NURS 125 Maternity Evolve Exam Test Bank

NURS 125 Maternity Evolve Exam Test Bank Maternity Evolve Exam 1. A nonstress test is performed, and the physician documents “accelerations lasting less than 15 seconds throughout fetal movement.” The nurse interprets these findings as: A. Normal B. Reactive C. Nonreactive Correct D. Inconclusive Rationale: A reactive nonstress test is a normal, or negative, result and indicates a healthy fetus. The result requires two or more fetal heart rate accelerations of at least 15 beats/min lasting at least 15 seconds from the beginning of the acceleration to the end, in association with fetal movement, during a 20minute period. A nonreactive test is an abnormal test, showing no accelerations or accelerations of less than 15 beats/min or lasting less than 15 seconds during a 40minute observation. An inconclusive result is one that cannot be interpreted because of the poor quality of the fetal heart rate recording. TestTaking Strategy: Use the process of elimination. Eliminate a reactive nonstress test and a normal nonstress test first because they are comparable or alike. To select from the remaining options, note the relationship between “less than 15 seconds” in the question and “nonreactive” in the correct option. If you had difficulty answering this question, review the interpretation of nonstress test results. 2. A nurse caring for a client in labor performs an assessment. The client is having consistent contractions less than 2 minutes apart. The fetal heart rate (FHR) is 170 beats/min, and fetal monitoring indicates a pattern of decreased variability. In light of these findings, the appropriate nursing action is: A. Contacting the physician Correct B. Documenting the findings C. Continuing to monitor the client D. Reassuring the client and her partner that labor is progressing normally Rationale: Signs of potential complications of labor include contractions consistently lasting 90 seconds or longer, contractions consistently occurring 2 minutes or less apart, fetal bradycardia, tachycardia, persistently decreased variability, or an irregular FHR. The normal FHR is 110 to 160 beats/min. Therefore, because the finding is abnormal, the physician must be contacted. Continuing to monitor the client delays necessary intervention. Reassuring the client that labor is progressing normally is incorrect. The nurse would document the data, actions taken, and the client’s response, but, of the options provided, contacting the physician is the most appropriate. TestTaking Strategy: Use the process of elimination and focus on the data in the question. Eliminate the options that are comparable or alike and indicate that the data in the question are normal findings. Review normal assessment findings during the labor process if you had difficulty with this question. 3. A stillborn infant was delivered a few hours ago. After the birth, the family remains together, holding and touching the baby. Which statement by the nurse is appropriate? A. “I know how you feel.” B. “This must be hard for you.” Correct C. “Now you have an angel in heaven.” D. “You’re young. You can have other children.” Rationale: Therapeutic communication helps the mother, father, and other family members express their feelings and emotions. “This must be hard for you” is a caring and empathetic response, focused on feelings and encouraging communication. The other options are nontherapeutic and may devalue the family members' feelings. TestTaking Strategy: Use your knowledge of therapeutic communication techniques. The correct option is the only option that is focused on the family members’ feelings. Review therapeutic communication techniques if you had difficulty with this question. 4. A rubella antibody screen is performed in a pregnant client, and the results indicate that the client is not immune to rubella. The nurse tells the client that: A. A rubella vaccine must be administered immediately B. A rubella vaccine must be administered after childbirth Correct C. She will not contract rubella if she is exposed to the disease D. She does not need to be concerned about being exposed to rubella Rationale: A prenatal rubella antibody screen is performed in every pregnant woman to determine whether she is immune to rubella, which can cause serious fetal anomalies. If she is not immune, rubella vaccine is offered after childbirth to keep her from contracting rubella during subsequent pregnancies. The vaccine is a live virus, and defects might occur in the fetus if the vaccine were administered during pregnancy or if the mother were to become pregnant soon after it was administered. Administering a rubella vaccine immediately places the fetus at risk. Telling the client that she does not need to be concerned about being exposed to rubella is incorrect, because the possibility of exposure, which could be harmful to the fetus, does exist. TestTaking Strategy: Use the process of elimination. Eliminate first the options that are comparable or alike (i.e., the client will not acquire rubella and does not need to be concerned about exposure). To select from the remaining options, recall that rubella vaccine is a live virus; this will direct you to the correct option. Review rubella vaccine and its implications during pregnancy if you had difficulty with this question. 5. A nurse caring for a client in the active stage of labor assesses the fetal status and notes a late deceleration on the monitor strip. In light of this finding, which nursing action is the priority? A. Documenting the finding B. Preparing for immediate birth C. Administering oxygen by way of face mask Correct D. Increasing the rate of the oxytocin (Pitocin) infusion Rationale: Late decelerations are a result of uteroplacental insufficiency stemming from decreased blood flow and oxygen transfer to the fetus during uterine contractions. This causes hypoxemia; therefore oxygen is necessary, making the administration of oxygen the correct choice. Late decelerations are considered an ominous sign but do not necessarily require immediate birth of the baby. The oxytocin infusion should be discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia, because the medication stimulates contractions, leading to increased uteroplacental insufficiency. Although the finding needs to be documented, documentation is not the priority action in this situation. TestTaking Strategy: Note the strategic word “priority” in the question. Use your knowledge of the ABCs — airway, breathing, and circulation — to answer the question. This will direct you to the correct option, the one that addresses oxygen. Review content on late decelerations if you had difficulty with this question. 6. A nurse provides instructions regarding postpartum exercises to a client who has delivered a newborn vaginally. The nurse tells the client that: A. The exercises should be delayed for 1 month to allow healing B. Performing such exercises in the postpartum period may result in stress urinary incontinence C. Alternating contraction and relaxation of the muscles of the perineal area should be practiced Correct D. Abdominal exercises will be started while the client is in the hospital as a means of evaluating tolerance Rationale: Postpartum exercises may be started soon after birth, although the woman should be encouraged to begin with simple exercises and gradually progress to more strenuous ones. Abdominal exercises are postponed until approximately 4 weeks after a cesarean birth. Kegel exercises (alternated contraction and relaxation of the muscles of the perineal area) are extremely important in strengthening the muscle tone of the perineal area after vaginal birth. Kegel exercises help restore the muscle tone that is often lost as pelvic tissues are stretched and torn during pregnancy and birth. Women who maintain muscle strength may benefit years later, experiencing continued urinary continence. TestTaking Strategy: Use the process of elimination. Note the relationship between the word “vaginally” in the question and “perineal area” in the correct option. Review the purpose and benefit of Kegel exercises if you had difficulty with this question. 