Contemporary Maternal Newborn Nursing 7th Edition by Patricia W. Ladewig – Test Bank

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Contemporary Maternal Newborn Nursing 7th Edition by Patricia W. Ladewig – Test Bank

Chapter 02_LO 01_Q01

Why is it important for the nurse to understand the type of family that a client comes from? Select all that apply.

  1. Family structure can influence finances and the ability to purchase nutritious foods.
  2. Many types of families exist, and it is important to address the persons who hold power within the family.
  3. The nurse can anticipate which problems a client will experience based on the type of family the client has.
  4. Understanding if the client’s family is nuclear or blended will help the nurse teach the client the appropriate information.
  5. The values of the family will be predictable if the nurse knows what type of family the client is a part of.

Correct Answers: 1, 2

Rationale:

  1. Dual-career/dual-earner families tend to have more stable finances, while single-parent families tend to have lower incomes. Nutrition impacts fetal growth and development, and nutritious foods tend to be more costly than nutrient-poor or junk food. Thus understanding the type of family can help the nurse determine the best education for the client.
  2. Understanding the family power is important so that the nurse will address the appropriate person(s). This will facilitate effective communication, as the nurse will be perceived as respectful of the family.
  3. Each client and family must be assessed as individuals, without making assumptions. Although generalities can be drawn based on the type of family that a client comes from or currently is part of, stereotypes must be avoided.
  4. Each client and family must be assessed as individuals, without making assumptions. Although generalities can be drawn based on the type of family that a client comes from or currently is part of, stereotypes must be avoided.
  5. Each client and family must be assessed as individuals, without making assumptions. Although generalities can be drawn based on the type of family that a client comes from or currently is part of, stereotypes must be avoided.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 2.1 Describe how family type can influence nursing care of the childbearing family.

 

Chapter 02_LO2 _Q02

The nurse is preparing a community presentation on family development. Which of the following statements should the nurse include?

  1. The youngest child’s age determines the family’s current stage.
  2. A family does not experience overlapping of stages.
  3. Family development ends when the youngest child leaves home.
  4. The stages describe the family’s progression over time.

Answer: 4

Rationale:

  1. The oldest child’s age is the marker for which stage the family is in, except for the two last stages, which occur after the children have left home.
  2. Families with more than one child can experience multiple stages simultaneously.
  3. Families with more than one child can experience multiple stages simultaneously.
  4. Family development stages describe the changes and adaptations that a family goes through over time as children are added to the family.

 

Assessment

Health Promotion and Maintenance

Application

Learning Outcome 2.2  Explain the changes that a childbearing family will undergo based on the developmental tasks to be completed.

 

Chapter 02_LO03 _Q03

The nurse is preparing to assess the development of a family new to the clinic. The nurse understands that the primary use of a family assessment tool is to:

  1. Obtain a comprehensive medical history of family members.
  2. Determine which clinic the client should be referred to.
  3. Predict how a family will likely change with the addition of children.
  4. Understand the physical, emotional, and spiritual needs of members.

Correct Answer: 4

Rationale:

  1. The focus of a family assessment is the family as one entity. Health of the family is one area that is explored using a family assessment tool.
  2. The family assessment tool facilitates understanding of the physical, emotional, and spiritual needs of members. Although referrals might take place as a result of the family assessment findings, understanding of the family is the primary reason the tool is used.
  3. The family assessment tool facilitates understanding of the physical, emotional, and spiritual needs of members. Family development models help predict how a family will likely change with the addition of children.
  4. This is the main reason for using a family assessment tool.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 2.3 Identify information that would be useful to collect when performing a family assessment.

 

 

 

 

Chapter 02_LO 04_Q04

A laboring client has been very quiet during labor, and has made no noise during contractions during the past four hours. The client is of Chinese descent. The nurse understands that this indicates that the client:

  1. Believes pain should be endured and not expressed.
  2. Is not in the active phase of labor yet.
  3. Will not need pain medication during her hospitalization.
  4. Has been abused by her husband and is afraid to verbalize fear.

Correct Answer: 1

Rationale:

  1. This is a common traditional Chinese belief.
  2. Because it is a common traditional Chinese belief to not express pain verbally, the nurse must assess for the progression of labor in other ways.
  3. Although it is a common traditional Chinese belief to not express pain verbally, the assumption cannot be made that no pain relief medication will be needed either during the labor and birth or the postpartum period.
  4. It is a common traditional Chinese belief to not express pain verbally, and does not indicate domestic abuse.

Cognitive level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Diagnosis

Learning Outcome: 2.4 Integrate the prevalent cultural norms of a family that affect childbearing and child rearing when providing care to that family.

 

 

Chapter 02_LO 04_Q05

 

A woman of Korean descent has just given birth to a son. Her partner wishes to give her sips of hot broth from a thermos he brought from home. The client has refused your offer of ice chips or other cold drinks. The nurse should:

  1. Explain to the client that she can have the broth if she will also drink cold water or juice.
  2. Encourage the partner to feed the client sips of broth. Ask if the client would like you to bring her some warm water to drink as well.
  3. Explain to the couple that food can’t be brought from home, but that the nurse will make hot broth for the client.

 

  1. Encourage the client to have the broth, after the nurse takes it to the kitchen and boils it first.

 

Correct Answer: 2

Rationale:

  1. Explaining to the client that she can have broth if she will drink cold water or juice first does not show cultural sensitivity and does not respect the client’s beliefs.
  2. Encouraging the partner to feed the client sips of broth and asking if the client would like you to bring her some warm water to drink as well is an approach that shows cultural sensitivity. The equilibrium model of health, based on the concept of balance between light and dark, heat and cold, is the foundation for this belief and practice.
  3. Explaining to the couple that the hospital does not allow food brought from home but that you will make hot broth for them is an incorrect response.
  4. Encouraging the client to have broth after you take it the kitchen and boil it first is an incorrect response because boiling first would make the broth too hot to drink.

Nursing Process: Intervention

Category of Client Need: Health Promotion: Growth and Development

Cognitive Level: Application

Learning Outcome: 2.4 Integrate the prevalent cultural norms of a family that affect childbearing and child rearing when providing care to that family.

 

 

Chapter 02_LO 05_Q06

The nurse works in a facility that cares for clients from a broad range of racial, ethnic, cultural, and religious backgrounds. Which statement should the nurse include in a presentation for nurses new to the facility on the client population of the facility?

