1.
To decrease the pain associated with an
episiotomy immediately after birth, the nurse would:
A) Offer warm blankets
B) Encourage the woman to void
C) Apply an ice pack to the site
D) Offer a warm sitz bath
A) Offer warm blankets
B) Encourage the woman to void
C) Apply an ice pack to the site
D) Offer a warm sitz bath
ANS;C
An ice pack is the first measure used after a vaginal birth to provide perineal comfort from edema, an episiotomy, or lacerations. Warm blankets would be helpful for the chills that the woman may experience. Encouraging her to void promotes urinary elimination and uterine involution. A warm sitz bath is effective after the first 24 hours.
An ice pack is the first measure used after a vaginal birth to provide perineal comfort from edema, an episiotomy, or lacerations. Warm blankets would be helpful for the chills that the woman may experience. Encouraging her to void promotes urinary elimination and uterine involution. A warm sitz bath is effective after the first 24 hours.
2.
A postpartum client has a fourth-degree
perineal laceration. The nurse would expect which of the following medications
to be ordered?
A) Ferrous sulfate (Feosol)
B) Methylergonovine (Methergine)
C) Docusate (Colace)
D) Bromocriptine (Parlodel)
A) Ferrous sulfate (Feosol)
B) Methylergonovine (Methergine)
C) Docusate (Colace)
D) Bromocriptine (Parlodel)
ANS;C
A stool softener such as docusate (Colace) may promote bowel elimination in a woman with a fourth-degree laceration, who may fear that bowel movements will be painful. Ferrous sulfate would be used to treat anemia. However, it is associated with constipation and would increase the discomfort when the woman has a bowel movement. Methylergonovine would be used to prevent or treat postpartum hemorrhage. Bromocriptine is used to treat hyperprolactinemia.
A stool softener such as docusate (Colace) may promote bowel elimination in a woman with a fourth-degree laceration, who may fear that bowel movements will be painful. Ferrous sulfate would be used to treat anemia. However, it is associated with constipation and would increase the discomfort when the woman has a bowel movement. Methylergonovine would be used to prevent or treat postpartum hemorrhage. Bromocriptine is used to treat hyperprolactinemia.
3.
Which statement would alert the nurse to
the potential for impaired bonding between mother and newborn?
A) "You have your daddy's eyes."
B) "He looks like a frog to me."
C) "Where did you get all that hair?"
D) "He seems to sleep a lot."
A) "You have your daddy's eyes."
B) "He looks like a frog to me."
C) "Where did you get all that hair?"
D) "He seems to sleep a lot."
ANS;B
Negative comments may indicate impaired bonding. Pointing out commonalities such as "daddy's eyes" and expressing pride such as "all that hair" are positive attachment behaviors. The statement about sleeping a lot indicates that the mother is assigning meaning to the newborn's actions, another positive attachment behavior.
Negative comments may indicate impaired bonding. Pointing out commonalities such as "daddy's eyes" and expressing pride such as "all that hair" are positive attachment behaviors. The statement about sleeping a lot indicates that the mother is assigning meaning to the newborn's actions, another positive attachment behavior.
4.
After a normal labor and birth, a client
is discharged from the hospital 12 hours later. When the community health nurse
makes a home visit 2 days later, which finding would alert the nurse to the
need for further intervention?
A) Presence of lochia serosa
B) Frequent scant voidings
C) Fundus firm, below umbilicus
D) Milk filling in both breasts
A) Presence of lochia serosa
B) Frequent scant voidings
C) Fundus firm, below umbilicus
D) Milk filling in both breasts
ANS;B
Infrequent or insufficient voiding may be a sign of infection and is not a normal finding on the second postpartum day. Lochia serosa, a firm fundus below the umbilicus, and milk filling the breasts are expected findings.
Infrequent or insufficient voiding may be a sign of infection and is not a normal finding on the second postpartum day. Lochia serosa, a firm fundus below the umbilicus, and milk filling the breasts are expected findings.
5.
A primipara client who is bottle feeding
her baby begins to experience breast engorgement on her third postpartum day.
Which instruction would be most appropriate to aid in relieving her discomfort?
A) "Express some milk from your breasts every so often to relieve the distention."
B) "Remove your bra to relieve the pressure on your sensitive nipples and breasts."
C) "Apply ice packs to your breasts to reduce the amount of milk being produced."
D) "Take several warm showers daily to stimulate the milk let-down reflex."
A) "Express some milk from your breasts every so often to relieve the distention."
B) "Remove your bra to relieve the pressure on your sensitive nipples and breasts."
C) "Apply ice packs to your breasts to reduce the amount of milk being produced."
D) "Take several warm showers daily to stimulate the milk let-down reflex."
ANS;C
For the woman with breast engorgement who is bottle feeding her newborn, encourage the use of ice packs to decrease pain and swelling. Expressing milk from the breasts and taking warm showers would be appropriate for the woman who was breast-feeding. Wearing a supportive bra 24 hours a day also is helpful for the woman with engorgement who is bottle feeding.
For the woman with breast engorgement who is bottle feeding her newborn, encourage the use of ice packs to decrease pain and swelling. Expressing milk from the breasts and taking warm showers would be appropriate for the woman who was breast-feeding. Wearing a supportive bra 24 hours a day also is helpful for the woman with engorgement who is bottle feeding.
6.
