Lippincott's Q&A Review for NCLEX-RN

he Nursi1ng Care of the Childbearing Family TEST 1 Antepartal Care ■ The Preconception Client ■ The Pregnant Client Receiving Prenatal Care ■ The Pregnant Client in Childbirth Preparation Classes ■ The Pregnant Client with Risk Factors ■ Managing Care Quality and Safety ■ Answers, Rationales, and Test Taking Strategies The Preconception Client 1. A client has obtained Plan B (levonorgestrel 0.75 mg, 2 tablets) as emergency contraception. After unprotected intercourse, the client calls the clinic to ask questions about taking the contraceptives. The nurse realizes the client needs further explanation when she makes which of the following responses? 3. After the nurse instructs a 20-year-old nul- ligravid client on how to perform a breast self- examination, which of the following client statements indicates that the teaching has been successful? ■ 1. ■ 2. ■ 3. ■ 4. “I can wait 3 to 4 days after intercourse to start taking these to prevent pregnancy.” “My boyfriend can buy Plan B from the phar- macy if he is over 18 years old.” “The birth control works by preventing ovula- tion or fertilization of the egg.” “I may feel nauseated and have breast tenderness or a headache after using the contraceptive.” ■ 1. ■ 2. ■ 3. ■ 4. “I should perform breast self-examination on the day my menstrual flow begins.” “It’s important that I perform breast self- examination on the same day each month.” “If I notice that one of my breasts is much smaller than the other, I shouldn’t worry.” “If there is discharge from my nipples, I should call my health care provider.” 2. An antenatal G 2, T 1, P 0, Ab 0, L 1 client is discussing her postpartum plans for birth control with her health care provider. In analyzing the avail- able choices, which of the following factors has the greatest impact on her birth control options? ■ 1. Satisfaction with prior methods. ■ 2. Preference of sexual partner. ■ 3. Breast- or bottle-feeding plan. ■ 4. History of clotting disease. 4. Assessment of a 16-year-old nulligravid client who visits the clinic and asks for information on con- traceptives reveals a menstrual cycle of 28 days. The nurse formulates a nursing diagnosis of Deficient knowledge related to ovulation and fertility manage- ment. Which of the following would be important to include in the teaching plan for the client? 30 ■ 1. ■ 2. ■ 3. ■ 4. The ovum survives for 96 hours after ovulation, making conception possible during this time. The basal body temperature falls at least 0.2° F after ovulation has occurred. Ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle. Most women can tell they have ovulated because of severe pain and thick, scant cervi- cal mucus. 5. Which of the following instructions about activities during menstruation would the nurse include when counseling an adolescent who has just begun to menstruate? 10. A 22-year-old nulligravid client tells the nurse that she and her husband have been consider- ing using condoms for family planning. Which of the following instructions should the nurse include about the use of condoms as a method for family planning? ■ 1. Using a spermicide with the condom offers added protection against pregnancy. ■ 2. Natural skin condoms protect against sexu- ally transmitted diseases. ■ 3. The typical failure rate for couples using con- doms is about 25%. ■ 4. Condom users commonly report penile gland sensitivity. 11. Which of the following would the nurse include in the teaching plan for a 32-year-old female client requesting information about using a dia- phragm for family planning? ■ 1. Douching with an acidic solution after inter- course is recommended. ■ 2. Diaphragms should not be used if the client develops acute cervicitis. ■ 3. The diaphragm should be washed in a weak solution of bleach and water. ■ 4. The diaphragm should be left in place for 2 hours after intercourse. 12. After being examined and fitted for a dia- phragm, a 24-year-old client receives instructions about its use. Which of the following client state- ments indicates a need for further teaching? ■ 1. ■ 2. ■ 3. ■ 4. Take a mild analgesic if needed for menstrual pain. Avoid cold foods if menstrual pain persists. Stop exercise while menstruating. Avoid sexual intercourse while menstruating. 6. After conducting a class for female adoles- cents about human reproduction, which of the fol- lowing statements indicates that the school nurse’s teaching has been effective? ■ 1. ■ 2. ■ 3. ■ 4. “Under ideal conditions, sperm can reach the ovum in 15 to 30 minutes, resulting in preg- nancy.” “I won’t become pregnant if I abstain from intercourse during the last 14 days of my menstrual cycle.” “Sperm from a healthy male usually remain viable in the female reproductive tract for 96 hours.” “After an ovum is fertilized by a sperm, the ovum then contains 21 pairs of chromosomes.” 7. A 20-year-old nulligravid client expresses a desire to learn more about the symptothermal method of family planning. Which of the following would the nurse include in the teaching plan? ■ 1. ■ 2. ■ 3. ■ 4. This method has a 50% failure rate during the first year of use. Couples must abstain from coitus for 5 days after the menses. Cervical mucus is carefully monitored for changes. The male partner uses condoms for significant effectiveness. ■ 1. ■ 2. ■ 3. ■ 4. “I can continue to use the diaphragm for about 2 to 3 years if I keep it protected in the case.” “If I get pregnant, I will have to be refitted for another diaphragm after the delivery.” “Before inserting the diaphragm I should coat the rim with contraceptive jelly.” “If I gain or lose 20 lb, I can still use the same diaphragm.” 8. Before advising a 24-year-old client desiring oral contraceptives for family planning, the nurse would assess the client for signs and symptoms of which of the following? 13. A 22-year-old client tells the nurse that she and her husband are trying to conceive a baby. When teaching the client about reducing the inci- dence of neural tube defects, the nurse would emphasize the need for increasing the intake of which of the following foods? Select all that apply. ■ 1. Leafy green vegetables. ■ 2. Strawberries. ■ 3. Beans. ■ 4. Milk. ■ 5. Sunflower seeds. ■ 6. Lentils. ■ ■ ■ ■ 1. Anemia. 2. Hypertension. 3. Dysmenorrhea. 4. Acne vulgaris. 9. After instructing a 20-year-old nulligravid cli- ent about adverse effects of oral contraceptives, the nurse determines that further instruction is needed when the client states which of the following as an adverse effect? ■ 1. Weight gain. ■ 2. Nausea. ■ 3. Headache. ■ 4. Ovarian cancer. Antepartal Care 31 32 The Nursing Care of the Childbearing Family 14. A couple is inquiring about vasectomy as a permanent method of contraception. Which teach- ing statement would the nurse include in the teach- ing plan? 18. A client is scheduled to have in vitro fertil- ization (IVF) as an infertility treatment. Which of the following client statements about IVF indicates that the client understands this procedure? ■ 1. “IVF requires supplemental estrogen to enhance the implantation process.” ■ 2. “The pregnancy rate with IVF is higher than that with gamete intrafallopian transfer.” ■ 3. “IVF involves bypassing the blocked or absent fallopian tubes.” ■ 4. “Both ova and sperm are instilled into the open end of a fallopian tube.” 19. A 20-year-old primigravid client tells the nurse that her mother had a friend who died from hemorrhage about 10 years ago during a vaginal delivery. Which of the following responses would be most helpful? ■ 1. “Today’s modern technology has resulted in a low maternal mortality rate.” ■ 2. “Don’t concern yourself with things that hap- pened in the past.” ■ 3. “In the United States, mothers seldom die in childbirth.” ■ 4. “What is it that concerns you about preg- nancy, labor, and delivery?” 