  1. “Our clients come from a broad range of backgrounds, but we have a good interpreter service.”
  2. “Many of our clients come from backgrounds different from your own, but it doesn’t cause problems for the nurses.”
  3. “Because most of the doctors are bilingual, we don’t have to deal with the differences in cultural backgrounds of our clients.”
  4. “Understanding the common values and health practices of our diverse clients will facilitate better care and health outcomes.”

Correct Answer: 4

Rationale:

  1. The role of a foreign language interpreter is to facilitate communication. The interpreter might or might not be able to interpret the cultural practices of clients. An example is a Spanish interpreter: The interpreter might be from Spain, but interprets language for clients from Guatemala and Nicaragua, countries about which the interpreter might know virtually nothing.
  2. Racial, ethnic, cultural, and religious backgrounds of clients have significant implications for how they perceive health, illness, and health care. It is important for nurses to understand the backgrounds of the client population that attend that facility.
  3. Bilingual physicians, like all physicians, have very busy schedules, and often do not understand nursing care. It is the responsibility of the nurse to become familiar with the backgrounds of the client population.
  4. Because of the implications for care based on cultural background, it is important for nurses to understand the backgrounds of the client population that attend the facility.

Cognitive level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 2.5 Explain the importance of cultural competency in providing nursing care to the childbearing family.

 

 

Chapter 02_LO 05_Q07

The nurse manager in a hospital with a large immigrant population is planning an in-service. The nurse manager is aware of how ethnocentrism affects nursing care. Which statement should the nurse manager include? “The belief that one’s own values and beliefs are the only or the best values:

  1. “Means that newcomers to the United States should adopt U.S. norms and values.”
  2. “Can create barriers to communication through misunderstanding.”
  3. “Leads to an expectation that all clients will exhibit pain the same way.”
  4. “Improves the quality of care provided to culturally diverse client bases.”

Answer: 2

Rationale:

  1. Although acculturation involves adoption of some of the majority culture’s practices and beliefs, each cultural group will continue to hold and express its own set of values and beliefs.
  2. Ethnocentrism is the conviction that one’s own values and beliefs either are the only ones that exist, or are the best. When the nurse assumes that a client has the same values and beliefs as the nurse, misunderstanding will frequently occur, which in turn can negatively impact nurse–client communication.
  3. Expression of pain is one area that varies greatly from one culture to another.
  4. The belief that one’s own values and beliefs are the best will not improve the quality of care provided to culturally diverse client bases.

Cognitive Level: Application

Category of Client Need: Psychosocial Integrity

Nursing Process: Planning

Learning Outcome 2.5  Explain the importance of cultural competency in providing nursing care to the childbearing family.

 

 

Chapter 02_LO 05_Q08

 

When preparing to teach a culturally diverse group of childbearing families about hospital birthing options, in order to be culturally competent, the nurse should:

  1. Understand that the families have the same values as the nurse.
  2. Teach the families how childbearing takes place in the United States.
  3. Insist that the clients answer questions instead of their husbands.
  4. Learn about the cultural groups that are likely to attend the class.

Answer: 4

Rationale:

  1. Assuming that the families have the same values is ethnocentrism.
  2. Although it is important to explain health care during pregnancy and childbearing, this is not the top priority.
  3. The husband’s answering questions might be a cultural norm, and insisting that the client answer could decrease the family’s trust in the health care system.
  4. Cultural competence is the development of skills and knowledge necessary to appreciate, understand, and work with individuals from other cultures than the culture of the nurse. Through gaining knowledge of the cultures that are likely to be encountered professionally, the nurse is able to understand the aspects of the client’s culture that might impact how care should best be given to be accepted by the client.

Cognitive Level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome 2.5 Explain the importance of cultural competency in providing nursing care to the childbearing family.

 

 

Chapter 02_LO 06_Q09

The nurse is admitting a Mexican woman scheduled for a cholecystectomy. The nurse uses a cultural assessment tool during the admission. Which question would be most important for the nurse to ask?

  1. “What other treatments have you used for your abdominal pain?”
  2. “What is your country of origin; where were you were born?”
  3. “When you talk to family members, how close do you stand?”
  4. “How would you describe your role within your family?”

Correct Answer: 1

Rationale:

  1. This question is most important because some traditional or folk remedies include the use of herbs. Because some herbs have medication interactions, this physiologic question is imperative to ask.
  2. Although this information is helpful, it is not a physiological issue. Asking about other treatments is a higher priority.
  3. Although understanding the client’s perception of appropriate personal space is helpful, it is not a physiological issue. Asking about other treatments is a higher priority.
  4. Although understanding the client’s family roles is helpful, it is not a physiological issue. Asking about other treatments is a higher priority.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 2.6 Interpret the information collected from a cultural assessment to provide culturally sensitive care.

 

Chapter 02_LO 07_Q10

The Labor and Delivery nurse is caring for a laboring client who has asked for a priest to visit her during labor. The client’s mother died during childbirth, and although there are no complications during the client’s pregnancy, she is fearful of her own death during labor. What is the best response of the nurse?

  1. “Nothing is going to happen to you. We’ll take very good care of you during your birth.”
  2. “Would you like to have an epidural so that you won’t feel the pain of the contractions?”
  3. “The priest won’t be able to prevent complications, and might get in the way of your providers.”
  4. “Would you like me to contact your parish or our hospital chaplain to come see you?”

Correct Answer: 4

Rationale:

  1. Avoid statements of false reassurance, as there are no guarantees in the outcomes during health care. Using these statements shuts down effective communication, as the client’s concern is downplayed.
  2. The client’s expressed concern is not about pain, it is a fear of death and a desire to see a priest. Address the client’s concerns directly.
  3. Although this statement is true, it is not therapeutic. It downplays the client’s concerns, and will shut down effective communication. Address the concerns the client expresses.
  4. When the client states she wants to see a priest, the nurse should attempt to make arrangements for this visit to occur in a timely manner. Most hospitals have a chaplaincy department that can provide assistance in obtaining the services of a wide variety of religious leaders. Depending on the day of the week and the time of day, the client’s own home parish church might be able to provide a priest for pastoral care at the bedside.

Cognitive level: Application

Category of Client Need: Psychosocial Integrity

Nursing Process: Planning

Learning Outcome: 2.7 Identify ways a nurse might accommodate the religious rituals and practices of the childbearing family.

 

Chapter 02_LO 08_Q11

The nurse is assessing a client who reports seeing an acupuncturist on a weekly basis to treat back pain. The nurse understands that acupuncture is an example of:

  1. A risky practice without evidence of efficacy.
  2. Folk remedy use.
  3. Complementary therapy.
  4. Alternative therapy.

