Foundations Of Maternal Newborn and Women’s Health Nursing, 6th Edition by Sharon Smith Murray – Test bank

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Foundations Of Maternal Newborn and Women’s Health Nursing, 6th Edition by Sharon Smith Murray – Test bank

Chapter 02: The Nurse’s Role in Maternity and Women’s Health Care

 

MULTIPLE CHOICE

 

  1. Which principle of teaching should the nurse use to ensure learning in a family situation?
a. Motivate the family with praise and positive feedback.
b. Learning is best accomplished with the lecture format.
c. Present complex subject material first while the family is alert and ready to learn.
d. Families should be taught using medical jargon so they will be able to understand the technical language used by physicians.

 

 

ANS:  A

Praise and positive feedback are particularly important when a family is trying to master a frustrating task such as breastfeeding. A lively discussion stimulates more learning than a straight lecture, which tends to inhibit questions. Learning is enhanced when the teaching is structured to present the simple tasks before the complex material. Even though a family may understand English fairly well, they may not understand the medical terminology or slang terms that are used.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   18, 19

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which nursing intervention is an independent function of the nurse?
a. Administering oral analgesics
b. Requesting diagnostic studies
c. Teaching the client perineal care
d. Providing wound care to a surgical incision

 

 

ANS:  C

Nurses are now responsible for various independent functions, including teaching, counseling, and intervening in nonmedical problems. Interventions initiated by the physician and carried out by the nurse are called dependent functions. Administrating oral analgesics is a dependent function; it is initiated by a physician and carried out by a nurse. Requesting diagnostic studies is a dependent function. Providing wound care is a dependent function; it is usually initiated by the physician through direct orders or protocol.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   24

OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. Which most therapeutic response to the client’s statement, “I’m afraid to have a cesarean birth” should be made by the nurse?
a. “Everything will be OK.”
b. “Don’t worry about it. It will be over soon.”
c. “What concerns you most about a cesarean birth?”
d. “The physician will be in later and you can talk to him.”

 

 

ANS:  C

The response, “What concerns you most about a cesarean birth” focuses on what the client is saying and asks for clarification, which is the most therapeutic response. The response, “Everything will be ok” is belittling the client’s feelings. The response, “Don’t worry about it. It will be over soon” will indicate that the client’s feelings are not important. The response, “The physician will be in later and you can talk to him” does not allow the client to verbalize her feelings when she wishes to do that.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   18

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which action should the nurse take to evaluate the client’s learning about performing infant care?
a. Demonstrate infant care procedures.
b. Allow the client to verbalize the procedure.
c. Routinely assess the infant for cleanliness.
d. Observe the client as she performs the procedure.

 

 

ANS:  D

The client’s correct performance of the procedure under the nurse’s supervision is the best proof of her ability. Demonstration is an excellent teaching method, but not an evaluation method. During verbalization of the procedure, the nurse may not pick up on techniques that are incorrect. It is not the best tool for evaluation. Routinely assessing the infant for cleanliness will not ensure that the proper procedure is carried out. The nurse may miss seeing that unsafe techniques being used.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   21

OBJ:   Nursing Process Step: Evaluation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A nurse is reviewing teaching and learning principles. Which situation is most conducive to learning?
a. An auditorium is being used as a classroom for 300 students.
b. A teacher who speaks very little Spanish is teaching a class of Hispanic students.
c. A class is composed of students of various ages and educational backgrounds.
d. An Asian nurse provides nutritional information to a group of pregnant Asian women.

 

 

ANS:  D

A client’s culture influences the learning process; thus, a situation that is most conducive to learning is one in which the teacher has knowledge and understanding of the client’s cultural beliefs. A large class is not conducive to learning. It does not allow questions, and the teacher cannot see nonverbal cues from the students to ensure understanding. The ability to understand the language in which teaching is done determines how much the client learns. Clients for whom English is not their primary language may not understand idioms, nuances, slang terms, informed usage of words, or medical terms. The teacher should be fluent in the language of the student. Developmental levels and educational levels influence how a person learns best. For the teacher to present the information in the best way, the class should be at the same level.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   20

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Psychosocial Integrity

 

  1. Which is the step of the nursing process in which the nurse determines the appropriate interventions for the identified nursing diagnosis?
a. Planning
b. Evaluation
c. Assessment
d. Intervention

 

 

ANS:  A

The third step in the nursing process involves planning care for problems that were identified during assessment. The evaluation phase is determining whether the goals have been met. During the assessment phase, data are collected. The intervention phase is when the plan of care is carried out.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   24

OBJ:   Nursing Process Step: Planning

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. Which goal is most appropriate for the collaborative problem of wound infection?
a. The client will not exhibit further signs of infection.
b. Maintain the client’s fluid intake at 1000 mL/8 hr.
c. The client will have a temperature of 98.6° F within 2 days.
d. Monitor the client to detect therapeutic response to antibiotic therapy.

 

 

ANS:  D

In a collaborative problem, the goal should be nurse-oriented and reflect the nursing interventions of monitoring or observing. Monitoring for complications such as further signs of infection is an independent nursing role. Intake and output is an independent nursing role. Monitoring a client’s temperature is an independent nursing role.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   18

OBJ:   Nursing Process Step: Planning

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. Which nursing intervention is correctly written?
a. Force fluids as necessary.
b. Observe interaction with the infant.
c. Encourage turning, coughing, and deep breathing.
d. Assist to ambulate for 10 minutes at 8 AM, 2 PM, and 6 PM.

 

 

ANS:  D

Interventions might not be carried out if they are not detailed and specific. “Force fluids” is not specific; it does not state how much. Encouraging the client to turn, cough, and breathe deeply is not detailed and specific. Observing interaction with the infant does not state how often this procedure should be done.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   25

OBJ:   Nursing Process Step: Planning

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. The client makes the statement: “I’m afraid to take the baby home tomorrow.” Which response by the nurse would be the most therapeutic?
a. “You’re afraid to take the baby home?”
b. “Don’t you have a mother who can come and help?”
c. “You should read the literature I gave you before you leave.”
d. “I was scared when I took my first baby home, but everything worked out.”

 

 

ANS:  A

This response uses reflection to show concern and open communication. The other choices are blocks to communication. Asking if the client has a mother who can come and help blocks further communication with the client. Telling the client to read the literature before leaving does not allow the client to express her feelings further. Sharing your feelings about your experience with a new baby blocks further communication with the client.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   18, 19

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. The nurse is writing an expected outcome for the nursing diagnosis—acute pain related to trauma of tissue, secondary to vaginal birth, as evidenced by client stating pain of 8 on a scale of 10. Which is a correctly stated expected outcome for this problem?
a. Client will state that pain is a 2 on a scale of 10.
b. Client will have a reduction in pain after administration of the prescribed analgesic.
c. Client will state an absence of pain 1 hour after administration of the prescribed analgesic.
d. Client will state that pain is a 2 on a scale of 10, 1 hour after the administration of the prescribed analgesic.

 

 

ANS:  D

The outcome should be client-centered, measurable, realistic, and attainable and have a time frame. Client stating that pain is now 2 on a scale of 10 lacks a time frame. Client having a reduction in pain after administration of the prescribed analgesic lacks a measurement. Client stating an absence of pain 1 hour after the administration of prescribed analgesic is unrealistic.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   25

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Physiologic Integrity

 

  1. Which nursing diagnosis should the nurse set as a priority for a laboring client?
a. Risk for anxiety related to upcoming birth
b. Risk for imbalanced nutrition related to NPO status
c. Risk for altered family processes related to new addition to the family
d. Risk for injury (maternal) related to altered sensations and positional or physical changes

 

 

ANS:  D

The nurse should determine which problem needs immediate attention. Risk for injury is the problem that has the priority at this time because it is a safety problem. Risk for anxiety, imbalanced nutrition, and altered family processes are not the priorities at this time.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   24, 25

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. Regarding advanced roles of nursing, which statement is true with regard to clinical practice?
a. Family nurse practitioners (FNPs) can assist with childbirth care in the hospital setting.
b. Clinical nurse specialists provide primary care to obstetric clients.
c. Neonatal nurse practitioners provide emergency care in the postbirth setting to high-risk infants.
d. A certified nurse midwife (CNM) is not considered to be an advanced practice nurse.

 

 

ANS:  C

Neonatal NPs provide care for the high-risk neonate in the birth room and in the neonatal intensive care unit, as needed. FNPs do not participate in childbirth care but can take care of uncomplicated pregnancies and postbirth care outside of the hospital setting. CNSs work in hospital settings but do not provide primary care services to clients. A CNM is an advanced practice nurse who receives additional certification in the specific area of midwifery.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   17

OBJ:   Nursing Process Step: Evaluation

MSC:  Client Needs: Management of Care: Legal Rights and Responsibilities

 

  1. You are taking care of a couple postbirth who are very eager to learn about bathing techniques that they can use for their newborn. Which teaching technique could the nurse use to facilitate parents learning about giving a bath to their newborn infant?
a. Provide direct, step-by-step demonstration to each parent separately to foster individual retention and comprehension.
b. Present information to parents prior to discharge so that the information will be current.
c. Have each parent bathe the newborn each time the infant comes to the room and provide commentary after the skill repetition.
d. Demonstrate bathing techniques on the newborn infant with parents in attendance.

 

 

ANS:  D

Demonstration of bathing techniques is a form of role modeling that would enhance teaching and learning outcomes. Presenting the information at the time of discharge will not allow for identification of concerns and/or evaluation of whether the skill has been acquired. Although it may be advantageous to have each parent bathe their newborn, this action would not be advised in terms of time management and safety related to maintenance of core temperature.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   21

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion: Teaching/Learning

 

  1. Which statement is true regarding the shortage of nurses in the United States?
a. There are a larger proportion of younger nurses in the workforce as compared with older nurses.
b. As a result of decreased RN-to-client ratios, there is a decrease in client mortality in the clinical setting.
c. Increased needs for baccalaureate nurses are not being met by current enrollment.
d. There are adequate classroom and clinical facilities for training RNs.