7. A client in the first trimester of pregnancy arrives at the clinic and reports that she has been experiencing vaginal bleeding. Threatened abortion is suspected, and the nurse provides instructions to the client regarding care. Which statement by the client indicates the need for further instruction? A. “I need to stay in bed for the rest of my pregnancy.” Correct B. “I need to avoid having sex until the bleeding has stopped.” C. “I need to watch for stuff that looks like tissue coming from my vagina.” D. “I need to count the number of perineal pads that I use each day and make a note of the amount and color of blood on each pad.” Rationale: Strict bed rest throughout the remainder of the pregnancy is not required. The woman is advised to curtail sexual activities until bleeding has ceased and for 2 weeks after the last evidence of bleeding, as recommended by the physician or nursemidwife. The woman is instructed to count the perineal pads she uses each day and to note the quantity and color of blood on each pad. The woman should also watch for the evidence of the passage of tissue. TestTaking Strategy: Use the process of elimination. Note the strategic words “need for further instruction” in the question, which indicate a negative event query and the need to select the incorrect client statement. Noting the words “stay in bed for the rest of my pregnancy” will direct you to this option. Review therapeutic management for threatened abortion if you had difficulty with this question. 8. A nurse is assessing the respiratory rate of a newborn. Which finding would the nurse document as normal? A. 20 breaths/min B. 25 breaths/min C. 50 breaths/min Correct D. 70 breaths/min Rationale: The normal respiratory rate for a newborn infant is 30 to 60 breaths/min. All of the other options are outside the normal range. TestTaking Strategy: Knowledge regarding the normal respiratory rate of a newborn is required to answer this question. If you are unfamiliar with the normal ranges for newborn vital signs, review this content. 9. A nurse notes that the laboratory report of a pregnant client with suspected HIV infection indicates leukopenia, thrombocytopenia, anemia, and an increased erythrocyte sedimentation rate. Which laboratory test that would further confirm the presence of HIV does the nurse anticipate that the physician will prescribe? A. Platelet count B. Angiotensin level C. Glomerular filtration rate D. Tlymphocyte determination Correct Rationale: HIV has a strong affinity for surface marker proteins on lymphocytes. This affinity of HIV for Tlymphocytes leads to significant cell destruction. Angiotensin is produced in the kidney and plays a role in blood pressure control. Glomerular filtration rate is an indicator of kidney function. The platelet count is important and may be used as an indicator of the effects of HIV, but the platelet count (thrombocytopenia) has already been addressed in the question. TestTaking Strategy: Use the process of elimination, focusing on the subject, the presence of HIV. Eliminate the platelet count, because this has already been addressed in the question (thrombocytopenia). Next eliminate the options that are comparable or alike in that they are related to kidney function. If you had difficulty with this question, review the clinical manifestations and pathology of HIV infection. 10. A nurse palpates the anterior fontanel of a neonate and notes that it feels soft. This nurse interprets this assessment data as: A. A normal finding Correct B. Indicative of dehydration C. Indicative of increased intracranial pressure D. Indicative of decreased intracranial pressure Rationale: The anterior fontanel, which is diamond shaped, is located on the top of the head. It measures 1 to 4 cm but varies because of molding and individual differences. It normally closes by 12 to 18 months of age. It may be described as soft, which is normal, or full and bulging, which may be indicative of increased intracranial pressure. Conversely, a depressed fontanel could mean that the neonate is dehydrated. TestTaking Strategy: Use the process of elimination, noting the strategic words “feels soft” in the question. Remember that the anterior fontanel is soft in the neonate. If you had difficulty answering this question, review normal assessment findings in the neonate. 11. A nurse provides information about the treatment for hypoglycemia to a client with gestational diabetes who will be taking insulin. The nurse tells the client that if signs and symptoms of hypoglycemia occur, she must immediately: A. Lie down B. Contact the physician Incorrect C. Drink 8 oz of diet soda D. Check her blood glucose level Correct Rationale: If signs and symptoms of hypoglycemia occur, the client should immediately check the blood glucose level. The results will determine the required treatment. If the blood glucose is less than 60 mg/dL, the client should immediately eat or drink something that contains 10 to 15 g of simple carbohydrate. Examples include a half cup (4 oz) of unsweetened fruit juice, a half cup (4 oz) of regular (not diet) soda, 5 or 6 LifeSavers candies, 1 tablespoon of honey or corn (Karo) syrup; 1 cup (8 oz) of milk; or 2 or 3 glucose tablets. The blood glucose is tested again 15 minutes after intake of the carbohydrate. If the glucose level is still below 60 mg/dL, the client should eat or drink another 10 to 15 g of simple carbohydrate. The blood glucose is tested once again 15 minutes after intake of the carbohydrate, and the physician is notified immediately if it is still below 60 mg/dL, because further intervention is necessary. Lying down will not increase the blood glucose level and will delay necessary intervention. TestTaking Strategy: Use the process of elimination and note the strategic word “immediately.” Remember that if hypoglycemia is suspected, a blood glucose test is needed to confirm its occurrence and then treatment measures must be taken immediately. Review the treatment measures for hypoglycemia if you had difficulty with this question. 12. A nurse is providing nutritional counseling to pregnant client with a history of cardiac disease. What does the nurse advise the client to eat? A. Water and pretzels B. Lowfat cheese omelet C. Nachos and fried chicken D. Apple and wholegrain toast Correct Rationale: The pregnant woman needs a wellbalanced diet high in iron and protein and adequate in calories for weight gain. Iron supplements that are taken during pregnancy tend to cause constipation. Constipation causes the client to strain during defecation, inadvertently performing the Valsalva maneuver, which causes blood to rush to the heart and overload the cardiac system. The pregnant woman, then, should increase her intake of fluids and fiber. An unlimited intake of sodium (pretzels, cheese, nachos) could cause overload of the circulating blood volume and contribute to the cardiac condition. TestTaking Strategy: Use the process of elimination and note that the client has a history of cardiac disease. Recalling the concepts of care of the client with cardiac disease and noting that the question involves a client who is pregnant will direct you to the correct option. Review dietary requirements and examples of foods containing those requirements for a cardiac client who is pregnant if you had difficulty with this question. 