20. A 19-year-old nulligravid client visiting the clinic for a routine examination asks the nurse about cervical mucus changes that occur during the menstrual cycle. Which of the following statements would the nurse expect to include in the client’s teaching plan? ■ 1. ■ 2. ■ 3. ■ 4. “Another method of contraception is needed until the sperm count is 0.” “Vasectomy is easily reversed if children are desired in the future.” “Vasectomy is contraindicated in males with prior history of cardiac disease.” “Vasectomy requires only a yearly follow-up once the procedure is completed.” 15. A 39-year-old multigravid client asks the nurse for information about female sterilization with a tubal ligation. Which of the following client state- ments indicates effective teaching? ■ 1. ■ 2. ■ 3. ■ 4. “My fallopian tubes will be tied off through a small abdominal incision.” “Reversal of a tubal ligation is easily done, with a pregnancy success rate of 80%.” “After this procedure, I must abstain from intercourse for at least 3 weeks.” “Both of my ovaries will be removed during the tubal ligation procedure.” 16. A 23-year-old nulliparous client visiting the clinic for a routine examination tells the nurse that she desires to use the basal body temperature method for family planning. The nurse should instruct the client to do which of the following? ■ 1. ■ 2. ■ 3. ■ 4. Check the cervical mucus to see if it is thick and sparse. Take her temperature at the same time every morning before getting out of bed. Document ovulation when her temperature decreases at least 1° F. Avoid coitus for 10 days after a slight rise in temperature. ■ 1. ■ 2. ■ 3. ■ 4. 21. About midway through the menstrual cycle, cervical mucus is thick and sticky. During ovulation, the cervix remains dry without any mucus production. As ovulation approaches, cervical mucus is abundant and clear. Cervical mucus disappears immediately after ovulation, resuming with menses. When instructing a client about the proper 17. A couple visiting the infertility clinic for the first time states that they have been trying to con- ceive for the past 2 years without success. After a history and physical examination of both partners, the nurse determines that an appropriate outcome for the couple would be to accomplish which of the following by the end of this visit? condoms for pregnancy prevention, which ■ 1. ■ 2. ■ 3. ■ 4. Choose an appropriate infertility treatment method. Acknowledge that only 50% of infertile couples achieve a pregnancy. Discuss alternative methods of having a fam- ily, such as adoption. Describe each of the potential causes and pos- sible treatment modalities. ■ 1. ■ 2. ■ 3. ■ 4. Place the condom over the erect penis before coitus. Withdraw the condom after coitus when the penis is flaccid. Ensure that the condom is pulled tightly over the penis before coitus. Obtain a prescription for a condom with non- oxynol 9. use of of the following instructions would be included to ensure maximum effectiveness? 22. A multigravid client will be using medroxy- progesterone acetate (Depo-Provera) as a family planning method. After the nurse instructs the cli- ent about this method, which of the following client statements indicates effective teaching? 26. When developing a teaching plan for an 18 year old client who asks about treatments for sexually transmitted diseases, the nurse should explain that? ■ 1. Acyclovir (Zovirax) can be used to cure her- pes genitalis. ■ 2. Chlamydia trachomatis infections are usually treated with penicillin. ■ 3. Ceftriaxone sodium (Rocephin) may be used to treat Neisseria gonorrhoeae infections. ■ 4. Metronidazole (Flagyl) is used to treat condy- lomata acuminata. 27. A couple is visiting the clinic because they have been unable to conceive a baby after 3 years of frequent coitus. After discussing the various causes of male infertility, the nurse determines that the male partner needs further instruction when he states which of the following as a cause? ■ 1. Seminal fluid with an alkaline pH. ■ 2. Frequent exposure to heat sources. ■ 3. Abnormal hormonal stimulation. ■ 4. Immunologic factors. 28. A 24-year-old woman is being assessed for a malformation of the uterus. The figure below indicates which of the following uterine malformations? ■ 1. Septate uterus. ■ 2. Bicornate uterus. ■ 3. Double uterus. ■ 4. Uterus didelphys. ■ 1. ■ 2. ■ 3. ■ 4. “This method of family planning requires monthly injections.” “I should have my first injection during my menstrual cycle.” “One possible adverse effect is absence of a menstrual period.” “This drug will be given by subcutaneous injections.” 23. Which of the following instructions should the nurse include in the teaching plan for a 30-year- old multiparous client who will be using an intra- uterine device (IUD) for family planning? ■ 1. ■ 2. ■ 3. ■ 4. Amenorrhea is a common adverse effect of IUDs. The client needs to use additional protection for conception. IUDs are more costly than other forms of con- traception. Severe cramping may occur when the IUD is inserted. 24. After counseling a 35-year-old client about breast self-examination and mammography, the nurse determines that the client has understood the instructions when the client states which of the fol- lowing? Antepartal Care 33 ■ 1. ■ 2. ■ 3. ■ 4. “I should have a mammogram every year once I’m 40.” “I should schedule a mammography examina- tion during my menstrual period.” “Mammography screening is inexpensive.” “Mammography is an extremely painful procedure.” 25. After instructing a 40-year-old woman about osteoporosis after menopause, the nurse determines that the client needs further instruction when the client states which of the following? ■ 1. ■ 2. ■ 3. ■ 4. “One cup of yogurt is the equivalent of one glass of milk.” “Women who do not eat dairy products should consider calcium supplements.” “African American women are at the greatest risk for osteoporosis.” “Estrogen therapy at menopause can reduce the risk of osteoporosis.” 34 The Nursing Care of the Childbearing Family The Pregnant Client Receiving Prenatal Care 29. A primagravid client at 16 weeks’ gestation has had an amniocentesis and has received teaching concerning signs and symptoms to report. Which statement indicates that the client needs further teaching? 34. A 30-year-old multigravid client has missed three periods and now visits the prenatal clinic because she assumes she is pregnant. She is experi- encing enlargement of her abdomen, a positive preg- nancy test, and changes in the pigmentation on her face and abdomen. These assessment findings reflect this woman is experiencing a cluster of which signs of pregnancy? ■ 1. Positive. ■ 2. Probable. ■ 3. Presumptive. ■ 4. Diagnostic. 35. An antenatal client receives education concerning medications that are safe to use during pregnancy. The nurse evaluates the client’s under- standing of the instructions and determines that she needs further information when she states which of the following? ■ 1. ■ 2. ■ 3. ■ 4. “I need to call if I start to leak fluid from my vagina.” “If I start bleeding, I will need to call back.” “If my baby does not move, I need to call my health care provider.” “If I start running a fever, I should let the office know.” 30. During a visit to the prenatal clinic, a preg- nant client at 32 weeks’ gestation complains of heartburn. The client needs further instruction when she says she must do what? ■ 1. Avoid highly seasoned foods. ■ 2. Avoid laying down right after eating. ■ 3. Eat small, frequent meals. ■ 4. Consume liquids only between meals. 