The nurse administers RhoGAM to an
Rh-negative client after delivery of an Rh-positive newborn based on the
understanding that this drug will prevent her from:
A) Becoming Rh positive
B) Developing Rh sensitivity
C) Developing AB antigens in her blood
D) Becoming pregnant with an Rh-positive fetus
A) Becoming Rh positive
B) Developing Rh sensitivity
C) Developing AB antigens in her blood
D) Becoming pregnant with an Rh-positive fetus
ANS;B
The woman who is Rh-negative and whose infant is Rh-positive should be given Rh immune globulin (RhoGAM) within 72 hours after childbirth to prevent sensitization.
The woman who is Rh-negative and whose infant is Rh-positive should be given Rh immune globulin (RhoGAM) within 72 hours after childbirth to prevent sensitization.
7.
Which of the following factors in a
client's history would alert the nurse to an increased risk for postpartum
hemorrhage?
A) Multiparity, age of mother, operative delivery
B) Size of placenta, small baby, operative delivery
C) Uterine atony, placenta previa, operative procedures
D) Prematurity, infection, length of labor
A) Multiparity, age of mother, operative delivery
B) Size of placenta, small baby, operative delivery
C) Uterine atony, placenta previa, operative procedures
D) Prematurity, infection, length of labor
ANS;C
Risk factors for postpartum hemorrhage include a precipitous labor less than three hours, uterine atony, placenta previa or abruption, labor induction or augmentation, operative procedures such as vacuum extraction, forceps, or cesarean birth, retained placental fragments, prolonged third stage of labor greater than 30 minutes, multiparity, and uterine overdistention such as from a large infant, twins, or hydramnios.
Risk factors for postpartum hemorrhage include a precipitous labor less than three hours, uterine atony, placenta previa or abruption, labor induction or augmentation, operative procedures such as vacuum extraction, forceps, or cesarean birth, retained placental fragments, prolonged third stage of labor greater than 30 minutes, multiparity, and uterine overdistention such as from a large infant, twins, or hydramnios.
8.
When teaching parents about their newborn,
the nurse describes the development of a close emotional attraction to a
newborn by the parents during the first 30 to 60 minutes after birth, which is
termed:
A) Reciprocity
B) Engrossment
C) Bonding
D) Attachment
A) Reciprocity
B) Engrossment
C) Bonding
D) Attachment
ANS;C
The development of a close emotional attraction to the newborn by parents during the first 30 to 60 minutes after birth describes bonding. Reciprocity is the process by which the infant's capabilities and behavioral characteristics elicit a parental response. Engrossment refers to the intense interest during early contact with a newborn. Attachment refers to the process of developing strong ties of affection between an infant and significant other.
The development of a close emotional attraction to the newborn by parents during the first 30 to 60 minutes after birth describes bonding. Reciprocity is the process by which the infant's capabilities and behavioral characteristics elicit a parental response. Engrossment refers to the intense interest during early contact with a newborn. Attachment refers to the process of developing strong ties of affection between an infant and significant other.
9.
Which practice would be least effective in
promoting bonding and attachment?
A) Allowing unlimited visiting hours on maternity units
B) Offering round-the-clock nursery care for all infants
C) Promoting rooming-in
D) Encouraging infant contact immediately after birth
A) Allowing unlimited visiting hours on maternity units
B) Offering round-the-clock nursery care for all infants
C) Promoting rooming-in
D) Encouraging infant contact immediately after birth
ANS;B
Factors that can affect attachment include separation of the infant and parents for long times during the day, such as if the infant was being cared for in the nursery throughout the day. Unlimited visiting hours, rooming-in, and infant contact immediately after birth promote bonding and attachment.
Factors that can affect attachment include separation of the infant and parents for long times during the day, such as if the infant was being cared for in the nursery throughout the day. Unlimited visiting hours, rooming-in, and infant contact immediately after birth promote bonding and attachment.
10.
Which instructions would the nurse include
in discharge teaching for parents of a newborn?
A) Introducing solid foods immediately to increase sleep cycle
B) Demonstrating comfort measures to quiet a crying infant
C) Encouraging daily outings to the shopping mall with the newborn
D) Allowing the infant to cry for at least an hour before picking him or her up
A) Introducing solid foods immediately to increase sleep cycle
B) Demonstrating comfort measures to quiet a crying infant
C) Encouraging daily outings to the shopping mall with the newborn
D) Allowing the infant to cry for at least an hour before picking him or her up
ANS;B
Discharge teaching typically would focus on several techniques to comfort a crying newborn. The nurse needs to emphasize the importance of responding to the newborn's cues, not allowing the infant to cry for an hour before being comforted. Information about solid foods is inappropriate for a newborn because solid foods are not introduced at this time. The mother and newborn need rest periods. Therefore, daily outings to a shopping mall would be inappropriate. Information about newborn sleep-wake cycles and measures for sensory enrichment and stimulation would be more appropriate.
Discharge teaching typically would focus on several techniques to comfort a crying newborn. The nurse needs to emphasize the importance of responding to the newborn's cues, not allowing the infant to cry for an hour before being comforted. Information about solid foods is inappropriate for a newborn because solid foods are not introduced at this time. The mother and newborn need rest periods. Therefore, daily outings to a shopping mall would be inappropriate. Information about newborn sleep-wake cycles and measures for sensory enrichment and stimulation would be more appropriate.