Correct Answer: 3

Rationale:

  1. Acupuncture has been a traditional Chinese medicine for over 3,000 years. Good evidence is available on the efficacy of acupuncture for treatment of chronic pain.
  2. A folk remedy is a practice of a cultural group that either has no evidence to support efficacy or has been found not to have an effect. Acupuncture has been a traditional Chinese medicine for over 3,000 years.
  3. Acupuncture is a therapy that is used in conjunction with conventional medical treatment, and therefore is an example of a complementary therapy.
  4. An alternative therapy is usually considered a substance or procedure that is used in place of conventional medicine. Acupuncture is categorized as a complementary therapy.

Cognitive level: Application

Category of Client Need: Physiologic Integrity

Nursing Process: Diagnosis

Learning Outcome: 2.8 Distinguish between complementary and alternative therapies.

 

Chapter 02_LO 08_Q12

 

The client states, “I am using homeopathic remedies to help with my morning sickness.” The nurse understands that the client is utilizing:

  1. A complementary therapy.
  2. An alternative therapy.
  3. Traditional Chinese medicine.
  4. Naturopathy.

Answer: 1

Rationale:

  1. A complementary therapy is that which is an adjunct to traditional medical treatment, and has been shown through rigorous scientific testing to be reliable.
  2. Alternative therapies are those that have not undergone rigorous scientific testing.
  3. Traditional Chinese medicine includes acupuncture and herbology.
  4. Naturopathy is an eclectic combination of nutrition, botanical medicine, homeopathy, acupuncture, hydrotherapy, and physiotherapy.

Cognitive Level: Analysis

Category of Client Need: Physiologic Integrity

Nursing Process: Assessment

Learning Outcome 2.8 Distinguish between complementary and alternative therapies.

 

Chapter 02_LO09_Q13

The client pregnant with her first child reports that her husband wants her to visit a homeopath for help with her nausea and vomiting. The client asks what the nurse’s opinion of homeopathy is. The best response by the nurse is:

  1. “Homeopathy is unproven and potentially dangerous. Avoid using homeopathic remedies.”
  2. “The FDA has approved homeopathic remedies, and practitioners undergo education and certification.”
  3. “I can’t give you advice about what alternatives to try. Go online and do some research to get information.”
  4. “Homeopathy is the same as herbal remedies. Some are safe during pregnancy and some are not.”

Correct Answer: 2

Rationale:

  1. Homeopathic remedies are not dangerous. Homeopathic remedies are FDA-approved, and have been proven to be effective in treating a wide range of chronic and acute illnesses and conditions.
  2. Homeopathic remedies are FDA-approved, and have been proven to be effective in treating a wide range of chronic and acute illnesses and conditions.
  3. It is appropriate for the nurse to provide factual information to educate a client who has asked a question. Not all clients have access to computers, nor do they know how to do an internet search.
  4. Herbalism and homeopathy are not the same. Herbs are available in many stores and preparations; some have been proven to be dangerous during pregnancy. Homeopathy is a system of “like curing like,” in which the symptom being treated would be a symptom of taking too much of the substance in a non-homeopathic form.

Cognitive level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Implementation

Learning Outcome: 2.9 Describe the benefits and risks of the various complementary and alternative therapies to the childbearing family.

 

 

Chapter 02_LO09_Q14

 

Complementary and alternative therapies have many benefits for the childbearing family and others. However, many of these remedies have associated risks. Which of the following situations would be considered risks? Select all that apply.

  1. Getting a massage from a licensed massage therapist for back pain, prescribed by the primary caregiver
  2. Trying out a homeopathic medicine from a friend to reduce swelling in the legs
  3. Getting a chiropractic treatment for low back pain due to discomforts of pregnancy without telling the primary health care provider
  4. Taking an herbal preparation suggested by a health food store worker for treatment of leg pain
  5. Joining a group that practices tai chi weekly to help with physical fitness and movement

Correct Answers: 2, 3, 4

 

Rationale:

  1. Getting a massage from a licensed massage therapist for back pain, prescribed by the primary caregiver, is a perfectly good use of complementary therapies.

 

  1. Trying out a homeopathic medicine from a friend to reduce swelling in your legs is a risk factor when considering these therapies. Lack of standardization, lack of regulation and research to substantiate their safety and effectiveness, and inadequate training and certification of some healers make some therapies risky.

 

  1. Getting a chiropractic treatment for low back pain due to discomforts of pregnancy without telling the primary health care provider is a risk factor when considering these therapies. Lack of standardization, lack of regulation and research to substantiate their safety and effectiveness, and inadequate training and certification of some healers make some therapies risky.

 

  1. Taking an herbal preparation suggested by a health food store worker for treatment of leg pain is a risk factor when considering these therapies. Lack of standardization, lack of regulation and research to substantiate their safety and effectiveness, and inadequate training and certification of some healers make some therapies risky.

 

  1. Joining a group that practices tai chi weekly to help with physical fitness and movement is a perfectly good use of complementary therapies.

Nursing Process: Assessment

Category of Client Need: Safe, Effective Care Environment: Management of Care

Cognitive Level: Analysis

Learning Outcome: 2.9 Describe the benefits and risks of the various complementary and alternative therapies to the childbearing family.

 

 

Chapter 02_LO 10_Q15

The Labor and Delivery unit nurse manager is incorporating complementary and alternative therapies into the unit’s policies and procedures. Which statement should the nurse manager make to the nursing staff during an in-service educational presentation?

  1. “Policies have been developed for using massage and aromatherapy.”
  2. “When clients ask questions you don’t know, tell them to look online.”
  3. “Because herbs are dangerous during pregnancy, we will not use them.”
  4. “Be sure to ask clients what alternative therapies they have used.”

Correct Answer: 1

Rationale:

  1. The development of written policies and procedures facilitates safe nursing practice, which in turn promotes client safety.
  2. Online information can vary in its accuracy. Reputable sources (electronic or print) should be recommended for further client education.
  3. This statement is false. Many herbs can be safely used during pregnancy.
  4. What the client has used in the past does not predict what she is open to using at present. It is more important to develop written policies and procedures.

Cognitive level: Application

Category of Client Need: Physiological Integrity

Nursing Process: Planning

Learning Outcome: 2.10 Formulate nursing care within the nurse practice act and with the informed consent of the client when using appropriate complementary therapies with childbearing families.