 

 

ANS:  C

According to an Institute of Medicine (IOM) report, by the year 2020, there will only be 50% of RNs with baccalaureate degrees. The required demand is at 80%. There are a larger proportion of older nurses in the workforce based on current research by the IOM. Increased RN-to-client ratios has resulted in decreased client mortality in the clinical setting. There are limitations of classroom and clinical facilities to train new nurses adequately.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   16

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion: Teaching/Learning

 

  1. A hospital has achieved Magnet status. Which indicators would be consistent with this type of certification?
a. There is stratification of communication in a directed manner between nursing staff and administration.
b. There is increased job satisfaction of nurses, with a low staff turnover rate.
c. Physicians are certified in their respective specialty areas.
d. All nurses have baccalaureate degrees and certification in their clinical specialty area.

 

 

ANS:  B

Magnet status is a certification offered by the ANCC (American Nurses Credentialing Center) in which hospitals apply based on designated criteria that consider nurse job satisfaction, staff patterns, strength, quality of nursing staff, and open communication. It is not based on physician status. Although the expectation is that at least 80% of the nurses will have baccalaureate degrees, most hospitals that achieve Magnet status have 50% of RNs at that level. Also, certification is not required for all nurses at this point. The expectation with Magnet status is that nurses will continue to expand their knowledge by earning additional degrees and certification.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   17

OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Health Promotion: Teaching/Learning

 

  1. Which of the following indicates a nurse’s role as a researcher?
a. Reading peer-reviewed journal articles
b. Working as a member of the interdisciplinary team to provide client care
c. Helping client to obtain home care post-discharge from the hospital
d. Delegating tasks to unlicensed personnel to allow for more teaching time with clients

 

 

ANS:  A

A nurse in a researcher role should look to improve her or his knowledge base by reading and reviewing evidence-based practice information as found in peer-reviewed journals. Working as a member of the interdisciplinary team to provide client care indicates that the nurse is working as a collaborator. Helping the client to obtain home care post-discharge from the hospital indicates that the nurse is working as a client advocate. Delegating tasks to unlicensed personnel to allow for more teaching time with clients indicates that the nurse is working as a manager.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   21

OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Health Promotion: Teaching/Learning

 

  1. A 16-year-old primipara has just completed her first prenatal visit with the health care provider. The nurse is preparing to teach her about nutrition during pregnancy. What must the nurse include in the patient’s teaching plan?
a. Provide her with pictures of dairy products.
b. Ask her, “Are you ready to hear this information now?”
c. Read directly from the pamphlet prepared for teen mothers.
d. Provide a comfortable and warm setting after she has put on her street clothes.

 

 

ANS:  D

The nurse must structure teaching for teens in a way that suits them best. For teaching to be most effective, the physical environment must be comfortable and distractions to learning must be kept at a minimum. Pictures, videos, and computer-based materials are more effective teaching tools for younger clients. Patients must have an attitude of readiness and openness for the teaching to be effective. However, if the environment is not conducive to learning, efforts for effective teaching will be minimized.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   18

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse states to the newly pregnant patient, “Tell me how you feel about being pregnant.” Which communication technique is the nurse using with this patient?
a. Clarifying
b. Paraphrasing
c. Reflection
d. Structuring

 

 

ANS:  A

The nurse is attempting to follow up and check the accuracy of the patient’s message. Paraphrasing is restating words other than those used by the patient. Reflection is verbalizing comprehension of what the patient has said. Structuring takes place when the nurse has set guidelines or set priorities.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   19

OBJ:   Nursing Process Step: Analysis       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The pregnant woman tells the nurse, “I think something may be wrong with my pregnancy.” Which statement by the nurse demonstrates therapeutic communication?
a. “Most women worry; I felt the same way when I was pregnant.”
b. “Tell me more about what concerns you about this pregnancy.”
c. “That is a very common concern, but your pregnancy will turn out just fine.”
d. “You should focus on taking care of yourself and not worry so much.”

 

 

ANS:  B

Questioning is a therapeutic communication technique in which additional information is elicited by using open-ended questions. The remaining options are examples of three behaviors that block communication—inappropriate self-disclosure, providing false reassurance, and giving advice.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   18

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. The nurse is formulating a nursing care plan for a postpartum client. Which actions by the nurse indicate use of critical thinking skills when formulating the care plan? (Select all that apply).
a. Using a standardized postpartum care plan
b. Determining priorities for each diagnosis written
c. Writing interventions from a nursing diagnosis book
d. Reflecting and suspending judgment when writing the care plan
e. Clustering data during the assessment process according to normal versus abnormal

 

 

ANS:  B, D, E

Critical thinking focuses on appraisal of the way the individual thinks, and it emphasizes reflective skepticism. Determining priorities, reflecting and suspending judgment, and clustering data are actions that indicate the use of critical thinking. Using a standardized care plan and writing interventions from a nursing diagnosis book do not show that reflection about the client’s individual care is being done.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   27

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Physiologic Integrity

 

  1. The nurse is teaching a group of nursing students about behaviors that can block or open lines of communication. Which behaviors open the lines of communication? (Select all that apply).
a. Sitting at the bedside
b. Leaning forward with arms relaxed
c. Acknowledging the client’s comments or feelings
d. Self-disclosing about your personal birth experience
e. Holding a laptop computer in front of your body during an interview

 

 

ANS:  A, B, C

Behaviors that open the lines of communication can be described as attending behaviors, which convey the nurse’s interest and a sincere desire to understand. Acknowledging the client’s comments or feelings is an attending behavior. Nonverbal behaviors are just as powerful as spoken words. The nurse should convey an open attitude, such as sitting at the bedside and leaning forward with arms relaxed while listening. Self-disclosing is inappropriate and closes lines of communication. Holding a laptop on your lap during the interview process is putting a barrier between the nurse and client.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   20

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Psychosocial Integrity

 

MATCHING

 

Match each term with the correct definition.

a. Calling attention to differences or inconsistencies in statements
b. Using nonverbal responses or succinct comments to encourage the person to continue
c. Restating in words other than those used by the woman what she seems to express; a form of clarification

 

 

  1. Directing

 

  1. Pinpointing

 

  1. Paraphrasing

 

  1. ANS:  B                    PTS:   1                    DIF:    Cognitive Level: Understanding

REF:   19                  OBJ:   Nursing Process Step: Planning

MSC:  Client Needs: Health Promotion and Maintenance

NOT:  Pinpointing is calling attention to differences or inconsistencies in statements. Directing is using nonverbal responses or succinct comments to encourage the person to continue. Paraphrasing is restating in words other than those used by the woman what she seems to express; it is a form of clarification.

 

  1. ANS:  A                    PTS:   1                    DIF:    Cognitive Level: Understanding

REF:   19                  OBJ:   Nursing Process Step: Planning

MSC:  Client Needs: Health Promotion and Maintenance

NOT:  Pinpointing is calling attention to differences or inconsistencies in statements. Directing is using nonverbal responses or succinct comments to encourage the person to continue. Paraphrasing is restating in words other than those used by the woman what she seems to express; it is a form of clarification.

 

  1. ANS:  C                    PTS:   1                    DIF:    Cognitive Level: Understanding

REF:   19                  OBJ:   Nursing Process Step: Planning

MSC:  Client Needs: Health Promotion and Maintenance

NOT:  Pinpointing is calling attention to differences or inconsistencies in statements. Directing is using nonverbal responses or succinct comments to encourage the person to continue. Paraphrasing is restating in words other than those used by the woman what she seems to express; it is a form of clarification.

Chapter 12: Processes of Birth

 

MULTIPLE CHOICE

 

  1. The husband of a laboring woman asks the nurse how he can help his wife throughout the first stage of labor. The nurse informs him that in addition to all that he’s doing now, he could tell her when the contractions are:
a. 2 minutes apart.
b. at their acme.
c. at their increment.
d. at their decrement.

 

 

ANS:  B

When the contraction is most intense, the coach can tell the laboring woman that this contraction will be over soon to help her remain focused. Describing the frequency of the contractions is not usually helpful. The increment occurs as the contraction begins in the fundus and spreads through the uterus. Calling attention to this phase may cause the woman to become tense. The woman does not need anyone to tell her that the contraction is decreasing in intensity.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   196, 197

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is explaining to a group of nursing students what occurs during active labor as the uterus contracts. Which statement explains the maternal-fetal exchange of oxygen and waste products during a contraction?
a. Is not significantly affected
b. Increases as blood pressure decreases
c. Diminishes as the spiral arteries are compressed
d. Continues except when placental functions are reduced

 

 

ANS:  C

During labor contractions, the maternal blood supply to the placenta gradually stops as the spiral arteries supplying the intervillous space are compressed by the contracting uterine muscle. The exchange of oxygen and waste products is affected by contractions. The exchange of oxygen and waste products decreases. The maternal blood supply to the placenta gradually stops with contractions.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   199

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. The nurse is directing an unlicensed assistive personnel (UAP) to take maternal vital signs between contractions. Which statement is the best rationale for assessing maternal vital signs between contractions?
a. Vital signs taken during contractions are not accurate.
b. During a contraction, assessing fetal heart rate is the priority.
c. Maternal blood flow to the heart is reduced during contractions.
d. Maternal circulating blood volume increases temporarily during contractions.