11.When developing the
plan of care for the parents of a newborn, the nurse identifies interventions
to promote bonding and attachment based on the rationale that bonding and
attachment are most supported by which measure?
A) Early parent-infant contact following birth
B) Expert medical care for the labor and birth
C) Good nutrition and prenatal care during pregnancy
D) Grandparent involvement in infant care after birth
A) Early parent-infant contact following birth
B) Expert medical care for the labor and birth
C) Good nutrition and prenatal care during pregnancy
D) Grandparent involvement in infant care after birth
ANS; A
Optimal bonding requires a period of close contact between the parents and newborn within the first few minutes to a few hours after birth. Expert medical care, nutrition and prenatal care, and grandparent involvement are not associated with the promotion of bonding.
Optimal bonding requires a period of close contact between the parents and newborn within the first few minutes to a few hours after birth. Expert medical care, nutrition and prenatal care, and grandparent involvement are not associated with the promotion of bonding.
12.
Which method would be most effective in
evaluating the parents' understanding about their newborn's care?
A) Demonstrate all infant care procedures
B) Allow the parents to state the steps of the care
C) Observe the parents performing the procedures
D) Routinely assess the newborn for cleanliness
A) Demonstrate all infant care procedures
B) Allow the parents to state the steps of the care
C) Observe the parents performing the procedures
D) Routinely assess the newborn for cleanliness
ANS;C
The most effective means to evaluate the parents' learning is to observe them performing the procedures. Parental roles develop and grow through interaction with their newborn. The nurse would involve both parents in the newborn's care and praise them for their efforts. Demonstrating the procedures to the parents and having the parents state the steps are helpful but do not guarantee that the parents understand them. Assessing the newborn for cleanliness would provide little information about parental learning.
The most effective means to evaluate the parents' learning is to observe them performing the procedures. Parental roles develop and grow through interaction with their newborn. The nurse would involve both parents in the newborn's care and praise them for their efforts. Demonstrating the procedures to the parents and having the parents state the steps are helpful but do not guarantee that the parents understand them. Assessing the newborn for cleanliness would provide little information about parental learning.
13.
A postpartum woman is having difficulty
voiding for the first time after giving birth. Which of the following would be
least effective in helping to stimulate voiding?
A) Pouring warm water over her perineal area
B) Having her hear the sound of water running nearby
C) Placing her hand in a basin of cool water
D) Standing her in the shower with the warm water on
A) Pouring warm water over her perineal area
B) Having her hear the sound of water running nearby
C) Placing her hand in a basin of cool water
D) Standing her in the shower with the warm water on
ANS;C
Helpful measures to stimulate voiding include placing her hand in a basin of warm water, pouring warm water over her perineal area, hearing the sound of running water nearby, blowing bubbles through a straw, standing in the shower with the warm water turned on, and drinking fluids.
Helpful measures to stimulate voiding include placing her hand in a basin of warm water, pouring warm water over her perineal area, hearing the sound of running water nearby, blowing bubbles through a straw, standing in the shower with the warm water turned on, and drinking fluids.
14. The nurse is assisting a postpartum woman out of
bed to the bathroom for a sitz bath. Which of the following would be a
priority?
A) Placing the call light within her reach
B) Teaching her how the sitz bath works
C) Telling her to use the sitz bath for 30 minutes
D) Cleaning the perineum with the peri-bottle
A) Placing the call light within her reach
B) Teaching her how the sitz bath works
C) Telling her to use the sitz bath for 30 minutes
D) Cleaning the perineum with the peri-bottle
ANS;A
Tremendous hemodynamic changes are taking place within the woman, and safety must be a priority. Therefore, the nurse makes sure that the emergency call light is within her reach should she become dizzy or lightheaded. Teaching her how to use the sitz bath, including using it for 15 to 20 minutes, is appropriate but can be done once the woman's safety is ensured. The woman should clean her perineum with a peri-bottle before using the sitz bath, but this can be done once the woman's safety needs are met.
Tremendous hemodynamic changes are taking place within the woman, and safety must be a priority. Therefore, the nurse makes sure that the emergency call light is within her reach should she become dizzy or lightheaded. Teaching her how to use the sitz bath, including using it for 15 to 20 minutes, is appropriate but can be done once the woman's safety is ensured. The woman should clean her perineum with a peri-bottle before using the sitz bath, but this can be done once the woman's safety needs are met.
15.Review of a
primiparous woman's labor and birth record reveals a prolonged second stage of
labor and extended time in the stirrups. Based on an interpretation of these
findings, the nurse would be especially alert for which of the following?
A) Retained placental fragments
B) Hypertension
C) Thrombophlebitis
D) Uterine subinvolution
A) Retained placental fragments
B) Hypertension
C) Thrombophlebitis
D) Uterine subinvolution
ANS;C
The woman is at risk for thrombophlebitis due to the prolonged second stage of labor, necessitating an increased amount of time in bed, and venous pooling that occurs when the woman's legs are in stirrups for a long period of time. These findings are unrelated to retained placental fragments, which would lead to uterine subinvolution, or hypertension.
The woman is at risk for thrombophlebitis due to the prolonged second stage of labor, necessitating an increased amount of time in bed, and venous pooling that occurs when the woman's legs are in stirrups for a long period of time. These findings are unrelated to retained placental fragments, which would lead to uterine subinvolution, or hypertension.
