NCSBN LESSON 3 HEALTH PROMOTION & MAINTENANCE
A nurse observes a newborn whose Apgar score was 8 Color RATIONALE- Acrocyanosis (blue hands and feet) is the most common
at one minute and then 9 at the five-minute evaluation. Apgar score deduction and is a normal adaptation in the newborn in response to
These scores would be more commonly related to the environment. If the environment is cool, then the hands and feet would
abnormalities in which of these areas? display a more bluish discoloration. On average it lasts for about 48 to 72 hours.
Recall that the maximum score is 10 for Apgar, so 1 or 2 points lower would
suggest a problem that is probably not as severe as a problem related to heart
rate, muscle tone or cry (respirations).
An anxious parent of a 4 year-old discusses with the "When a child of this age asks a question, give a simple answer." RATIONALE
nurse how to answer the child's question: "Where do During discussions related to sexuality, honesty is very important. However,
babies come from?" What is the best response by the honesty does not mean imparting every fact of life associated with the question.
nurse to the parent? When children ask one question, they are looking for one answer. When they are
ready, they will ask about the other pieces of information by the use of specific
questions.
The registered nurse is preparing a client and her Enlargement of the breasts RATIONALE -Of all the options, the most commonly
healthy newborn for discharge and provides information expected physical finding due to maternal hormones is breast engorgement. This
about hormonal effects in newborns. The licensed can occur in both boys and girls. Mongolian blue spots commonly appear at birth
practical nurse understands that which finding in the or shortly thereafter; they are flat, blue, or blue-gray skin markings near the
newborn is due to the maternal hormones? buttocks. The newborn scrotum can be filled with clear fluid (which was
squeezed into the scrotum during the birth process); it will be reabsorbed over
the next few months. Lanugo is the fine downy hair that may be present on the
backs and shoulders of newborns, particularly premature infants.
A home health nurse is making an initial visit to a 70 Identify learning needs RATIONALE- With the focus on health promotion, the
year-old client. What should be the first action to meet nurse should first identify any learning needs. Once learning needs are identified,
the client's health needs? the nurse would know if meal planning assistance is needed. Reviewing
medications and discussing health history are part of the initial assessment.
Helpful hint: since this is a very general question, you should look for a response
that's more general.
The nurse is discussing modifiable cardiac risk factors Smoking cessation RATIONALE Stopping smoking is the priority for clients at risk
with a group of adults. Which topic should the nurse for cardiac disease because of the effects of reduced oxygenation and
reinforce as the priority intervention? constriction of blood vessels. Notice that three of the options are all actions that
indirectly reduce cardiac risk factors. Ask yourself which of the options should
happen first or which one would have an immediate impact on the body: weight,
stress, exercise or smoking?
The nurse is measuring blood pressure at a community Get your blood pressure checked again within the next 48 to 72 hours"
health fair. When the nurse tells someone that his blood RATIONALE- The blood pressure reading is moderately high and should be
pressure is 160/96 mm Hg, he states, "My blood rechecked within a few days. Since the client states it is "usually much lower" the
pressure is usually much lower." What is the best elevated BP could be a concern but it is not clear what the client considers to be
response to this statement? a "much lower" BP. The nurse should measure the blood pressure in the other
arm and compare the two readings. Waiting two or three weeks for follow-up is
too long.
The nurse practices in a long-term care facility and Decrease in total body water and an increase in proportion body fat RATIONALE
understands that older adults are at greater risk for Because older clients have a decline in lean body mass and changes in total
experiencing adverse effects from medications. What body water in which to distribute medications, more medication remains in the
physiologic changes could contribute to these adverse circulatory system with potential for medication toxicity. Increased proportion of
effects? body fat results in greater amounts of fat-soluble medications being absorbed,
leaving less in the circulation, and thus increasing the duration of action of the
medication.
A client is forgetful and experiences short-term memory Confirm that no hearing loss RATIONALE Hearing loss may result in the client
loss. When collecting data about short-term memory answering questions inappropriately, which may be misinterpreted as a short-
loss, which action should the nurse take first? term memory loss. Asking clients to state their birthdate is used to assess long-
term memory. Observing the client during activity may be done for mobility
concerns or deficits. Having the client read something can be used to assess
vision problems.
A 14 year-old boy with a history of hemophilia A was Often take part in active sports RATIONALE Adolescent hemophiliacs should be
admitted after a fall while playing basketball. In aware that contact sports may trigger bleeding. However, developmental
understanding his behavior and assisting in planning characteristics of adolescents, such as impulsivity, inexperience and peer
care for this client, what should the nurse recognize pressure, often place them in unsafe situations. Adolescents do not want to
concerning the behavior of adolescents with a chronic appear differently to their peers and would probably not willingly offer information
disease? about their disease to others.