 

 

ANS:  D

During uterine contractions, blood flow to the placenta temporarily stops, causing a relative increase in the mother’s blood volume, which in turn temporarily increases blood pressure and slows the pulse. Vital signs are altered by contractions but are considered accurate for a period of time. It is important to monitor the fetal response to contractions, but the question is concerned with the maternal vital signs. Maternal blood flow is increased during a contraction.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   198

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. Uncontrolled maternal hyperventilation during labor results in:
a. metabolic acidosis.
b. metabolic alkalosis.
c. respiratory acidosis.
d. respiratory alkalosis.

 

 

ANS:  D

Rapid deep respirations cause the laboring woman to lose carbon dioxide through exhalation, resulting in respiratory alkalosis. Hyperventilation does not cause respiratory acidosis, metabolic acidosis, or metabolic alkalosis.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   198

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet?
a. Extension
b. Engagement
c. Internal rotation
d. External rotation

 

 

ANS:  B

Engagement occurs when the presenting part fully enters the pelvic inlet. Extension occurs when the fetal head meets resistance from the tissues of the pelvic floor and the fetal neck stops under the symphysis. This causes the fetal head to extend. Internal rotation occurs when the fetus enters the pelvic inlet. The rotation allows the longest fetal head diameter to conform to the longest diameter of the maternal pelvis. External rotation occurs after the birth of the head. The head then turns to the side so the shoulders can internally rotate and are positioned with their transverse diameter in the anteroposterior diameter of the pelvic outlet.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   209

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The laboring client asks the nurse how the labor contractions work to dilate the cervix. The best response by the nurse is that labor contractions facilitate cervical dilation by:
a. promoting blood flow to the cervix.
b. contracting the lower uterine segment.
c. enlarging the internal size of the uterus.
d. pulling the cervix over the fetus and amniotic sac.

 

 

ANS:  D

Effective uterine contractions pull the cervix upward at the same time the fetus and amniotic sac are pushed downward. Blood flow decreases to the uterus during a contraction. The contractions are stronger at the fundus. The internal size becomes smaller with the contractions; this helps push the fetus down.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   198

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. Pregnant clients can usually tolerate the normal blood loss associated with childbirth because they have:
a. a higher hematocrit.
b. increased leukocytes.
c. increased blood volume.
d. a lower fibrinogen level.

 

 

ANS:  C

Women have a significant increase in blood volume during pregnancy. After birth, the additional circulating volume is no longer necessary. The hematocrit decreases with pregnancy because of the high fluid volume. Leukocyte levels increase during labor, but that is not the reason for the toleration of blood loss. Fibrinogen levels increase with pregnancy.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   198

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. The nurse is assessing the duration of a client’s labor contractions. Which action does the nurse implement to assess the duration of labor contractions?
a. Assess the strongest intensity of each contraction.
b. Assess uterine relaxation between two contractions.
c. Assess from the beginning to the end of each contraction.
d. Assess from the beginning of one contraction to the beginning of the next.

 

 

ANS:  C

Duration of labor contractions is the average length of contractions from beginning to end. Assessing the strongest intensity of each contraction assesses the strength or intensity of the contractions. Assessing uterine relaxation between two contractions is the interval of the contraction phase. Assessing from the beginning of one contraction to the beginning of the next is the frequency of the contractions.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   196, 197

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. Which event is the best indicator of true labor?
a. Bloody show
b. Cervical dilation and effacement
c. Fetal descent into the pelvic inlet
d. Uterine contractions every 7 minutes

 

 

ANS:  B

The conclusive distinction between true and false labor is that contractions of true labor cause progressive change in the cervix. Bloody show can occur before true labor. Fetal descent can occur before true labor. False labor may have contractions that occur this frequently but is usually inconsistent.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   198

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. Which factor ensures that the smallest anterior-posterior diameter of the fetal head enters the pelvis?
a. Station
b. Flexion
c. Descent
d. Engagement

 

 

ANS:  B

The anterior-posterior diameter of the head varies with how much it is flexed. In the most favorable situation, the head is fully flexed and the anterior-posterior diameter is the suboccipitobregmatic, averaging 9.5 cm. The station is the relationship of the fetal presenting part to the level of the ischial spine. Descent is the moving of the fetus through the birth canal. Engagement occurs when the largest diameter of the fetal presenting part has passed the pelvic outlet.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   209

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. An increase in urinary frequency and leg cramps after the 36th week of pregnancy most likely indicates:
a. lightening.
b. breech presentation.
c. urinary tract infection.
d. onset of Braxton-Hicks contractions.

 

 

ANS:  A

As the fetus descends toward the pelvic inlet near the end of pregnancy, increased pelvic pressure occurs, resulting in greater urinary frequency and more leg cramps. Breech presentation does not cause urinary frequency and leg cramps. A urinary tract infection may cause urinary frequency but with burning and would not cause leg cramps. Braxton-Hicks contractions are irregular and mild and occur throughout the pregnancy.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   207

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A nullipara client has progressed to the active phase of labor. The nurse understands that this phase of labor, on the average, for a nullipara will last how long?
a. 50 minutes
b.  hours
c. 6 to 7 hours
d. 8 to 10 hours

 

 

ANS:  D

The active phase of labor for a nullipara lasts 8 to 10 hours. The second phase of labor lasts 50 minutes for a nullipara. The transition phase lasts  hours for a nullipara. A multipara’s active phase of labor is 6 to 7 hours.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   208

OBJ:   Nursing Process Step: Evaluation   MSC:  Client Needs: Physiologic Integrity

 

  1. A client just delivered a baby by the vaginal route. The client asks the nurse why the baby’s head is not round, but oval. Which explanation should the nurse give to the client?
a. This results from molding.
b. This results from lightening.
c. This results from the fetal lie.
d. This results from the fetal presentation.

 

 

ANS:  A

The sutures and fontanels allow the bones of the fetal head to move slightly, changing the shape of the fetal head so it can adapt to the size and shape of the pelvis. Lightening is the descent of the fetus toward the pelvic inlet before labor. Lie is the relationship of the long axis of the fetus to the long axis of the mother. Presentation is the fetal part that first enters the pelvic outlet.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   201

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. A client whose cervix is dilated to 5 cm is considered to be in which phase of labor?
a. Latent phase
b. Active phase
c. Second stage
d. Third stage

 

 

ANS:  B

The active phase of labor is characterized by cervical dilation of 4 to 7 cm. The latent phase is from the beginning of true labor until 3 cm of cervical dilation. The second stage of labor begins when the cervix is completely dilated until the birth of the baby. The third stage of labor is from the birth of the baby until the expulsion of the placenta.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   212

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. The nurse is assessing a client in the active phase of labor. What should the nurse expect during this phase?
a. The client is sociable and excited.
b. The client is requesting pain medication.
c. The client begins to experience the urge to push.
d. The client experiences loss of control and irritability.

 

 

ANS:  B

During the active phase of labor, contraction intensity and discomfort increase to the point where women often request pain medication. Sociability and excitability occur during the latent phase. The urge to push occurs at the end of the transition phase or the second stage of labor. Loss of control and irritability occur during the transition phase of labor.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   212

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Physiologic Integrity

 

  1. A laboring client asks the nurse how she will know that the contraction is at its peak. The nurse explains that the contraction peaks during which stage of measurement?
a. The acme
b. The interval
c. The increment
d. The decrement

 

 

ANS:  A

The acme is the peak or period of greatest strength during the middle of a contraction cycle. The interval is the period between the end of the contraction and the beginning of the next. The increment is the beginning of the contraction until it reaches the peak. The decrement occurs after the peak until the contraction ends.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   196, 197

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. A client in labor presents with a breech presentation. The nurse understands that a breech presentation is associated with:
a. more rapid labor.
b. a high risk of infection.
c. maternal perineal trauma.
d. umbilical cord compression.

 

 

ANS:  D

The umbilical cord can compress between the fetal body and maternal pelvis when the body has been born but the head remains within the pelvis. Breech presentation is not associated with a more rapid labor. There is no higher risk of infection with a breech birth. There is no higher risk for perineal trauma with a breech birth.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   202, 203

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. The primary difference between the labor of a nullipara and that of a multipara is:
a. total duration of labor.
b. level of pain experienced.
c. amount of cervical dilation.
d. sequence of labor mechanisms.

 

 

ANS:  A

Multiparas usually labor more quickly than nulliparas, making the total duration of their labor shorter. The level of pain is individual to the woman, not the number of labors she has experienced. Cervical dilation is the same for all labors. The sequence of labor mechanisms is the same with all labors.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   214

OBJ:   Nursing Process Step: Evaluation   MSC:  Client Needs: Physiologic Integrity

 

  1. Which maternal factor may inhibit fetal descent?
a. A full bladder
b. Decreased peristalsis
c. Rupture of membranes
d. Reduction in internal uterine size

 

 

ANS:  A

A full bladder may inhibit fetal descent because it occupies space in the pelvis needed by the fetal presenting part. Peristalsis does not influence fetal descent. Rupture of membranes will assist in the fetal descent. Contractions will reduce the internal uterine size to assist fetal descent.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   198

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. Which assessment finding would cause a concern for a client who had delivered vaginally?
a. Estimated blood loss (EBL) of 500 mL during the birth process
b. White blood cell count of 28,000 mm3 postbirth
c. Client complains of fingers tingling
d. Client complains of thirst

 

 

ANS:  C

A client’s complaint of fingers tingling may represent respiratory alkalosis due to hyperventilation breathing patterns during labor. As such it requires intervention by the nurse to have the client slow breathing down and restore normal carbon dioxide levels.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   198

OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Physiologic Integrity/Reduction of Risk Potential

 

  1. Which clinical findings would be considered to be normal for a preterm fetus during the labor period?
a. Baseline tachycardia
b. Baseline bradycardia
c. Fetal anemia
d. Acidosis

 

 

ANS:  A

Because the nervous system is immature, it is expected that the preterm fetus will have a baseline tachycardia because of stimulation of the sympathetic nervous system. Baseline bradycardia, fetal anemia, and acidosis would indicate abnormal findings and fetal compromise.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   199

OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Physiologic Integrity/Reduction of Risk Potential

 

  1. On admission to the labor and birth unit, a 38-year-old female, gravida 4, para 3, at term in early labor is found to have a transverse lie on vaginal examination. What is the priority intervention at this time?
a. Perform a vaginal exam to denote progress.
b. Notify the health care provider.
c. Initiate parenteral therapy.
d. Apply oxygen via nasal cannula at 8 L/min.

