. follow through with her plans but be prepared to pump her milk into bottles if necessary. defer breast-feeding plans until after the neonate is discharged. RATIONALE: In addition to the physiological benefits of breast milk for preterm neonates, the psychological advantages include promotion of bonding. Mothers who want to breast-feed should be given the opportunity do so and assisted in pumping their milk if the neonate can't suckle immediately. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application Four days postpartum, a client asks if her vaginal discharge is normal. What type of lochia is typical at this time? Rubra Serosa Alba None RATIONALE: On the 4th to 10th postpartum days, the client should have lochia serosa. The flow pales and becomes pink or brown. Lochia alba, which is yellow or white, begins on the 10th day and usually lasts until the 14th day; however, it can last several weeks. Lochia rubra lasts for the first 3 days after delivery. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis A multipara just delivered twins. You're aware that this client is at risk for early postpartum hemorrhage because of: a long induced labor. macrosomia of the neonates. uterine atony. retained placental fragments. RATIONALE: Uterine atony caused by an overstretched uterus increases the risk that a multipara who has delivered twins will experience early postpartum hemorrhage. A long labor can put a client at risk for uterine atony, but multiparas usually have short labors. Twin fetuses are unlikely to have macrosomia (abnormally large size). Retained placental fragments are more likely to cause late hemorrhage. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Comprehension You check a postpartum client frequently for bleeding after delivery. What's considered excessive bleeding? One peripad soaked through in 15 minutes or less One peripad soaked through in 30 minutes or less One peripad soaked through per hour One peripad soaked through in 2 hours
RATIONALE: If one peripad is soaked through in 15 minutes or less, the client's bleeding is considered excessive. Note, however, that lochia amount varies from woman to woman. Women who breast-feed tend to have less lochia discharge than those who don't because the natural release of oxytocin during breast-feeding strengthens uterine contractions. Lochial flow increases on exertion, especially the first few times the woman gets out of bed. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Comprehension A client is in the intensive care unit after a delivery complicated by pregnancy-induced hypertension and magnesium toxicity. The client received magnesium sulfate therapy followed by an I.V. bolus of calcium gluconate to treat hypermagnesemia. You should be alert for which adverse reaction to calcium gluconate? Hypertension Arrhythmias Pulmonary edema Tachycardia RATIONALE: You should monitor the client for cardiac arrhythmias caused by calcium gluconate. Hypotension and bradycardia, rather than hypertension and tachycardia, are other adverse reactions. Pulmonary edema is uncommon. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Analysis About 8% of all births are complicated by postpartum hemorrhage. The most common cause of postpartum hemorrhage is uterine atony. Risk factors for uterine atony include: low parity. oligohydramnios. use of anesthesia or analgesia. small-for-gestational-age fetus. RATIONALE: Anesthesia and analgesia generally result in relaxation of muscle, including the uterine muscle, and overdistention of the uterus may result in uterine atony. Multiparity, polyhydramnios, and a large fetus can also result in overstretching of the uterus. Low parity, oligohydramnios, and small-for-gestational-age fetuses don't cause uterine atony. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Analysis A 22-year-old client experienced a precipitous labor and birth, resulting in a perineal laceration that extended through the perineal body. This laceration would be classified as a: first-degree laceration. second-degree laceration. third-degree laceration. fourth-degree laceration. RATIONALE: A second-degree laceration extends through the muscles of the perineal body. A first-degree laceration extends through the skin and structures superficial to the muscles. A third-degree laceration continues through the anal sphincter. A fourth-degree laceration involves the anterior rectal wall. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Comprehension A couple is grieving over the death of their infant who was born with multiple congenital anomalies. Which is an appropriate response from the nurse?