The nurse is providing care for an adolescent. Which Provide discussion of concerns without the presence of parents or guardians
intervention best demonstrates the nurse's sensitivity to RATIONALE While the family is an important component in the care of an
an adolescent's need for autonomy? adolescent, it is also important to spend time alone with the adolescent. This is
an opportunity for the nurse to hear the teen's perspective and to really listen to
his/her concerns.
, NCSBN LESSON 3 HEALTH PROMOTION & MAINTENANCE
Fetal Station the relationship between the presenting part of the baby with the mother's pelvis
Fetal Lie the relationship between the head to tailbone axis for both the fetus and the
mother
Fetal Attitude the relationship of the fetal body parts to one another
Fetal Presentation portion of the fetus that enters the pelvic inlet first (cephalic, breech,
LOA (left occiput anterior): fetal occiput is on the left side of the maternal pelvis toward the front and the fetal
face is toward the rear of the pelvis
ROA (right occiput anterior): fetal occiput is on the right side of the maternal pelvis toward the front and the
fetal face is toward the rear of the pelvis
LOP (left occiput posterior): fetal occiput is on the left side of the maternal pelvis toward the rear and the fetal
face is toward the front of the pelvis
ROP (right occiput posterior): fetal occiput is on the right side of the maternal pelvis toward the rear and the
fetal face is toward the front of the pelvis
Dilating stage Begins with the first true labor contractions to complete dilatation of the cervix
(10 cm)
Latent (early) or prodromal contractions last from 30 to 45 seconds with the intensity gradually increasing;
frequency of contractions is from 5 to 20 minutes dilation is from 0 to 3
centimeters
bloody show is usually present
the mother is usually able to walk and talk during this phase; diversion is usually
welcomed
Active or accelerated contractions become stronger and last longer, usually 45 to 60 seconds;
frequency is from 3 to 5 minutes cervix dilates from 4 to 7 centimeters the mother
is not able to walk, tends to withdraw from the surrounding environment but
desires companionship and encouragement
Transient or transitional contractions are sharp, more intensified, lasting 60 to 90 seconds; frequency of
contractions is from 2 to 3 minutes cervix dilates from 8 to 10 centimeters
increase in the bloody show mother feels an urge to push or to have a bowel
movement
Rh positive mother + Rh positive father = Rh positive baby...no precautions are needed.
Rh negative mother + Rh negative father = Rh negative baby...no precautions are needed.
Rh positive mother + Rh negative father = baby could be either Rh positive or Rh negative...no precautions are needed.
A nurse observes a newborn whose Apgar score was 8 Color RATIONALE- Acrocyanosis (blue hands and feet) is the most common
at one minute and then 9 at the five-minute evaluation. Apgar score deduction and is a normal adaptation in the newborn in response to
These scores would be more commonly related to the environment. If the environment is cool, then the hands and feet would
abnormalities in which of these areas? display a more bluish discoloration. On average it lasts for about 48 to 72 hours.
Recall that the maximum score is 10 for Apgar, so 1 or 2 points lower would
suggest a problem that is probably not as severe as a problem related to heart
rate, muscle tone or cry (respirations).
An anxious parent of a 4 year-old discusses with the "When a child of this age asks a question, give a simple answer." RATIONALE
nurse how to answer the child's question: "Where do During discussions related to sexuality, honesty is very important. However,
babies come from?" What is the best response by the honesty does not mean imparting every fact of life associated with the question.
nurse to the parent? When children ask one question, they are looking for one answer. When they are
ready, they will ask about the other pieces of information by the use of specific
questions.
The registered nurse is preparing a client and her Enlargement of the breasts RATIONALE -Of all the options, the most commonly
healthy newborn for discharge and provides information expected physical finding due to maternal hormones is breast engorgement. This
about hormonal effects in newborns. The licensed can occur in both boys and girls. Mongolian blue spots commonly appear at birth
practical nurse understands that which finding in the or shortly thereafter; they are flat, blue, or blue-gray skin markings near the
newborn is due to the maternal hormones? buttocks. The newborn scrotum can be filled with clear fluid (which was
squeezed into the scrotum during the birth process); it will be reabsorbed over
the next few months. Lanugo is the fine downy hair that may be present on the
backs and shoulders of newborns, particularly premature infants.
A home health nurse is making an initial visit to a 70 Identify learning needs RATIONALE- With the focus on health promotion, the
year-old client. What should be the first action to meet nurse should first identify any learning needs. Once learning needs are identified,
the client's health needs? the nurse would know if meal planning assistance is needed. Reviewing
medications and discussing health history are part of the initial assessment.
Helpful hint: since this is a very general question, you should look for a response
that's more general.