 

 

ANS:  B

A transverse lie is considered to be an abnormal presentation so the physician should be notified and the process of a C section as the birth method should be initiated. The information provided relative to transverse lie was found on vaginal exam. At this point, the priority is to prepare for a surgical birth because assessment data also indicate that the client is in early labor; thus, a vaginal birth is not imminent. Although initiating parenteral therapy will be required, it is not the priority at this time. Application of oxygen is not required because there is no evidence of fetal or maternal distress.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   202

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. An assessment finding that would indicate to the nurse that cervical dilation and/or effacement has occurred is:
a. onset of irregular contractions.
b. cephalic presentation at 0 station.
c. bloody mucus drainage from vagina.
d. fetal heart tones (FHTs) present in the lower right quadrant.

 

 

ANS:  C

Cervical dilation and/or effacement results in loss of the mucous plug as well as rupture of small capillaries in the cervix; irregular contractions, cephalic presentation, and FHTs in the lower right quadrant do not indicate the onset of cervical ripening.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   207

OBJ:   Nursing Process Step: Analysis       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. If a notation on the client’s health record states that the fetal position is LSP, this means that the:
a. head is in the right posterior quadrant of the pelvis.
b. head is in the left anterior quadrant of the pelvis.
c. buttocks are in the left posterior quadrant of the pelvis.
d. buttocks are in the right upper quadrant of the abdomen.

 

 

ANS:  C

LSP explains the position of the fetus in the maternal pelvis. L = left side of the pelvis, S = sacrum (fetus is in breech presentation), P = posterior quadrants of the pelvis. When the head is in the right posterior quadrant of the pelvis, the position is ROP. When the head is in the left anterior quadrant of the pelvis, the position is ROA. When the buttocks are in the upper quadrant of the abdomen, the position would be ROA, ROP, LOA, LOP, LOT, or ROT.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   204

OBJ:   Nursing Process Step: Analysis       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The assessment finding which indicates that the client is in the active phase of the first stage of labor is:
a. 80% effacement.
b. dilation of 5 cm.
c. presence of bloody show.
d. regular contraction every 3 to 4 minutes.

 

 

ANS:  B

The active phase of labor is defined by cervical dilation between 4 to 7 cm. Effacement, bloody show, and regular contractions are not parameters whereby the phases of labor are defined.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   212

OBJ:   Nursing Process Step: Analysis       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. To determine if the client is in true labor, the nurse would assess for changes in:
a. cervical dilation.
b. amount of bloody show.
c. fetal position and station.
d. pattern of uterine contractions.

 

 

ANS:  A

Cervical changes are the only indication of true labor and are used to determine true and false labor. Changes in the amount of bloody show, fetal position and station, and pattern of uterine contractions are unreliable indicators of true labor.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   208

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. The health care provider for a laboring patient makes the following entry into the patient’s record: 3/50%/-1. What instruction will the nurse implement with the patient?
a. “You will need to remain in bed attached to the electronic fetal monitor.”
b. “Breathe with me slowly, in through your nose and out through your mouth.”
c. “I will begin the administration of 1000 mL of IV fluid so you can have an epidural.”
d. “Your partner will need to change into scrub attire to attend the imminent birth.”

 

 

ANS:  B

This client is in the latent phase of the first stage of labor. Use slow, deep chest breathing patterns early in labor to conserve energy for the upcoming process. There is no mention in the stem that the membranes are ruptured, which may prohibit the patient from ambulating. Ambulating during early labor uses gravity to facilitate fetal descent. This is desired because the head is at -1 station. Epidural placement during early labor may slow down the labor process. There is no indication that birth is imminent because the patient is 3 cm dilated.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   212

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The examiner indicates to the labor nurse that the fetus is in the left occiput anterior (LOA) position. To facilitate the labor process, how will the nurse position the laboring patient?
a. On her back
b. On her left side
c. On her right side
d. On her hands and knees

 

 

ANS:  B

LOA is the desired fetal position for the birthing process. Positioning the patient on her left side will accomplish two objectives: (1) by the use of gravity, the fetus will most likely stay in the LOA position; and (2) increase perfusion of the placenta and increase oxygen to the fetus. Positioning the patient on her back decreases placental perfusion. Positioning on her right may facilitate internal rotation and move the fetus out of the LOA position. The hands and knees position is reserved to decrease cord compression, facilitate the fetus out of a posterior position, or increase oxygenation in the presence of hypoxia. Because none of these conditions are present, there is no need to implement this position.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   204

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

The primipara at 39 weeks’ gestation states to the nurse, “I can breathe easier now.” What is the nurse’s best response?

a. “You labor will start any day now since the baby has dropped.”
b. “That process is called lightening. Do you have to urinate more frequently?”
c. “Contact your health care provider when your contractions are every 5 minutes for 1 hour.”
d. “You will likely not feel you baby’s movements as much now, so do not be concerned.”

 

 

ANS:  B

As the fetus descends toward the pelvic inlet (dropping), the woman notices that she breathes more easily because upward pressure on her diaphragm is reduced. However, increased pressure on her bladder causes her to urinate more frequently. Pressure of the fetal head in the pelvis also may cause leg cramps and edema. Lightening (descent of the fetus toward the pelvic inlet before labor) is most noticeable in primiparas and occurs about 2 to 3 weeks before the natural onset of labor. Instructions for labor, although correct, do not address the patient’s statement of being able to breathe easier. Fetal movement continues throughout the final weeks of gestation. A decrease in fetal movement is a concerning sign and the health care provider must be notified.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   207

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse assess a laboring patient’s contraction pattern and notes the frequency at every 3 to 4 minutes, duration 50 to 60 sections, and the intensity is moderate by palpation. What is the most accurate documentation for this contraction pattern?
a. Stage 1, latent phase
b. Stage 2, latent phase
c. Stage 1, active phase
d. Stage 2, active phase

 

 

ANS:  C

In the active phase of stage 1, contractions are about 2 to 5 minutes apart, with a duration of about 40 to 60 seconds and an intensity that ranges from moderate to strong. During the latent phase of stage 1, the interval between contractions shortens until contractions are about 5 minutes apart. Duration increases to 30 to 40 seconds by the end of the latent phase. During stage 2, latent phase, the woman is resting and preparing to push; she likely has not experienced the Ferguson reflex. She is actively bearing down during the active phase of the second stage.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   212

OBJ:   Nursing Process Step: Analysis       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A laboring patient states to the nurse, “I have to push!” What is the next nursing action?
a. Contact the health care provider.
b. Examine the patient’s cervix for dilation.
c. Review with her how to bear down with contractions.
d. Ask her partner to support her head with each push.

 

 

ANS:  B

When the cervix is completely dilated, the head can descend through the pelvis and stimulate the Ferguson, or pushing, reflex. Cervical dilation must first be confirmed because premature pushing efforts may result in cervical edema and corresponding delay in dilation. Once complete dilation has been confirmed, the nurse can notify the health care provider. Teaching positioning and pushing efforts is accomplished once complete dilation has been confirmed.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   199

OBJ:   Nursing Process Step: Analysis       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. After birth of the placenta the patient states, “All of a sudden I feel very cold.” What is the best nursing action in response to this statement?
a. Place a warm blanket over the patient.
b. Place the baby on the patient’s abdomen.
c. Tell the patient that chills are expected after birth.
d. “What do you mean by your words ‘very cold’?”

 

 

ANS:  A

Many women are chilled after birth. The cause of this reaction is unknown but probably relates to the sudden decrease in effort, loss of the heat produced by the fetus, decrease in intraabdominal pressure, and fetal blood cells entering the maternal circulation. The chill lasts for about 20 minutes and subsides spontaneously. A warm blanket, hot drink, or soup may help relieve the chill and make the woman more comfortable. Placing the baby on her abdomen may result in transfer of heat and make her feel even colder. Reassurance is appropriate after the blanket is provided. Validation of an expected physical response to the birthing process results in a delay of care and is unnecessary.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   214

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. A 28-year-old gravida 1, para 0 client who is at term calls the labor and birth unit stating that she thinks she is in labor. She states that she does have some vaginal discharge and feels wet but it is not bloody in nature. She relates a contraction pattern that is irregular, ranging from 5 to 7 minutes and lasting 30 seconds. What questions would be used during the process of phone triage by the nurse? (Select all that apply.)
a. Ask her if her if she thinks that her membranes have ruptured.
b. Ask her if she has any evidence of bloody show.
c. Have her keep monitoring her contraction pattern and call you back if they become more regular.
d. Ask her when her she has her next scheduled visit with her health care provider.
e. Tell her to come into the hospital for evaluation.

 

 

ANS:  A, E

The cornerstone of obstetric triage is reassurance of maternal-fetal well-being. Thus, in view of the assessment data that the client provided, the nurse should ascertain membrane status and ask the client to come in for evaluation. The client has already indicated that the vaginal discharge was not bloody in nature. Having the client continue to monitor at home would not provide assurance of maternal-fetal well-being. Asking the client about the next scheduled physician visit does not address current health concerns of impending labor.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   208

OBJ:   Nursing Process Step: Evaluation

MSC:  Client Needs: Physiologic Integrity/Physiologic Adaptation

 

  1. A client asks the nurse how she can tell if labor is real? What should the nurse give as an explanation? (Select all that apply.)
a. In true labor, the cervix begins to dilate.
b. In true labor, the contractions are felt in the abdomen and groin.
c. In true labor, contractions often resemble menstrual cramps during early labor.
d. In true labor, contractions are inconsistent in frequency, duration, and intensity in the early stages.
e. In true labor your contractions tend to increase in frequency, duration, and intensity with walking.

