Flashcard list for: OB/Peds NCLEX-PN Questions

Question Answer Side 3

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

4. During the first two trimesters of pregnancy, meternal blood pressure normally decreases by 5-10 mmHg in both systolic and diastolic pressures. This decrease is due to peripheral vasodilation caused by pregnancy hormones. 4. "My craving are probably caused by iron deficiency." A 22-year-old client at 7 weeks' gestation RATIONALE attended the first trimester class on 1. Appropriate weight gain for pregnancy nutrition. Which of the following is between 25 and 35 lbs. statements indicatea a need for further 2. Intrauterinie growth retardation can be teaching? caused by poor maternal diets. The 1. "I should gain around 30 pounds by my U.S.F.D.A. recommends following the due date." food pyramid recommendations for 2. "Planning meals around the food improving dietary intake. pyramid guide is best." 3. Canned foods lose some nutrients in 3. "Frozen foods are more nutritious than processing. Foods that are frozen are canned foods." processed less and more nutritious. 4. "My craving are probably caused by 4. Pica is more related to cultural values iron deficiency." and beliefs than to dietary deficiencies. Pica is more likely to cause iron deficiency than to be caused by it. 1. Slow, deep breathing RATIONALE 1. This client is in the early phase of labor; slow, deep breathing and relaxation A client admitted to the obstetric unit with techniques are usually effective in contractions every 8-10 minutes, with relieving contraction pain during this cervical effacement of 100%, and dilation phase. of 3 cm, reported that she and her support 2. Rapid, shallow breathing, or person planned to use prepared childbirth hyperventilation, is inappropriate for any techniques. The nurse would expect the phase of labor. couple to utilize which of the following pain 3. Local anesthesia is used for numbing of relief methods during this phase of labor? the perineum immediately before 1. Slow, deep breathing performance of an episiotomy and 2. Rapid, shallow breathing delivery of the fetus during the last phase 3. Local anesthesia of the first stage of labor. 4. Narcotic analgesia 4. Narcotic analgesia is not appropriate for use during early phases of labor. It can slow or stop labor if given before 5 cm dilation. In addition, minimizing use of narcotics is preferred when prepared childbirth techniques are used. A 30-year-old gravida 5, para 4 (all 3. "The father's sperm determines if the female) client at 12 weeks' gestation asks baby is male or female." the nurse, "Do you think I'm having a boy? If I don't have a boy this time, my husband RATIONALE will probably divorce me." Which of the following explanations by the nurse would 1. The sex chromosome of males is XY; be most accurate? the sex chromosome for females is XX. The mother contributes one X