13. A neonate is irritable, cries incessantly, and has a temperature of 99.4° F. The neonate is also tachypneic, diaphoretic, feeding poorly, and hyperactive in response to environmental stimuli. The nurse determines that these signs and symptoms are consistent with: A. Sepsis B. Hypercalcemia Incorrect C. Intraventricular hemorrhage D. Neonatal abstinence syndrome Correct Rationale: Neonatal abstinence syndrome is the term given to the group of signs and symptoms associated with drug withdrawal in the neonate. Drug withdrawal causes a hyperactive response in the infant because of the increased central nervous system (CNS) stimulation. This hyperactive response and the signs and symptoms of drug withdrawal seem to be most apparent around 1 week of age. Sepsis, hypercalcemia, and intraventricular hemorrhage cause symptoms of CNS depression. TestTaking Strategy: Use the process of elimination, focusing on the data in the question. Note the strategic word “hyperactive,” which indicates CNS stimulation and should direct you to the correct option. If you had difficulty with this question, review the signs and symptoms of drug withdrawal in the neonate. 14. A nurse is assisting a physician in performing a physical examination of a client who has just been told that she is pregnant. The physician tells the nurse that the Goodell sign is present. The nurse understands that this sign is indicative of: A. The presence of fetal movement B. A high risk for spontaneous abortion C. An increase in vascularity and hyptertrophy of the cervix Correct D. The presence of human chorionic gonadotropin (hCG) in the urine Incorrect Rationale: In the early weeks of pregnancy, the cervix becomes more vascular and slightly hypertrophic; this is referred to as the Goodell sign. The edematous appearance of the cervix will be noted during pelvic examination by the examiner. hCG is noted in maternal urine in a urine pregnancy test. The Goodell sign does not indicate the presence of fetal movement or a risk for spontaneous abortion. TestTaking Strategy: Knowledge regarding the Goodell sign is required to answer this question. It is necessary to know that the sign consists of increased vascularity and hypertrophy of the cervix. If you had difficulty with this question, review the changes in the cervix that occur during pregnancy. 15. A nurse is monitoring a client in labor for signs of intrauterine infection. Which sign, indicative of infection, would prompt the nurse to contact the healthcare provider? A. Maternal fatigue B. Clear amniotic fluid C. Strongsmelling amniotic fluid Correct D. A fetal heart rate of 140 beats/min Rationale: Signs associated with intrauterine infection includes fetal tachycardia (rising baseline or faster than 160 beats/min, a maternal fever (38° C or 100.4° F), foul or strongsmelling amniotic fluid, or cloudy or yellow amniotic fluid. The normal fetal heart rate is 110 to 160 beats/min. Clear amniotic fluid is normal. Maternal fatigue normally occurs during labor. TestTaking Strategy: Focus on the subject of the question, a sign of intrauterine infection. Eliminate the options that are comparable or alike in that they are normal expectations during labor. Review the signs of intrauterine infection if you had difficulty with this question. 16. A nurse is assessing the uterine fundus of a client who has just delivered a baby and notes that the fundus is boggy. The nurse massages the fundus, and then presses to expel clots from the uterus. To prevent uterine inversion during this procedure, the nurse: A. Has the client void before the uterine assessment B. Tells the woman to bear down during fundal message C. Simultaneously provides pressure over the lower uterine segment Correct D. Asks the client to take slow, deep breaths during fundal assessment Rationale: After massaging a boggy fundus until it is firm, the nurse presses the fundus to expel clots from the uterus. The nurse must also keep one hand pressed firmly just above the symphysis (over the lower uterine segment) the entire time. Removing the clots allows the uterus to contract properly. Providing pressure over the lower uterine segment prevents uterine inversion. Having the client void before uterine assessment will not prevent uterine inversion. Telling the woman to bear down while the nurse performs fundal message and asking the client to take slow, deep breaths during fundal assessment also will not prevent uterine inversion. TestTaking Strategy: Use the process of elimination, focusing on the subject, prevention of uterine inversion. Visualizing each of the actions in the options and relating the action to the subject of the question will direct you to the correct option. Review fundal assessment and massage if you had difficulty with this question. 17. A nurse assists a pregnant client who is in the second trimester into lithotomy position on the examining table in the obstetrician’s office. The client suddenly becomes dizzy, lightheaded, nauseated, and pale. The nurse immediately: A. Positions the client on her side Correct B. Calls the physician to see the client C. Places a cool washcloth on the client’s forehead D. Checks the client’s blood pressure, pulse, and respirations Rationale: Supine hypotension may occur during the second and third trimesters when a woman is placed in the lithotomy position, in which the weight of the abdominal contents may compress the vena cava and aorta, causing a drop in blood pressure and a feeling of faintness. Other signs and symptoms include pallor, dizziness, breathlessness, tachycardia, nausea, clammy (damp, cool) skin, and sweating. The nurse would immediately position the woman on her side. Placing a cool washcloth on the client’s forehead or checking the client’s vital signs will not eliminate this problem. The physician must be contacted if the symptoms do not subside, but this would not be the immediate action. TestTaking Strategy: Use the process of elimination and note the strategic word “immediately.” Focusing on the data in the question and determining that the client is experiencing supine hypotension will direct you to the correct option. Review the manifestations of supine hypotension and the interventions for treating this occurrence if you had difficulty with this question. 18. A nurse is monitoring a newborn who has been admitted to the nursery. The nurse notes that the anterior fontanel measures 4 cm across and bulges when the infant is at rest. In light of this observation, what is the appropriate nursing action? A. Notifying the physician Correct B. Documenting the finding C. Assessing the infant’s blood pressure D. Reassessing the fontanel in 30 minutes Rationale: The anterior fontanel, which is diamond shaped, is located on the top of the head. It should be flat and soft. It measures 1 to 4 cm, varying as a result of molding and individual differences. It normally closes by 12 to 18 months of age. Although the anterior fontanel may bulge slightly when the infant cries, bulging at rest may indicate increased intracranial pressure. If this is suspected, the physician is notified. The other options would delay necessary treatment. TestTaking Strategy: Use the process of elimination and note the strategic words “bulges when the infant is at rest.” Recalling that the fontanel should be soft and flat will direct you to the correct option. Review normal newborn assessment findings if you had difficulty with this question. 