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At her first prenatal clinic visit a primigravida has blood drawn for a rubella antibody
screening test, and the results are positive. What intervention is important when the
nurse discusses this finding with the client? - ANSWER Asking her whether she has
had German measles and when she had the disease
A woman visits the prenatal clinic because an over-the-counter pregnancy test has
rendered a positive result. After the initial examination verifies the pregnancy, the nurse
explains some of the metabolic changes that occur during the first trimester of
pregnancy. (Select all that apply.) - ANSWER Sleep needs increase.
Fluid retention increases.
Calcium requirements increase.
The nurse reads the history of a neonate admitted to the nursery and discovers that the
infant's mother was listed as gravida 1 para 1 before the baby was born. How should
the nurse use these data to gather more information? - ANSWER To consider that
someone recorded the gravida and para incorrectly
The nurse is obtaining a health history from a client with endometriosis. What
consequences can occur as a result of this disorder? (Select all that apply.) - ANSWER
Metrorrhagia
Bowel strictures
Voiding difficulties
A 20-year-old woman is known to be heterozygous for the cystic fibrosis (CF) gene. Her
husband's genotype is unknown at present and the couple is expecting their first child.
What should the nurse tell the couple about the probability of their baby's having CF? -
ANSWER 25% or less
A nurse is instructing a client to cough and deep-breathe after an emergency cesarean
birth. The client says, "Get out of here. Can't you see that I'm in pain?" Which response
will be the most effective? - ANSWER "If you can't cough, try taking six very deep
breaths."
A client with endometriosis asks the nurse what side effects to expect from leuprolide
(Lupron). What should the nurse include in the response? - ANSWER Weight gain
By how much should the nurse instruct a pregnant client to increase her daily protein
,intake? - ANSWER 10 g
An estrogen-progestin oral contraceptive is prescribed for a client. Which adverse
effects should the nurse teach the client to report to the health care provider? (Select all
that apply.) - ANSWER Chest pain
Breast soreness
Calf tenderness
In the second hour after a client gives birth, her uterus is found to be firm, above the
level of the umbilicus, and to the right of midline. What is the appropriate nursing
intervention at this time? - ANSWER Assisting the client to the bathroom to empty her
bladder
A pregnant client has a positive group B Streptoccus (GBS) test at 36 weeks' gestation.
What is the priority instruction that the nurse will include in the client's teaching plan? -
ANSWER "This information will be in your prenatal record, but please remind your
labor and delivery nurse of this finding."
The nurse has completed a prenatal class for women who are expecting their first
babies. Which statement by a pregnant woman indicates the need for additional
teaching? - ANSWER "During pregnancy it's safe for me to use my regular herbal
remedies."
A 63-year-old woman with the diagnosis of estrogen-receptor positive cancer of the
breast undergoes lumpectomy and radiation therapy, and tamoxifen (Nolvadex) is
prescribed. The client asks the nurse how long she will have to take the medication. The
nurse responds: - ANSWER "You'll need to take it for 5 years, after which it will be
discontinued."
A client who is taking an oral contraceptive calls the nurse with concerns about side
effects of the medication. Which adverse effect of this medication should alert the nurse
to inform the client to immediately stop the contraceptive and contact the health care
provider? (Select all that apply.) - ANSWER Visual disturbances
Persistent headaches
A 35-year-old client is scheduled for a vaginal hysterectomy. She asks the nurse about
the changes she should expect after surgery. How should the nurse respond? -
ANSWER surgical induced menopause
A woman is admitted for a hysterectomy and bilateral salpingo-oophorectomy. The
nurse reviews the client's gynecological history. What condition does the client have that
causes the nurse to anticipate an abdominal, rather than a vaginal, hysterectomy? -
ANSWER Large uterine fibroids
, The nurse should explain to the newly pregnant primigravida that the fetal heartbeat will
first be heard with: - ANSWER Electronic Doppler ultrasonography at 10 to 12 weeks
A client is receiving an epidural anesthetic during labor. For which side effect should the
nurse monitor the client? - ANSWER Urine retention
During labor a client begins to experience dizziness and tingling of her hands. What
should the nurse instruct the client to do? - ANSWER Breathe into her cupped hands
A 36-year-old primigravida, accompanied by her husband, is admitted to the birthing unit
at 39 weeks' gestation. External fetal monitoring is instituted. What should the nurse
consider when a fetus is being monitored? - ANSWER The machinery may be
frightening to a laboring couple.
A nurse is evaluating the rate of involution of a client's uterus on the second postpartum
day. Where does the nurse expect the fundus to be located? - ANSWER One or two
fingerbreadths below the umbilicus
The transmission of which microorganism that causes maternal mastitis is minimized by
frequent handwashing by nursing staff members? - ANSWER Staphylococcus aureus
A nurse helps a client to the bathroom to void several times during the first stage of
labor. This is done because a full bladder: - ANSWER May inhibit the progress of labor
A client starting her second trimester asks a nurse in the prenatal clinic whether she can
safely take an over-the-counter (OTC) medicine now that she is past the first 3 months
of pregnancy. The nurse explains why she should consult with her health care provider
before taking any oral medications. What physiological alteration associated with
pregnancy may change the client's response to medication? - ANSWER Longer
gastrointestinal emptying time
An older female client tells the nurse in the clinic that she has a cystocele that was
diagnosed a year ago. She has urinary frequency and burning on urination. The client
asks, "The doctor wanted me to have surgery for the cystocele last year, but I can
manage with peripads. It won't hurt not to have surgery, will it?" How should the nurse
respond? - ANSWER "Yes, you're risking kidney damage."
A client states that she wishes to use the calendar method of birth control. The nurse
concludes that the client understands how to calculate the beginning of the fertile period
when she states, "I will: - ANSWER Subtract 18 days from the length of my shortest
cycle"