 

Chapter 14_LO01_Q01

The nurse is responding to phone calls. Which call should the nurse return first?

  1. 37 weeks’ gestation, reports no fetal movement for 24 hours.
  2. 29 weeks’ gestation, reports increased fetal movement.
  3. 32 weeks’ gestation, reports decreased fetal movement X 2 days.
  4. 35 weeks’ gestation, reports decreased fetal movement X 4 hours.

Correct Answer: 1

Rationale:

  1. A lack of fetal movement in a fetus in the third trimester can indicate fetal hypoxia or fetal death. This client is the highest priority.
  2. Increased fetal movement is not indicative of a problem.
  3. Although decreased fetal movement can indicate intrauterine growth restriction or fetal hypoxia, this client is not the highest priority.
  4. Although decreased fetal movement can indicate intrauterine growth restriction or fetal hypoxia, four hours is a very short amount of time to assess decreased fetal movement.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 14.1 Identify pertinent information to be discussed with the woman regarding her own assessment of fetal activity and methods of recording fetal activity.

 

Chapter 14_LO01_Q02

A woman at 28 weeks’ gestation is asked to keep a fetal activity diary and to bring the results with her to her next clinic visit. One week later, she calls the clinic and anxiously tells the nurse that she has not felt the baby move for over 30 minutes. The most appropriate initial comment by the nurse would be:

  1. “You need to come to the clinic right away for further evaluation.”
  2. “Have you been smoking?”
  3. “When did you eat last?”
  4. “Your baby might be asleep.”

Answer: 4

Rationale:

  1. The mother would need to come to the clinic only if there had been no fetal activity for several hours.
  2. Smoking also typically will stimulate the infant.
  3. After meals, an infant typically is active and moving.
  4. Lack of fetal activity for 30 minutes typically is insignificant, and means only that the infant is sleeping. If the mother truly is concerned, in 30 minutes, she could eat a complex-carbohydrate snack. This would stimulate the infant, and the mother should have fetal activity. But at present, this is an indicator the infant is sleeping.

Cognitive Level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Diagnosis

Learning Outcome: 14.1 Identify pertinent information to be discussed with the woman regarding her own assessment of fetal activity and methods of recording fetal activity.

 

 

Chapter 14_LO02 _Q03

The nurse is preparing a client in her second trimester for a three-dimensional ultrasound examination. Which statement indicates that teaching had been effective?

  1. “If the ultrasound is normal, it means my baby has no abnormalities.”
  2. “The nuchal translucency measurement will diagnose Down syndrome.”
  3. “I might be able to see who the baby looks like with the ultrasound.”
  4. “Measuring the length of my cervix will determine if I will deliver early.”

Correct Answer: 3

Rationale:

  1. Not all fetal anomalies are detectable by ultrasound.
  2. Nuchal translucency measurements are screening, not diagnostic, for trisomies 13, 18, and 21.
  3. Ultrasounds provide a very clear photo-like image of the fetus, often providing parents the opportunity to identify a familial characteristic such as nose shape.
  4. Transvaginal ultrasound is used to measure the cervical length as a screening for risk for preterm labor. However, a normal-length cervix does not preclude preterm birth.

Cognitive level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Evaluation

Learning Outcome: 14.2  Describe the methods, clinical applications, and results of ultrasound in the nursing care management of the pregnant woman.

 

Chapter 14_LO02 _Q04

A woman is at 32 weeks’ gestation. Her fundal height measurement at this clinic appointment is 26 centimeters. After reviewing her ultrasound results, the health care provider asks the nurse to schedule the client for a series of sonograms to be done every two weeks. The nurse should make sure that the client understands that the main purpose for this is to:

  1. Assess for congenital anomalies.
  2. Evaluate fetal growth.
  3. Determine fetal presentation.
  4. Rule out a suspected hydatidiform mole.

Answer: 2

Rationale:

  1. Assessment of anomalies would require only one ultrasound.
  2. A person who is at 32 weeks’ gestation should measure 32 cm of fundal height. When a discrepancy between fundal height and measurement exists, the purpose of serial ultrasounds is to monitor fetal growth.
  3. Fetal presentation would require only one ultrasound.
  4. Ruling out a hydatidiform mole would require only one ultrasound.

Cognitive Level: Application

Category of Client Need: Physiological Integrity: Reduction of Risk Potential

Nursing Process: Diagnosis

Learning Outcome: 14.2  Describe the methods, clinical applications, and results of ultrasound in the nursing care management of the pregnant woman.

 

Chapter 14_LO02 _Q05

In assisting with an abdominal ultrasound procedure for determination of fetal age, the nurse:

  1. Asks the woman to sign an operative consent form prior to the procedure.
  2. Has the woman empty her bladder before the test begins.
  3. Assists the woman into a supine position on the examining table.
  4. Instructs the woman to eat a fat-free meal two hours before the scheduled test time.

Answer: 3

Rationale:

  1. Abdominal ultrasounds are not invasive procedures, and do not require a consent form.
  2. The recommendation is that the client have a full bladder to help elevate the uterus out of the pelvic cavity for better visualization.
  3. Clients are placed in a supine position on the table.
  4. Dietary intake is not relevant to the ultrasound.

Cognitive Level: Application

Category of Client Need: Physiological Integrity: Reduction of Risk Potential

Nursing Process: Implementation

Learning Outcome: 14.2  Describe the methods, clinical applications, and results of ultrasound in the nursing care management of the pregnant woman.

 

Chapter 14_LO03 _Q06

The prenatal clinic nurse is responding to a client who has had an assessment for fetal well-being. Which statement indicates that the client understands the test result?

  1. “The normal Doppler velocimetry wave result indicates my placenta is getting enough blood to the baby.”
  2. “The reactive non-stress test means that my baby is not growing because of a lack of oxygen.”
  3. “Because my contraction stress test was positive, we know that my baby will tolerate labor well.”
  4. “My biophysical profile score of 6 points to everything being normal and healthy for my baby.”

Correct Answer: 1

Rationale:

  1. The Doppler velocimetry test looks at blood flow through the umbilical artery. A normal result indicates there is no vasospasm decreasing blood flow to the placenta; therefore the baby is getting an adequate blood supply.
  2. The non-stress test utilizes external fetal monitoring to assess the fetal heart rate in relationship to fetal movement. When accelerations in the fetal heart rate are associated with fetal movement (a reactive result), the fetus is well oxygenated, and the placenta is functioning well.
  3. A contraction stress test creates mild contractions. The presence of decelerations is termed a positive result, and indicates a lack of adequate placental functioning.
  4. The biophysical profile score should be 8 (with adequate amniotic fluid) or 10. A score of 6 is abnormal, and indicates that further assessment is needed.