19. A nurse midwife performs an assessment of a pregnant client and documents the station of the fetal head as it is reflected in the figure below. The nurse reviews the assessment findings and determines that the fetal presenting part is: A. At +1 station B. At –1 station C. At zero station Correct D. Stationed at the bottom of the coccyx Rationale: Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. It is measured in centimeters and is noted as a negative number above the line, a positive number below the line, and zero at the line. TestTaking Strategy: Knowing that station is measured in centimeters, with the ischial spines as a reference point, will assist you in answering this question. Focus on the figure and note that the fetal head is at zero station. Review station if you had difficulty with this question. 20. A client is admitted to the hospital for an emergency cesarean delivery. Contractions are occurring every 15 minutes, the client has a temperature of 100° F, and the client reports that she last ate 2 hours ago. The client also states that “everything happened so fast" and that she has had no preparation for the cesarean delivery. Which of the following actions should the nurse take first? A. Continuing to time the contractions B. Beginning teaching about the cesarean delivery C. Reporting the time of last food intake to the physician Correct D. Giving acetaminophen (Tylenol) to lower the client’s temperature Rationale: The nurse should report the time of last food intake to the physician. General anesthesia may be used for an emergency cesarean delivery. Gastric contents are very acidic and can produce chemical pneumonitis if aspirated. Continued monitoring and client instruction are correct nursing actions but are of lesser priority than reporting the time of last oral intake. Giving acetaminophen (Tylenol) is incorrect because it requires a physician’s prescription. TestTaking Strategy: Note the strategic word “first” and use your knowledge of the ABCs — airway, breathing, and circulation — to find the correct option, which pertains to breathing (maintaining an open airway). Review client preparation for an emergency cesarean delivery if you had difficulty with this question. 21. A nurse is monitoring a client who was given an epidural opioid for a cesarean birth. The nurse notes that the client’s oxygen saturation on pulse oximetry is 92%. The nurse first: A. Contacts the physician B. Documents the findings C. Instructs the client to take several deep breaths Correct D. Administers 100% oxygen by way of face mask Rationale: If the client has been given an epidural opioid, the nurse should monitor the client’s respiratory status closely. If the oxygen saturation falls below 95%, the nurse instructs the client to take several deep breaths to increase the level. Although the finding would be documented, action is required to increase the oxygen saturation level. It is not necessary to contact the physician. If the deep breaths fail to increase the oxygen saturation level, the physician is notified and may prescribe oxygen. TestTaking Strategy: Use the process of elimination and focus on the data in the question. Noting the oxygen saturation level will assist you in eliminating this option. Noting the strategic word “first” will direct you to the correct option. Review care of the client after a cesarean birth if you had difficulty with this question. 22. A nurse is monitoring a client in the third trimester of pregnancy who has a diagnosis of severe preeclampsia. Which finding would prompt the nurse to contact the physician? A. Complaint of feeling hot B. Enlargement of the breasts C. Diaphoresis and tachycardia Correct D. Periods of fetal movement followed by quiet periods Rationale: Disseminated intravascular coagulation (DIC) is a complication of preeclampsia. Physical examination reveals unusual bleeding, spontaneous bleeding from the woman’s gums or nose, or the presence of petechiae around a blood pressure cuff placed on the woman’s arm. Excessive bleeding may occur from a site of slight trauma such as a venipuncture site, an intramuscular or subcutaneous injection site, a nick sustained during shaving of the perineum or abdomen, or injury inflicted during insertion of a urinary catheter. Tachycardia and diaphoresis indicate impending shock as a result of blood loss. Breast enlargement, fetal movement with rest periods, and complaints of feeling hot are all normal occurrences in the last trimester of pregnancy. TestTaking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they are normal occurrences in pregnancy. Review the complications associated with severe preeclampsia if you had difficulty with this question. 23. A nurse is monitoring a pregnant client with sepsis for signs of disseminated intravascular coagulopathy (DIC). Which of the following laboratory findings causes the nurse to suspect DIC? A. Increased platelet count B. Increased fibrinogen level C. Shortened prothrombin time D. Increased fibrin degradation products Correct Rationale: DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Petechiae, oozing from injection sites, and hematuria are indicative of DIC. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and therefore prolonged times); and fibrin plugs may clog the microvasculature diffusely rather than in an isolated area. Fibrinogen and platelets are decreased, prothrombin and activated partial thromboplastin times are prolonged, and fibrin degradation products are increased. TestTaking Strategy: Use the process of elimination. Recalling the pathophysiology of DIC will direct you to the correct option. Review laboratory findings in DIC if you had difficulty with this question. 24. A nurse is caring for a client experiencing hypotonic labor contractions. The client is discouraged by the lack of progress with labor but refuses an amniotomy or oxytocin (Pitocin) stimulation. The nurse determines that the client’s behavior may be a result of: A. Concern about her own and the baby’s wellbeing Correct B. The high level of pain caused by these contractions C. Inability to rest between the frequent contractions D. The normal lack of control clients feel during the transition phase of labor Rationale: Clients have concerns when labor does not proceed as expected and often are worried about the effects of treatments and invasive procedures on themselves and on the fetus. Hypotonic contractions generally occur during the active phase of labor, after a normal latent phase. These contractions are typically of poor intensity and infrequent; they are not painful but cause a very slow progression of labor. Therefore the high level of pain, inability to rest between contractions, and normal lack of control felt during the transition phase of labor are all incorrect. TestTaking Strategy: Use the process of elimination, focusing on the subject, hypotonic labor contractions. Thinking about the pathophysiology of hypotonic labor will direct you to the correct option. Also, noting that the client is refusing treatments will assist you in answering correctly. Review the characteristics of hypotonic labor contractions and the psychosocial reactions associated with this disorder if you had difficulty with this question. 