"Things happened for the best. Try to think of the positives." "I know this is a difficult time. How are you doing with all of this?" "You have an angel in heaven. You're young. You can have another child." "It would have been hard to have cared for a child with all those defects." RATIONALE: The parents need someone willing to listen and offer support, care, and understanding. Cliches such as those expressed in the other options don't foster therapeutic communication and should be avoided. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: Coping and adaptation COGNITIVE LEVEL: Application A client who had a cesarean delivery because of a breech presentation asks you, "Will I be able to have a normal delivery the next time?" Your best response is: "There's a chance you can have a vaginal delivery." "After you've had a cesarean delivery, you can't have a vaginal delivery." "Vaginal delivery would be extremely dangerous for you." "You shouldn't have any problems having a vaginal delivery." RATIONALE: Many women who have had a cesarean delivery can deliver vaginally after a trial of labor, especially if the mother had a low transverse incision. However, facilities for a cesarean delivery should be available throughout labor. The procedure isn't without risk, so you shouldn't tell the client not to anticipate any problems. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: Coping and adaptation COGNITIVE LEVEL: Application A 21-year-old primigravida has an emergency cesarean delivery under general anesthesia because of unanticipated fetal distress. One postoperative intervention is to help her to turn every 2 hours. Which condition is this intervention intended to prevent? Pressure ulcers Muscle stiffness Respiratory complications Venous stasis RATIONALE: General anesthesia and postoperative pain may lead to immobility, which predisposes a postoperative client to respiratory complications. Changing positions, along with coughing and deep breathing, can help prevent these complications. It's unlikely that an otherwise healthy young woman would develop pressure ulcers during a brief postoperative period. Muscle stiffness would be decreased with frequent turning, but this isn't the most important reason for turning. Turning may also decrease venous stasis, but leg exercises are more effective for decreasing venous stasis in the early postoperative period. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Comprehension In the fourth stage of labor, a full bladder increases the risk of what postpartum complication? Hemorrhage RATIONALE: A full bladder prevents the uterus from contracting completely, increasing the risk of hemorrhage. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Knowledge The nurse is caring for a postpartum mother suspected of developing postpartum psychosis. Which of the following statements accurately characterize this disorder? Select all that apply:
Symptoms start 2 days after delivery. The disorder is common in postpartum women. Symptoms include delusions and hallucinations. Suicide and infanticide are uncommon in this disorder. The disorder rarely occurs without psychiatric history. RATIONALE: A postpartum woman should be suspected of psychosis if she exhibits manic-depressive behaviors (delusions or hallucinations), generally starting within 4 weeks postpartum. Typically, the woman has a past history of a psychiatric disorder and treatment. The disorder occurs in less then 1% of postpartum mothers. It's considered a medical emergency. Suicide and infanticide are common. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: Psychosocial adaptation COGNITIVE LEVEL: Analysis A mother with a past history of varicose veins has just delivered her first baby. The nurse suspects that the mother has developed a pulmonary embolus. Which of the data below would lead to this nursing judgment? Select all that apply: Sudden dyspnea Chills, fever Diaphoresis Hypertension Confusion RATIONALE: Sudden dyspnea with diaphoresis and confusion are classic signs and symptoms of dislodgment of a thrombus (stationary blood clot) from a varicose vein becoming an embolus (moving clot) that lodges itself into the pulmonary circulation. Chills and fever would indicate an infection. A client with an embolus could be hypotensive, not hypertensive. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis The nurse is instructing a client about breast-feeding. Which instructions should she include to help prevent the mother from developing mastitis? Select all that apply: Wash the nipples with soap and water. Change the breast pads frequently. Expose the nipples to air for part of each day. Wash hands before handling the breast and breast-feeding. Make sure that the baby grasps the nipple only. Release the baby's grasp on the nipple before removing the baby from the breast. RATIONALE: Because mastitis is an infection frequently associated with a break in the skin surface of the nipple, measures to prevent cracked and fissured nipples help prevent mastitis. Changing breast pads frequently and exposing the nipples to air for part of the day help keep the nipples dry and prevent irritation. Washing hands before handling the breast reduces the chance of accidentally introducing organisms into the breast. Releasing the baby's grasp on the nipple before removing the baby from the breast also reduces the chance of irritation. Nipples should be washed with water only; soap tends to remove the natural oils and increases the chance of cracking. The baby should grasp both the nipple and areola. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Comprehension An ovarian stimulant, such as clomiphene (Clomid), may be prescribed for infertility if the cause of infertility is: anovulation. ovarian cysts. ovarian agenesis. ovarian dysgenesis.