16.
The nurse is describing a transient,
self-limiting mood disorder that affects mothers after childbirth, identifying
this as postpartum:
A) Depression
B) Psychosis
C) Bipolar disorder
D) Blues
A) Depression
B) Psychosis
C) Bipolar disorder
D) Blues
ANS;D
Postpartum blues are manifested by mild depressive symptoms of anxiety, irritability, mood swings, tearfulness, increased sensitivity, feelings of being overwhelmed, and fatigue. They are usually self-limiting and require no formal treatment other than reassurance and validation of the woman's experience as well as assistance in caring for herself and her newborn. Postpartum depression is a major depressive episode associated with childbirth. Postpartum psychosis is at the severe end of the continuum of postpartum emotional disorders. Bipolar disorder refers to a mood disorder typically involving episodes of depression and mania.
Postpartum blues are manifested by mild depressive symptoms of anxiety, irritability, mood swings, tearfulness, increased sensitivity, feelings of being overwhelmed, and fatigue. They are usually self-limiting and require no formal treatment other than reassurance and validation of the woman's experience as well as assistance in caring for herself and her newborn. Postpartum depression is a major depressive episode associated with childbirth. Postpartum psychosis is at the severe end of the continuum of postpartum emotional disorders. Bipolar disorder refers to a mood disorder typically involving episodes of depression and mania.
17.A woman who is 2
weeks postpartum calls the clinic and says, "My left breast hurts."
After further assessment on the phone, the nurse suspects the woman has
mastitis. In addition to pain, the nurse would assess for which of the
following?
A) An inverted nipple on the affected breast
B) No breast milk in the affected breast
C) An ecchymotic area on the affected breast
D) Hardening of an area in the affected breast
A) An inverted nipple on the affected breast
B) No breast milk in the affected breast
C) An ecchymotic area on the affected breast
D) Hardening of an area in the affected breast
ANS;D
Mastitis is characterized by a tender, hot, red, painful area on the affected breast. An inverted nipple is not associated with mastitis. With mastitis, the breast is distended with milk, the area is inflamed (not ecchymotic), and there is breast tenderness.
Mastitis is characterized by a tender, hot, red, painful area on the affected breast. An inverted nipple is not associated with mastitis. With mastitis, the breast is distended with milk, the area is inflamed (not ecchymotic), and there is breast tenderness.
18.
When reviewing the causes of late
postpartum hemorrhage, which of the following would the nurse identify as the
most common cause?
A) Retained placental fragments
B) Uterine atony
C) Cervical or vaginal lacerations
D) Uterine inversion
A) Retained placental fragments
B) Uterine atony
C) Cervical or vaginal lacerations
D) Uterine inversion
ANS;A
Late postpartum hemorrhage is typically due to subinvolution secondary to retained placental fragments, distended bladder, uterine myoma, and infection. Uterine atony, lacerations, and uterine inversion would most likely lead to early postpartum hemorrhage.
Late postpartum hemorrhage is typically due to subinvolution secondary to retained placental fragments, distended bladder, uterine myoma, and infection. Uterine atony, lacerations, and uterine inversion would most likely lead to early postpartum hemorrhage.
19.
Which of the following would be essential
to implement to prevent late postpartum hemorrhage?
A) Administering broad-spectrum antibiotics
B) Inspecting the placenta after delivery for intactness
C) Manually removing the placenta at delivery
D) Applying pressure to the umbilical cord to remove the placenta
A) Administering broad-spectrum antibiotics
B) Inspecting the placenta after delivery for intactness
C) Manually removing the placenta at delivery
D) Applying pressure to the umbilical cord to remove the placenta
ANS;B
After the placenta is expelled, a thorough inspection is necessary to confirm its intactness because tears or fragments left inside may indicate an accessory lobe or placenta accreta. These can lead to profuse hemorrhage because the uterus is unable to contract fully. Administering antibiotics would be appropriate for preventing infection, not postpartum hemorrhage. Manual removal of the placenta or excessive traction on the umbilical cord can lead to uterine inversion, which in turn would result in hemorrhage.
After the placenta is expelled, a thorough inspection is necessary to confirm its intactness because tears or fragments left inside may indicate an accessory lobe or placenta accreta. These can lead to profuse hemorrhage because the uterus is unable to contract fully. Administering antibiotics would be appropriate for preventing infection, not postpartum hemorrhage. Manual removal of the placenta or excessive traction on the umbilical cord can lead to uterine inversion, which in turn would result in hemorrhage.
20.
A multipara client develops
thrombophlebitis after delivery. Which of the following would alert the nurse
to the need for immediate intervention?
A) Dyspnea, diaphoresis, hypotension, and chest pain
B) Dyspnea, bradycardia, hypertension, and confusion
C) Weakness, anorexia, change in level of consciousness, and coma
D) Pallor, tachycardia, seizures, and jaundice
A) Dyspnea, diaphoresis, hypotension, and chest pain
B) Dyspnea, bradycardia, hypertension, and confusion
C) Weakness, anorexia, change in level of consciousness, and coma
D) Pallor, tachycardia, seizures, and jaundice
ANS;A
Sudden unexplained shortness of breath and complaints of chest pain along with diaphoresis and hypotension suggest pulmonary embolism, which requires immediate action. Other signs and symptoms include tachycardia, apprehension, hemoptysis, syncope, and sudden change in the woman's mental status secondary to hypoxemia. Anorexia, seizures, and jaundice are unrelated to a pulmonary embolism.