25. A woman with severe preeclampsia delivers a healthy newborn infant and continues to receive magnesium sulfate therapy in the postpartum period. Twentyfour hours after delivery, the client begins passing more than 100 mL of urine every hour. The nurse recognizes this volume of urine output as an indication of: A. Imminent seizures B. Hyperkalemia C. Highoutput renal failure D. Diminished edema and vasoconstriction in the brain and kidneys Correct Rationale: In this client, diuresis is a positive sign, indicating that edema and vasoconstriction in the brain and kidneys have decreased. Diuresis also reflects increased tissue perfusion in the kidneys. Clients with severe preeclampsia are not considered out of danger until birth and diuresis have taken place. Diuresis is not an indication of impending seizures. Although renal failure is a complication of severe preeclampsia, it is not the highoutput type of failure. Potassium is lost through the urine; therefore hyperkalemia is not associated with diuresis. TestTaking Strategy: Use the process of elimination. Recalling that oliguria is associated with severe preeclampsia will help you determine that diuresis in this scenario is associated with an improvement in preeclampsia. This will direct you to the correct option. If you had difficulty with this question, review the expected responses to treatment of severe preeclampsia. 26. A pregnant woman reports to the clinic complaining of loss of appetite, weight loss, and fatigue, and tuberculosis is suspected. A sputum culture reveals Mycobacterium tuberculosis. The nurse, providing instructions to the mother regarding therapeutic management of the disease, tells the mother that: A. The infant must be isolated from the mother after birth B. Maternal medication will not be started until the baby is born C. The infant will require medication therapy immediately after birth D. The mother may need to take isoniazid (INH), pyrazinamide, and rifampin (Rifadin) for a total of 9 months Correct Rationale: More than one medication may be used to prevent the growth of resistant organisms in the pregnant woman with tuberculosis. Treatment must be continued for a prolonged period. The preferred treatment for the pregnant woman is isoniazid plus rifampin for a total of 9 months. Ethambutol is added initially if drug resistance is suspected. Pyridoxine (vitamin B6 ) is often administered with isoniazid to prevent fetal neurotoxicity. The infant will be tested at birth and may be started on preventive isoniazid therapy. Skin testing of the infant should be repeated at 3 months, and isoniazid may be stopped if the result remains negative. If the result is positive, the infant should receive isoniazid for at least 6 months. If the mother’s sputum is free of organisms, the infant does not need to be isolated from the mother while in the hospital. TestTaking Strategy: Knowledge regarding the therapeutic management of the mother with tuberculosis and that of the infant is required to answer this question. Eliminate the options containing the closedended words “must,” “not,” and “immediately.” If you had difficulty with this question, review treatment measures for the mother with tuberculosis. 27. A nurse is performing an assessment of a client who is at 20 weeks of gestation. The nurse asks the client to void, then measures the fundal height in centimeters. Which approximate measurement does the nurse expect to see? A. 20 cm Correct B. 28 cm C. 32 cm D. 40 cm Rationale: During the second and third trimesters (weeks 18 to 30), the height of the fundus in centimeters is approximately the same as the number of weeks of gestation, if the woman’s bladder is empty at the time of measurement. If the fundal height exceeds the number of weeks of gestation, additional assessment is necessary to investigate the cause for the unexpectedly large uterine size. An unexpected increase in uterine size may indicate that the estimated date of delivery is incorrect and the pregnancy is more advanced than previously thought. If the estimated date of delivery is correct, more than one fetus may be present. TestTaking Strategy: Knowledge regarding the expected findings in fundal height during the second or third trimester is required to answer this question. Remember that the height of the fundus in centimeters during the second and third trimesters is approximately the same as the number of weeks of gestation. If you are unfamiliar with the interpretation of fundal height, review this content. 28. A client who delivered a healthy newborn 11 days ago calls the clinic and tells the nurse that she is experiencing a white vaginal discharge. The nurse tells the client: A. To perform a vaginal douche B. To come to the clinic for a checkup C. That this is an indication of an infection D. That this is a normal postpartum occurrence Correct Rationale: For the first 3 days following childbirth, lochia consists almost entirely of blood, with small particles of decidua and mucus, and is called lochia rubra because of its red color. The amount of blood decreases by about the fourth day, and which time the lochia changes from red to pink or browntinged; this stage is called lochia serosa. By about the 11th day, the erythrocyte component of lochia has decreased and the discharge becomes white or creamcolored. This final stage is known as lochia alba. Lochia alba contains leukocytes, decidual cells, epithelial cells, fat, cervical mucus, and bacteria. It is present in most women until the third week after childbirth but may persist for as long as 6 weeks. Lochia alba is a normal finding during the postpartum course, and no intervention is required, so the other options are incorrect. TestTaking Strategy: Use your knowledge of expected postpartum findings to answer the question. Recalling the normal expected occurrences in regard to vaginal discharge will direct you to the correct option. Also, noting that the incorrect options are comparable or alike will direct you to the correct option. Review normal postpartum findings in regard to lochia if you had difficulty with this question. 29. A nurse is caring for a client receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. Which of the following findings would prompt the nurse to stop the infusion? A. Contractions every 3 minutes B. Nonreassuring fetal heart rate pattern Correct C. Soft uterine tone palpated between contractions D. The presence of three contractions every 10 minutes Rationale: The goal of labor augmentation is to achieve three goodquality contractions (of appropriate intensity and duration) in a 10minute period. The uterus should return to resting tone between contractions, and there should be no evidence of fetal distress. If a nonreassuring fetal heart rate pattern is detected, the oxytocin infusion is stopped. A nonreassuring fetal heart rate pattern is associated with fetal hypoxia. TestTaking Strategy: Use the process of elimination and your knowledge of the ABCs (airway, breathing, and circulation). Eliminate the options that are comparable or alike (i.e., contractions every 3 minutes and occurrence of three contractions every 10 minutes). The correct option, of the two that remain, is the one that indicates a problem with circulation. Review the expected outcomes and the signs of complications associated with oxytocin infusion if you had difficulty with this question. 