chromosome to the fetus, the father contributes either an X or a Y chromosome. 2. The heart rate of the fetus is neither 1. "Girls probably run in your family, faster nor slower according to fetal there's nothing you can do about it." gender. The range for the fetal heart rate 2. "The heartbeat of the baby is fast, that is 110-160 bpm regardless of gender. means it's a boy." 3. Meiosis results in the X and Y 3. "The father's sperm determines if the chromosomes of the male splitting so that baby is male or female." each sperm carries either an X or a Y 4. "Don't worry, you are carrying this baby chromosome, thus determining the low, that means it's a boy." gender of the fetus. 4. How a fetus is carried is related to meternal uterine and abdominal muscle tone. The gender of the fetus does not determine how high or low it is carried. 2. "The size of the breasts doesn't matter. All women have about the same amount of milk-producing tissue." A client at term states, "I would like to breastfeed, but my mother-in-law told me RATIONALE my breasts are too small and I won't have enough milk for my baby." The best 1. The volume of breast milk produced is response by the nurse would be which of related to how often the breasts are the following? emptied of milk. Formula supplementation decreases breast milk production since 1. "Your breasts are small, but if you don't the infant nurses less often. produce enough milk, you can give the 2. The amount of milk producing glandular baby some formula." tissue in all women is approximately the 2. "The size of the breasts doesn't matter. same. The size of large breasts is due to All women have about the same amount increased fatty tissue. of milk-producing tissue." 3. An infant is more efficient at emptying a 3. "You will produce more milk if you use a breast than a breast pump. In addition, breast pump and then give it to your baby oral stimulation of the nipples by the infant in a bottle." stimulates the release of oxytocin, which 4. "Milk production is increased by the triggers the let-down reflex. hormone estrogen. You can ask your 4. Estrogen does not stimulate milk doctor for a prescription to take." production. Oxytocin and prolactin are the hormones responsible for breast milk production and breastfeeding success. A 32-hour-old baby has yellowish skin 4. Encourage the mother to increase the undertones and a serum bilirubin level of frequency of breastfeeding sessions. 14 mg/100 mL. The blood type of the baby is B+. The mother's blood type os O+. The RATIONALE infant is being breast-fed. The nurse would include which of the following 1. Bilirubin levels in excess of 12 mg/100 measures in her plan of care? mL may indicate the presence of a pathological process. This jaundice is 1. No special measures are necessary, most likely due to an ABO incompatibility. newborns normally get a little jaundiced. 2. Breastfeeding jaundice occurs around 2. Tell the mother to stop breast-feeding the third day of age. Encouraging early and give the baby formula instead. and frequent feedings at the breast lowers 3. Place the infant under the bililights and neonatal bilirubin levels. prepare for an exchange transfusion. 3. Light therapy requires an order from the

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

1. hCG is a hormone produced by the placenta that stimulates the corpus luteum to persist and secrete estrogen and progesterone, which maintains the pregnancy for the first 20 weeks of gestation. It is found in maternal blood and urine. nurse monitor? 2. PG is a major phospholipid of surfactant. The presence of PG in 1. Human chorionic gonadotropin (hCG) amniotic fluid indicates fetal lung maturity. 2. Phosphatidylgycerol (PG) 3. AFP is a plasma protein that is 3. a-Fetoprotein (AFP) produced by the fetus. Abnormally high or 4. Partial thromboplastin time (PTT) low levels can indicate fetal anomalies. AFP levels are drawn from maternal blood. 4. PTT levels are drawn to determine if sodium warfarin levels are at a therapeutic level in women with thromboembolic disease. 4. "Dizygotic twins come from two A client at 12 weeks' gestation has just different eggs and sperm." been told that she is carrying dizygotic twins. She asks the nurse what the RATIONALE difference is between monozygotic and dizygotic twins. Which of the following 1. Monozygotic twins (identical) develop explanations by the nurse would be most from one fertilized egg that splits into accurate? identical halves early in embryonic development. 1. "Monozygotic twins come from two 2. Dizygotic twins develop from two different eggs and sperm." different ova fertilized by two different 2. "Dizygotic twins come from one sperm. fertilized egg that split." 3. Once an egg has been penetrated by a 3. "Monozygotic twins come from one egg single sperm, chemical changes take and two sperm." place that prevent multiple sperm 4. "Dizygotic twins come from two different fertilization. eggs and sperm." 4. See rationale 2. A 20-year-old client has come to the 2. "Missed menses and breast tenderness obstetric clinic because her menstrual are presumptive signs of pregnancy." period is 7 days late. She tells the nurse, "I'm sure I'm pregnant because my period RATIONALE is late and my breasts are tender." Which of the following responses by the nurse 1. The only positive signs of pregnancy would be most accurate? are auscultation of fetal heart tones, visualization of the fetus by ultrasound, 1. "Missed menses and breast tenderness and fetal movement felt by the health-care are positive signs of pregnancy." provider. 2. "Missed menses and breast tenderness 2. Presumptive signs of pregnancy are are presumptive signs of pregnancy." amenorrhea, fatigue, breast tenderness 3. "Missed menses and breast tenderness and enlargement, morning sickness, and are probable signs of pregnancy." quickening. 4. "Missed menses and breast tenderness 3. Probable signs of pregnancy are are negative signs of pregnancy." Hegar's sign, ballottement, poristive pregnancy test, and Goodell's sign. 4. Amenorrhea and breast tenderness are