Cognitive level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Evaluation

Learning Outcome: 14.3 Describe the use, procedure, information obtained, and nursing considerations for Doppler velocimetry, non-stress test, contraction stress test, and biophysical profile test.

 

Chapter 14_LO03 _Q07

At 32 weeks’ gestation, a woman is scheduled for a second non-stress test (following the one she had at 28 weeks’ gestation). Which response by the client would indicate an adequate understanding of this procedure?

  1. “I can’t get up and walk around during the test.”
  2. “I’ll have an IV started before the test.”
  3. “I must avoid drinks containing caffeine for 24 hours before the test.”
  4. “I need to have a full bladder for this test.”

Answer: 1

Rationale:

  1. The purpose of the non-stress test is to determine the results of movement on fetal heart rate. The client will have to lie still on her side during the procedure.
  2. There is no IV needed to administer medications.
  3. Caffeine might cause the infant to be more active and cause the test to go more quickly.
  4. Clients usually are asked to have their bladders full only for ultrasounds.

Cognitive Level: Application

Category of Client Need: Physiological Integrity: Reduction of Risk Potential

Nursing Process: Evaluation

Learning Outcome: 14.3 Describe the use, procedure, information obtained, and nursing considerations for Doppler velocimetry, non-stress test, contraction stress test, and biophysical profile test.

 

 

Chapter 14_LO03 _Q08

During a non-stress test, the nurse notes that the fetal heart rate decelerates about 15 beats during a period of fetal movement. The decelerations occur twice during the test, and last 20 seconds each. The nurse realizes these results will be interpreted as:

  1. A negative test.
  2. A reactive test.
  3. A non-reactive test.
  4. An equivocal test

Answer: 3

Rationale:

  1. Non-stress tests are scored as either reactive or non-reactive.
  2. A reactive stress test has the expected results of an increase in heart rate of 15 beats per minute for 15 seconds or more.
  3. In a non-reactive stress test, the reactivity criteria are not met. Since this client experienced a deceleration during the test, this is considered non-reactive.
  4. Non-stress tests are scored as either reactive or non-reactive.

Cognitive Level: Application

Category of Client Need: Physiological Integrity: Reduction of Risk Potential

Nursing Process: Diagnosis

Learning Outcome: 14.3 Describe the use, procedure, information obtained, and nursing considerations for Doppler velocimetry, non-stress test, contraction stress test, and biophysical profile test.

 

Chapter 14_LO03 _Q09

A pregnant woman is having a nipple-stimulated contraction stress test. Which result indicates hyperstimulation?

  1. The fetal heart rate decelerates when three contractions occur within a 10-minute period.
  2. The fetal heart rate accelerates when contractions last up to 60 seconds.
  3. There are more than five fetal movements in a 10-minute period.
  4. There are more than three uterine contractions in a 6-minute period.

Answer: 4

Rationale:

  1. Decelerations are considered a positive contraction stress test.
  2. The acceleration of the heart rate is considered a negative contraction stress test.
  3. The fetal movement is considered a negative contraction stress test.
  4. Hyperstimulation is characterized by contractions closer than or equal to every 6 minutes, or lasting longer than 90 seconds.

Cognitive Level: Analysis

Category of Client Need: Physiological Integrity: Reduction of Risk Potential

Nursing Process: Diagnosis

Learning Outcome: 14.3 Describe the use, procedure, information obtained, and nursing considerations for Doppler velocimetry, non-stress test, contraction stress test, and biophysical profile test.

 

 

Chapter 14_LO03 _Q10

Of all the clients who have been scheduled to have a biophysical profile, the nurse should check with the physician and clarify the order for which client?

  1. A gravida with intrauterine growth restriction
  2. A gravida with mild hypertension of pregnancy
  3. A gravida who is post-term
  4. A gravida who complains of decreased fetal movement for two days

Answer: 2

Rationale:

  1. The infant who has intrauterine growth problems might be compromised due to placental insufficiency.
  2. The biophysical profile is used when there is a risk of placental and/or fetal compromise. The gravida with mild hypertension will need to be monitored more closely throughout the pregnancy, but is not a candidate at present for a biophysical profile.
  3. The infant who is post-term might be compromised due to placental insufficiency.
  4. The gravida who is experiencing decreased fetal movement for two days needs assessment of the placenta and the fetus.

Cognitive Level: Analysis

Category of Client Need: Physiological Integrity: Reduction of Risk Potential

Nursing Process: Planning

Learning Outcome: 14.3 Describe the use, procedure, information obtained, and nursing considerations for Doppler velocimetry, non-stress test, contraction stress test, and biophysical profile test.

 

 

Chapter 14_LO04_Q11

The nurse is reviewing amniocentesis results. Care was appropriate if the client:

  1. Who is Rh-positive received RhoGAM after the amniocentesis.
  2. Was monitored for 30 minutes after completion of the test.
  3. Began vaginal spotting before leaving for home after the test.
  4. Identified that she takes insulin before each meal and at bedtime.

Correct Answer: 2

Rationale:

  1. Only Rh-negative clients receive RhoGAM after amniocentesis. The Rh-positive client should not ever receive RhoGAM.
  2. 20–30 minutes of fetal monitoring is performed to assess for fetal well-being and to rule out injury of the fetus or placenta during the exam.
  3. Vaginal spotting after the amniocentesis is not an expected finding. A client experiencing vaginal bleeding of any amount after amniocentesis requires additional assessment, and should not be sent home.
  4. Whether or not a client takes insulin has nothing to do with amniocentesis. This answer does not relate to the question asked.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Evaluation

Learning Outcome: 14.4 Explain the use of amniocentesis as a diagnostic tool.

 

 

Chapter 14_LO04_Q12

Each of the following pregnant women is scheduled for a 14-week antepartal visit. In planning care, the nurse would give priority teaching on amniotic fluid alpha-fetoprotein (AFP) screening to which client?

  1. 28-year-old with history of rheumatic heart disease
  2. 18-year-old with exposure to HIV
  3. 20-year-old with a history of preterm labor
  4. 35-year-old with a child with spina bifida

Answer: 4

Rationale:

  1. The client with rheumatic heart disease would need to be monitored for pregnancy and the stressors it places on the client.
  2. The client with HIV exposure needs HIV testing and protection education.
  3. The client with a history of preterm labor needs education on prevention and signs and symptoms of preterm labor.
  4. Alpha-fetoprotein (AFP) is elevated in multigestational pregnancies and in pregnancies with neural tube defects such as spina bifida and Down syndrome. The 35-year-old is considered to be of advanced maternal age, and is at risk for having a child with Down syndrome, and with the past history of a child with spina bifida, would be highly encouraged to have the AFP screening.