30. A nurse assessing a pregnant woman in labor notes the presence of early decelerations on the fetal monitor tracing. Which of the following situations would the nurse suspect in light of this observation? A. Umbilical cord compression B. Pressure on the fetal head during a contraction Correct C. Adequate pacemaker activity of the fetal heart D. Uteroplacental insufficiency during a contraction Rationale: Early decelerations, which result from pressure on the fetal head during a contraction, are not associated with fetal compromise and require no intervention. Variable decelerations suggest umbilical cord compression. Late decelerations are an ominous pattern in labor because they suggest uteroplacental insufficiency during a contraction. "Shortterm variability" refers to the difference between successive heartbeats, indicating that the natural pacemaker activity of the fetal heart is working properly. TestTaking Strategy: The ability to interpret and evaluate fetal monitoring patterns is required to answer this question. Relate early decelerations to pressure on the fetal head during a contraction to assist in answering questions similar to this one. If you are unfamiliar with early decelerations and their significance, review this content. 31. A delivery room nurse performing an initial assessment on a newborn notes that the ears are low set. In light of this finding, which nursing action is appropriate initially? A. Notifying the physician Correct B. Documenting the finding C. Taping the ears so they lie flat against the head D. Covering the ears with gauze pads and taping the pads to the head Rationale: Low or oddly placed ears are associated with a variety of congenital defects, including Down syndrome, and should be reported immediately. Taping the ears and covering them with gauze are unacceptable nursing interventions. Although the finding would be documented, the appropriate initial action is notification of the physician. TestTaking Strategy: Knowledge regarding the normal assessment findings in a newborn is required to answer this question. Recalling that lowset ears are an abnormal finding will direct you to the correct option. Review normal assessment findings in a newborn if you had difficulty with this question. 32. A nurse is reviewing the criteria for early discharge of a newborn infant. Which of the following, if noted in the infant, would indicate that the criteria for early discharge have been met? Select all that apply. A. The infant has urinated. Correct B. The infant has passed 1 stool. Correct C. Vital signs are documented as normal. Correct D. The infant has completed one successful feeding. E. The infant has shown no evidence of jaundice in the first 6 hours of life. Rationale: Criteria for early discharge in the newborn infant include no evidence of significant jaundice in the 24 hours after birth. The infant should have urinated and passed at least one stool, completed at least two successful feedings, and have normal vital signs for at least 12 hours. TestTaking Strategy: Note the strategic words “have been met.” Read each option carefully and think about the expected assessment findings for a newborn. This will direct you to the correct options. Review the criteria for early discharge of a newborn if you are unfamiliar with them. 33. A nurse is performing assessments every 30 minutes on a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings would prompt the nurse to contact the physician? A. Urine output of 20 mL B. Deep tendon reflexes of 2+ C. Respirations of 10 breaths/min Correct D. Fetal heart tone of 116 beats/min Rationale: Magnesium sulfate depresses the respiratory rate. If the rate is 12 breaths/min or slower, continuation of the medication must be reassessed. Acceptable urine output is 30 mL/hr or more. Urine output of 20 mL in 30 minutes is adequate. Deep tendon reflexes of 2+ are normal. The fetal heart tone is within normal limits for a resting fetus. TestTaking Strategy: Note the strategic words “contact the physician.” Use the process of elimination, noting the assessment finding that is abnormal and requires further intervention. Also, use your knowledge of the ABCs (airway, breathing, and circulation) to identify the correct option. Review assessment findings in preeclampsia and the effects of magnesium sulfate if you had difficulty with this question. 34. A nurse provides instructions to a breastfeeding mother who is experiencing breast engorgement about measures for treating the problem. The nurse tells the mother to: A. Take a cool shower just before breastfeeding B. Avoid breastfeeding during the night time hours to ensure adequate rest C. Gently massage the breasts during breastfeeding to help empty the breasts Correct D. Apply heat packs to the breasts for 15 to 20 minutes between feedings to reduce swelling Rationale: Gently massaging the breasts during breast feeding will help empty the breasts. The mother should not avoid breastfeeding during the night; instead, she should breastfeed every 2 hours or pump the breasts. The nurse instructs the woman to apply ice packs, not heat packs, to the breasts between feedings to reduce swelling. It may be helpful for the mother to stand in a warm shower just before feeding to foster relaxation and letdown. TestTaking Strategy: Focus on the subject, breast engorgement, and think about its characteristics. Use the process of elimination and visualize each of the descriptions in the options to identify the measure that will be helpful. If you had difficulty answering the question, review the measures for breast engorgement. 35. A nurse is caring for a postpartum client who had a lowlying placenta. The nurse assesses the client most closely for: A. Seizures B. Infection C. Hemorrhage Correct D. A vaginal hematoma Rationale: The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, making this site more prone to bleeding. The client with a lowlying placenta is not at greater risk for seizures, postpartum infection, or vaginal hematoma. TestTaking Strategy: Focus on the client’s diagnosis, a lowlying placenta. Recalling the anatomy and physiology of the lower segment of the uterus will direct you to the correct option. Review the complications associated with a lowlying placenta if you had difficulty with this question. 36. When, during the normal postpartum course, would the nurse expect to note the fundal assessment shown in the figure? A. 4 days after delivery B. The day after delivery C. Immediately after delivery Correct D. When the client’s bladder is full Rationale: Immediately after delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. Location of the fundus above the umbilicus may indicate the presence of blood clots in the uterus that need to be expelled by means of fundal massage. A fundus that is not located in the midline may indicate a full bladder. The fundus descends 1 or 2 cm every 24 hours, so it should be located farther below the umbilicus with every succeeding postpartum day. TestTaking Strategy: Focus on the figure and note that the fundus is at the level of the umbilicus. Recalling normal postpartum assessment findings in the mother and recalling the normal anatomy will assist in directing you to the correct option. If you had difficulty with this question, review normal postpartum assessment findings in regard to involution. 