presumptive signs of pregnancy. 3. Increasing heart rate RATIONALE A client is seen in the emergency room at 1. Increased temperature may be a sign 16 weeks' gestation with pelvic cramping of infection; however, the risk of infection and bright red vaginal bleeding. Which of is greatest during the first 72 hours after the following signs and symptoms should spontaneous abortion or operative the nurse observe the client for? procedures. 2. The client is at risk for excess blood 1. Increased temperature loss. The pulse pressure decreases with 2. Increased pulse pressure hemorrhage. 3. Increasing heart rate 3. An increased pulse in the prescence of 4. Increased blood pressure visible bleeding indicates excessive blood loss. 4. Increased blood pressure at this stage of pregnancy would be a symptom of a hydatidiform mole. 1. Hypotension RATIONALE The anesthetist has just placed an 1. Hypotension is common with epidural epidural catheter dosed with bupivacaine anesthesia because the sympathetic hydrochloride (Marcaine) in a client at nerves are also blocked by the term in active labor. The nurse should medication, which results in vasodilation. observe the client for which of the 2. Hypertension is not a side effect of following side effects? epidural anesthesia. 3. Hyperventilation is not a side effect of 1. Hypotension epidural anesthesia. A client is more likely 2. Hypertension to hyperventilate during painful 3. Hyperventilation contractions. Epidural anesthesia relieves 4. Hypoventilation contraction pain. 4. Hypoventilation is possible if epidural narcotics are used. An epidural narcotic (such as fentanyl) was not used in this case. A client at 12 weeks' gestation has a 2. Partial thromboplastin time history of thromboembolitic disease. The client is placed on daily heparin therapy. RATIONALE The nurse should monitor the results of which of the following laboratory tests? 1. The PT is assessed to maintain correct dosages of warfarin (Coumadin). 1. Prothrombin time Coumadin crosses the placental barrier 2. Partial thromboplastin time and is contraindicated in pregnancy. 3. Bleeding time 2. The PTT is evaluated to determine the 4. Clotting time effectiveness of heparin therapy. 3. A bleeding time is obtained preoperatively to determine how quickly blood clots to maintain homeostasis. It is not routinely performed on pregnant women, and is unnecessary for a pregnant woman on heparin therapy.

A postpartum client complains of sharp pain in the calf of her right leg when RATIONALE walking. The nurse notes that the leg has a circumscribed area of redness, warmth, 1. These are symptoms of and tenderness. Which of the following thrombophlebitis; massage of the area nursing actions is most appropriate in this can break the thrombus from the venous client's nursing care? wall and cause an embolus. 2. Local application of heat is one of the 1. Instructing the client to massage the treatments for superficial thrombosis. affected area to relieve the tenderness 3. The client with symptoms of 2. Applying cold packs to the affected area thrombophlebitis should be placed on bed to decrease inflammation rest. 3. Encourage the client to ambulate to 4. Administration of analgesics, local increase circulation. application of heat, bed rest for 5-7 days, 4. Elevating the affected extremity to and elevation of the affected extremity are promote venous blood flow. often all that is needed to treat superficial thrombophlebitis. 3. Physical assessment of the infant RATIONALE 1. The third stage of labor is the stage of delivery of the placenta. The placenta will spontaneously separate from the uterine A client has just started the third stage of wall and be expelled by uterine labor. Which of the following nursing contractions. Maternal pushing is actions have priority at this time? unnecessary. 2. Oxytocin should not be administered 1. Encouraging the client to push until after the placenta is delivered, which 2. Administration of an oxytocic usually occurs 5-7 minutes after delivery medication of the infant. 3. Physical assessment of the infant 3. The infant's physical condition is a 4. Promotion of the bonding process priority at on eand five minutes after delivery. The physical assessment done at this time is known as Apgar scoring. 4. Initiation of the bonding process as soon as possible after birth is important, bu the physical stability of the newborn is most important at this time. A client who delivered 45 minutes ago 2. "That is called molding. It usually lasts comes into the transitional nursery to see for a few days." her infant. She askss the nurse, "My baby's head is shpaed like a cone? Will it RATIONALE stay like that?" Which of the following responses by the nurse is most accurate? 1. Caput succedaneum is an area of generalized edema of the scalp that was 1. "That is called a caput. It usually lasts present at birth. for 3 or 4 days." 2. Molding is an overlapping of the skull 2. "That is called molding. It usually lasts bones at the occiput of the skull. The for a few days." infant skull has a cone shaped 3. "That is called a cephalhematoma. It appearance.