Cognitive Level: Analysis

Category of Client Need: Health Promotion and Maintenance: Prevention and/or Early Detection of Health Problems

Nursing Process: Planning

Learning Outcome: 14.4 Explain the use of amniocentesis as a diagnostic tool.

 

 

Chapter 14_LO05_Q13

The nurse is creating a client education brochure describing amniocentesis. Which statement is most important for the nurse to include in the brochure?

  1. “Prior to the amniocentesis, you will be asked to sign a consent form.”
  2. “After the amniocentesis, your vital signs will be monitored.”
  3. “During the amniocentesis, you might experience leaking of fluid.”
  4. “Following the amniocentesis, you can return to normal activities.”

Correct Answer: 2

Rationale:

  1. This is a true statement, but direct client care, including monitoring for complications, is a higher priority.
  2. Vital signs are monitored and fetal monitoring is performed after amniocentesis to verify that both mother and fetus are physiologically stable after the test is completed.
  3. Leaking of fluid is a complication of amniocentesis indicating rupture of membranes.
  4. Activity should be restricted for 24 hours after the amniocentesis to help prevent complications.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 14.5 Describe the nurse’s role and responsibilities in assisting during amniocentesis.

 

Chapter 14_LO06_Q14

The pregnant client and her partner are both 40 years old. The nurse is explaining the options of chorionic villus sampling (CVS) and amniocentesis for genetic testing. The nurse should intervene if the client states:

  1. “Amniocentesis results are available sooner than CVS results are.”
  2. “CVS carries a higher risk of limb abnormalities.”
  3. “Amniocentesis cannot detect a neural tube defect.”
  4. “CVS is performed through my belly or my cervix.”

Correct Answer: 1

Rationale:

  1. Amniocentesis results take longer to process, and must be done at a later gestational age than CVS.
  2. Limb and facial or jaw anomalies are associated with CVS, but not with amniocentesis.
  3. Amniocentesis will allow genetic testing. Neural tube defects are not genetic in nature; therefore, they are not detected by either amniocentesis or CVS.
  4. CVS can be performed through either a transabdominal or a transvaginal approach.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Evaluation

Learning Outcome: 14.6 Compare the advantages and disadvantages of chorionic villus sampling (CVS) to amniocentesis.

 

Chapter 14_LO06_Q15

The client and her partner are carriers of sickle-cell disease. They are considering prenatal diagnosis with either amniocentesis or chorionic villus sampling (CVS). Which statements indicate that further teaching is needed on these two diagnostic procedures? Select all that apply.

  1. “Chorionic villus sampling carries a lower risk of miscarriage.”
  2. “Amniocentesis can be done earlier in my pregnancy than CVS.”
  3. “Neither test will conclusively diagnose sickle-cell disease in our baby.”
  4. “The diagnosis comes sooner if we have CVS, not amniocentesis.”
  5. “Amniocentesis is more accurate in diagnosis than the CVS.”

Answer: 4, 5

Rationale:

  1. CVS carries twice the risk of spontaneous abortion as compared with amniocentesis. Both tests will diagnose genetic disorders.
  2. An amniocentesis is not done until around 14 weeks’ gestation, when there is enough amniotic fluid to test. A CVS is done in the first 8 weeks of pregnancy.
  3. This is a true statement.
  4. CVS is performed at 8–12 weeks’ gestation, and amniocentesis is performed at 11–14 weeks.
  5. Both are equally diagnostic, but because CVS is performed earlier in pregnancy, and the results are usually back in about 24 hours, the greatest advantage to CVS is earlier diagnostic information.

Cognitive Level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Evaluation

Learning Outcome 14.6 Compare the advantages and disadvantages of chorionic villus sampling (CVS) to amniocentesis.

 

Chapter 32_LO01_Q01

The home care nurse is visiting a newborn and mother couplet. Which nursing action has the highest priority?

  1. Establish rapport with the family members.
  2. Review the hospital medical records.
  3. Determine sleeping arrangements of the newborn.
  4. Examine the umbilical cord stump.

Correct Answer: 1

Rationale:

  1. It is critical to establish rapport with the family members prior to beginning any assessments. A therapeutic relationship must exist to obtain accurate information or provide education.
  2. Although this is important, record review should be done prior to arriving at the home, so that the nurse is prepared. Establishing a therapeutic relationship is a higher priority at the onset of the visit.
  3. This is less important than establishing a therapeutic relationship at the onset of the visit.
  4. This is less important than establishing a therapeutic relationship at the onset of the visit.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 32.1 Identify the main purposes and components of home visits during the postpartal period.

 

Chapter 32_LO02 _Q02

The nurse is teaching experienced postpartum nurses about home care visits. Which statements indicate that teaching was effective? Select all that apply.

  1. “I should tell the family to put any guns or knives away.”
  2. “It is best to wear professional street clothes to visits.”
  3. “If I encounter a crime in progress, I should leave the area.”
  4. “Jewelry is a good way to demonstrate my professionalism.”
  5. “Ignoring my ‘gut’ feelings might lead to an unsafe situation.”

Correct Answers: 3, 5

Rationale:

  1. The nurse should leave immediately if guns or knives are visible.
  2. It is best to wear clothing that identifies the nurse as a health care professional, such as scrubs or a lab coat.
  3. Personal safety is paramount. If a crime is encountered, the nurse should leave immediately and call 911.
  4. Jewelry should be avoided, as it might make the nurse a target of robbery.
  5. When a situation feels instinctually unsafe, the nurse should leave immediately.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Evaluation

Learning Outcome: 32.2 Examine strategies and actions a nurse should take to ensure personal safety during a home visit.

 

Chapter 32_LO02 _Q03

Which of the following safety devices is most appropriate for the nurse making home visits?

  1. Personal handgun
  2. Cellular phone
  3. Can of mace
  4. Map of the area

Answer: 2

Rationale:

  1. Personal handguns and mace are not permissible or legal for nurses to carry on home visits.
  2. Cellular phones provide a means of contact, and are advisable for the nurse to carry.
  3. Personal handguns and mace are not permissible or legal for nurses to carry on home visits.
  4. A map of the area should be checked before leaving for a visit, and the route traced.