Sudden unexplained shortness of breath and complaints of chest pain along with diaphoresis and hypotension suggest pulmonary embolism, which requires immediate action. Other signs and symptoms include tachycardia, apprehension, hemoptysis, syncope, and sudden change in the woman's mental status secondary to hypoxemia. Anorexia, seizures, and jaundice are unrelated to a pulmonary embolism.
21.
A client experienced prolonged labor with
prolonged premature rupture of membranes. The nurse would be alert for which of
the following in the mother and the newborn?
A) Infection
B) Hemorrhage
C) Trauma
D) Hypovolemia
A) Infection
B) Hemorrhage
C) Trauma
D) Hypovolemia
ANS;A
Although hemorrhage, trauma, and hypovolemia may be problems, the prolonged labor with the prolonged premature rupture of membranes places the client at high risk for a postpartum infection. The rupture of membranes removes the barrier of amniotic fluid so bacteria can ascend.
Although hemorrhage, trauma, and hypovolemia may be problems, the prolonged labor with the prolonged premature rupture of membranes places the client at high risk for a postpartum infection. The rupture of membranes removes the barrier of amniotic fluid so bacteria can ascend.
22.
When assessing the postpartum woman, the
nurse uses indicators other than pulse rate and blood pressure for postpartum
hemorrhage because:
A) These measurements may not change until after the blood loss is large
B) The body's compensatory mechanisms activate and prevent any changes
C) They relate more to change in condition than to the amount of blood lost
D) Maternal anxiety adversely affects these vital signs
A) These measurements may not change until after the blood loss is large
B) The body's compensatory mechanisms activate and prevent any changes
C) They relate more to change in condition than to the amount of blood lost
D) Maternal anxiety adversely affects these vital signs
ANS;A
The typical signs of hemorrhage do not appear in the postpartum woman until as much as 1,800 to 2,100 mL of blood has been lost. In addition, accurate determination of actual blood loss is difficult because of blood pooling inside the uterus and on perineal pads, mattresses, and the floor.
The typical signs of hemorrhage do not appear in the postpartum woman until as much as 1,800 to 2,100 mL of blood has been lost. In addition, accurate determination of actual blood loss is difficult because of blood pooling inside the uterus and on perineal pads, mattresses, and the floor.
23.
The nurse would be alert for which of the
following immediately after a woman with abruptio placentae gives birth?
A) Severe uterine pain
B) Board-like abdomen
C) Appearance of petechiae
D) Inversion of the uterus
A) Severe uterine pain
B) Board-like abdomen
C) Appearance of petechiae
D) Inversion of the uterus
ANS;C
A complication of abruptio placentae is disseminated intravascular coagulation (DIC), which is manifested by petechiae, ecchymoses, and other signs of impaired clotting. Severe uterine pain, a board-like abdomen, and uterine inversion are not associated with abruptio placentae.
A complication of abruptio placentae is disseminated intravascular coagulation (DIC), which is manifested by petechiae, ecchymoses, and other signs of impaired clotting. Severe uterine pain, a board-like abdomen, and uterine inversion are not associated with abruptio placentae.
24.
Which of the following assessment findings
in a postpartum client would be most alarming?
A) Leg pain on ambulation with mild ankle edema
B) Calf pain with dorsiflexion of the foot.
C) Perineal pain with swelling along the episiotomy
D) Sharp stabbing chest pain with shortness of breath
A) Leg pain on ambulation with mild ankle edema
B) Calf pain with dorsiflexion of the foot.
C) Perineal pain with swelling along the episiotomy
D) Sharp stabbing chest pain with shortness of breath
ANS; D
Sharp stabbing chest pain with shortness of breath suggests pulmonary embolism, an emergency that requires immediate action. Leg pain on ambulation with mild edema suggests superficial venous thrombosis. Calf pain on dorsiflexion of the foot may indicate deep vein thrombosis or a strained muscle or contusion. Perineal pain with swelling along the episiotomy might be a normal finding or suggest an infection. Of the conditions, pulmonary embolism is the most urgent..
Sharp stabbing chest pain with shortness of breath suggests pulmonary embolism, an emergency that requires immediate action. Leg pain on ambulation with mild edema suggests superficial venous thrombosis. Calf pain on dorsiflexion of the foot may indicate deep vein thrombosis or a strained muscle or contusion. Perineal pain with swelling along the episiotomy might be a normal finding or suggest an infection. Of the conditions, pulmonary embolism is the most urgent..
25.
Which of the following would the nurse
least expect to administer to a woman experiencing postpartum hemorrhage?
A) Oxytocin
B) Methylergonovine
C) Carboprost
D) Terbutaline
A) Oxytocin
B) Methylergonovine
C) Carboprost
D) Terbutaline
ANS;D
Terbutaline is a tocolytic agent used to halt preterm labor. It would not be used to treat postpartum hemorrhage. Oxytocin, methylergonovine, and carboprost are drugs used to manage postpartum hemorrhage.
Terbutaline is a tocolytic agent used to halt preterm labor. It would not be used to treat postpartum hemorrhage. Oxytocin, methylergonovine, and carboprost are drugs used to manage postpartum hemorrhage.