 

 

ANS:  A, C, E

In true labor, the cervix begins to dilate, contractions often resemble menstrual cramps in the early stage, and labor contractions increase in frequency, duration, and intensity with walking. False labor contractions are felt in the abdomen and groin and the contractions are inconsistent in frequency, duration, and intensity.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   208

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. The nurse who elects to practice in the area of obstetrics often hears discussion regarding the four Ps. What are the four Ps that interact during childbirth? (Select all that apply.)
a. Powers
b. Passage
c. Position
d. Passenger
e. Psyche

 

 

ANS:  A, B, D, E

  • Powers: The two powers of labor are uterine contractions and pushing efforts. During the first stage of labor, through full cervical dilation, uterine contractions are the primary force moving the fetus through the maternal pelvis. At some point after full dilation, the woman adds her voluntary pushing efforts to propel the fetus through the pelvis.
  • Passage: The passage for birth of the fetus consists of the maternal pelvis and its soft tissues. The bony pelvis is more important to the successful outcome of labor because bones and joints do not yield as readily to the forces of labor.
  • Passenger: This is the fetus plus the membranes and placenta. Fetal lie, attitude, presentation, and position are all factors that affect the fetus as passenger.
  • Psyche: The psyche is a crucial part of childbirth. Marked anxiety, fear, or fatigue decreases the woman’s ability to cope.

Position is not one of the four Ps.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   199

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. The nurse is planning care for a client during the fourth stage of labor. Which interventions should the nurse plan to implement? (Select all that apply.)
a. Offer the client a warm blanket.
b. Place an ice pack on the perineum.
c. Massage the uterus if it is boggy.
d. Delay breastfeeding until the client is rested.
e. Explain to the client that the lochia will be light pink in color.

 

 

ANS:  A, B, C

The fourth stage of labor lasts from the birth of the placenta through the first 1 to 4 hours after birth. Many women are chilled after birth. A warm blanket, hot drink, or soup may help relieve the chill and make the woman more comfortable. Localized discomfort from birth trauma such as lacerations, episiotomy, edema, or hematoma is evident as the effects of local and regional anesthetics diminish. Ice packs on the perineum limit this edema and hematoma formation. A soft (boggy) uterus and increasing uterine size are associated with postpartum hemorrhage because large blood vessels at the placenta site are not compressed. The uterus should be massaged if it is not firm. The fourth stage is the best time to initiate breastfeeding if maternal and infant problems are absent. The vaginal drainage after childbirth is called lochia. The three stages are lochia rubra, lochia serosa, and lochia alba. Lochia rubra, consisting mostly of blood, is present in the fourth stage of labor. The color of the lochia will be bright red not pink.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   214

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Physiologic Integrity

 

  1. Which should the nurse expect to assess in the third stage of labor that indicates the placenta has separated from the uterine wall? (Select all that apply.)
a. A gush of blood appears.
b. The uterus rises upward in the abdomen.
c. The fundus descends below the umbilicus.
d. The cord descends further from the vagina.
e. The uterus becomes boggy and soft, with an elongated shape.

 

 

ANS:  A, B, D

Four signs suggest placenta separation. The uterus has a spherical shape. The uterus rises upward in the abdomen as the placenta descends into the vagina and pushes the fundus upward. The cord descends further from the vagina. A gush of blood appears as blood trapped behind the placenta is released. The fundus rises upward above the umbilicus. A boggy uterus with an elongated shape would not be expected.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   214

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. The nurse is teaching a group of nursing students about factors that have a role in starting labor. Which should the nurse include in the teaching session? (Select all that apply.)
a. Progesterone levels become higher than estrogen levels.
b. Natural oxytocin in conjunction with other substances plays a role.
c. Stretching, pressure, and irritation of the uterus and cervix increase.
d. The secretion of prostaglandins from the fetal membranes decreases.

 

 

ANS:  B, C

Factors that appear to have a role in starting labor include the following: (1) natural oxytocin plays a part in labor’s initiation in conjunction with other substances; and (2) stretching, pressure, and irritation of the uterus and cervix increase as the fetus reaches term size. The progesterone levels drop and estrogen levels increase. There is an increase in the secretion of prostaglandins from the fetal membranes.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   207

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Physiologic Integrity

 

MATCHING

 

Match each term with the correct definition.

a. The fetal part that enters the pelvic inlet first
b. The orientation of the long axis of the fetus to the long axis of the woman
c. Relation of a fixed reference point on the fetus to the quadrants of the maternal pelvis

 

 

  1. Position

 

  1. Fetal lie

 

  1. Presentation

 

  1. ANS:  C                    PTS:   1                    DIF:    Cognitive Level: Understanding

REF:   201                OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Physiologic Integrity

NOT:  The position is the relation of a fixed reference point on the fetus to the quadrants of the maternal pelvis. The fetal lie is the orientation of the long axis of the fetus to the long axis of the woman. The presentation is the fetal part that enters the pelvic inlet first.

 

  1. ANS:  B                    PTS:   1                    DIF:    Cognitive Level: Understanding

REF:   202                OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Physiologic Integrity

NOT:  The position is the relation of a fixed reference point on the fetus to the quadrants of the maternal pelvis. The fetal lie is the orientation of the long axis of the fetus to the long axis of the woman. The presentation is the fetal part that enters the pelvic inlet first.

 

  1. ANS:  A                    PTS:   1                    DIF:    Cognitive Level: Understanding

REF:   202                OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Physiologic Integrity

NOT:  The position is the relation of a fixed reference point on the fetus to the quadrants of the maternal pelvis. The fetal lie is the orientation of the long axis of the fetus to the long axis of the woman. The presentation is the fetal part that enters the pelvic inlet first.

Chapter 24: The Childbearing Family with Special Needs

 

MULTIPLE CHOICE

 

  1. A pregnant client who abuses cocaine admits to exchanging sex for her drug habit. This behavior puts her at a greater risk for:
a. postmature birth.
b. Sexually transmitted diseases.
c. Hypotension and vasodilation.
d. Depression of the central nervous system.

 

 

ANS:  B

Sex acts exchanged for drugs place the woman at increased risk for sexually transmitted diseases because of having multiple partners and lack of protection. Premature delivery of the infant is one of the most common problems associated with cocaine use during pregnancy. Cocaine causes hypertension and vasoconstriction. Cocaine is a central nervous system stimulant.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   487

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. During which phase of the cycle of violence does the batterer become contrite and remorseful?
a. Battering
b. Honeymoon
c. Tension-building
d. Increased drug taking

 

 

ANS:  B

During the honeymoon phase, the battered person wants to believe that the battering will never happen again, and the batterer will promise anything to get back into the home. During the battering phase, violence actually occurs, and the victim feels powerless. During the tension-building phase, the batterer becomes increasingly hostile, swears, threatens, throws things, and pushes the battered person. Often, the batterer increases the use of drugs during the tension-building phase.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   499

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Psychosocial Integrity

 

  1. Which is a major barrier to health care for teen mothers?
a. Health care workers have a positive attitude.
b. The hospital or clinic is within walking distance of the girl’s home.
c. Seeing a different nurse and/or health care provider at every visit.
d. The institution is open days, evenings, and Saturday by special arrangement.

 

 

ANS:  C

Whenever possible, the teen should be scheduled to see the same nurses and practitioners for continuity of care. A positive attitude of the health care providers is important in teen pregnancy care. If the hospital or clinic were within walking distance of the girl’s home, it would prevent the teen from missing appointments because of transportation problems. If the institution were open days, evenings, and Saturday by special arrangement, this would be helpful for teens who work, go to school, or have other time of day restrictions. Scheduling conflicts are a major barrier to health care.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   480, 482

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Psychosocial Integrity

 

  1. In planning sex education classes for the 12- to 15-year-old age group, more emphasis should be placed on which?
a. How to set limits for sexual behavior
b. The inaccuracy of information from peers
c. The use of oral contraceptives to prevent unwanted pregnancy
d. The use of condoms to prevent sexually transmitted diseases as well as pregnancy

 

 

ANS:  A

Setting limits for sexual behavior is particularly important for younger teenagers who may be pressured to become sexually active before they are physically and emotionally ready. Oral contraceptives are not the preferred method of birth control for teenagers because they forget to take them, and they do not protect against STIs. The use of condoms is appropriate and an important concept to discuss but should not be the emphasis.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   477

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which should the nurse do when counseling a teenage client who has decided to relinquish her baby for adoption?
a. Question her about her feelings regarding adoption.
b. Tell her she can always change her mind about adoption.
c. Affirm her decision while acknowledging her maturity in making it.
d. Ask her if anyone is coercing her into the decision to relinquish her baby.

 

 

ANS:  C

A supportive affirming approach by the nurse will strengthen the client’s resolve and help her appreciate the significance of the event. It is important for the nurse to support and affirm the decision the client has made. This will strengthen the client’s resolve to follow through. Later the client should be given an opportunity to express her feelings. Telling her that she can always change her mind about adoption should not be an option after the baby is born and placed with the adoptive parents. It is important that the teenager be treated as an adult, with the assumption that she is capable of making an important decision on her own.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   496

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. A client who is older than 35 years may have difficulty achieving pregnancy because:
a. prepregnancy medical attention is lacking.
b. personal risk behaviors influence fertility.
c. she has used contraceptives for an extended time.
d. her ovaries may be affected by the aging process.