37. A nurse is caring for a client in labor who has sickle cell anemia. Which intervention does the nurse implement to help prevent a sickling crisis? A. Maintaining strict asepsis B. Monitoring the maternal vital signs C. Administering oxygen as prescribed Correct D. Placing a wedge under the client’s hip Rationale: Oxygen is administered continuously during labor to the client with sickle cell anemia to help ensure adequate oxygenation and prevent sickling. Maintaining asepsis, monitoring vital signs, and placing a wedge under the hip are interventions required of all clients, with or without sickle cell anemia. Although they are appropriate nursing interventions, they are not used to prevent sickling crisis. TestTaking Strategy: Use the process of elimination, focusing on the subject, prevention of sickling crisis. Also, use your knowledge of the ABCs (airway, breathing, and circulation). The correct option involves oxygenation. Review care of the client in labor who has sickle cell anemia if you had difficulty with this question. 38. A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 19, 2013. Using Nagele’s Rule, the nurse calculates the estimated date of delivery as: A. May 26, 2014 B. June 12, 2014 C. June 26, 2014 Correct D. May 12, 2014 Rationale: Accurate use of Nagele’s Rule requires that the woman have a regular 28day menstrual cycle. It is calculated by subtracting 3 months from the first day of the LMP, adding 7 days, and then adding 1 year to that date. First day of the LMP: September 19, 2013; subtract 3 months: June 19, 2013; add seven days: June 26, 2013; add 1 year: June 26, 2014. TestTaking Strategy: Knowledge regarding the use of Nagele’s Rule is required to answer this question. Use this rule to calculate the estimated date of delivery. Review Nagele’s Rule if you had difficulty with this question. 39. A nurse is preparing to care for a client experiencing dystocia. To which of the following interventions does the nurse give priority? A. Monitoring fetal status Correct B. Providing comfort measures C. Changing the client’s position D. Informing the client’s partner of the progress of the labor Rationale: The priority intervention is monitoring fetal status. Once this is done, the nurse provides maternal comfort measures, including positioning the client, because this may decrease anxiety and hasten the progression of labor. Keeping the client’s partner informed of the progress of the labor is also an important aspect of client care during labor but is not an immediate priority. TestTaking Strategy: Note the strategic word “priority.” Use Maslow’s Hierarchy of Needs theory and your knowledge of the ABCs (airway, breathing, and circulation) to answer the question. Remember that physiological needs are the priority. Review priority nursing interventions for the client with dystocia if you had difficulty with this question. 40. A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing intervention in the care of this client? A. Providing pain relief Correct B. Preparing the client for amniotomy C. Monitoring the oxytocin (Pitocin) infusion closely D. Encouraging the client to ambulate every 30 minutes Rationale: Management of hypertonic uterine dysfunction depends on the cause. Relief of pain is the primary intervention in promoting a normal labor pattern. Therapeutic management of hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate labor progression. The client with hypertonic uterine dysfunction would be encouraged to rest, not to ambulate every 30 minutes. TestTaking Strategy: Use the process of elimination, focusing on the strategic words “hypertonic” and “priority.” This, plus knowledge of the management of this condition, should direct you to the correct option. Also eliminate the options that are therapeutic measures for hypotonic uterine dysfunction and would stimulate labor (i.e., oxytocin augmentation and amniotomy). If you had difficulty with this question, review the management of hypertonic uterine dysfunction. 41. Placental abruption is suspected in a client who is experiencing vaginal bleeding. On assessment, which of the following findings would the nurse expect to note? A. Abdomen soft to palpation B. Uterine tender to palpation Correct C. Uterine contractions every 3 to 5 minutes D. Lack of uterine irritability or tetanic contractions Rationale: Vaginal bleeding in a pregnant client is most often caused by placenta previa or a placental abruption. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and boardlike on palpation as the blood penetrates the myometrium, causing uterine irritability and maternal tenderness. A normal uterine contraction pattern is unusual in the presence of a placental abruption. A sustained tetanic contraction may occur if the client is in labor and the uterine muscle cannot relax. TestTaking Strategy: Focus on the diagnosis, placental abruption. Remember that uterine pain and tenderness occurs with an abruption. Review the characteristics of placental abruption if you had difficulty with this question. 42. A client admitted to the maternity unit 12 hours ago has been experiencing strong contractions every 3 minutes but has remained at station 0. The fetal heart rate on admission was 140 beats/min and regular. The fetal heart rate is slowing, and a persistent nonreassuring fetal heart rate pattern is present. The appropriate nursing action in this situation is: A. Preparing to induce labor B. Turning the client on her left side C. Preparing the client for a cesarean delivery Correct D. Continuing to monitor the fetal heart rate pattern Rationale: Dystocia, failure of labor to progress, and a persistent nonreassuring fetal heart rate pattern are indications of the need for cesarean delivery. Induction of labor is not indicated in this case because the client has been in labor for 12 hours without progress and signs of fetal distress are present. Placing the client on her left side will increase oxygen to the uterus by relieving pressure on the aorta and the inferior vena cava. However, this intervention would be implemented with any client in labor, not specifically with a client experiencing dystocia. Monitoring the fetal heart rate pattern is also appropriate for any client in labor and is not the appropriate nursing action in this situation. TestTaking Strategy: Focus on the data presented in the question. Eliminate turning the client on her left side and monitoring the fetal heart rate pattern first, because these are nursing actions for all clients in labor. Induction of labor is not indicated in this case, because the client has been in labor for 12 hours and the fetus is in distress. Review the indications for cesarean delivery if you had difficulty with this question. 43. A nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative, refusing any interventions until her husband arrives at the hospital. The nurse analyzes the client’s behavior as most likely the result of: A. Emotional immaturity B. A stubborn personality C. Anxiety and the need for support Correct D. An undiagnosed psychiatric disorder Rationale: Any of the situations identified in the options could contribute to the client’s behavior, but the most likely reason is anxiety. Anxiety is the only emotion that supports the information identified in the question. The client may be anxious about the unknown effects of complications and want the presence of a support person while she deals with the crisis. There is no information in the question to support the other options. TestTaking Strategy: Use the process of elimination, focusing on the data in the question. Noting the strategic words “refusing any interventions until her husband arrives” will direct you to the correct option. Additionally, there is no information in the question to support the remaining options. Review the psychosocial aspects of care for a client with a partial placental abruption if you had difficulty with this question. 