Cognitive Level: Application

Category of Client Need: Safe, Effective Care Environment: Safety and Infection Control

Nursing Process: Planning

Learning Outcome: 32.2 Examine strategies and actions a nurse should take to ensure personal safety during a home visit.

 

Chapter 32_LO03 _Q04

The postpartum home care client asks the nurse why the visit is taking place. Which response is best? “We make home care visits to:

  1. “Reinforce any teaching that you didn’t quite grasp in the hospital.”
  2. “Verify that both you and the baby are safe and doing well.”
  3. “Provide a service that leads to better statistical outcomes.”
  4. “Thoroughly assess your baby to make sure he is growing.”

Correct Answer: 2

Rationale:

  1. Although reinforcement of hospital teaching is one aspect of a home care visit, this response is not therapeutically worded.
  2. Physical safety of both mom and baby are the main goals of the postpartum home care visit.
  3. Although mandated insurance coverage came about as a result of statistical analysis of outcomes of mothers and babies, the actual physical safety of mom and baby is the main reason for postpartum home care visits.
  4. This is only half of why home care visits are performed after birth. The mother is also assessed.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Implementation

Learning Outcome: 32.3 Identify the goals and nursing approaches to fostering a caring relationship in the home.

 

Chapter 32_LO04_Q05

The home care nurse is examining a newborn. The newborn is noted to be sleeping in a basket on a pillow with a stuffed animal, a fluffy blanket covering the infant. The most important nursing action is to:

  1. Remove the stuffed animal from the basket and place it on the floor.
  2. Teach the parents the risk of SIDS from soft items in the infant’s bed.
  3. Make certain that the blanket is firmly tucked under the baby.
  4. Ask if the color of the blanket has cultural significance.

Correct Answer:  2

Rationale:

  1. Both the fluffy blanket and the stuffed animal increase the risk of SIDS. Both should be removed after the parents are taught that these items are safety hazards.
  2. This is the highest priority.
  3. A fluffy blanket should not be used. The parents need education on fluffy items’ being a health hazard.
  4. Cultural significance is important, but physical safety of the newborn is a higher priority.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Implementation

Learning Outcome: 32.4 Describe the assessment and care of the newborn during postpartal home care.

 

Chapter 32_LO04_Q06

A postpartum client calls the telephone triage nurse and reports that her 2-month-old infant has a fever. She asks the nurse what to give the baby. The nurse suggests:

  1. Tylenol.
  2. Aspirin.
  3. Advil.
  4. Motrin.

Answer: 1

Rationale:

  1. Tylenol is the medication recommended by pediatricians for its antipyretic action, and also because it has a minimum of side effects in the proper form and dose.
  2. Aspirin, while also an antipyretic, has many other actions and side effects, and would not be recommended.
  3. Advil and Motrin are similar non-steroidal anti-inflammatory drugs (NSAIDs), and are not recommended for infants.
  4. Advil and Motrin are similar non-steroidal anti-inflammatory drugs (NSAIDs), and are not recommended for infants.

Cognitive Level: Application

Category of Client Need: Physiological Integrity: Pharmacological and Parental Therapies

Nursing Process: Implementation

Learning Outcome: 32.4 Describe the assessment and care of the newborn during postpartal home care.

 

Chapter 32_LO05_Q07

The nurse is performing a postpartum home care visit. Which teaching has the highest priority?

  1. Teach or review how to bathe the baby.
  2. Teaching how to thoroughly child-proof the house
  3. How many wet diapers the baby should have daily
  4. Prevention of deformational plagiocephaly

Correct Answer: 3

Rationale:

  1. Although knowing how to bathe a newborn is important, adequate hydration is a higher priority.
  2. Child-proofing the home is not necessary until the baby begins to crawl. This is a low priority at this time.
  3. Wet diapers are an indication of hydration of the newborn. This is the highest priority.
  4. Preventing flat spots on the back or side of the head is primarily a cosmetic issue. Hydration is a higher priority.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 32.5 Identify the goals for reinforcement of parent teaching in the home, and of appropriate interventions.

 

Chapter 32_LO05_Q08

To prevent sudden infant death syndrome (SIDS), the nurse encourages the parents of a term infant to place the infant in which position when the infant is sleeping?

  1. On the parents’ waterbed
  2. Swaddled in the infant swing
  3. On his back
  4. On his stomach

Answer: 3

Rationale:

  1. On the parents’ waterbed, on his stomach, or swaddled in the infant swing can increase the risks of SIDS.
  2. On the parents’ waterbed, on his stomach, or swaddled in the infant swing can increase the risks of SIDS.
  3. Research has shown that sleeping on the back decreases the risk of SIDS.
  4. On the parents’ waterbed, on his stomach, or swaddled in the infant swing can increase the risks of SIDS.

Cognitive Level: Application

Category of Client Need: Health Promotion and Maintenance: Prevention and/or Early Detection of Disease

Nursing Process: Implementation

Learning Outcome: 32.5 Identify the goals for reinforcement of parent teaching in the home, and of appropriate interventions.

 

Chapter 32_LO06_Q09

The postpartum home care nurse is assessing the mother, and finds her temperature to be 101.6°F. What is the most important nursing action?

  1. Ask the client how often and how well the baby is nursing.
  2. Determine the frequency of the mother’s voiding and stooling.
  3. Verify how many hours of sleep she is getting per day.
  4. Assess the odor and color of the lochia and perineum.

Correct Answer:  4

Rationale:

  1. A fever might indicate mastitis. Palpation of the breasts for warm or hardened areas is much better than asking about feedings, because mothers of good feeders can develop mastitis.
  2. If she is voiding frequently, she might have a UTI, but the frequency of bowel movements is not related to a UTI.
  3. Although it is common for new mothers to be fatigued, fatigue does not cause a fever.
  4. If the lochia is malodorous, or the perineum is reddened or malodorous, an infection is present that could be causing the fever.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Implementation

Learning Outcome: 32.6 Describe the nursing care and teaching needs of the postpartal mother and family in the first home visit based on the assessment findings and possible causes of alterations.

 

Chapter 32_LO07_Q10

The home care nurse is seeing a client at six weeks postpartum. Which statement made by the client requires immediate intervention?

  1. “The baby sleeps seven hours each night now.”
  2. “My flow is red, and I need to wear a pad.”
  3. “My breasts no longer leak between feedings.”
  4. “I started back on the pill two weeks ago.”