 

 

ANS:  D

Once the mature woman decides to conceive, a delay in becoming pregnant may occur because of the normal aging of the ovaries. Prepregnancy medical care is available and encouraged. The older adult participates in fewer risk behaviors than the younger adult. The problem is the age of the ovaries, not the past use of contraceptives.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   484

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. What is most likely to be a concern for an older mother?
a. Nutrition and diet planning
b. Exercise and fitness
c. Having enough rest and sleep
d. Effective contraceptive methods

 

 

ANS:  C

The woman who delays childbearing may have unique concerns, one of which is having less energy than younger mothers. The older mother is better off financially and can afford better nutrition. Information about exercise and fitness is readily available. The older mother usually has more financial means to search out effective contraceptive methods.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   484, 485

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Psychosocial Integrity

 

  1. Which is the most dangerous effect on the fetus of a client who smokes cigarettes while pregnant?
a. Intrauterine growth restriction
b. Genetic changes and anomalies
c. Extensive central nervous system damage
d. Fetal addiction to the substance inhaled

 

 

ANS:  A

The major consequences of smoking tobacco during pregnancy are low-birth-weight infants, prematurity, and increased perinatal loss. Cigarettes normally will not cause genetic changes or extensive central nervous system damage. Addiction is not a normal concern with the neonate.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   486

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A client at 24 weeks of gestation says she has a glass of wine with dinner every evening. Which is the reason the nurse should give to counsel her to eliminate all alcohol intake?
a. The fetus is placed at risk for altered brain growth.
b. The fetus is at risk for severe nervous system injury.
c. The client will be at risk for abusing other substances as well.
d. A daily consumption of alcohol indicates a risk for alcoholism.

 

 

ANS:  A

The brain grows most rapidly in the third trimester and is most vulnerable to alcohol exposure during this time. The major concerns are mental retardation, learning disabilities, high activity level, and short attention span. The risk to the client for abusing other substances is not the major risk for the infant. It has not been proven that daily consumption of alcohol indicates a risk for alcoholism.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   487

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which is an example of healthy grieving?
a. The mother exhibits an absence of crying or expression of feelings.
b. The parents do not mention the baby in conversation with family members.
c. The mother asks that the baby be taken away from the delivery area quickly.
d. While holding the baby, the mother says to her husband, “He has your eyes and nose.”

 

 

ANS:  D

Attachment behaviors are necessary for healthy grieving. Absence of crying and not mentioning the baby may be signs of denial. By not seeing the baby, attachment and therefore healthy grieving will not occur.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   482

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Psychosocial Integrity

 

  1. A client has delivered twins. The first twin was stillborn, and the second is in the intensive care nursery, recovering quickly from respiratory distress. The client is crying softly and says, “I wish my baby could have lived.” Which is the most therapeutic response?
a. “How soon do you plan to have another baby?”
b. “Don’t be sad. At least you have one healthy baby.”
c. “I have a friend who lost a twin and she’s doing just fine now.”
d. “I am so sorry about your loss. Would you like to talk about it?”

 

 

ANS:  D

The nurse should recognize the woman’s grief and its significance. Asking her about plans for another baby is denying the loss of the other infant. Pointing out the health of another baby is belittling her feelings. Stating that the nurse has a friend who lost a twin is denying the loss of the infant and her grief and belittling her feelings.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   492

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which is an appropriate nursing measure when a baby has an unexpected defect?
a. Remove the baby from the delivery area immediately.
b. Inform the parents immediately that something is wrong.
c. Tell the parents that the baby has to go to the nursery immediately.
d. Explain the defect and show the baby to the parents as soon as possible.

 

 

ANS:  D

Parents experience less anxiety when they are told about the defect as early as possible and are allowed to touch and hold the baby. The parents should be able to touch and hold the baby as soon as possible. The nurse should not take the baby away; this would raise anxiety levels of the parents. They should be told about the defect and allowed to see the baby.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   492

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Psychosocial Integrity

 

  1. Which statement correctly describes the incidence of intimate partner violence (IPV) in the United States?
a. Intimate partner violence seldom occurs during pregnancy.
b. Each year about 42.4 million women experience intimate partner violence.
c. The largest number of intimate partner violence is in the lower socioeconomic classes.
d. Intimate partner violence is second only to automobile accidents as the most frequent cause of injury to women.

 

 

ANS:  B

IPV occurs to approximately 42.4 million women each year. IPV occurs frequently during pregnancy. IPV victims come from all different backgrounds and socioeconomic classes. Intimate partner violence is a more common cause of injury than automobile accidents.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   497

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Psychosocial Integrity

 

  1. A client who is 6 months pregnant has sought medical attention, saying she fell down the stairs. Which scenario would cause an emergency department nurse to suspect that the woman has been battered?
a. She avoids making eye contact and is hesitant to answer questions.
b. The woman and her partner are having an argument that is loud and hostile.
c. The woman has injuries on various parts of her body that are in different stages of healing.
d. Examination reveals a fractured arm and fresh bruises. Her husband asks her about her pain.

 

 

ANS:  C

The battered woman often has multiple injuries in various stages of healing. It is more normal for the woman to have a flat affect. A loud and hostile argument is not always an indication of battering. Often the batterer will be attentive and refuse to leave the woman’s bedside.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   500

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Psychosocial Integrity

 

  1. When the nurse is alone with a battered client, the client seems extremely anxious and says, “It was all my fault. The house was so messy when he got home and I know he hates that.” Which is the best response by the nurse?
a. “No one deserves to be hurt. It’s not your fault. How can I help you?”
b. “What else do you do that makes him angry enough to hurt you?”
c. “He will never find out what we talk about. Don’t worry. We’re here to help you.”
d. “You have to remember that he is frustrated and angry, so he takes it out on you.”

 

 

ANS:  A

The nurse should stress that the client is not at fault. Asking what the woman did to make him angry enough to hurt the client is placing the blame on the woman. The nurse cannot promise that the batterer will not learn of the conversation. Often the batterer will find out about the conversation. Explaining the batterer’s actions is placing the blame on the woman and finding excuses for the batterer.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   501

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which environment can assist a pregnant teen to achieve the task of establishing a stable identity?
a. Home schooling
b. Alternative education program
c. School-based mothers’ program
d. Continuing mainstream high school classes

 

 

ANS:  C

A school-based mothers’ program that provides peer support is important. Home schooling, alternative education, and continuing mainstream high school classes would not provide as much peer support.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   478

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Psychosocial Integrity

 

  1. Which complication of adolescent pregnancy should the nurse plan to monitor?
a. Anemia
b. Placenta previa
c. Abruptio placenta
d. Incompetent cervix

 

 

ANS:  A

Adolescent pregnancies are at increased risk for anemia, nutritional deficiencies, pregnancy-associated hypertension, HIV and other STDs, short interval until next pregnancy, and depression. They do not have a higher incidence of placenta previa, abruptio placentae, or incompetent cervix.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   479

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Physiologic Integrity

 

  1. Which antidepressant is no longer recommended for use during pregnancy?
a. Sertraline (Zoloft)
b. Paroxetine (Paxil)
c. Fluoxetine (Prozac)
d. Citalopram (Celexa)

 

 

ANS:  B

Paroxetine (Paxil) is no longer recommended for use during pregnancy because there have been reports of congenital malformations. Zoloft, Prozac, and Celexa are antidepressants used during pregnancy, if indicated that without the medication the pregnant client would be at risk for severe depression.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   487, 488

OBJ:   Nursing Process Step: Evaluation

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. Women who become pregnant after the age of 35 are more likely to:
a. have multiple births because of increased fertility rates.
b. be hypotensive during the pregnancy.
c. have fewer obstetric complications due to stronger pelvic structure.
d. have a child who has a trisomy 21 abnormality.

 

 

ANS:  D

Mature woman who become pregnant often have issues with conception and can experience infertility. There is no causal relationship between maternal age and hypotension during pregnancy. Women older than 35 are more likely to have obstetric complications for a variety of reasons. Women older than 35 are more likely to develop chromosomal abnormalities, specifically Down syndrome, which is trisomy 21.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   484

OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Physiologic Integrity/Physiologic Adaption

 

  1. A pregnant client tells you during a clinic visit that she is concerned about her significant other’s change in behavior during the course of the pregnancy. She relates feelings of being afraid but emphatically denies any physical or verbal threats. She confides in you that she has been using her mobile phone to find out more information about this subject. What is the most appropriate nursing response?
a. Tell her that all relationships change during pregnancy and give herself and her significant other some time to adapt to this situation by spending quality time with one another.
b. Tell the client that you are concerned for her and the baby; provide her with a phone number for a safe house just in case she needs to act quickly and leave the home situation.
c. Explore in more detail the client’s feelings but tell her that you are concerned about searching information on the Internet as a stimulus trigger for potential abuse.
d. Do not let the client leave the clinic office and call the domestic abuse hotline number to report the incident.