31. The nurse is teaching a new prenatal client about her iron deficiency anemia during pregnancy. Which statement indicates that the client needs further instruction about her anemia? ■ 1. ■ 2. ■ 3. ■ 4. “If I am constipated, Milk of Magnesia is okay but mineral oil is not.” “If I have heartburn, it is safe to use Tums, Rolaids, Mylanta, and Maalox.” “I can take Tylenol if I have a headache.” “If I need to have a bowel movement, Ex-Lax is preferred.” ■ 1. ■ 2. ■ 3. ■ 4. “I will need to take iron supplements now.” “I may have anemia because my family is of Asian descent.” “I am considered anemic if my hemoglobin is below 11 g/dL.” “The workload on my heart is increased when there is not enough oxygen in my system.” 36. When preparing a 20-year-old client who reports missing one menstrual period and suspects that she is pregnant for a radioimmunoassay preg- nancy test, the nurse should tell the client which of the following about this test? 32. Following a positive pregnancy test, a client begins discussing the changes that will occur in the next several months with the nurse. The nurse should include which of the following information about changes the client can anticipate in the first trimester? ■ 1. Differentiating the self from the fetus. ■ 2. Enjoying the role of nurturer. ■ 3. Preparing for the reality of parenthood. ■ 4. Experiencing ambivalence about pregnancy. 33. An antenatal primagravid client has just been informed that she is carrying twins. The plan of care includes educating the client concerning factors that put her at risk for problems during the pregnancy. The nurse realizes the client needs further instruc- tion when she indicates carrying twins puts her at risk for which of the following? ■ 1. Preterm labor. ■ 2. Twin-to-twin transfusion. ■ 3. Anemia. ■ 4. Group B Streptococcus. ■ 1. ■ 2. ■ 3. ■ 4. It has a high degree of accuracy within 1 week after ovulation. It is identical in nature to an over-the-counter home pregnancy test. A positive result is considered a presumptive sign of pregnancy. A urine sample is needed to obtain quicker results. 37. After instructing a female client about the radioimmunoassay pregnancy test, the nurse deter- mines that the client understands the instructions when the client states that which of the following hormones is evaluated by this test? ■ 1. Prolactin. ■ 2. Follicle-stimulating hormone. ■ 3. Luteinizing hormone. ■ 4. Human chorionic gonadotropin (hCG). 38. Using Nägele’s rule for a client whose last normal menstrual period began on May 10, the nurse determines that the client’s estimated date of delivery would be which of the following? ■ 1. January 13. ■ 2. January 17. ■ 3. February 13. ■ 4. February 17. 39. After instructing a primigravid client about the functions of the placenta, the nurse determines that the client needs additional teaching when she says that which of the following hormones is pro- duced by the placenta? ■ 1. Estrogen. ■ 2. Progesterone. ■ 3. Human chorionic gonadotropin (hCG). ■ 4. Testosterone. 40. The nurse assesses a woman at 24 weeks’ gestation and is unable to find the fetal heart beat. The fetal heart beat was heard at the cli- ent’s last visit 4 weeks ago. According to priority, the nurse should do the following tasks in which order? 42. A 20-year-old married client with a positive pregnancy test states, “Is it really true? I can’t believe I’m going to have a baby!” Which of the following responses by the nurse would be most appropriate at this time? ■ 1. “Would you like some booklets on the preg- nancy experience?” ■ 2. “Yes it is true. How does that make you feel?” ■ 3. “You should be delighted that you are pregnant.” ■ 4. “Weren’t you and your husband trying to have a baby?” 43. A newly diagnosed pregnant client tells the nurse, “If I’m going to have all of these discomforts, I’m not sure I want to be pregnant!” The nurse inter- prets the client’s statement as an indication of which of the following? ■ 1. Fear of pregnancy outcome. ■ 2. Rejection of the pregnancy. ■ 3. Normal ambivalence. ■ 4. Inability to care for the newborn. 44. A client, approximately 11 weeks pregnant, and her husband are seen in the antepartal clinic. The client’s husband tells the nurse that he has been experiencing nausea and vomiting and fatigue along with his wife. The nurse interprets these findings as suggesting that the client’s husband is experiencing which of the following? ■ 1. Ptyalism. ■ 2. Mittelschmerz. ■ 3. Couvade syndrome. ■ 4. Pica. 45. A primigravid client asks the nurse if she can continue to have a glass of wine with dinner during her pregnancy. Which of the following would be the nurse’s best response? Antepartal Care 35 1. Call the health care provider. 2. Explain that the fetal heart beat could not be found at this time. 3. Obtain different equipment and recheck. 4. Ask client if baby is or has been moving. 41. A primiparous client at 10 weeks’ gestation questions the nurse about the need for an ultra- sound. She states “I don’t have health insurance and I can’t afford it. I feel fine, so why should I have the test?” The nurse should incorporate which statements as the underlying reason for performing the ultrasound now? Select all that apply. ■ 1. “We must view the gross anatomy of the fetus.” ■ 2. “We need to determine gestational age.” ■ 3. “We want to view the heart beating to deter- mine that the fetus is viable.” ■ 4. “We must determine fetal position.” ■ 5. “We must determine that there is a sufficient nutrient supply for the fetus.” ■ 1. ■ 2. ■ 3. ■ 4. “The effects of alcohol on a fetus during preg- nancy are unknown.” “You should limit your consumption to beer and wine.” “You should abstain from drinking alcoholic beverages.” “You may have 1 drink or 2 oz of alcohol per day.” 46. Examination of a primigravid client com- plaining of increased vaginal secretions since becoming pregnant reveals clear, highly acidic vaginal secretions. The client denies any perineal itching or burning. The nurse interprets these find- ings as a response related to which of the following? ■ 1. ■ 2. ■ 3. ■ 4. A decrease in vaginal glycogen stores. Development of a sexually transmitted disease. Prevention of expulsion of the cervical mucus plug. Control of the growth of pathologic bacteria. 36 The Nursing Care of the Childbearing Family 47. When measuring the fundal height of a primigravid client at 20 weeks’ gestation, the nurse will locate the fundal height at which of the follow- ing points? 52. The nurse is discussing dietary concerns with pregnant teens. Which of the following choices are convenient for teens yet nutritious for both the mother and fetus? Select all that apply. ■ 1. ■ 2. ■ 3. ■ 4. Halfway between the client’s symphysis pubis and umbilicus. At about the level of the client’s umbilicus. Between the client’s umbilicus and xiphoid process. Near the client’s xiphoid process and com- pressing the diaphragm. ■ 1. ■ 2. ■ 3. ■ 4. ■ 5. ■ 6. Milkshake or yogurt with fresh fruit or gra- nola bar. Chicken nuggets with tater tots. Cheese pizza with spinach and mushroom topping. Peanut butter with crackers and a juice drink. Buttery light popcorn with diet cola. Cheeseburger with tomato, lettuce, pickle, ketchup, and baked potato. 48. A primigravida at 8 weeks’ gestation tells the nurse that she wants an amniocentesis because there is a history of Hemophilia A in her family. The nurse informs the client that she will need to wait until she is 15 weeks gestation for the amniocente- sis. Which of the following provides the most appro- priate rationale for the nurse’s statement regarding amniocentesis at 15 weeks’ gestation? 