4. A clotting time is a ficitonal test. 4. Elevating the affected extremity to promote venous blood flow.

usually lasts for a few weeks." 4. "That is called a nevi. It usually lasts several months."

3. A cephalhematoma is a collection of blood between the skull bone and its periosteum. It is one-sided(does not cross suture lines), and appears within the first 2 days after delivery. 4. Nevi (also known as 'stork bites')are pink areas on the upper eyelids, nose, upper lip, lower occiput, and the nape of the neck. 2. "If my baby has at least two wet diapers and one bowel movement a day, he is getting enough to eat."

A 20-year-old primiparous client, who is breastfeeding, is preparing to be RATIONALE discharged home with her newborn son. The nusre has completed discharge 1. The cord stump should be cleaned with instructions on newborn care. Which of the solution ordered by the health-care the following statements by the client provider daily until it falls off. Cord care would indicate a need for further helps the cord to dry and prevents teaching? infection. 2. A breastfeeding infant should have at 1. "I should clean the cord stump with least six wet diapers daily. Adequate alcohol or peroxide every day until it falls urinary output is a reliable indicator of off." adequate intake of breast milk. 2. "If my baby has at least two wet diapers 3. The infant should be dressed as and one bowel movement a day, he is parents would dress themselves. getting enough to eat." Overdressing can cause prickly heat rash. 3. "I should dress my baby in clothing I Wrapping the infant in a light blanket would be comfortable in, plus a light maintains body temperature and makes blanket." the infant feel secure. 4. "I should nurse my baby whenever he 4. Breast milk is more completely and acts hungry and for as long as he wants to quickly digested than formula. Breast-fed nurse." infants should be fed on deman. It is important for the infant to completely empty the breast, so infant sucking time at the breast should also not be limited. The nurse is planning care for a client who 4. The client will maintain physiological had a spontaneous vaginal delivery with homeostasis. epidural anesthesia over an intact perineum. She is currently in the fourth RATIONALE stage of labor. Which of the following nursing goals would be most appropriate 1. The fourth stage of labor is the for this client? immediate (approx. 1 hour) postpartum period. Epidural anesthesia takes 1. The client will ambulate in the room approximately an hour to wear off. The without assistance. client will be unable to ambulate during 2. The client will turn, coudh, and deep this time. In addition, all postpartum breathe 10 times an hour. clients should be assisted with ambulation 3. The client's epsiotomy will remain the first few times out of bed. clean, dry, and intact. 2. Pulmonary hygiene is important in 4. The client will maintain physiological clients with a respiratory condition, or homeostasis. those who have undergone an operative procedure. The client doesn't have an episiotomy.