26 .A client asks the nurse what a third degree laceration
is. She was informed that she had one. The nurse
explains that this is:
a. that extended their anal sphincter
b. through the skin and into the muscles
c. that involves anterior rectal wall
d. that extends through the perineal muscle.
b. through the skin and into the muscles
c. that involves anterior rectal wall
d. that extends through the perineal muscle.
ANS; (A)
that extended their anal
sphincter
Third degree laceration involves all in the second degree
laceration and the external sphincter of the rectum. Options B, C and D are
under the second degree laceration.
27. Betina 30 weeks AOG discharged with a diagnosis of placenta previa. The nurse knows that the client understands her care at home when she says:
a. I am happy to note that we can have sex occasionally when I
have no bleeding.
b. I am afraid I might have an operation when my due comes
c. I will have to remain in bed until my due date comes
d. I may go back to work since I stay only at the office.
b. I am afraid I might have an operation when my due comes
c. I will have to remain in bed until my due date comes
d. I may go back to work since I stay only at the office.
ANS; (C)
I will have to remain in
bed until my due date comes
Placenta previa means that the placenta is the presenting part. On
the first and second trimester there is spotting. On the third trimester there
is bleeding that is sudden, profuse and painless.
28. The uterus has already risen out of the pelvis and is experiencing farther into the abdominal area at about the:
a. 8th week of pregnancy
b. 10th week of pregnancy
c. 12th week of pregnancy
d. 18th week of pregnancy
b. 10th week of pregnancy
c. 12th week of pregnancy
d. 18th week of pregnancy
ANS; (D)
18th
week of pregnancy
On the 8th week of pregnancy, the uterus is still within the
pelvic area. On the 10th week, the uterus is still within the pelvic area. On
the 12th week, the uterus and placenta have grown, expanding into the abdominal
cavity. On the 18th week, the uterus has already risen out of the pelvis and is
expanding into the abdominal area.
29. Which of the following urinary symptoms does the pregnant woman most frequently experience during the first trimester:
a. frequency
b. dysuria
c. incontinence
d. burning
b. dysuria
c. incontinence
d. burning
ANS; (A)
frequency
Pressure and irritation of the bladder by the growing uterus
during the first trimester is responsible for causing urinary frequency.
Dysuria, incontinence and burning are symptoms associated with urinary tract
infection
5. Mrs. Jimenez went to the health center for pre-natal check-up. the student nurse took her weight and revealed 142 lbs. She asked the student nurse how much should she 30.gain weight in her pregnancy.
5. Mrs. Jimenez went to the health center for pre-natal check-up. the student nurse took her weight and revealed 142 lbs. She asked the student nurse how much should she 30.gain weight in her pregnancy.
a. 20-30 lbs
b. 25-35 lbs
c. 30- 40 lbs
d. 10-15 lbs
b. 25-35 lbs
c. 30- 40 lbs
d. 10-15 lbs
ANS; (B) 25-35 lbs
A weight gain of 11. 2 to 15.9 kg (25 to 35 lbs) is currently
recommended as an average weight gain in pregnancy. This weight gain consists
of the following: fetus- 7.5 lb; placenta- 1.5 lb; amniotic fluid- 2 lb;
uterus- 2.5 lb; breasts- 1.5 to 3 lb; blood volume- 4 lb; body fat- 7 lb; body
fluid- 7 lb.
31. The nurse is preparing Mrs. Jordan for cesarean delivery. Which of the following key concept should the nurse consider when implementing nursing care?
a. Explain the surgery, expected outcome and kind of anesthetics.
b. Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth.
c. Arrange for a staff member of the anesthesia department to explain what to expect post-operatively.
d. Instruct the mother’s support person to remain in the family lounge until after the delivery.
ANS; (B)
Modify
preoperative teaching to meet the needs of either a planned or emergency
cesarean birth.
A key point to consider when preparing the client for a cesarean
delivery is to modify the preoperative teaching to meet the needs of either
planned or emergency cesarean birth, the depth and breadth of instruction will
depend on circumstances and time available.
32. Bettine Gonzales is hospitalized for the treatment of severe preecplampsia. Which of the following represents an unusual finding for this condition?
a. generalized edema
b. proteinuria 4+
c. blood pressure of 160/110
d. convulsions
b. proteinuria 4+
c. blood pressure of 160/110
d. convulsions
ANS; (D)
convulsions
Options A, B and C are findings of severe preeclampsia.
Convulsions is a finding of eclampsia—an obstetrical emergency.
33. Nurse Geli explains to the client who is 33 weeks pregnant and is experiencing vaginal bleeding that coitus:
a. Need to be modified in any way by either partner
b. Is permitted if penile penetration is not deep.
c. Should be restricted because it may stimulate uterine activity.
d. Is safe as long as she is in side-lying position.
b. Is permitted if penile penetration is not deep.
c. Should be restricted because it may stimulate uterine activity.
d. Is safe as long as she is in side-lying position.
ANS; (C)
Should
be restricted because it may stimulate uterine activity.
Coitus is restricted when there is watery discharge, uterine
contraction and vaginal bleeding. Also those women with a history of
spontaneous miscarriage may be advised to avoid coitus during the time of
pregnancy when a previous miscarriage occurred.