53. An antenatal client is discussing her anemia with the nurse in the prenatal clinic. After a discus- sion about sources of iron to be incorporated into her daily meals, the nurse knows the client needs further instruction when she responds with which of the following? ■ 1. “I can meet two goals when I drink milk, lots of iron and meeting my calcium needs at the same time.” ■ 2. “Drinking coffee, tea, and sodas decrease the absorption of iron.” ■ 3. “I can increase the absorption of iron by drinking orange juice when I eat.” ■ 4. Cream of wheat and molasses are excellent sources of iron.” 54. The nurse instructs a primigravid client to increase her intake of foods high in magnesium because of its role with which of the following? ■ 1. ■ 2. ■ 3. ■ 4. Fetal development needs to be complete before testing. The volume of amniotic fluid needed for test- ing will be available by 15 weeks. Cells indicating Hemophilia A are not pro- duced until 15 weeks’ gestation. Fetal anomalies are associated with amnio- centesis prior to 15 weeks’ gestation. 49. After instructing a primigravid client about desired weight gain during pregnancy, the nurse determines that the teaching has been successful when the client states which of the following? ■ 1. ■ 2. ■ 3. ■ 4. “A total weight gain of approximately 20 lb (9 kg) is recommended.” “A weight gain of 6.6 lb (3 kg) in the second and third trimesters is considered normal.” “A weight gain of about 12 lb (5.5 kg) every trimester is recommended.” “Although it varies, a gain of 25 to 35 lb (11.4 to 14.5 kg) is about average.” ■ 1. ■ 2. ■ 3. ■ 4. Prevention of demineralization of the moth- er’s bones. Synthesis of proteins, nucleic acids, and fats. Amino acid metabolism. Synthesis of neural pathways in the fetus. 50. When developing a teaching plan for a client who is 8 weeks pregnant, which of the following foods would the nurse suggest to meet the client’s need for increased folic acid? ■ 1. Spinach. ■ 2. Bananas. ■ 3. Seafood. ■ 4. Yogurt. 51. The nurse instructs a primigravid client about the importance of sufficient vitamin A in her diet. The nurse knows that the instructions have been effective when the client indicates that she should include which of the following in her diet? ■ 1. Buttermilk and cheese. ■ 2. Strawberries and cantaloupe. ■ 3. Egg yolks and squash. ■ 4. Oranges and tomatoes. 55. When caring for a primigravid client at 9 weeks’ gestation who immigrated to the United States from Vietnam 1 year ago, the nurse would assess the client’s diet for a deficiency of which of the following? ■ 1. Calcium. ■ 2. Vitamin E. ■ 3. Vitamin C. ■ 4. Iodine. 56. Which of the following statements by a prim- igravid client scheduled for chorionic villi sampling indicates effective teaching about the procedure? ■ 1. ■ 2. ■ 3. ■ 4. “A fiberoptic fetoscope will be inserted through a small incision into my uterus.” “I can’t have anything to eat or drink after midnight on the day of the procedure.” “The procedure involves the insertion of a thin catheter into my uterus.” “I need to drink 32 to 40 oz of fluid 1 to 2 hours before the procedure.” 57. A 34-year-old multiparous client at 16 weeks’ gestation who received regular prenatal care for all of her previous pregnancies tells the nurse that she has already felt the baby move. The nurse interprets this as which of the following? 61. The nurse is assessing fetal position for a 32-year-old client in her eighth month of pregnancy. As shown below, the fetal position can be described as which of the following? ■ 1. Left occipital transverse. ■ 2. Left occipital anterior. ■ 3. Right occipital transverse. ■ 4. Right occipital anterior. 62. Which of the following statements by the nurse would be most appropriate when responding to a primigravid client who asks, “What should I do about this brown discoloration across my nose and cheeks?” ■ 1. ■ 2. ■ 3. ■ 4. The possibility that the client is carrying twins. Unusual because most multiparous clients do not experience quickening until 30 weeks’ gestation. Evidence that the client’s estimated date of delivery is probably off by a few weeks. Normal because multiparous clients can expe- rience quickening between 14 and 20 weeks’ gestation. 58. Which diagnostic test would be the most important to have for a primigravid client in the second trimester of her pregnancy? ■ 1. Culdocentesis to detect abnormalities. ■ 2. Chorionic villus sampling. ■ 3. Ultrasound testing. ■ 4. α-fetoprotein (AFP) testing. 59. When performing Leopold’s maneuvers, which of the following would the nurse ask the cli- ent to do to ensure optimal comfort and accuracy? ■ 1. Breathe deeply for 1 minute. ■ 2. Empty her bladder. ■ 3. Drink a full glass of water. ■ 4. Lie on her left side. 60. The nurse performed Leopold’s maneuvers and determined that the fetal position is LOA. Identify the area where the nurse would place the Doppler to most easily hear fetal heart sounds. ■ 1. ■ 2. ■ 3. ■ 4. “This usually disappears after delivery.” “It is a sign of skin melanoma.” “The discoloration is due to dilated capillaries.” “It will fade if you use a prescribed cream.” 63. A 36-year-old primigravid client at 22 weeks’ gestation without any complications to date is being seen in the clinic for a routine visit. The nurse should assess the client’s fundal height to: ■ 1. Determine the level of uterine activity. ■ 2. Identify the need for increased weight gain. ■ 3. Assess the location of the placenta. ■ 4. Estimate the fetal gestational age. 64. After the nurse reviews the physician’s explanation of amniocentesis with a multigravid cli- ent, which of the following indicates that the client understands a serious risk of the procedure.? ■ 1. Premature rupture of the membranes. ■ 2. Possible premature labor. ■ 3. Fetal limb malformations. ■ 4. Fetal organ malformations. Antepartal Care 37 38 The Nursing Care of the Childbearing Family 65. A primigravid client at 28 weeks’ gestation tells the nurse that she and her husband wish to drive to visit relatives who live several hundred miles away. Which of the following recommenda- tions by the nurse would be best? 69. A nurse is eating lunch at a restaurant when she sees a pregnant woman showing signs of airway obstruction. When the nurse asks the woman if she needs help, the woman nods her head yes. Indicate the area where the nurse’s fist should be placed to effectively administer thrusts to clear the foreign body from the airway. ■ 1. ■ 2. ■ 3. ■ 4. “Try to avoid traveling anywhere in the car during your third trimester.” “Limit the time you spend in the car to a maximum of 4 to 5 hours.” “Taking the trip is okay if you stop every 1 to 2 hours and walk.” “Avoid wearing your seat belt in the car to prevent injury to the fetus.” 66. The nurse is teaching a woman who is 18 weeks pregnant about seat belt safety. Identify the area that indicates that the client understands where the lap portion of the seat belt should be placed. 67. Which of the following recommendations would be most helpful to suggest to a primigravid client at 37 weeks’ gestation who is complaining of leg cramps? 71. A primigravid adolescent client at approxi- mately 15 weeks’ gestation who is visiting the prenatal clinic with her mother is to undergo alphafetoprotein (AFP) screening. When developing the teaching plan for this client, the nurse should include which of the following? ■ 1. ■ 2. ■ 3. ■ 4. Change positions frequently throughout the day. Alternately flex and extend the legs. Straighten the knee and flex the toes toward the chin. Lie prone in bed with the legs elevated. ■ 1. ■ 2. ■ 3. ■ 4. Ultrasonography usually accompanies AFP testing. Results are usually very accurate until 20 weeks’ gestation. A clean-catch midstream urine specimen is needed. Increased levels of AFP are associated with neural tube defects. 68. Which of the following recommendations would be the most appropriate preventive measure to suggest to a primigravid client at 30 weeks’ gesta- tion who is experiencing occasional heartburn? 