3. The most common complication of the fourth stage of labor is uterine atony and hemorrhage. 2. Firm fundus 1-2 bingerfbreadths above the umbilicus and midline with moderate lochia rubra A client delivered a term infant 6 hours ago. Which of the following assessment findings indicate normal postpartum progression? 1. Firm fundus at the umbilicus and midline with moderate lochia rubra 2. Firm fundus 1-2 bingerfbreadths above the umbilicus and midline with moderate lochia rubra 3. Firm fundus 1-2 fingerbreadths above the umbilicus and deviated to the right side with moderate lochia rubra 4. Firm fundus 3-4 fingerbreadths below the umbilicus and midline with moderate lochia rubra RATIONALE 1. The fundal height is approximately 2 fingerbreadths below the umbilicus immediately after delivery. The fundal height increases to 1 fingerbreadth above the umbilicus within 12 hours. The fundal height will decrease approximately 1-2 fingerbreadths a day afterward. Lochia rubra will be present for 3-4 days after delivery. 2. Fundal height increases to 1 fingerbreadth above the umbilicus within 12 hours after delivery. 3. Fundal deviation to one side or the other indicates a full bladder and risk for hemorrhage. 4. The fundal height is 3-4 fingerbreadths below the umbilicus by the fourth to fifth postpartum day. 3. Hemoglobin = 10 g/dL RATIONALE

1. WBC counts indicate the presence or absence of infection. The normal range for WBCs in pregnancy is 9-15 mm3. There is no evidence of infection. 2. The normal hematocrit in pregnancy 1. White blood count = 14 mm3 ranges from 32%-45%. 2. Hematocrit = 32% 3. The normal hemoglobin in pregnancy 3. Hemoglobin = 10 g/dL ranges from 11-12 g/dL. This client is 4. Serum glucose = 105 g/dL slightly anemic. 4. The normal serum glucose in pregnancy ranges from 65-110 g/dL. A laboring client received epidural 2. Assessing the client hourly for bladder anesthesia with bupivacaine hydrochloride distention (Marcaine) for contraction pain 1 hour ago. Considering the effects of epidural RATIONALE anesthesia, which of the following nursing measures are important her care? 1. Respiratory depression is associated with epidural narcotics. Marcaine is an 1. Assessing the client hourly for anesthetic agent. respiratory depression 2. The woman may not sense the urge to 2. Assessing the client hourly for bladder void because of decreased sensation to distention the area. Pain caused by bladder 3. Assessing the client hourly for uterine distention can last for long periods of time.

A client is pregnant at 12 weeks' gestation. Which of the following lab tests would the nurse need to interpret that would indicate a need for change in the client's plan of care?

atony 4. Assessing the client hourly for hypertension A client arrived on the OB unit at term with mild irregular contractions. Findings from a sterile vaginal exam were as follow: cervical dilation of 3 cm, membranes were intact, and the presenting part at -1 station. An external fetal monitor was placed and the fetal heart tracing revealed a baseline of 130 with accelerations to the 150s during contractions. Which of the following nursing acitons would be most appropriate considering the client's situation?

3. Uterine atony is associated with administration of oxytoxic drugs. It is not an effect of epidural anesthesia. 4. Maternal hypertension is not an effect of epidural anesthesia. 4. Send the client home and encourage her to ambulate. RATIONALE

1. This is a reassuring fetal heart pattern; no immediate nursin gactions othe rthan comfort measures are necessary. 2. There ais no fetal distresss. 3. The client is in no need for fluid volume expansion; neither she nor the fetus is in 1. Prepare the client for an immediate distress. operative delivery. 4. This client is in very early labor. The 2. Turn the client to her left side and fetal heart pattern is reassuring. adminster oxygen. Ambulation at home would stimulate labor 3. Notify the registered nurse to start an and descent of the presenting part and intravenous infusion stat. decrease hospitalization time. 4. Send the client home and encourage her to ambulate. 3. "Breastfeeding itself is effective at preventing pregnancy." A 6-week postpartum client, who is breastfeeding, asks for information on birth control methods that do not affect breast milk production. Which of the following statements would indicate the client needs further instruction? RATIONALE