44. During a prenatal visit, the nurse notes that an adolescent pregnant client with diabetes mellitus has lost 10 lb during the first 15 weeks of gestation. The nurse discusses the weight loss with the client, and the client states, “I don’t eat regular meals.” The appropriate response is: A. “Weight loss could hurt your baby.” B. “Let’s make a list of what you’re eating.” Correct C. “I’ll have the doctor review your diet history.” D. “It’s all right to gain weight during pregnancy.” Rationale: It is important for the nurse to obtain additional information from the client. The nurse is using the therapeutic communication tool of validation and clarification to obtain more information about the client’s diet. The other options will block communication. The statement regarding harm to the baby devalues the client and shows disapproval. Informing the physician is avoiding the issue, and telling the client that it is all right to gain weight provides false reassurance. TestTaking Strategy: Use your knowledge of therapeutic communication techniques. Note that making a list of what the client is eating will encourage communication. It is also a means of gathering assessment data, the first step in the nursing process. Review therapeutic communication techniques if you had difficulty with this question. 45. A nurse instructs a pregnant client about foods that are high in folic acid. Which item does the nurse tell the client is the best source of folic acid? A. Milk B. Steak C. Chicken D. Lima beans Correct Rationale: The best sources of folic acid are liver; kidney, pinto, lima, and black beans; and fresh darkgreen leafy vegetables. Other good sources of folic acid are orange juice, peanuts, refried beans, and peas. Milk is high in calcium. Chicken and steak are high in protein. TestTaking Strategy: Use the process of elimination and focus on the subject, the best source of folic acid. Eliminate the options that are comparable or alike in that they are high in protein. Next eliminate milk, recalling that milk is high in calcium. Review the foods high in folic acid if you had difficulty with this question. 46. Rho(D) immune globulin (RhoGam) is prescribed for a client after delivery. Before administering the medication, the nurse reviews the client’s history. Which of the following findings is a contraindication to administration of the medication? A. A previous hypersensitivity reaction to immune globulin Correct B. Delivery of an Rhpositive infant by an Rhnegative woman C. Amniocentesis in an Rhnegative woman carrying an Rhpositive fetus D. Known or suspected entry of Rhpositive fetal blood cells to the circulation of an Rhnegative woman Rationale: One contraindication to the administration of Rho (D) immune globulin is previous hypersensitivity to immune globulin. Rho (D) immune globulin is indicated when an Rhnegative client is exposed to Rhpositive fetal blood cells in any way, including amniocentesis. The other options are all indications for administering RhoGam. TestTaking Strategy: Use the process of elimination and focus on the subject, a contraindication. Read each option carefully and note the word “hypersensitivity” in the correct option. Review the contraindications to and precautions for the administration of this medication if you had difficulty with this question. 47. A nurse is assisting a midwife who is assessing a client for ballottement. Which action does the nurse anticipate that the midwife will employ to test for ballottement? A. Assessing the cervix for thinning B. Auscultating for fetal heart sounds C. Performing a sudden tap on the cervix Correct D. Palpating the abdomen for fetal movement Rationale: Near midpregnancy, a sudden tap on the cervix during a vaginal exam may cause the fetus to rise in the amniotic fluid and then rebound to its original position, a phenomenon known as ballottement. The examiner feels the rebound when the fetus falls back down. Ballottement has no relationship to cervical assessment findings, fetal heart sounds, or external palpation of fetal movement. TestTaking Strategy: Knowledge regarding the assessment of ballottement is required to answer this question. It is necessary to know that when the cervix is tapped, the fetus floats upward in the amniotic fluid and that the rebound is known as ballottement. If you are unfamiliar with this assessment technique, review this procedure. 48. A nurse is preparing to assess the fetal heartbeat in a pregnant woman who is at gestational week 12. Which piece of equipment does the nurse use to assess the fetal heartbeat? A. Fetoscope B. Adult stethoscope C. Electronic Doppler Correct D. Fetal heart monitor Rationale: The fetal heartbeat can be heard with the use of a fetoscope at 18 to 20 weeks’ gestation. When an electronic Doppler ultrasound device is used, the fetal heartbeat can be detected as early as 10 weeks’ gestation. An adult stethoscope will not adequately produce the fetal heartbeat. A fetal heart monitor is used during labor or in other situations when the fetal heart rate requires continuous monitoring. TestTaking Strategy: Use the process of elimination. Eliminate an adult stethoscope first by focusing on the subject, fetal heart rate. To select from the remaining options, note the words “gestational week 12,” which will direct you to the correct option. If you had difficulty with this question, review the methods of assessing the fetal heart rate. 49. A postpartum client asks a nurse when she may safely resume sexual activity. The nurse tells the client that she may resume sexual activity: A. At any time B. In 2 to 4 weeks Correct C. After the 6week physician checkup D. When her normal menstrual period has resumed Rationale: Usually a woman may engage safely in sexual intercourse during the second to fourth week after childbirth as long as she experiences no discomfort during intercourse. The other options are incorrect. Engaging in intercourse too early in the postpartum course could result in further injury to perineal tissues damaged during childbirth. It usually takes about 3 weeks for an episiotomy to heal; therefore, it is unnecessary to wait 6 weeks. Menstruation may not resume in a postpartum woman for 12 weeks to 6 months after childbirth. TestTaking Strategy: Knowledge of the instructions given to a new mother regarding sexual activity after delivery is required to answer this question. Recalling that it takes about 3 weeks for an episiotomy to heal will direct you to the correct option. Review postpartum instructions if you had difficulty with this question. 50. A clinic nurse is developing a plan of care for a pregnant client with AIDS. Which problem does the nurse identify as the priority to be addressed in the plan of care? A. Poor hygiene B. Inverted nipples C. History of IV drug use Correct D. Intake of fewer than 6 glasses of fluid daily Rationale: AIDS is a breakdown in immune function caused by a retrovirus known