Correct Answer: 2

Rationale:

  1. This is an expected finding, and does not require intervention.
  2. By six weeks postpartum, lochia should be minimal in amount, requiring only a pantiliner, and should be brown or pinkish in color. Red, heavy flow is not an expected finding, and requires intervention.
  3. This is an expected finding, and does not require intervention.
  4. This is an appropriate time frame for restarting birth control pills, and does not require intervention.

Cognitive level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 32.7 Relate the anticipated progress at 6 weeks of the mother and family to the assessment, identification of possible alterations, and care of the mother and

family in the home visit.

 

 

Chapter 32_LO07_Q11

The new mother hesitantly asks the nurse at the six-week postpartum visit about resumption of sexual activity. To promote comfort, the nurse suggests:

  1. The female superior position.
  2. Using Vaseline for lubrication.
  3. The male superior position.
  4. Douching before and after, to avoid infection.

Answer: 1

Rationale:

  1. The female superior position puts the least amount of pressure against the healing perineum, and creates more control of movement for the woman.
  2. Using Vaseline for lubrication is not recommended, as it is not water-soluble. K-Y Jelly is the recommended lubricant.
  3. The male superior position creates more pressure on the perineum.
  4. Douching before and after to avoid infection is never recommended.

Cognitive Level: Application

Category of Client Need: Health Promotion and Maintenance: Prevention and/or Early Detection of Disease

Nursing Process: Implementation

Learning Outcome: 32.7 Relate the anticipated progress at 6 weeks of the mother and family to the assessment, identification of possible alterations, and care of the mother and

family in the home visit.

 

Chapter 32_LO08_Q12

The postpartum nurse is performing a home care visit to a first-time mother on her third day after delivery.  She reports that her nipples are becoming sore. What statement indicates that further teaching is needed?

  1. “I should try to keep the baby awake, and not let him stay latched onto the breast when he is asleep.”
  2. “Watching how much areola is visible will help me see if he has a good mouthful of breast or not.”
  3. “My nipples will heal if I switch to bottle-feeding for about three days while I pump my breasts.”
  4. “Rotating breastfeeding positions will allow the sore areas of my nipples to have less friction.”

Correct Answer: 3

Rationale:

  1. This strategy will help prevent or heal nipple soreness.
  2. This strategy will determine whether the baby is slipping down so that he is latched on just to the nipple instead of the areola. Babies need to be latched fully onto the areola to heal nipple soreness.
  3. Switching to formula-feeding and breast-pumping is a last resort, and will decrease milk supply. Watching the latch is more important.
  4. This statement is true.

Cognitive level: Knowledge

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Evaluation

Learning Outcome: 32.8 Identify the common concerns of breastfeeding mothers following discharge, and corresponding remedies.

 

 

Chapter 32_LO09_Q13

The postpartum home care nurse has four visits to make to breastfeeding mothers. Which client is experiencing an expected outcome?

  1. Breasts are engorged; placing fresh cabbage leaves inside her bra
  2. Sore and cracked nipples; using baby oil to facilitate healing
  3. Frequent breast leakage; changing breast pads once per day
  4. Concerns about milk supply; supplementing with formula

Correct Answer: 1

Rationale:

  1. Fresh green cabbage leaves help reduce engorgement.
  2. Baby oil and other petroleum-based products should be avoided during breastfeeding, as they prolong nipple soreness, and must be washed off prior to feeding, which also increases nipple trauma.
  3. Breast pads should be changed every few hours, as breast milk is warm and rich in nutrients that bacteria find ideal for growth, which could lead to infection.
  4. Breast milk supply is regulated by demand. If a baby receives formula supplements after nursing, he will not nurse as often as he would have had he only received breast milk. This leads to decreased milk production. To increase milk production, mothers should be told to increase their fluid intake and nurse the infant more frequently.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 32.9 Describe the nursing care for mothers and newborns experiencing difficulty in breastfeeding following discharge based on assessment data and rationale.

 

Chapter 32_LO09_Q14

The breastfeeding postpartum client reports sore nipples to the nurse making a home visit. The intervention with the highest priority is:

  1. Infant positioning.
  2. Use of the breast shield.
  3. Use of breast pads.
  4. Type of soap used.

Answer: 1

Rationale:

  1. Infant positioning is a critical factor in nipple soreness. Changing positions alters the focus of greatest stress and promotes more complete breast emptying.
  2. Use of the breast shield, use of breast pads, and type of soap used are not critical factors in alleviating nipple soreness.
  3. Use of the breast shield, use of breast pads, and type of soap used are not critical factors in alleviating nipple soreness.
  4. Use of the breast shield, use of breast pads, and type of soap used are not critical factors in alleviating nipple soreness.

Cognitive Level: Application

Category of Client Need: Physiological Integrity: Basic Care and Comfort

Nursing Process: Implementation

Learning Outcome: 32.9 Describe the nursing care for mothers and newborns experiencing difficulty in breastfeeding following discharge based on assessment data and rationale.

 

Chapter 32_LO10_Q15

Before a newborn and mother are discharged from the hospital, the nurse informs the parents about the normal screening tests for newborns. Which of the following are good reasons for having the screening tests done?

  1. The tests will prevent infants from developing phenylketonuria.
  2. The tests will detect such disorders as hypertension and diabetes.
  3. The tests will detect disorders that cause mental retardation, physical handicaps, or death if left undiscovered.
  4. The tests will prevent sickle-cell anemia, galactosemia, and hemocystinuria.

 

Answer: 3

Rationale:

  1. The normal screening tests for newborns are done to detect disorders that cause mental retardation, physical handicaps, or death if left undiscovered. The testing will not prevent any disorders, and will not detect hypertension or diabetes.
  2. The normal screening tests for newborns are done to detect disorders that cause mental retardation, physical handicaps, or death if left undiscovered. The testing will not prevent any disorders, and will not detect hypertension or diabetes.
  3. The normal screening tests for newborns are done to detect disorders that cause mental retardation, physical handicaps, or death if left undiscovered. The testing will not prevent any disorders, and will not detect hypertension or diabetes.
  4. The normal screening tests for newborns are done to detect disorders that cause mental retardation, physical handicaps, or death if left undiscovered. The testing will not prevent any disorders, and will not detect hypertension or diabetes.

 

Cognitive Level: Application

 

Category of Client Need: Physiological Integrity: Reduction of Risk Potential

Nursing Process: Planning

Learning Outcome: 32.10 Identify follow-up care available to postpartal families in addition to home visits.

 

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