1. Condoms are a mechanical barrier method of contraception with an effectiveness rate of 88%. Condom usage does not interfere with breast feeding. 2. Depo-Provera is an injectable form of progestin with an effectiveness rate of 1. "Using condoms would be a good 99.7%. Pregnancy is prevented for 3 choice for me." months. It is safe for use during lactation 2. "I can use Dep-Provera and breastfeed once the milk supply is established. without problems." 3. High prolactin levels with exclusive 3. "Breastfeeding itself is effective at breastfeeding can delay ovulation for up preventing pregnancy." to 6 months. However, it is an 4. "I can use contraceptive foam for birth unpredictable method of birth control. control." 4. The effectiveness of the contraceptive foams range from 72%-82%. It has no hormones to affect lactation, and is safe for use during the postpartum period. An antepartum client at 16 weeks' 1. Client drug allergies gestation has tested positive for gonorrhea. All tests for other sexually RATIONALE transmitted infections were negative. Which fo the following information is most 1. Gonorrhea is usually treated with important in planning her nursing care? penicillin. Drug allergies to penicillin are

1. Client drug allergies 2. Fishy-smelling discharge 3. The presence of a chancre 4. The presence of vesicles

ocmmon and can result in an anaphylactic reaction. 2. A malodorous vaginal discharge is cause by Gardnerella vaginalis. 3. A chancre is seen with syphilis. 4. Vesicles are seen with herpes.

A non-insulin-dependent diabetic has just found out she is pregnant. She asks th 2. "You can control your blood sugar with eclinic nurse what she shoudl do about insulin injectons." her diabetes. The most appropriate response by the nurse would be which of RATIONALE the following? 1. Oral hypoglycemic agents cross the 1. "You can control your blood sugar with placenta and cna cause fetal anomalies. oral hypoglycemic agents." 2. Insulin does not cross the placenta and 2. "You can control your blood sugar with is safe for use in pregnancy. insulin injectons." 3. Only gestational diabetes can be 3. "You can control your blood sugar with treated with diet during pregnancy. dietary changes." 4. Only gestation diabetes can be treated 4. "You can control your blood sugar by with exercise during pregnancy. exercising more." 3. "This test is for neural tube defects." An insulin-dependent diabetic at 18 RATIONALE weeks' gestation has arrived for afetoprotein testing. She asks the nurse 1. Analysis of amniotic fluid from why this test is being performed. Which of amniocentesis allows determination of the following explanations by the nurse fetal gender. would be most accurate? 2. The presence of phosphatidylglycerol and the L/S ratio determine fetal lung 1. "This test is to determine the sex of maturity. It is obtained from amniotic fluid. your baby." 3. AFP is a mternal blood test that can 2. "This test is for fetal lung maturity." detect neural tube defects (The most 3. "This test is for neural tube defects." common anomaly) in fetuses of diabetic 4. "This test is to determine glycemic women. It can also indicate the presence control." of Down's syndrome. 4. Glycemic control is determined by hemoglobin A1c, A meternal blood test. A postpartum client had a spontaneous 2. Call the health-care provider vaginal delivery 30 minutes ago. During the postpartum assessment, the nurse RATIONALE notes that there is constant tricling of bright red vaginal bleeding in the presence 1. Uteirne atony would reveal a constant of a contracted uterus at midline. Which trickle of bright red blood in the prexence action by the nurse would be most of a boggy uterus. appropriate in this situation? 2. Excessive lochia in the presence of a contracted uterus suggests lacerations of 1. Massage the fundus the birth canal. The HCP must be notified 2. Call the health-care provider so the laceration can be repaired. 3. Have the client empty her bladder 3. Excessive bleeding caused by a full 4. Increase the oxytocin (Pitocin) infusion bladder would reveal a uterus that was high and deviated to one side. 4. Increasing the rate of an infusion of oxytocin would not correct the problem of