RATIONALE: Clomiphene is given for anovulation (absence of ovulation). It's contraindicated in the presence of ovarian cysts. Clomiphene or other drugs won't improve ovarian agenesis (absence of ovaries) or ovarian dysgenesis (abnormal ovaries). NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Comprehension Which of the following disorders commonly causes infertility in women? Chickenpox Crohn's disease Endometriosis Schizophrenia RATIONALE: In endometriosis, endometrial tissue is found outside the uterine cavity. This tissue can cause inflammation and scarring that result in tubal adhesions or obstruction. As a result, the uterus isn't able to accommodate an enlarging fetus, resulting in spontaneous abortion. Schizophrenia, Crohn's disease, and chickenpox don't affect the female reproductive system. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis A 38-year-old client confides that she has been trying to become pregnant for the past 3 months but so far has been unsuccessful. She's crying and tells you that she has decided that she's infertile. What's your best response? "You're 38 years old. You may have waited too long to try to have a baby." "It's probably too soon for you to decide you're infertile." "I'm not qualified to decide if you're infertile. You should see an infertility specialist." "You have no family history of infertility, so you'll probably have a baby someday." RATIONALE: The definition of infertility is 1 year of unprotected intercourse without conception. The only appropriate response is that the client has drawn a conclusion too soon. Infertility isn't always related to age or family history. An infertility specialist is probably not necessary at this time. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: Coping and adaptation COGNITIVE LEVEL: Application Which of the following conditions could cause infertility? Ovulatory failure Thin cervical mucus Uterine structural defects An elevated number of sperm RATIONALE: Ovulatory failure, thickened cervical mucus, an acidic vaginal environment, and an inadequate number or inadequate motility of sperm may cause infertility. Uterine structural defects aren't related to conception. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Comprehension A client, in conjunction with her physician, has decided to attempt in vitro fertilization. Which statement is accurate regarding in vitro fertilization? It requires the presence of patent fallopian tubes. The fertilized egg is placed in the woman's fallopian tube. Eggs are fertilized in the laboratory and then implanted into the uterus.
Donor sperm ensures a better outcome than using the partner's sperm. RATIONALE: In vitro fertilization occurs when a harvested egg is fertilized in the laboratory and subsequently placed into the uterus. This technology doesn't require the presence of patent fallopian tubes. Gamete intrafallopian tube transfer or zygote intrafallopian transfer are approaches that require patent fallopian tubes. There's no evidence that donor sperm provides a better outcome than a partner's sperm unless the partner is known to have decreased number or motility of sperm or abnormal sperm structure. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis After the birth of her fourth child, a 25-year-old client asks about natural family planning. Which of the following statements is correct? Breast-feeding prevents ovulation and can be used as a method of birth control. Vaginal douching after intercourse washes away the sperm and prevents fertilization. If menstrual cycles are irregular, the rhythm method can be used to predict the days the egg can be fertilized. Combining body temperature assessment and cervical mucus changes is a reliable method of birth control. RATIONALE: The symptothermal method of combining temperature assessment with cervical mucus assessment is the most reliable natural family planning method. Women generally experience amenorrhea when they're breastfeeding, but the absence of periods doesn't mean ovulation isn't occurring, so conception can still take place. Douching may give the sperm more momentum as they pass through the female reproductive system; it isn't a method of birth control. The rhythm method is unreliable if a woman has irregular menstrual periods. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Comprehension A 36-year-old woman has been trying to become pregnant for the past 2 years. The physician has scheduled a hysterosalpingogram to investigate possible causes of infertility. The purpose of a hysterosalpingogram is to: assess the response of the endometrium to progesterone production. reveal endometriosis, pelvic adhesions, tubal occlusions, and polycystic ovaries. allow visualization of the uterine cavity and fallopian tubes by means of X-ray. identify abnormalities, verify follicular development and maturity, and confirm intrauterine versus ectopic pregnancy. RATIONALE: A hysterosalpingogram provides an image of the uterine cavity and fallopian tubes using X-ray. An endometrial biopsy assesses the response of the endometrium to progesterone production. A laparoscopy shows endometriosis, pelvic adhesions, tubal occlusions, and polycystic ovaries. Ultrasonography may identify abnormalities, verify follicular development and maturity, and confirm intrauterine versus ectopic pregnancy. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis A 38-year-old woman asks about in vitro fertilization and embryo transfer. Which of the following statements is correct about this procedure? Oocytes are retrieved from the ovary, placed in a catheter with washed motile sperm, and then transferred into the fallopian tube. The embryo is transferred to the uterus of a woman who has contracted with the couple to carry the pregnancy. Unexplained infertility with normal tubal anatomy and patency and absence of previous tubal disease is an indication for this procedure. The woman's eggs are collected from the ovaries, fertilized in the laboratory with sperm, and then transferred to her uterus after normal embryo development has occurred.