34. Mrs. Precilla Abuel, a 32 year old mulripara is admitted to labor and delivery. Her last 3 pregnancies in short stage one of labor. The nurses decide to observe her closely. The physician determines that Mrs. Abuel’s cervix is dilated to 6 cm. Mrs. Abuel states that she is extremely uncomfortable. To lessen Mrs. Abuel’s discomfort, the nurse can advise her to:
a. lie face down
b. not drink fluids
c. practice holding breaths between contractions
d. assume Sim’s position
b. not drink fluids
c. practice holding breaths between contractions
d. assume Sim’s position
ANS; (D)
assume Sim’s position
When the woman is in Sim’s position, this puts the weight of the
fetus on bed, not on the woman and allows good circulation in the lower
extremities
35. Which is true regarding the fontanels of the newborn?
35. Which is true regarding the fontanels of the newborn?
a. The anterior is large in shape when compared to the posterior
fontanel.
b. The anterior is triangular shaped; the posterior is diamond shaped.
c. The anterior is bulging; the posterior appears sunken.
d. The posterior closes at 18 months; the anterior closes at 8 to 12 months.
b. The anterior is triangular shaped; the posterior is diamond shaped.
c. The anterior is bulging; the posterior appears sunken.
d. The posterior closes at 18 months; the anterior closes at 8 to 12 months.
ANS; (A)
The anterior is large in
shape when compared to the posterior fontanel.
The anterior fontanel is larger in size than the posterior
fontanel. Additionally, the anterior fontanel, which is diamond shaped closes
at 18 month, whereas the posterior fontanel, which is triangular in shape
closes at 8 to 12 weeks. Neither fontanel should appear bulging, which may
indicate increases ICP or sunken, which may indicate hydration.
36. Mrs. Quijones gave birth by spontaneous delivery to a full term baby boy. After a minute after birth, he is crying and moving actively. His birth weight is 6.8 lbs. What do you expect baby Quijones to weigh at 6 months?
a. 13 -14 lbs
b. 16 -17 lbs
c. 22 -23 lbs
d. 27 -28 lbs
b. 16 -17 lbs
c. 22 -23 lbs
d. 27 -28 lbs
ANS; (A)
13 -14
lbs
The birth weight of an infant is doubled at 6 months and is
tripled at 12 months
37. During the first hours following delivery, the post partum client is given IVF with oxytocin added to them. The nurse understands the primary reason for this is:
a. To facilitate elimination
b. To promote uterine contraction
c. To promote analgesia
d. To prevent infection
b. To promote uterine contraction
c. To promote analgesia
d. To prevent infection
ANS; (B)
To
promote uterine contraction
Oxytocin is a hormone produced by the pituitary gland that
produces intermittent uterine contractions, helping to promote uterine
involution.
38. Nurse Luis is assessing the newborn’s heart rate. Which of the following would be considered normal if the newborn is sleeping?
38. Nurse Luis is assessing the newborn’s heart rate. Which of the following would be considered normal if the newborn is sleeping?
a. 80 beats per minute
b. 100 beats per minute
c. 120 beats per minute
d. 140 beats per minute
b. 100 beats per minute
c. 120 beats per minute
d. 140 beats per minute
ANS; (B)
100
beats per minute
The normal heart rate for a newborn that is sleeping is
approximately 100 beats per minute. If the newborn was awake, the normal heart
rate would range from 120 to 160 beats per minute.
.39. The infant with Down Syndrome should go through which of the Erikson’s developmental stages first?
a. Initiative vs. Self doubt
b. Industry vs. Inferiority
c. Autonomy vs. Shame and doubt
d. Trust vs. Mistrust
b. Industry vs. Inferiority
c. Autonomy vs. Shame and doubt
d. Trust vs. Mistrust
ANS; (D)
Trust vs. Mistrust
The child with Down syndrome will go through the same first stage,
trust vs. mistrust, only at a slow rate. Therefore, the nurse should
concentrate on developing on bond between the primary caregiver and the child
40. The child with phenylketonuria (PKU) must maintain a low phenylalanine diet to prevent which of the following complications?
a. Irreversible brain damage
b. Kidney failure
c. Blindness
d. Neutropenia
b. Kidney failure
c. Blindness
d. Neutropenia
ANS; (A)
Irreversible brain damage
The child with PKU must maintain a strict low phenylalanine diet
to prevent central nervous system damage, seizures and eventual death
41. Which age group is with imaginative minds and creates imaginary friends?
41. Which age group is with imaginative minds and creates imaginary friends?
a. Toddler
b. Preschool
c. School
d. Adolescence
b. Preschool
c. School
d. Adolescence
ANS; (B)
Preschool
During preschool, this is the time when children do imitative
play, imaginative play—the occurrence of imaginative playmates, dramatic play
where children like to act, dance and sing
42. Which of the following situations would alert you to a potentially developmental problem with a child?
a. Pointing to body parts at 15 months of age.
b. Using gesture to communicate at 18 months.
c. Cooing at 3 months.
d. Saying “mama” or “dada” for the first time at 18 months of age.
b. Using gesture to communicate at 18 months.
c. Cooing at 3 months.
d. Saying “mama” or “dada” for the first time at 18 months of age.
ANS; (D)
Saying
“mama” or “dada” for the first time at 18 months of age.
A child should say “mama” or “dada” during 10 to 12 months of age.
Options A, B and C are all normal assessments of language development of a
child.