a lacerated birth canal. The nurse enters the room of a 4. Knowledge deficit related to breastfeeding client who delivered 3 hours breastfeeding techniques ago and who is in tears. "I just don't know what I'm doing wrong!" she sobs. "I can't RATIONALE get my baby to take the nipple!" Which of the following nursing diagnoses would be 1. One session of breastfeeding problems most appropriate in this case? does not result in altered parenting. 2. The difficulty is in infant latch-on, not 1. Altered parenting related to difficulty in sore nipples. breastfeeding 3. Success in breastfeeding has little to do 2. Altered comfort related to sore nipples with bonding/attachment. 3. Altered bonding process related to 4. Instruction and assistance from the maternal frustration nurse would most likely result in 4. Knowledge deficit related to successful latch-on and breastfeeding. breastfeeding techniques 4. Give the baby to his mother and point out his features. RATIONALE A client delivered her first infant 1 day ago at term. Which of the following actions by 1. Giving the mother pictures of her baby the nurse would most likely promote the is appropriate only when an infant is too ill attachment process? for physical contact. 2. Descriptions of the infant do not replace 1. Take pictures of the baby for the mother physical contact between mother an to see. dbaby. 2. Tell the mother what her baby looks 3. Direct physical contact between mother like. and baby is most likely to promote 3. Take the mother to the nursery window attachment. to see her baby. 4. The combination of direct physical 4. Give the baby to his mother and point contact between mother and baby and out his features. discussion of the child's physical and personality attributes assists the mother in recognizing her infant as a distinct individual who is yet a part of her. This process is the beginnings of attachment. A 20-year-old multipara at 18 weeks 1. "Eat a serving of live culture yogurt gestation reports symptoms of thick white daily." vaginal dishcarge and intense itching. A wet mount specimen reveals budding RATIONALE yeast cells with a diagnosis of Candida albicans. The client asks how to prevent 1. Evidence indicates that ingestion of future infections. Which of the following live-culture yogurt decreases the responses by the nurse is most accurate? incidence of vaginal yeast infections. 2. Vinegar and water douches decrease 1. "Eat a serving of live culture yogurt vaginal pH and inhibit the growth of yeast daily." cells. However, douching is not 2. "Douche after intercourse with vinegar recommended in pregnancy. and water." 3. Douching with live-culture yogurt 3. "Douche with live culture yogurt daily." decreases vaginal pH. However douching 4. "Take antibiotics as ordered until all are is not recommended in pregnancy. gone." 4. All antimicrobials cross the placenta; many can cause fetal organ damage. In

A 24-year-old primipara at 32 weeks' gestation comes into the clinic with complaints of nasal stuffiness, nosebleeds, and bilateral hearing loss. She asks why she is having these symptoms. Which of the following explanations by the nurse is most accurate? 1. "This sounds like a bad cold, you need to take a decongestant." 2. "These symptoms are common in pregnancy because pregnancy hormones cause increased blood flow, which causes head congestion." 3. "These are symptoms of a major problem. You need to be referred to a specialist." 4. "This sounds like a sinus infection. It is caused by exposure to allergens, such as cat dander or plant pollen. You need to take antibiotics and antihistamines."

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

RATIONALE A client in the second trimester of pregnancy has blood drawn for routine 12- 1. Blood volume increases by 30%-50% in week lab work. Which of the following pregnancy. This causes hemodilution of results would be considered normal for RBCs and physiological anemia. Normal this stage of pregnancy? hemoglobin levels in pregnancy range from 11-12 g/dL. 1. Hemoglobin of 11 g/mL 2. Plethora is not a normal finding in 2. Hemoglobin of 18 g/mL pregnancy. 3. Serum glucose of 80 3. Normal serum glucose in pregnancy is 4. RBC count of 4 65. 4. This is a normal RBC count for nonpregnant individuals. Normal RBCs in pregnancy range from 11-12. A nurse educator teaching a prenatal 1. "My areolas will get smaller and lighter class asked for feedback from the class in color." on the topic "Breast Changes During Pregnancy." Which of the following RATIONALE statements from on eo fthe attendees would indicate further instruction is 1. Pregnancy causes the areolas to needed? darken and enlarge. 2. Breast tenderness and swelling ar 1. "My areolas will get smaller and lighter almost universal findings in pregnancy. in color." 3. Pregnancy causes darkening of the