RATIONALE: In vitro fertilization refers to fertilization of the ovum in a laboratory. The woman's eggs are collected from the ovaries, fertilized in the laboratory with sperm, and then transferred to her uterus after normal embryo development has occurred. In gamete intrafallopian transfer, oocytes are retrieved from the ovary, placed in a catheter with washed motile sperm, and then transferred into the fallopian tube. An indication for gamete intrafallopian transfer would be unexplained infertility with normal tubal anatomy and patency and absence of previous tubal disease. Transferring the embryo to another woman's uterus refers to using a gestational carrier, otherwise known as surrogate motherhood. This woman would have contracted with the couple to carry the pregnancy. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Comprehension A 28-year-old client who has been unable to conceive is diagnosed with endometriosis. You explain that endometriosis can cause infertility due to: anovulation. infections with purulent discharge. adhesions in endometrial tissue. tube destruction. RATIONALE: In endometriosis, cyclical bleeding in endometrial tissue causes adhesions to form. These adhesions can block the passage of the ovum from the ovary to the fallopian tube. Endometriosis doesn't cause anovulation, infection, or tube destruction. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Comprehension A client at the fertility clinic has been prescribed danazol (Danocrine) for endometriosis. You explain that danazol acts by: increasing growth of normal endometrium. suppressing growth of endometrial cells. increasing the chance of normal ovulation. suppressing early menopause. RATIONALE: Danazol suppresses production of estrogen and progesterone by interfering with the production of follicle-stimulating and luteinizing hormone, thus stopping the menstrual cycle. This causes a woman to go into a state of pseudomenopause, suppressing the growth of endometrial cells. Danazol inhibits ovulation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Application Trisomy 21 is a genetic disorder that produces which of the following clinical manifestations? Webbed neck Cleft lip and palate Rocker-bottom feet Small mouth with protruding tongue RATIONALE: A small mouth with a protruding tongue is typical in an infant with trisomy 21 (Down syndrome). Other facial characteristics associated with this condition include a short, wide head with a flat occiput, up-slanting eyes, a short nose with a flat nasal bridge, and low-set ears. A webbed neck occurs in Turner's syndrome. Rockerbottom feet are characteristic of trisomy 18. A cleft lip and palate are characteristic of trisomy 13. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Analysis
The incidence of which of the following disorders increases in mothers between ages 35 and 40? Anemia Trisomy 21 Incompetent cervix Rh incompatibility RATIONALE: The incidence of Down syndrome (trisomy 21), a chromosomal disorder, increases to 1:300 for women ages 35 to 40. Beyond age 40, it increases to between 1:30 and 1:50. Rh incompatibility, anemia, and incompetent cervix aren't related to the mother's age. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Comprehension Which of the following statements about phenylketonuria (PKU) is correct? Screening for PKU is done by urine studies. PKU is caused by deficiency of a liver enzyme. There's no treatment for PKU; it results in mental retardation. No prenatal diagnosis or carrier detection studies are available. RATIONALE: PKU results from a deficiency in phenylalanine hydroxylase, a liver enzyme that converts phenylalanine to tyrosine. The major feature of this disease is mental retardation if the affected neonate ingests phenylalanine over time. The gene for this disease has been identified; prenatal diagnosis and carrier detection studies are available. Screening of neonates is done by a capillary blood sample before discharge from the hospital. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Analysis Which of the following statements regarding sickle cell anemia is accurate? It's a dominant hereditary disease. It occurs only in clients of African descent. Hemoglobin S causes red blood cells to clog small blood vessels. Normal adult hemoglobin A is formed but functions poorly. RATIONALE: Sickle cell anemia is an autosomal recessive defect in which normal adult hemoglobin doesn't form. Instead, hemoglobin S (which is shaped like a sickle and causes occlusion of blood vessels) forms, resulting in chronic anemia, increased incidence of infection, and pain in the bones, lungs, and spleen. It typically occurs in people of African descent. It may also occur in those whose country of origin borders on the Mediterranean Sea, India, or the Middle East. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Comprehension Which of the following assessment findings occurs most commonly in a client with fragile X syndrome? Short stature Mental retardation Undeveloped genitalia Round, moonlike face RATIONALE: People with fragile X syndrome generally display large testes after puberty; long, narrow faces; large or protuberant ears; and mild to severe mental retardation, which is often accompanied by behavioral disorders. Short stature isn't associated with the syndrome. In rare cases, the person appears normal. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and
maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application Which of the following chromosomal abnormalities causes males to have poorly developed secondary sex characteristics and small testes? Down syndrome Edward's syndrome Klinefelter's syndrome Patau's syndrome RATIONALE: Because of the influence of an extra X chromosome, a boy with Klinefelter's syndrome has poorly developed secondary sex characteristics and small testes. Down syndrome is caused by trisomy of chromosome 21. Edward's syndrome results from trisomy of chromosome 18. Patau's syndrome is caused by a trisomy of chromosome 13. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Comprehension Alpha-fetoprotein (AFP) level is used to assess for which birth defect? Trisomy 18 Down syndrome Neural tube defect Turner's syndrome RATIONALE: Neural tube defects can be detected by measuring AFP level because fetuses with these defects leak AFP into the amniotic fluid, causing elevated levels. Chromosome analysis is used to diagnose chromosomal disorders, such as trisomy 18 and Turner's syndrome. The triple screen is used to diagnose Down syndrome. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Knowledge Hemophilia is an example of an X-linked recessive inheritance pattern. With this type of genetic defect: male children are carriers of the defect. female children aren't carriers of the defect. only male children fully manifest the disorder. inheritance patterns are similar to those for cystic fibrosis. RATIONALE: Because hemophilia is inherited as an X-linked recessive trait, only male children fully manifest hemophilia. The female infant with two X chromosomes can counter the effect of the abnormal gene, whereas males with only one X chromosome can't. A female who inherits this X-linked recessive trait is a carrier but won't develop the disease. Cystic fibrosis is inherited by an autosomal-recessive pattern of inheritance; both males and females can get the disease. It isn't linked to a sex chromosome. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease COGNITIVE LEVEL: Comprehension A parent visits the clinic with her 16-year-old daughter who has been diagnosed with Turner's syndrome. When you assess the daughter, you anticipate that she will have: microcephaly. congenital heart disease. psychomotor retardation. juvenile external genitalia.
RATIONALE: Client diagnosed with Turner's syndrome are missing an X chromosome (a sex chromosome) and have immature ovaries, juvenile external genitalia, and underdeveloped breasts. These clients are usually short and have webbing of the neck; intelligence may also be impaired. Microcephaly and psychomotor retardation are associated with cri du chat syndrome or trisomy 18. Congenital heart disease may be present with multifactorial genetic inheritance. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Comprehension The cause of cleft palate is thought to be: a specific teratogen. trisomy of the G chromosome. an X-linked gene. multiple genetic and environmental factors. RATIONALE: Cleft palate occurs in about 1 in 2,500 births. It results from embryonic failures in development associated with multiple genetic and environmental factors during 6 to 12 weeks' gestation. It isn't specifically associated with a teratogen and isn't associated with Down syndrome (trisomy of the G chromosome). Cleft palate is more common in females, but it isn't related to an X-linked chromosome. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Comprehension Emergency contraception refers to: taking prescribed high doses of an oral contraceptive. elective pregnancy termination by various methods. douching with a strong vinegar solution immediately after intercourse. inserting a spermicidal suppository after intercourse if condom leakage is suspected. RATIONALE: Taking a larger-than-usual dose of an oral contraceptive as soon as possible but not later than 72 hours after unprotected intercourse followed by a second dose 12 hours after the first dose may prevent pregnancy. Contraception refers to prevention of pregnancy, not termination of pregnancy. Douching may force the sperm up toward the cervical os. Vaginal spermicidal suppositories must melt before they become effective, which takes 15 minutes. This may be too late to prevent pregnancy. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Analysis A client comes to the clinic for her postpartum checkup. The client tells you that she would like to use oral contraceptives. Before prescribing the oral contraceptive norethindrone (Micronor), the physician must check the client's history for which condition that contraindicates the use of this drug? Diabetes mellitus Asthma Kidney disease Thromboembolic disease RATIONALE: Norethindrone is contraindicated in clients with a history of thromboembolic disease. Because thromboembolism is a known adverse reaction to norethindrone therapy, use of the medication in a client with a history of thromboembolic disorder places the client at greater risk for developing the potentially fatal disorder. Norethindrone should be used cautiously in clients with diabetes mellitus, asthma, and kidney disease, but its use isn't contraindicated in these clients. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Application