72. Which of the following statements best identifies the rationale for why the nurse reinforces the need for continued prenatal care throughout the pregnancy with an adolescent primigravid client? ■ 1. ■ 2. ■ 3. ■ 4. Eat smaller and more frequent meals during the day. Take a pinch of baking soda with water before meals. Decrease fluid intake to four glasses daily. Drink several cups of regular tea throughout the day. ■ 1. ■ 2. ■ 3. ■ 4. Pregnant adolescents are at high risk for pregnancy-induced hypertension. Gestational diabetes during pregnancy com- monly develops in adolescents. Adolescents need additional instruction related to common discomforts. The father of the baby is rarely involved in the pregnancy. 70. When performing Leopold’s maneuvers on a primigravid client at 22 weeks’ gestation, the nurse per- forms the first maneuver to do which of the following? ■ 1. ■ 2. ■ 3. ■ 4. Locate the fetal back and spine. Determine what is in the fundus. Determine whether the fetal head is at the pelvic inlet. Identify the degree of fetal descent and flexion. 73. Which of the following would be included in the teaching plan about pregnancy-related breast changes for a primigravid client? 77. When teaching a primigravid client how to do Kegel exercises, the nurse explains that the expected outcome of these exercises is to: ■ 1. Prevent vulvar edema. ■ 2. Alleviate lower back discomfort. ■ 3. Strengthen the perineal muscles. ■ 4. Strengthen the abdominal muscles. 78. During a routine clinic visit, a 25-year-old multigravid client who initiated prenatal care at 10 weeks’ gestation and is now in her third trimes- ter states, “I’ve been having strange dreams about the baby. Last week I dreamed he was covered with hair.” The nurse should tell the mother: ■ 1. ■ 2. ■ 3. ■ 4. Growth of the milk ducts is greatest during the first 8 weeks of gestation. Enlargement of the breasts indicates adequate levels of progesterone. Colostrum is usually secreted by about the 16th week of gestation. Darkening of the areola occurs during the last month of pregnancy. 74. A primigravid client at 32 weeks’ gestation is enrolled in a breast-feeding class. Which of the fol- lowing statements indicate that the client understands the breast-feeding education? Select all that apply. ■ 1. ■ 2. ■ 3. ■ 4. “Dreams like the ones that you describe are very unusual. Please tell me more about them.” “Commonly when a mother has these dreams, she is trying to cope with becoming a parent.” “Dreams about the baby late in pregnancy usually mean that labor is about to begin soon.” “It’s not uncommon to have dreams about the baby, particularly in the third trimester.” ■ 1. ■ 2. ■ 3. ■ 4. ■ 5. ■ 6. “My milk supply will be adequate since I have increased a whole bra size during pregnancy.” “I can hold my baby several different ways during feedings.” “If my infant latches on properly, I won’t develop mastitis.” “If I breast-feed, my uterus will return to prepregnancy size more quickly.” “Breast milk can be expressed and stored at room temperature since it is natural.” “I need to feed my baby when I see feeding cues and not wait until she is crying.” 79. A primigravid client at 36 weeks’ gesta- tion tells the nurse that she has been experiencing insomnia for the past 2 weeks. Which of the follow- ing suggestions would be most helpful? 75. When planning a class for primigravid clients about the common discomforts of pregnancy, which of the following physiologic changes of pregnancy should the nurse include in the teaching plan? ■ 1. ■ 2. ■ 3. ■ 4. Practice relaxation techniques before bedtime. Drink a cup of hot chocolate before bedtime. Drink a small glass of wine with dinner. Exercise for 30 minutes just before bedtime. ■ 1. ■ 2. ■ 3. ■ 4. The temperature decreases slightly early in pregnancy. Cardiac output increases by 25% to 50% dur- ing pregnancy. The circulating fibrinogen level decreases as much as 50% during pregnancy. The anterior pituitary gland secretes oxytocin late in pregnancy. 80. Which of the following client statements indicates a need for additional teaching about self- care during pregnancy? 76. When teaching a primigravid client at 24 weeks’ gestation about the diagnostic tests to determine fetal well-being, which of the following should the nurse include? ■ 1. ■ 2. ■ 3. ■ 4. “I should use nonskid pads when I take a shower or bath.” “I should avoid using soap on my nipples to prevent drying.” “I should sit in a hot tub for 20 minutes to relax after working.” “I should avoid douching even if my vaginal secretions increase.” ■ 1. ■ 2. ■ 3. ■ 4. A fetal biophysical profile involves assess- ments of breathing movements, body move- ments, tone, amniotic fluid volume, and fetal heart rate reactivity. A reactive nonstress test is an ominous sign and requires further evaluation with fetal echocardiography. Contraction stress testing, performed on most pregnant women, can be initiated as early as 16 weeks’ gestation. Percutaneous umbilical blood sampling uses a needle inserted through the vagina to obtain a sample. 81. To obtain the obstetric conjugate measurement, the nurse would do which of the following? ■ 1. ■ 2. ■ 3. ■ 4. Add 1.5 cm to the transverse diameter. First measure the angle of the pubic arch. Subtract 1.5 to 2 cm from the diagonal conju- gate. Measure the diameter of the pelvic inlet. Antepartal Care 39 40 The Nursing Care of the Childbearing Family The Pregnant Client in Childbirth Preparation Classes 82. The nurse is developing a teaching plan for a client entering the third trimester of her pregnancy. The nurse should include which of the following in the plan? Select all that apply. ■ 1. Differentiating the fetus from the self. ■ 2. Ambivalence concerning pregnancy. ■ 3. Experimenting with mothering roles. ■ 4. Realignment of roles and tasks. ■ 5. Trying various caregiver roles. ■ 6. Concern about labor and delivery. 83. A new antenatal G 6, P 4, Ab 1 client attends her first prenatal visit with her husband. The nurse is assessing this couple’s psychological response to their pregnancy. Which of the following requires the most immediate follow up? 87. During a 2-hour childbirth preparation class focusing on the labor and delivery process for primi- gravid clients, the nurse is describing the maneuvers that the fetus goes through during the labor process when the head is the presenting part. In which order do these maneuvers occur? 1. Engagement 2. Flexion 3. Descent 4. Internal rotation ■ 1. ■ 2. ■ 3. ■ 4. The couple are concerned with financial changes this pregnancy causes. The couple expresses ambivalence about the current pregnancy. The father of the baby states that the preg- nancy has changed the mother’s focus. The father of the baby is irritated that the mother is not like she was before pregnancy. 88. A primigravid client in a Preparation for Par- enting class asks how much blood is lost during an uncomplicated delivery. The nurse should tell the woman: ■ 1. “The maximum blood loss considered within normal limits is 500 mL.” ■ 2. “The minimum blood loss considered within normal limits is 1,000 mL.” ■ 3. “Blood loss during a delivery is rarely esti- mated unless there is a hemorrhage.” ■ 4. “It would be very unusual if you lost more than 100 mL of blood during the delivery.” 89. Which of the following statements by a primigravid client about the amniotic fluid and sac indicates the need for further teaching? 84. When preparing a prenatal class about endo- crine changes that normally occur during pregnancy, the nurse should include information about which of the following subjects? ■ 1. ■ 2. ■ 3. ■ 4. Human placental lactogen maintains the cor- pus luteum. Progesterone is responsible for hyperpigmen- tation and vascular skin changes. Estrogen relaxes smooth muscle in the respi- ratory tract. The thyroid enlarges with an increase in basal metabolic rate. 85. When developing a series of parent classes on fetal development, which of the following should the nurse include as being developed by the end of the third month (9 to 12 weeks)? ■ 1. External genitalia. ■ 2. Myelinization of nerves. ■ 3. Brown fat stores. ■ 4. Air ducts and alveoli. 