 

 

ANS:  C

All health care providers should take comments of potential abuse seriously. Because there is no confirmation of abuse by the client’s admission, additional investigation is warranted. Based on the facts presented, the nurse should be concerned that the client’s significant other might be alerted to a potential trigger of violent behavior.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   499

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. The nurse is seeing a 17-year-old female in the clinic for complaints of acne. The nurse plans on taking advantage of this teachable moment with the teen. What topics will the nurse include in the teen’s teaching plan?
a. Smoking habits, folic acid intake, and heart disease
b. Hyperlipidemia, distracted driving, and menstrual history
c. Sexual activity, contraception, and screening for violence
d. Optimum weight, hypothyroidism, and sexually transmitted diseases

 

 

ANS:  C

All the topics mentioned are worthy of discussion. However, sexual activity, contraception, and screening for violence have priority related to the age and gender of the patient. Because adolescents are often seen by a health care provider for various reasons before they become pregnant, counseling to improve health for a future pregnancy should be offered to them during any health care visit. Smoking cessation, attaining optimum weight, folic acid intake, and screening for violence are topics that should be discussed with all young women so that any future pregnancy has the most positive outcome.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   477

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A patient has just acknowledged that she is 20 weeks pregnant and confides to the nurse that she has a daily heroin habit. The nurse discusses treatment options for the patient. Which patient statement requires follow-up?
a. “My plan is to visit the outpatient clinic daily for treatment.”
b. “I will see my health care provider at least every 2 weeks.”
c. “My baby will not have to go through withdrawal when I take methadone.”
d. “With oral methadone, my baby and I are at decreased risk of infection.”

 

 

ANS:  C

Pregnant women who use heroin are often prescribed an alternative drug such as methadone, a synthetic opiate. Methadone can be taken orally once daily and is long- acting, providing consistent blood levels to decrease the adverse fetal effects of wide swings in blood levels found with heroin use. Methadone also reduces the risk of infections from contaminated needles and drug-seeking behavior, such as prostitution. At therapeutic levels, it does not produce the euphoria or sedation of heroin and allows the woman to have a relatively normal lifestyle. The woman who receives a daily dose of methadone in a drug treatment program is more likely to receive prenatal care. However, the newborn must withdraw from methadone after birth.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   488

OBJ:   Nursing Process Step: Evaluation   MSC:  Client Needs: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. Which nursing diagnoses may apply to the childbearing family with special needs? (Select all that apply.)
a. Risk for spiritual distress
b. Risk for injury
c. Readiness for enhanced nutrition
d. Ineffective breathing pattern
e. Situational low self-esteem

 

 

ANS:  A, B, E

A childbearing family with special needs may be at risk to develop spiritual distress, experience injury, and exhibit situational low self-esteem. There are no supportive data to hypothesize an ineffective breathing pattern and/or readiness for enhanced nutrition.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   501

OBJ:   Nursing Process Step: Nursing Diagnosis

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Many teens wait until the second or even third trimester to seek prenatal care. The nurse should understand that the reasons behind this delay include which of the following? (Select all that apply.)
a. Continuing to deny the pregnancy
b. Uncertainty about where to go for care
c. Lack of realization that they are pregnant
d. A desire to gain control over their situation
e. Wanting to hide the pregnancy as long as possible

 

 

ANS:  A, B, C, E

Denying the pregnancy, uncertainty about where to go for care, lack of realization of pregnancy, and wanting to hide the pregnancy are all valid reasons for the teen to delay seeking prenatal care. A desire to gain control is not a reason to delay seeking health care.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   480

OBJ:   Nursing Process Step: Diagnosis     MSC:  Client Needs: Psychosocial Integrity

 

  1. Which characteristics of fetal alcohol syndrome (FAS) should the nurse expect to assess in affected neonates? (Select all that apply.)
a. Hydrocephaly
b. Low activity
c. Epicanthal folds
d. Short palpebral fissures
e. Flat midface, with a low nasal bridge

 

 

ANS:  C, D, E

Common facial anomalies associated with FAS include microcephaly, short palpebral fissures (the openings between the eyelids), epicanthal folds, flat midface with a low nasal bridge, indistinct philtrum (groove between the nose and upper lip), and a thin upper lip. Microcephaly is present, not hydrocephaly. Central nervous system impairment includes a high activity level, not a low one.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   487

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. Which congenital defects in a newborn are associated with long-term parenting problems? (Select all that apply.)
a. Polydactyl
b. Cleft lip and palate
c. Ventral septal defect
d. Ambiguous genitalia

 

 

ANS:  B, D

Although any defect in a newborn produces extreme concern and anxiety, certain defects are associated with long-term parenting problems. Accepting an infant with facial or genital anomalies is particularly difficult for the family and community. Polydactyl and ventral septal defects are reparable, with good outcomes.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   492

OBJ:   Nursing Process Step: Evaluation   MSC:  Client Needs: Psychosocial Integrity

 

MATCHING

 

Match each term with the correct definition.

a. A powerful short-acting CNS stimulant
b. CNS depressants that produce a feeling of mental dullness, drowsiness, and finally stupor
c. Active constituent is tetrahydrocannabinol, which crosses the placenta and accumulates in the fetus

 

 

  1. Marijuana

 

  1. Cocaine

 

  1. Opiates

 

  1. ANS:  C                    PTS:   1                    DIF:    Cognitive Level: Understanding

REF:   487                OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Physiologic Integrity

NOT:  Cocaine is a powerful short-acting CNS stimulant. Opiates are CNS depressants that produce a feeling of mental dullness, drowsiness, and finally stupor. The active constituent in marijuana is tetrahydrocannabinol, which crosses the placenta and accumulates in the fetus.

 

  1. ANS:  A                    PTS:   1                    DIF:    Cognitive Level: Understanding

REF:   487                OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Physiologic Integrity

NOT:  Cocaine is a powerful short-acting CNS stimulant. Opiates are CNS depressants that produce a feeling of mental dullness, drowsiness, and finally stupor. The active constituent in marijuana is tetrahydrocannabinol, which crosses the placenta and accumulates in the fetus.

 

  1. ANS:  B                    PTS:   1                    DIF:    Cognitive Level: Understanding

REF:   488                OBJ:   Nursing Process Step: Assessment

MSC:  Client Needs: Physiologic Integrity

NOT:  Cocaine is a powerful short-acting CNS stimulant. Opiates are CNS depressants that produce a feeling of mental dullness, drowsiness, and finally stupor. The active constituent in marijuana is tetrahydrocannabinol, which crosses the placenta and accumulates in the fetus.

Chapter 34: Women’s Health Problems

 

MULTIPLE CHOICE

 

  1. Which are the most common sites of breast cancer metastasis?
a. Kidneys
b. Bones and liver
c. Heart and blood vessels
d. Central nervous system

 

 

ANS:  B

Metastasis occurs when the cancer cells spread to the vascular sites, commonly the lungs, liver, and bones. Kidney metastasis is uncommon. Metastasis to the heart and blood vessels is uncommon. The brain is one of the final areas to be reached by metastasis.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   730

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. Which sexually transmitted disease can be cured?
a. Herpes
b. AIDS
c. Chlamydia
d. Venereal warts

 

 

ANS:  C

The usual treatment for chlamydial bacterial infection is doxycycline hyclate or tetracycline. Concurrent treatment of all sexual partners is needed to prevent recurrence. Because no cure is known for herpes, treatment focuses on pain relief and preventing secondary infections. Because no cure is known for AIDS, prevention and early detection are the main focus. Condylomata acuminata is caused by the human papillomavirus. No treatment eradicates the virus.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   750

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. Which statement by a client diagnosed with premenstrual syndrome indicates that further health teaching is needed?
a. “I will not eat chips or pickles.”
b. “I’ll eat only three meals per day.”
c. “Drinking alcohol makes me more depressed.”
d. “Coffee and chocolate can make me more irritable and nervous.”

 

 

ANS:  B

The client should be encouraged to eat six small meals a day to decrease the risk of hypoglycemia. Less intake of salty foods helps decrease fluid retention. Alcohol consumption aggravates depression. Caffeine consumption increases irritability, insomnia, anxiety, and nervousness.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   739

OBJ:   Nursing Process Step: Evaluation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A benign breast condition that includes dilation and inflammation of the collecting ducts is:
a. fibroadenoma.
b. ductal ectasia.
c. intraductal papilloma.
d. chronic cystic disease.

 

 

ANS:  B

Generally occurring in women approaching menopause, ductal ectasia results in a firm irregular mass in the breast, enlarged axillary nodes, and nipple discharge. Fibroadenoma is evidenced by fibrous and glandular tissues. They are felt as firm, rubbery, and freely mobile nodules. Intraductal papillomas develop in the epithelium of the ducts of the breasts; as the mass grows, it causes trauma or erosion within the ducts. Chronic cystic disease causes pain and tenderness. The cysts that form are multiple, smooth, and well delineated.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   729

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. Which client is most at risk for fibroadenoma of the breast?
a. Janice, 38 years old
b. Helen, 50 years old
c. Mary, 16 years old
d. Anna, 27 years old

 

 

ANS:  C

Although it may occur at any age, fibroadenoma is most common in the teenage years. Ductal ectasia becomes more common as a client approaches menopause. Intraductal papilloma develops most often just before or during menopause. Fibrocystic breast changes are more common during the reproductive years.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   729

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. Which statement is true about primary dysmenorrhea?
a. Primary dysmenorrhea is experienced by all women.
b. It is unaffected by oral contraceptives.
c. It occurs in young multiparous women.
d. It may be caused by excessive endometrial prostaglandin.

 

 

ANS:  D

Some women produce excessive endometrial prostaglandin during the luteal phase of the menstrual cycle. Prostaglandin diffuses into endometrial tissue and causes uterine cramping. Primary dysmenorrhea is not experienced by all women. Oral contraceptives can be a treatment choice. It occurs in young nulliparous women.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   737

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. A client states, “I’m sure that I am suffering from PMS. How can I get my doctor to take this seriously?” The nurse’s best response is:
a. “Men are not usually sympathetic to PMS sufferers.”
b. “You are probably right. You should remind your doctor of your symptoms every time you visit.”
c. “Since you feel certain you are right, you should just treat yourself with over-the-counter medications.”
d. “You should keep a daily record of the occurrence and severity of your symptoms for 3 months.”