pigment in the nipples and causes them to 2. "My breasts will be tender and swollen." become more erectile. 3. "The nipples will get darker and more 4. Breast enlargement is caused by the erect." influence of progesterone and estrogen. 4. "My breasts will enlarge and may feel Nodularity is caused by an increase in the lumpy." size of the mammary glands during the second trimester. 4. "Many women have mixed emotions when they are first pregnant." A 36-year-old professional woman who is RATIONALE pregnant for the first time at 10 weeks' gestation tells the nurse that her 1. Ambivalent feelings about pregnancy pregnancy was planned, bu that "I'm are common in all women. In addition, this feeling like maybe this wasn't such a good response is a block to therapeutic idea." Which of the following responses by communication. The nurse is telling the the nurse would be most appropriate? client how she "should" feel. 2. Even women with a desired pregnancy 1. "These are unnatural feelings. You have ambivalent feelings. Such feelings should be happy to be pregnant." do not necessarily mean the woman 2. "Maybe you should consider abortion desires an abortion. since you feel this way." 3. "Mother love" does not necessarily 3. "Don't worry, you'll feel differently once appear right after birth, especially in a first the baby is born." pregnancy. It may take time for such 4. "Many women have mixed emotions feelings to grow. when they are first pregnant." 4. Ambivalence is a normal response experienced by any individual preparing for a new role. 2. B-, antibody+ RATIONALE 1. AFP is drawn in the second trimester A 20-year-old client came in fo rher first around 18 weeks' gestation. Low AFP prenatal appointment at 10 weeks' may indicate Down's syndrome. gestation. Blood is drawn for routine 2. Antibodies formed by a mother prenatal screening. Which of the following because of an ABO or Rh incompatibility lab results would indicate a risk to the cause erythroblastosis fetalis. Blood and fetus for erythroblastosis fetalis? Rh typing an dantibody screening can alert the HCP to the possible development 1. Low a-fetoprotein of this condition. 2. B-, antibody+ 3. The L/S ratio is obtained from amniotic 3. L:S ratio of 2:1 fluid analysis and indicates fetal lung 4. O+, antibodymaturity.. 4. There is a possibility of ABO incompatibility that could result in erythroblastosis fetalis; however the antibody screen is negative. A client is in active labor at term with 3. Turn the client to her left side. cervical findings of 5 cm dilated, effacement of 90% station -1. The FHR RATIONALE baseline is in the 120s with long-term variability. Three late decelerations were 1. Compression of the major vessels of noted within the last hour with a quick the pelvis occurs with a supine position.

return to the 150s and then baseline. Which of the following nursing actions would be most appropriate? 1. Position the client on her back so the monitor strip is more accurate. 2. Prepare for a stat cesarean section. 3. Turn the client to her left side. 4. Encourage the client to ambulate.

This will compromise placental perfusion and contribute to fetal distress. 2. Fetal reserves are still present as evidenced by long-term variability, "shoulders," and a return to baseline. An operative delivery is not yet required. 3. Late decelerations are caused by decreased uteroplacental perfusion. Positioning a woman on her left side promotes fetal well-being by increasing placental perfusion and subsequent fetal oxygenation. This position change may stop the late decelerations. 4. Ambulation will stimulate uterine contractions and promote fetal descent. Increased frequency and/or intensity of contractions will impair uterine perfusion. 1. Epigastric discomfort

RATIONALE A client in the 26th week of gestation has been admitted to the OB unit with a 1. Epigastric pain/discomfort is a sign of diagnosis of PIH. Which of the following impending seizure in the client with symptoms would indicate worsening of the severe PIH. disease? 2. A blood pressure reading of 140/90 mm Hg indicates hypertension. Hypertension 1. Epigastric discomfort is considered severe when diastolic blood 2. BP of 140/90 mm Hg pressures exceed 110 mm Hg. 3. 2+ deep tendon reflexes 3. Normal deep tendon reflexes are 2+. 4. 2+ dependent edema 4. Dependent edema is a normal finding of pregnancy. Edema of the hands or face or pitting edema indicate a worsening of the disease.