86. A primigravid client attending parenthood classes tells the nurse that there is a history of twins in her family. What should the nurse tell the client? ■ 1. Monozygotic twins result from fertilization of two ova by different sperm. ■ 2. Monozygotic twins occur by chance regard- less of race or heredity. ■ 3. Dizygotic twins are usually of the same sex. ■ 4. Dizygotic twins occur more often in primi- gravid than in multigravid clients. ■ 1. ■ 2. ■ 3. ■ 4. “The amniotic fluid helps to dilate the cervix once labor begins.” “Fetal nutrients are provided by the amniotic fluid.” “Amniotic fluid provides a cushion against impact of the maternal abdomen.” “The fetus is kept at a stable temperature by the amniotic fluid and sac.” 90. During a childbirth preparation class, a primigravid client at 36 weeks’ gestation tells the nurse, “My lower back has really been bothering me lately.” Which of the following exercises suggested by the nurse would be most helpful? ■ 1. Pelvic rocking. ■ 2. Deep breathing. ■ 3. Tailor sitting. ■ 4. Squatting. 91. A client is experiencing pain during the first stage of labor. What should the nurse instruct the client to do to manage her pain? Select all that apply. ■ 1. Walk in the hospital room. ■ 2. Use slow chest breathing. ■ 3. Request pain medication on a regular basis. ■ 4. Lightly massage her abdomen. ■ 5. Sip ice water. 92. During a Preparation for Parenting class, one of the participants asks the nurse, “How will I know if I am really in labor?” The nurse should tell the participant which of the following about true labor contractions? 96. The nurse is obtaining information to support the need for improved prenatal care services in the community. Which of the following information is most important to include? ■ 1. The maternal mortality rate. ■ 2. The infant mortality rate. ■ 3. The perinatal mortality rate. ■ 4. The neonatal mortality rate. The Pregnant Client with Risk Factors 97. A multigravid client at 32 weeks’ gestation has experienced hemolytic disease of the newborn in a previous pregnancy. The nurse should prepare the client for frequent antibody titer evaluations obtained from which of the following? ■ 1. Placental blood. ■ 2. Amniotic fluid. ■ 3. Fetal blood. ■ 4. Maternal blood. 98. A client with a past medical history of ventricular septal defect repaired in infancy is seen at the prenatal clinic. She is complaining of dyspnea with exertion and being very tired. Her vital signs are 98, 80, 20, BP 116/72. She has + 2 pedal edema and clear breath sounds. As the nurse plans this client’s care, which of the following is her cardiac classification according to the New York Heart Association Cardiac Disease classification? ■ 1.ClassI. ■ 2.ClassII. ■ 3. Class III. ■ 4.ClassIV. 99. A primigravid client has completed her first prenatal visit and blood work. Her laboratory test for the hepatitis B surface antigen (HBsAg) is posi- tive. The nurse can advise the client that the plan of care for this newborn will include? Select all that apply. ■ 1. ■ 2. ■ 3. ■ 4. “Walking around helps to decrease true con- tractions.” “True labor contractions may disappear with ambulation, rest, or sleep.” “The duration and frequency of true labor contractions remain the same.” “True labor contractions are felt first in the lower back, then the abdomen.” 93. After instructing participants in a childbirth education class about methods for coping with dis- comforts in the first stage of labor, the nurse deter- mines that one of the pregnant clients needs further instruction when she says that she has been practic- ing which of the following? ■ 1. Biofeedback. ■ 2. Effleurage. ■ 3. Guided imagery. ■ 4. Pelvic tilt exercises. 94. After a Preparation for Parenting class ses- sion, a pregnant client tells the nurse that she has had some yellow-gray frothy vaginal discharge and local itching. The nurse’s best action is to advise the client to do which of the following? ■ 1. ■ 2. ■ 3. Use an over-the-counter cream for yeast infections. Schedule an appointment at the clinic for an examination. Administer a vinegar douche under low pressure. Prepare for preterm labor and delivery. ■ 1. ■ 2. ■ 3. ■ 4. ■ 5. ■ 6. Hepatitis B immune globulin at birth. Series of three hepatitis B vaccinations per recommended schedule. Hepatitis B screening when born. Isolation of infant during hospitalization. Universal precautions for mother and infant. Contraindication for breast-feeding because the mother is HBsAg positive. ■ 4. 95. The topic of physiologic changes that occur during pregnancy is to be included in a parenting class for primigravid clients who are in their first half of pregnancy. Which of the following would be important for the nurse to include in the teaching plan? ■ 1. ■ 2. ■ 3. ■ 4. Decreased plasma volume. Increased risk for urinary tract infections. Increased peripheral vascular resistance. Increased hemoglobin levels. Antepartal Care 41 42 The Nursing Care of the Childbearing Family 100. A woman who has had asthma since she was a child and it is under control when the client takes her medication correctly and consistently is now pregnant for the first time. Which of the following client statements concerning asthma during preg- nancy indicates the need for further instruction? 104. After conducting a presentation to a group of adolescent parents on the topic of adolescent pregnancy, the nurse determines that one of the parents needs further instruction when the parent says that adolescents are at greater risk for which of the following? ■ 1. Denial of the pregnancy. ■ 2. Low-birth-weight infant. ■ 3. Cephalopelvic disproportion. ■ 4. Congenital anomalies. 105. A dilatation and curettage (D&C) is scheduled for a primigravid client admitted to the hospital at 10 weeks’ gestation with abdominal cramping, bright red vaginal spotting, and passage of some of the products of conception. The nurse should assess the client further for the expression of which of the following feelings? ■ 1. Ambivalence. ■ 2. Anxiety. ■ 3. Fear. ■ 4. Guilt. 106. When providing care to the client who has undergone a dilatation and curettage (D&C) after a spontaneous abortion, the nurse administers hydroxyzine (Vistaril) as ordered. Which of the fol- lowing is an expected outcome? ■ 1. Absence of nausea. ■ 2. Minimized pain. ■ 3. Decreased uterine cramping. ■ 4. Improved uterine contractility. 107. On entering the room of a client who has undergone a dilatation and curettage (D&C) for a spontaneous abortion, the nurse finds the client cry- ing. Which of the following comments by the nurse would be most appropriate? ■ 1. ■ 2. ■ 3. ■ 4. “I need to continue taking my asthma medica- tion as prescribed.” “It is my goal to prevent or limit asthma attacks.” “During an asthma attack, oxygen needs con- tinue to be high for mother and fetus.” “Bronchodilators should be used only when necessary because of the risk they present to the fetus.” 101. A woman at 22 weeks’ gestation has right upper quadrant pain radiating to her back. She rates the pain as 9 on a scale of 1 to 10 and says that it has occurred 2 times in the last week for about 4 hours at a time. She does not associate the pain with food. Which of the following nursing measures is the highest priority for this client? ■ 1. ■ 2. ■ 3. ■ 4. Educate the client concerning changes occurring in the gallbladder as a result of pregnancy. Refer the client to her health care provider for evaluation and treatment of the pain. Discuss nutritional strategies to decrease the possibility of heartburn. Support the client’s use of acetaminophen (Tylenol) to relieve pain. 102. A client in the triage area who is at 19 weeks’ gestation states that she has not felt her baby move in the past week and no fetal heart tones are found. While evaluating this client, the nurse identifies her as being at the highest risk for developing which problem? ■ 1. Abruptio placentae. ■ 2. Placenta previa. ■ 3. Disseminated intravascular coagulation. ■ 4. Threatened abortion. 