 

 

ANS:  D

Symptom charting for at least 3 months is necessary to make an accurate diagnosis of PMS. Suggesting lack of sympathy from men is an inaccurate statement and will not help the client with the present problem. Reminding the physician of the symptoms will not assist in making a diagnosis. Listing symptoms for 3 months will help the physician make the diagnosis better. The client should not treat herself with over-the-counter medications.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   738, 739

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which should the nurse stress in teaching a client to deal with the symptoms of PMS?
a. Decrease her consumption of caffeine.
b. Drink a small glass of wine with her evening meal.
c. Decrease her fluid intake to prevent fluid retention.
d. Eat three large meals a day to maintain glucose levels.

 

 

ANS:  A

Caffeine increases irritability, insomnia, anxiety, and nervousness. Alcohol aggravates depression and should be avoided. Fluid intake should not be decreased. Six smaller meals a day will help maintain glucose levels.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   739

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A client, age 49, confides in the nurse that she has started experiencing pain with intercourse. She asks, “Is there anything I can do about this?” The nurse’s best response is:
a. “No, it is part of the aging process.”
b. “Water-soluble vaginal lubricants may provide relief.”
c. “You need to be evaluated for a sexually transmitted disease.”
d. “You may have vaginal scar tissue that is producing the discomfort.”

 

 

ANS:  B

Loss of lubrication, with resulting discomfort in intercourse, is a symptom of estrogen deficiency. It is part of the aging process, but the use of lubrication will help relieve the symptoms. This is a normal occurrence with the aging process and does not indicate an STD. It is caused by loss of lubrication with the decrease in estrogen. Scar tissue problems would have occurred earlier.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   741

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which client is most likely to have osteoporosis?
a. A 50-year-old client on estrogen therapy
b. A 55-year-old client with a sedentary lifestyle
c. A 65-year-old client who walks 2 miles each day
d. A 60-year-old client who takes supplemental calcium

 

 

ANS:  B

Risk factors for the development of osteoporosis include smoking, alcohol consumption, sedentary lifestyle, family history of the disease, and a high-fat diet. Hormone therapy may prevent bone loss. Weight-bearing exercises have been shown to increase bone density. Supplemental calcium will help prevent bone loss, especially when combined with vitamin D.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   743

OBJ:   Nursing Process Step: Assessment  MSC:  Client Needs: Physiologic Integrity

 

  1. A client with a history of a cystocele should contact the physician if she experiences:
a. backache.
b. constipation.
c. urinary frequency and burning.
d. involuntary loss of urine when she coughs.

 

 

ANS:  C

Urinary frequency and burning are symptoms of cystitis, a common problem associated with cystocele. Back pain is a symptom of uterine prolapse. Constipation may be a problem with rectoceles. Involuntary loss of urine during coughing is stress incontinence and is not an emergency.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   745

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. Which should the nurse teach to assist a client to regain control of her urinary sphincter?
a. Do Kegel exercises.
b. Void every hour while awake.
c. Drink 8 to 10 glasses of water each day.
d. Allow the bladder to become distended before voiding.

 

 

ANS:  A

Kegel exercises, tightening and relaxing the pubococcygeal muscle, will improve control of the urinary sphincter. A prescribed schedule may help, but every hour is too frequent. Restricting fluids will cause bladder irritation, which exacerbates the problem. Drinking adequate fluids will not help the problem. Overdistention of the bladder will cause incontinence.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   746

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The physician diagnoses a 3-cm cyst in the ovary of a 28-year-old client. You expect the initial treatment to include:
a. beginning hormone therapy.
b. scheduling a laparoscopy to remove the cyst.
c. examining the client after her next menstrual period.
d. aspirating the cyst and sending the fluid to pathology.

 

 

ANS:  C

Most ovarian cysts regress spontaneously. Cysts in women of childbearing age may decrease within one cycle, so treatment is not necessary at this point. It is too early to anticipate removal of the cysts. Most ovarian cysts regress spontaneously within one cycle. A transvaginal ultrasound examination will help determine if the cyst is fluid-filled or solid. The cyst can then be removed if warranted.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   748

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Physiologic Integrity

 

  1. The drug of choice to treat gonorrhea is:
a. penicillin G (Pfizerpen).
b. tetracycline (Achromycin).
c. ceftriaxone (Rocephin).
d. acyclovir (Zovirax).

 

 

ANS:  C

Ceftriaxone is effective for treatment of all gonococcal infections. Penicillin G is used to treat syphilis. Tetracycline is used to treat chlamydial infections. Acyclovir is used to treat herpes genitalis.

 

PTS:   1                    DIF:    Cognitive Level: Understanding     REF:   750

OBJ:   Nursing Process Step: Planning       MSC:  Client Needs: Physiologic Integrity

 

  1. Which option could be used for the treatment and management of a client who reports mild pain associated with a clinical diagnosis of fibrocystic breast disease?
a. Chamomile tea as a relaxant therapy
b. Danazol (Danocrine)
c. Tamoxifen (Nolvadex)
d. Over-the-counter nonsteroidal antiinflammatory drug (NSAID) therapy

 

 

ANS:  D

Because the client is reporting mild pain, NSAIDs may provide adequate pain relief and comfort. It is recommended that tea, coffee, and/or other stimulants be limited or restricted for clients with fibrocystic breast disease. Danazol is typically used for moderate to severe pain for clients with fibrocystic breast disease because its use is associated with more serious side effects. The client reports mild pain so this would not be warranted. Tamoxifen is a selective estrogen receptor modulator (SERM) used for the treatment of breast cancers and also for moderate to severe pain in fibrocystic breast disease. The client reports mild pain, so this would not be warranted.

 

PTS:   1                    DIF:    Cognitive Level: Application          REF:   729

OBJ:   Nursing Process Step: Evaluation

MSC:  Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies

 

  1. Which treatment option minimizes the development of lymphedema in the surgical management of a client with breast cancer?
a. Radical mastectomy procedure
b. Radiation therapy
c. Sentinel lymph node mapping
d. Ultrasound

 

 

ANS:  C

The use of sentinel lymph node mapping identifies only those affected lymph node tissues that require surgical removal so it helps minimize the development of lymphedema in the surgical management of a client with breast cancer. Radical mastectomy is associated with lymphedema in the postsurgical breast cancer client because of the removal of lymph node tissue. Radiation therapy is not associated with a decrease in lymphedema for the breast cancer client. Ultrasound as an intervention does not affect the development of lymphedema.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   731

OBJ:   Nursing Process Step: Planning

MSC:  Client Needs: Physiologic Integrity/Physiologic Adaptation

 

  1. You are taking care of a client who has had a colporrhaphy. Which option would indicate a priority assessment during the postoperative period?
a. Documentation of a pessary in the operative procedure notes by the physician
b. Removal of vaginal packing as ordered by the physician
c. Use of a cell saver for transfusion therapy in the postoperative period
d. Order for removal of staples 2 to 3 days post-procedure

 

 

ANS:  B

Vaginal packing is typically used in this type of pelvic surgery so it is a priority assessment that its removal be verified and documented. A pessary would be used as a nonsurgical intervention for a client who has had uterine prolapse and was not a surgical candidate based on medical history. A cell saver is used in orthopedic surgeries that are at risk for blood loss so that the client’s own blood can be re-infused based on established protocol. There are no staples used in this type of surgical procedure, which is also known as an A & P (anterior and posterior) repair.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   746

OBJ:   Nursing Process Step: Implementation

MSC:  Client Needs: Safe and Effective Care Environment/Establishing Priorities

 

  1. In reviewing genetic testing for a female client, you note the presence of BRCA1, BRCA2, and CHEK2. How should these findings be interpreted?
a. There is no increased likelihood that the client will develop breast or ovarian cancer.
b. There is an increased likelihood only for the development of breast cancer in a woman.
c. More information is needed to interpret these findings based on the client’s family history and the client’s current and past medical history.
d. A radical bilateral mastectomy is required immediately because the cancer may have already undergone sub-metastasis.

 

 

ANS:  C

The presence of genetic markers (BRCA1, BRCA2, and CHEK2) provides strong indicators of the increased risk for the development of breast cancer in males and females and ovarian cancer. It is important to obtain additional information so that a treatment plan can be developed and implemented to improve client outcomes. There is an increased likelihood that the client will develop breast or ovarian cancer, but stating that there is an increased likelihood only for the development of breast cancer in a woman fails to include that men are also at risk of developing breast cancer. At this point, surgical intervention is speculative because the presence of biomarkers does not indicate that sub-metastasis has occurred or that the cancer has even developed.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   748

OBJ:   Nursing Process Step: Evaluation

MSC:  Client Needs: Physiologic Integrity/Reduction of Risk Potential

 

MULTIPLE RESPONSE

 

  1. A 38-year-old client presents to the clinic office complaining of increased bilateral tenderness of her breasts prior to the onset of menses. On questioning the client, this presentation has occurred off and on for several years, but the pain has increased. Physical examination reveals lumpy areas bilaterally on the upper outer quadrants of each breast tissue. The areas of concern are approximately 2 cm in size. Based on this assessment, what diagnostic testing would be required? (Select all that apply.)
a. Ultrasound examination
b. Open biopsy
c. Fine-needle aspiration (FNA) biopsy
d. CBC with differential
e. Mammogram

 

 

ANS:  A, C, E

Based on the clinical presentation, the client may have fibrocystic breast disease. Although this condition is typically benign, the fact that the client has noted a change in tenderness should be evaluated. Ultrasound, FNA, and mammography may be indicated to provide a baseline for comparison and rule out any malignancy. An open or surgical biopsy is not indicated at the present time but may be needed if the other test results indicate any pathology. Blood work is not indicated at this time relative to the diagnosis.

 

PTS:   1                    DIF:    Cognitive Level: Analysis               REF:   728

OBJ:   Nursing Process Step: Planning

MSC:  Client Needs: Physiologic Integrity/Reduction of Risk Potential

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