43. Isabelle, a 2 year old girl loves to move around and oftentimes manifests negativism and temper tantrums. What is the best way to deal with her behavior?
a. Tell her that she would not be loved by others is she behaves
that way..
b. Withholding giving her toys until she behaves properly.
c. Ignore her behavior as long as she does not hurt herself and others.
d. Ask her what she wants and give it to pacify her.
b. Withholding giving her toys until she behaves properly.
c. Ignore her behavior as long as she does not hurt herself and others.
d. Ask her what she wants and give it to pacify her.
ANS; (C)
Ignore her behavior as
long as she does not hurt herself and others.
If a child is trying to get attention or trying to get something
through tantrums—ignore his/her behavior
44. Baby boy Villanueva, 4 months old, was seen at the pediatric clinic for his scheduled check-up. By this period, baby Villanueva has already increased his height by how many inches?
44. Baby boy Villanueva, 4 months old, was seen at the pediatric clinic for his scheduled check-up. By this period, baby Villanueva has already increased his height by how many inches?
a. 3 inches
b. 4 inches
c. 5 inches
d. 6 inches
b. 4 inches
c. 5 inches
d. 6 inches
ANS; (B)
4 inches
From birth to 6 months, the infant grows 1 inch (2.5 cm) per
month. From 6 to 12 months, the infant grows ½ inch (1.25 cm) per month
45. Alice, 10 years old was brought to the ER because of Asthma. She was immediately put under aerosol administration of Terbutaline. After sometime, you observe that the child does not show any relief from the treatment given. Upon assessment, you noticed that both the heart and respiratory rate are still elevated and the child shows difficulty of exhaling. You suspect:
a. Bronchiectasis
b. Atelectasis
c. Epiglotitis
d. Status Asthmaticus
b. Atelectasis
c. Epiglotitis
d. Status Asthmaticus
ANS; (D)
Status Asthmaticus
Status asthmaticus leads to respiratory distress and bronchospasm
despite of treatment and interventions. Mechanical ventilation maybe needed due
to respiratory failure.
46. Nurse Jonas assesses a 2 year old boy with a tentative diagnosis of nephroblastoma. Symptoms the nurse observes that suggest this problem include:
a. Lymphedema and nerve palsy
b. Hearing loss and ataxia
c. Headaches and vomiting
d. Abdominal mass and weakness
b. Hearing loss and ataxia
c. Headaches and vomiting
d. Abdominal mass and weakness
ANS; (D)
Abdominal
mass and weakness
Nephroblastoma or Wilm’s tumor is caused by chromosomal
abnormalities, most common kidney cancer among children characterized by
abdominal mass, hematuria, hypertension and fever
47. Which of the following danger sings should be reported immediately during the antepartum period?
47. Which of the following danger sings should be reported immediately during the antepartum period?
a. blurred vision
b. nasal stuffiness
c. breast tenderness
d. constipation
b. nasal stuffiness
c. breast tenderness
d. constipation
ANS; (A)
blurred
vision
Danger signs that require prompt reporting are leaking of amniotic
fluid, blurred vision, vaginal bleeding, rapid weight gain and elevated blood
pressure. Nasal stuffiness, breast tenderness, and constipation are common
discomforts associated with pregnancy.
48. Nurse Jacob is assessing a 15 month old child with acute otitis media. Which of the following symptoms would the nurse anticipate finding?
a. periorbital edema, absent light reflex and translucent tympanic
membrane
b. irritability, purulent drainage in middle ear, nasal congestion and cough
c. diarrhea, retracted tympanic membrane and enlarged parotid gland
d. Vomiting, pulling at ears and pearly white tympanic membrane
b. irritability, purulent drainage in middle ear, nasal congestion and cough
c. diarrhea, retracted tympanic membrane and enlarged parotid gland
d. Vomiting, pulling at ears and pearly white tympanic membrane
ANS; (B)
irritability,
purulent drainage in middle ear, nasal congestion and cough
Irritability, purulent drainage in middle ear, nasal congestion
and cough, fever, loss of appetite, vomiting and diarrhea are clinical
manifestations of otitis media. Acute otitis media is common in children 6
months to 3 years old and 8 years old and above. Breast fed infants have higher
resistance due to protection of Eustachian tubes and middle ear from breast
milk.
49. Which of the following is the most appropriate intervention to reduce stress in a preterm infant at 33 weeks gestation?
a. Sensory stimulation including several senses at a time
b. tactile stimulation until signs of over stimulation develop
c. An attitude of extension when prone or side lying
d. Kangaroo care
b. tactile stimulation until signs of over stimulation develop
c. An attitude of extension when prone or side lying
d. Kangaroo care
ANS; (D)
Kangaroo care
Kangaroo care is the use of skin-to-skin contact to maintain body
heat. This method of care not only supplies heat but also encourages
parent-child interaction
50. The parent of a client with albinism would need to be taught which preventive healthcare measure by the nurse:
a. Ulcerative colitis diet
b. Use of a high-SPF sunblock
c. Hair loss monitoring
d. Monitor for growth retardation
b. Use of a high-SPF sunblock
c. Hair loss monitoring
d. Monitor for growth retardation
ANS; (B)
Use of a high-SPF sunblock
Without
melanin production, the child with albinism is at risk for severe sunburns.
Maximum sun protection should be taken, including use of hats, long sleeves,
minimal time in the sun and high-SPF sunblock, to prevent any problems
