A married 35-year-old client is to undergo a tubal Answer: Has a son and daughter and feels that her family is complete.
ligation. The factor in the history that contributes most
to the healthy resolution of any emotional problem Rationale:Many couples in their 30s who are happy with their families and
associated with sterilization is that the client: feel that they are complete choose sterilization as their method of
contraception. Sterilization by means of tubal ligation should have no effect
on dysmenorrhea, because the hormonal influence does not change. The
decision to undergo sterilization should not be made by others, only by the
woman herself. Decisions regarding sterilization should not be made during
pregnancy or in the immediate postpartum period, especially if the client is
stressed.
A nurse places a newly admitted client with Answer: The probability of tonic-clonic seizures is reduced.
worsening preeclampsia in a private room. Why is it
important for this client to be in a nonstimulating Rationale: Even minimal sensory stimuli can trigger an exaggerated cerebral
environment? response such as seizures; therefore a nonstimulating environment is most
therapeutic. Women with preeclampsia do not have respiratory problems.
Although respiration may become depressed with magnesium sulfate
therapy, a quiet environment will have no effect on respiration. A
nonstimulating environment does not reduce the severity of headaches
resulting from hypertension and has no relationship to the effects of
antihypertensive drugs.
Maternal Childs 1
, Page 2 Maternal Childs
Which statement made by a pregnant client to a nurse Answer: "The baby gets food from the amniotic fluid."
indicates that the client does not understand the
teaching about fetal growth and development? Rationale: The amniotic fluid serves as a protective environment; the fetus
depends on the placenta, along with the umbilical blood vessels, for
nutrients and oxygen. "The baby is smaller if the mother smokes," "The baby's
oxygen is provided by the mother," and "The baby's umbilical cord has two
arteries and one vein" are all true statements, and further teaching would not
be required.
A nurse in the clinic determines that a 4-day-old Answer: Chlamydia trachomatis infection
neonate who was born at home has a purulent
discharge from the eyes. What condition does the Rationale: Chlamydia trachomatis infection occurs 3 to 4 days after birth; if it
nurse suspect? is not treated prophylactically with an antibiotic at birth or within 3 days,
chronic follicular conjunctivitis with conjunctival scarring will occur. HIV
infection in the newborn does not manifest with conjunctivitis. The high
oxygen concentrations given to severely compromised preterm infants
cause vasoconstriction of retinal capillaries, which can lead to blindness;
there are no data to indicate that this infant was preterm, severely
compromised, or received oxygen. A chemical conjunctivitis occurs within
the first 48 hours and is not purulent.
Maternal Childs 2