Which of the following choices is a disadvantage to using vaginal spermicides to prevent pregnancy? Difficulty of getting the spermicide Difficulty of applying the spermicide Detailed instructions for using the spermicide Reapplication that is necessary each time intercourse occurs RATIONALE: The client may feel that having to reapply spermicide each time intercourse occurs is inconvenient, thus decreasing the likelihood that the client will use it regularly. Spermicides have few instructions for use, are readily available, and are easy to apply. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Analysis A vasectomy is considered 100% effective after: about 2 weeks. about 4 weeks. two consecutive sperm counts show zero sperm. the ejaculate has been tested at the first postoperative visit. RATIONALE: Some sperm remain in the proximal vas deferens after vasectomy, and it may take 1 week to several months to clear the proximal ducts of sperm. Only sperm counts can determine when the proximal ducts have been cleared. The client should use contraception until two consecutive sperm counts show zero sperm. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Comprehension Potential complications after a vasectomy include: loss of the ability to ejaculate. inability to achieve or maintain an erection. decreased testosterone affecting male sexual characteristics. external bleeding, suture reactions, and reactions to anesthesia. RATIONALE: Potential complications of a vasectomy include external bleeding, suture reactions, and reactions to anesthesia. The procedure doesn't affect potency, ejaculation volume, or testosterone production or function. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis Which of the following family planning methods requires the couple to assess the quality of cervical mucus throughout the menstrual cycle? Rhythm method Coitus interruptus Natural family planning Basal body temperature record RATIONALE: Natural family planning requires assessment of cervical mucus, which is minimal and not stretchy until ovulation occurs. At the time of ovulation, the cervical mucus is present in greater quantity, stretchy, and more favorable to penetration by sperm. The rhythm method requires knowledge of the variations in the woman's menstrual cycle to determine the likelihood of ovulation. Coitus interruptus is withdrawal of the penis before ejaculation in an attempt to avoid conception. The basal body temperature method requires tracking the woman's temperature for several months to determine a pattern characterized by a decrease and then an increase in temperature for several days at the time of ovulation. NURSING PROCESS STEP:
Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application As a contraceptive method, breast-feeding (without supplementation) during the first 6 months after delivery works similarly to which contraceptive? Condoms Diaphragms Spermicidal gels Hormonal contraceptives RATIONALE: As a contraceptive method, breast-feeding works most similarly to hormonal contraceptives. Full breast-feeding maintains high levels of prolactin, which acts as an ovulatory suppressant. Condoms, diaphragms, and spermicidal gels don't suppress ovulation. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Comprehension Which part of the male anatomy is severed during a vasectomy? Ejaculatory duct Epididymis Penile urethra Vas deferens RATIONALE: The vas deferens is ligated during a vasectomy. The vas deferens is a tubular structure that connects the epididymis to the ejaculatory duct. The penile urethra, ejaculatory duct, and epididymis aren't involved in the procedure. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Knowledge Which of the following family planning methods, though sometimes used, actually increases the likelihood of pregnancy? Calendar method Vaginal douching Coitus interruptus Basal body temperature method RATIONALE: Vaginal douching increases the risk of pregnancy because the flow of the douching solution is likely to push sperm closer to an ovum rather than rinse them away. The calendar method and basal body temperature method have high rates of accuracy if used correctly and meticulously. Although coitus interruptus isn't an effective method of contraception, it doesn't increase the risk of pregnancy more than using no contraception. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis Which explanation best accounts for how a vaginal contraceptive ring prevents pregnancy? It creates a thick mucus that inhibits cervical penetration. It thickens cervical mucus. It forms a thick coat around the ovum so that sperm can't penetrate. It prevents released ova from dividing, even if they're fertilized. RATIONALE: The vaginal contraceptive ring contains the hormones estrogen and progestin, which inhibit ovulation and thicken cervical mucus, preventing sperm from getting to the egg. The vaginal contraceptive ring doesn't coat the ovum directly or alter it. NURSING PROCESS STEP: Analysis CLIENT NEEDS
CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Comprehension A postpartum woman indicates that she would like to become pregnant again as soon as pregnancy is safe. Which contraceptive would be appropriate for this client until she can become pregnant again? Birth control pills A barrier method Intrauterine device (IUD) Medroxyprogesterone (Depo-Provera) RATIONALE: A woman who desires pregnancy again soon after a birth should use a barrier method of contraception. Use of a barrier method allows her body to return to a normal hormonal state in which she can achieve pregnancy. A hormonal method lengthens the time it takes her body to achieve a normal hormonal state because of the influence of exogenous hormones. An IUD wouldn't be inserted for a short interval. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Analysis A 17-year-old client comes in for her 6-week postpartum visit. She has been breast-feeding and hopes to continue as long as possible. She asks for suggestions regarding choice of contraceptive methods. You advise her that: breast-feeding is sufficient contraception. taking birth control pills is contraindicated while breast-feeding. at her age, she shouldn't have another pregnancy, so she should abstain. the medroxyprogesterone (Depo-Provera) injection can be given after lactation is well established. RATIONALE: Medroxyprogesterone can be given after lactation is well established, but a trial period using a progestin-only pill may be indicated before the injection to make sure that the progesterone doesn't cause a reduced milk supply. This birth control method is a good choice for teenagers because it doesn't require compliance during the 3-month period that it's effective. Breast-feeding isn't a reliable birth control method. Progestin-only birth control pills can be used while nursing. Telling the client that she shouldn't become pregnant again is inappropriate. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Application Mifepristone (RU 486) induces spontaneous abortion when administered in early pregnancy, thus providing women with an alternative to aspiration (suction) abortion. Mifepristone induces abortion by acting: as a progesterone antagonist. on estrogen receptor sites. directly on placental attachment. on coagulation factors. RATIONALE: Progesterone is essential for maintaining pregnancy. Mifepristone (RU 486) disrupts the pregnancy before implantation of the fertilized egg by acting against progesterone. It doesn't act on estrogen receptor sites, placental attachment, or coagulation factors. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Comprehension Women with recurrent urinary tract infections (UTIs) should avoid which type of birth control method? Diaphragms Male condoms Oral contraceptives
Injectable contraceptives (Depo-Provera) RATIONALE: Pressure from a diaphragm on the urethra may interfere with complete bladder emptying, predisposing the client to infections. Male condoms and hormonal contraceptives don't affect UTIs. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Analysis When teaching couples how to use the basal body temperature method of birth control, you should tell them to: check the woman's oral temperature every day 1 hour after rising. abstain from intercourse until a drop in temperature occurs about midcycle. abstain from intercourse from the onset of menses through the 3rd day of elevated temperature that occurs after a drop in temperature. be aware that this method is half as effective as hormonal contraceptives in the prevention of pregnancy. RATIONALE: Basal body temperature decreases at the time of ovulation and then rises abruptly during the fertile period of the next 3 days. Basal body temperature is a brittle measurement and may be unreliable if taken after arising in the morning. The risk of becoming pregnant is three times greater for a woman using the basal body temperature method than that of a woman taking hormonal contraceptives. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Growth and development through the life span COGNITIVE LEVEL: Application

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A registered nurse (RN) who obtains histories, performs physical examinations, and manages care (in consultation with

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