103. A 40-year-old client at 8 weeks’ gestation has a 3-year-old child with Down syndrome. The nurse is discussing amniocentesis and chorionic villus sampling as genetic screening methods for the expected baby. The nurse is confident that the teaching has been understood when the client states which of the following? ■ 1. ■ 2. ■ 3. ■ 4. “Are you having a great deal of uterine pain?” “Commonly spontaneous abortion means a defective embryo.” “I’m truly sorry you lost your baby.” “You should try to get pregnant again as soon as possible.” ■ 1. ■ 2. ■ 3. ■ 4. “Each test identifies a different part of the infant’s genetic makeup.” “Chorionic villus sampling can be performed earlier in pregnancy.” “The test results take the same length of time to be completed.” “Amniocentesis is a more dangerous proce- dure for the fetus.” 108. Rho(D) immune globulin (RhoGAM) is ordered for a client before she is discharged after a spontaneous abortion. The nurse instructs the cli- ent that this drug is used to prevent which of the following? ■ 1. Development of a future Rh-positive fetus. ■ 2. An antibody response to Rh-negative blood. ■ 3. A future pregnancy resulting in abortion. ■ 4. Development of Rh-positive antibodies. 109. A multigravid client who stands for long peri- ods while working in a factory visits the prenatal clinic at 35 weeks’ gestation, stating, “The varicose veins in my legs have really been bothering me lately.” Which of the following instructions would be helpful? Antepartal Care 43 Managing Care Quality and Safety 114. The nurse is reviewing results for clients who are having antenatal testing. The assessment data from which client warrants prompt notification of the health care provider and a further plan of care? ■ 1. Primigravida who reports fetal movement 6 times in 2 hours. ■ 2. Multigravida who had a positive oxytocin challenge test. ■ 3. Primigravida whose infant has a biophysical profile of 9. ■ 4. Multigravida whose infant has a reactive non- stress test. 115. A client asks the nurse why taking folic acid is so important before and during pregnancy. The nurse should instruct the client that: ■ 1. ■ 2. ■ 3. ■ 4. Perform slow contraction and relaxation of the feet and ankles twice daily. Take frequent rest periods with the legs elevated above the hips. Avoid support hose that reach above the leg varicosities. Take a leave of absence from your job to avoid prolonged standing. 110. A multigravid client at 36 weeks’ gestation has been diagnosed with condylomata acuminata. Which of the following should the nurse include when teaching the client about the disorder and cur- rent therapies? ■ 1. ■ 2. ■ 3. ■ 4. “Folic acid is important in preventing neu- ral tube defects in newborns and preventing anemia in mothers.” “Eating foods with moderate amounts of folic acid helps regulate blood glucose levels.” “Folic acid consumption helps with the absorption of iron during pregnancy.” “Folic acid is needed to promote blood clotting and collagen formation in the newborn.” ■ 1. ■ 2. ■ 3. ■ 4. Cryotherapy may be used to remove the warts. Podophyllin solution may be used to decrease the size of the warts. A 25% trichloroacetic acid solution can eradi- cate the disorder. Condylomata acuminata has been associated with ovarian cancer. 111. A primigravid client at 8 weeks’ gestation tells the nurse that since having had sexual relations with a new partner 2 weeks ago, she has noticed flu- like symptoms, enlarged lymph nodes, and clusters of vesicles on her vagina. The nurse refers the client to a physician because the nurse suspects which of the following sexually transmitted diseases? ■ 1. Gonorrhea. ■ 2. Chlamydia trachomatis infection. ■ 3. Syphilis. ■ 4. Herpes genitalis. 112. While caring for a 24-year-old primigravid client scheduled for emergency surgery because of a probable ectopic pregnancy, the nurse should: 116. A nurse is assigned to the obstetrical triage area. When beginning the assignment, the nurse is given a report about four clients waiting to be seen. Place the clients in the order in which the nurse should see them. 2. A multiparous client at 32 weeks’ gesta- tion asking for assistance with finding a new physician. 3. A single mother at 4 months postpartum fear- ful of shaking her baby when he cries. ■ 1. ■ 2. ■ 3. ■ 4. Prepare to witness an informed consent for surgery. Assess the client for massive external bleeding. Explain that the fallopian tube can be salvaged. Monitor the client for uterine contractions. 113. A 30-year-old G 4, P 3 client at 30 weeks’ ges- tation is admitted to the hospital for evaluation. The client has experienced two neonatal deaths because of hemolytic disease of the newborn. An amniocen- tesis is to be performed to evaluate bilirubin density. The nurse should obtain a specimen container that is which of the following? ■ 1. Dark. ■ 2. Clear. ■ 3. Green. ■ 4. Amber. 1. A primigravid client at 10 weeks’ gestation complaining of not feeling well with nausea and vomiting, urinary frequency, and fatigue. 4. An antenatal client at 16 weeks’ gestation who has occasional sharp pain on her left side radi- ating from her symphysis to her fundus. 44 The Nursing Care of the Childbearing Family 117. The health care provider at a prenatal clinic has ordered multivitamins for a woman who is 3 months’ pregnant. The client calls the nurse to report that she has gone to the pharmacy to fill her prescription but is unable to buy it as it costs too much. The nurse should refer the client to: ■ 1. The charge nurse. ■ 2. The hospital finance office. ■ 3. Her hospital social worker. ■ 4. Her insurance company. Answers, Rationales, and Test Taking Strategies The answers and rationales for each question fol- low below, along with keys ( ) to the client need (CN) and cognitive level (CL) for each question. Use these keys to further develop your test-taking skills. For additional information about test-taking skills and strategies for answering questions, refer to pages 10–21, and pages 25–26 in Part 1 of this book. The Preconception Client 1. 1. Plan B is a series of contraceptive pills sim- ilar in composition to birth control pills that have been used for the past 30 years. Plan B is the brand name for levonorgestrel 0.75 mg. Pills are most effective if taken immediately after unprotected intercourse and then again 12 hours later. Males can purchase this contraceptive as long as they are over 18 years of age. Common side effects include nau- sea, breast tenderness, vertigo, and stomach pain. CN: Physiological adaptation; CL: Evaluate 2. 3. Birth control plans are influenced primarily by whether the mother is breast- or bottle-feeding her infant. The maternal milk supply must be well estab- lished prior to the initiation of most hormonal birth control methods. Low dose oral contraceptives would be the exception. Use of estrogen/progesterone based pills and progesterone only pills are commonly initi- ated from 4 to 6 weeks postpartum because the milk supply is well established by this time. Prior experi- ences with birth control methods have an impact on the method chosen as does the preferences of the cli- ent’s partner; however, they are not the most influen- tial factors. A history of blood clots or thrombophle- bitis is the second most important factor as several methods will be eliminated because of their potential to place the client at risk for clotting disorders. CN: Pharmacological and parenteral therapies; CL: Analysis 3. 