The nurse is discussing modifiable cardiac risk factors Smoking cessation RATIONALE Stopping smoking is the priority for clients at risk
with a group of adults. Which topic should the nurse for cardiac disease because of the effects of reduced oxygenation and
reinforce as the priority intervention? constriction of blood vessels. Notice that three of the options are all actions that
indirectly reduce cardiac risk factors. Ask yourself which of the options should
happen first or which one would have an immediate impact on the body: weight,
stress, exercise or smoking?
The nurse is measuring blood pressure at a community Get your blood pressure checked again within the next 48 to 72 hours"
health fair. When the nurse tells someone that his blood RATIONALE- The blood pressure reading is moderately high and should be
pressure is 160/96 mm Hg, he states, "My blood rechecked within a few days. Since the client states it is "usually much lower" the
pressure is usually much lower." What is the best elevated BP could be a concern but it is not clear what the client considers to be
response to this statement? a "much lower" BP. The nurse should measure the blood pressure in the other
arm and compare the two readings. Waiting two or three weeks for follow-up is
too long.
The nurse practices in a long-term care facility and Decrease in total body water and an increase in proportion body fat RATIONALE
understands that older adults are at greater risk for Because older clients have a decline in lean body mass and changes in total
experiencing adverse effects from medications. What body water in which to distribute medications, more medication remains in the
physiologic changes could contribute to these adverse circulatory system with potential for medication toxicity. Increased proportion of
effects? body fat results in greater amounts of fat-soluble medications being absorbed,
leaving less in the circulation, and thus increasing the duration of action of the
medication.
A client is forgetful and experiences short-term memory Confirm that no hearing loss RATIONALE Hearing loss may result in the client
loss. When collecting data about short-term memory answering questions inappropriately, which may be misinterpreted as a short-
loss, which action should the nurse take first? term memory loss. Asking clients to state their birthdate is used to assess long-
term memory. Observing the client during activity may be done for mobility
concerns or deficits. Having the client read something can be used to assess
vision problems.
A 14 year-old boy with a history of hemophilia A was Often take part in active sports RATIONALE Adolescent hemophiliacs should be
admitted after a fall while playing basketball. In aware that contact sports may trigger bleeding. However, developmental
understanding his behavior and assisting in planning characteristics of adolescents, such as impulsivity, inexperience and peer
care for this client, what should the nurse recognize pressure, often place them in unsafe situations. Adolescents do not want to
concerning the behavior of adolescents with a chronic appear differently to their peers and would probably not willingly offer information
disease? about their disease to others.
The nurse is providing care for an adolescent. Which Provide discussion of concerns without the presence of parents or guardians
intervention best demonstrates the nurse's sensitivity to RATIONALE While the family is an important component in the care of an
an adolescent's need for autonomy? adolescent, it is also important to spend time alone with the adolescent. This is
an opportunity for the nurse to hear the teen's perspective and to really listen to
his/her concerns.
, NCSBN LESSON 3 HEALTH PROMOTION & MAINTENANCE
Fetal Station the relationship between the presenting part of the baby with the mother's pelvis
Fetal Lie the relationship between the head to tailbone axis for both the fetus and the
mother
Fetal Attitude the relationship of the fetal body parts to one another
Fetal Presentation portion of the fetus that enters the pelvic inlet first (cephalic, breech,
LOA (left occiput anterior): fetal occiput is on the left side of the maternal pelvis toward the front and the fetal
face is toward the rear of the pelvis
ROA (right occiput anterior): fetal occiput is on the right side of the maternal pelvis toward the front and the
fetal face is toward the rear of the pelvis
LOP (left occiput posterior): fetal occiput is on the left side of the maternal pelvis toward the rear and the fetal
face is toward the front of the pelvis
ROP (right occiput posterior): fetal occiput is on the right side of the maternal pelvis toward the rear and the
fetal face is toward the front of the pelvis
Dilating stage Begins with the first true labor contractions to complete dilatation of the cervix
(10 cm)
Latent (early) or prodromal contractions last from 30 to 45 seconds with the intensity gradually increasing;
frequency of contractions is from 5 to 20 minutes dilation is from 0 to 3
centimeters
bloody show is usually present
the mother is usually able to walk and talk during this phase; diversion is usually
welcomed
Active or accelerated contractions become stronger and last longer, usually 45 to 60 seconds;
frequency is from 3 to 5 minutes cervix dilates from 4 to 7 centimeters the mother
is not able to walk, tends to withdraw from the surrounding environment but
desires companionship and encouragement
Transient or transitional contractions are sharp, more intensified, lasting 60 to 90 seconds; frequency of
contractions is from 2 to 3 minutes cervix dilates from 8 to 10 centimeters
increase in the bloody show mother feels an urge to push or to have a bowel
movement
Rh positive mother + Rh positive father = Rh positive baby...no precautions are needed.
Rh negative mother + Rh negative father = Rh negative baby...no precautions are needed.
Rh positive mother + Rh negative father = baby could be either Rh positive or Rh negative...no precautions are needed.