4. The nurse determines that the client has understood the instructions when the client says that she will notify her physician if she notices discharge or bleeding because this may be symptom- atic of underlying disease. Ideally, breast self-exam- ination should be performed about 1 week after the onset of menses because hormonal influences on breast tissue are at a low ebb at this time. The client should perform breast self-examination on the same day each month only if she has stopped menstruat- ing (as with menopause). The client’s breasts should mirror each other. If one breast is significantly larger than the other, or if there is “pitting” of breast tissue, a tumor may be present. CN: Reduction of risk potential; CL: Evaluate 4. 3. For a client with a menstrual cycle of 28 days, ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle. Stated another way, the menstrual period begins about 2 weeks after ovulation has occurred. Ovulation does not usually occur during the menses component of the cycle when the uterine lining is being shed. In most women, the ovum survives for about 12 to 24 hours after ovulation, during which time conception is possible. The basal body tem- perature rises 0.5° to 1.0° F when ovulation occurs. Although some women experience some pelvic discomfort during ovulation (mittelschmerz), severe or unusual pain is rare. After ovulation, the cervical mucus is thin and copious. CN: Health promotion and maintenance; CL: Create 5. 1. The nurse should instruct the client to take a mild analgesic, such as ibuprofen, if menstrual pain or “cramps” are present. The client should also eat foods rich in iron and should continue moderate exercise during menstruation, which increases ab- dominal tone. Avoiding cold foods will not decrease dysmenorrhea. Sexual intercourse is not prohibited during menstruation, but the male partner should wear a condom to prevent exposure to blood. CN: Health promotion and maintenance; CL: Apply 6. 1. Under ideal conditions, sperm can reach the ovum in 15 to 30 minutes. This is an important point to make with adolescents who may be sexu- ally active. Many people believe that the time in- terval is much longer and that they can wait until after intercourse to take steps to prevent conception. Without protection, pregnancy and sexually transmit- ted diseases can occur. When using the abstinence or calendar method, the couple should abstain from intercourse on the days of the menstrual cycle when the woman is most likely to conceive. Using a 28-day Antepartal Care 45 cycle as an example, a couple should abstain from coitus 3 to 4 days before ovulation (days 10 through 14) and 3 to 4 days after ovulation (days 15 through 18). Sperm from a healthy male can remain viable for 24 to 72 hours in the female reproductive tract. If the female client ovulates after coitus, there is a possibil- ity that fertilization can occur. Before fertilization, the ovum and sperm each contain 23 chromosomes. After fertilization, the conceptus contains 46 chromo- somes unless there is a chromosomal abnormality. CN: Health promotion and maintenance; CL: Evaluate 7. 3. The symptothermal method is a natural method of fertility management that depends on knowing when ovulation has occurred. Because regu- lar menstrual cycles can vary by 1 to 2 days in either direction, the symptothermal method requires daily basal body temperature assessments plus close moni- toring of cervical mucus changes. The method relies on abstinence during the period of ovulation, which occurs approximately 14 days before the beginning of the next cycle. Abstinence from coitus for 5 days after menses is unnecessary because it is unlikely that ovulation will occur during this time period (days 1 through 10). Typically, the failure rate for this method is between 10% and 20%. Although a condom may increase the effectiveness of this method, most clients who choose natural methods are not interested in chemical or barrier types of family planning. CN: Health promotion and maintenance; CL: Create 8. 2. Before advising a client about oral con- traceptives, the nurse needs to assess the client for signs and symptoms of hypertension. Clients who have hypertension, thrombophlebitis, obesity, or a family history of cerebral or cardiovascular accident are poor candidates for oral contraceptives. In addi- tion, women who smoke, are older than 40 years of age, or have a history of pulmonary disease should be advised to use a different method. Iron-deficiency anemia, dysmenorrhea, and acne are not contrain- dications for the use of oral contraceptives. Iron- deficiency anemia is a common disorder in young women. Oral contraceptives decrease the amount of menstrual flow and thus decrease the amount of iron lost through menses, thereby providing a beneficial effect when used by clients with anemia. Low-dose oral contraceptives to prevent ovulation may be ef- fective in decreasing the severity of dysmenorrhea (painful menstruation). Dysmenorrhea is thought to be caused by the release of prostaglandins in response to tissue destruction during the ischemic phase of the menstrual cycle. Use of oral contracep- tives commonly improves facial acne. CN: Reduction of risk potential; CL: Analyze 9. 4. The nurse determines that the client needs further instruction when the client says that one of the adverse effects of oral contraceptive use is ovarian cancer. Some studies suggest that ovar- ian and endometrial cancer are reduced in women using oral contraceptives. Other adverse effects of oral contraceptives include weight gain, nausea, headache, breakthrough bleeding, and monilial infections. The most serious adverse effect is throm- bophlebitis. CN: Pharmacological and parenteral therapies; CL: Evaluate 10. 1. The typical failure rate of a condom is approximately 12% to 14%. Adding a spermicide can decrease this potential failure rate because it offers additional protection against pregnancy. Natural skin condoms do not offer the same protec- tion against sexually transmitted diseases caused by viruses as latex condoms do. Unlike latex condoms, natural skin (membrane) condoms do not prevent the passage of viruses. Most condom users report decreased penile gland sensitivity. However, some users do report an increased sensitivity or aller- gic reaction (such as a rash) to latex, necessitating the use of another method of family planning or a switch to a natural skin condom. CN: Health promotion and maintenance; CL: Apply 11. 2. The teaching plan should include a cau- tion that a diaphragm should not be used if the client develops acute cervicitis, possibly aggravated by contact with the rubber of the diaphragm. Some studies have also associated diaphragm use with in- creased incidence of urinary tract infections. Douch- ing after use of a diaphragm and intercourse is not recommended because pregnancy could occur. The diaphragm should be inspected and washed with mild soap and water after each use. A diaphragm should be left in place for at least 6 hours but no longer than 24 hours after intercourse. More spermi- cidal jelly or cream should be used if intercourse is repeated during this period. CN: Reduction of risk potential; CL: Create 12. 4. The client would need additional instruc- tions when she says that she can still use the same diaphragm if she gains or loses 20 lb. Gaining or losing more than 15 lb can change the pelvic and vaginal contours to such a degree that the dia- phragm will no longer protect the client against pregnancy. The diaphragm can be used for 2 to 3 years if it is cared for and well protected in its case. The client should be refitted for another diaphragm after pregnancy and delivery of a newborn be- cause weight changes and physiologic changes of 46 The Nursing Care of the Childbearing Family pregnancy can alter the pelvic and vaginal contours, thus affecting the effectiveness of the diaphragm. The client should use a spermicidal jelly or cream before inserting the diaphragm. CN: Reduction of risk potential; CL: Evalua