Families Module 1 Exam-Questions and Answers

Families Module 1 Exam A client at 36 weeks gestation is scheduled for a routine ultrasound prior to an amniocentesis. After teaching the client about the purpose for the ultrasound, which of the following client statements would indicate to the nurse in charge that the client needs further instruction? A. The ultrasound will help to locate the placenta B. The ultrasound identifies blood flow through the umbilical cord C. The test will determine where to insert the needle D. The ultrasound locates a pool of amniotic fluid Before amniocentesis, a routine ultrasound is valuable in locating the placenta, locating a pool of amniotic fluid, and showing the physician where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this. The nurse is caring for a primigravida at about 2 months and 1-week gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she says: A. "Nausea and vomiting can be decreased if I eat a few crackers before arising." B. "If I start to leak colostrum, I should cleanse my nipples with soap and water." C. "If I have a vaginal discharge, I should wear nylon underwear." D. "Leg cramps can be alleviated if I put an ice pack on the area." Eating dry crackers before arising can assist in decreasing the common discomfort of nausea and vomiting. Avoiding strong food odors and eating a high-protein snack before bedtime can also help. A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells the client that the usual treatment for partial placenta previa is which of the following? A. Activity limited to bed rest B. Platelet infusion C. Immediate cesarean delivery D. Labor induction with oxytocin Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring of the client's bleeding. The nurse plans to instruct the postpartum client about methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan? A. Feeding the neonate a maximum of 5 minutes per side on the first day B. Wearing a supportive brassiere with nipple shields C. Breast-feeding the neonate at frequent intervals D. Decreasing fluid intake for the first 24 to 48 hours Prevention of breast engorgement is key. The best technique is to empty the breast regularly with feeding. Engorgement is less likely when the mother and neonate are together, as in single room maternity care continuous rooming-in, because nursing can be done conveniently to meet the neonate's and mother's needs Which of the following would the nurse most likely expect to find when assessing a pregnant client with abruption placenta? A. Excessive vaginal bleeding B. Rigid, board-like abdomen C. Titanic uterine contractions D. Premature rupture of membranes The most common assessment finding in a client with abruption placenta is a rigid or boardlike abdomen. Pain, usually reported as a sharp stabbing sensation high in the uterine fundus with the initial separation, also is common. While the client is in active labor with twins and the cervix is 5 cm dilates, the nurse observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the following would be the nurse's most appropriate action? A. Note the fetal heart rate patterns B. Notify the physician immediately C. Administer oxygen at 6 liters by mask D. Have the client pant-blow during the contractions The nurse should contact the physician immediately because the client is most likely experiencing hypotonic uterine contractions. These contractions tend to be painful but ineffective. The usual treatment is oxytocin augmentation unless cephalopelvic disproportion exists. A 31-year-old multipara is admitted to the birthing room after initial examination reveals her cervix to be at 8 cm, completely effaced (100 %), and at 0 station. What phase of labor is she in? A. Active phase B. Latent phase C. Expulsive phase D. Transitional phase The transitional phase of labor extends from 8 to 10 cm; it is the shortest but most difficult and intense for the patient. Option A: The active phase extends from 4 to 7 cm; it is moderate for the patient. Option B: The latent phase extends from 0 to 3 cm; it is mild in nature. Option C: The expulsive phase begins immediately after the birth and ends with separation and expulsion of the placenta. For a patient in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring (EFM) device. What must occur before the internal EFM can be applied? A. The membranes must rupture B. The fetus must be at 0 station C. The cervix must be dilated fully D. The patient must receive anesthesia Internal EFM can be applied only after the patient's membranes have ruptured when the fetus is at least at the -1 station, and when the cervix is dilated at least 2 cm. Although the patient may receive anesthesia, it is not required before application of an internal EFM device. A patient with pregnancy-induced hypertension probably exhibits which of the following symptoms? A. Proteinuria, headaches, vaginal bleeding B. Headaches, double vision, vaginal bleeding C. Proteinuria, headaches, double vision D. Proteinuria, double vision, uterine contractions A patient with pregnancy-induced hypertension complains of a headache, double vision, and sudden weight gain. A urine specimen reveals proteinuria. Options A, B, and D: Vaginal bleeding and uterine contractions are not associated with pregnancy-induced hypertension. Because cervical effacement and dilation are not progressing in a patient in labor, the doctor orders I.V. administration of oxytocin (Pitocin). Why must the nurse monitor the patient's fluid intake and output closely during oxytocin administration? A. Oxytocin causes water intoxication B. Oxytocin causes excessive thirst C. Oxytocin is toxic to the kidneys D. Oxytocin has a diuretic effect The nurse should monitor fluid intake and output because prolonged oxytocin infusion may cause severe water intoxication, leading to seizures, coma, and death. Option B: Excessive thirst results from the work of labor and limited oral fluid intake—not oxytocin. Options C and D: Oxytocin has no nephrotoxic or diuretic effects. In fact, it produces an antidiuretic effect. The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest but most difficult part of this stage? A. Active phase B. Complete phase C. Latent phase D. Transitional phase The transitional phase, which lasts 1 to 3 hours, is the shortest but most difficult part of the first stage of labor. This phase is characterized by intense uterine contractions that occur every 1 ½ to 2 minutes and last 45 to 90 seconds. Option A: The active phase lasts 4 ½ to 6 hours; it is characterized by contractions that start out moderately intense, grow stronger, and last about 60 seconds. Option B: The complete phase occurs during the second, not first, stage of labor. Option C: The latent phase lasts 5 to 8 hours and is marked by mild, short, irregular contractions. The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The nurse should tell the patient that she can expect to feel the fetus move at which time? A. Between 10 and 12 weeks' gestation B. Between 16 and 20 weeks' gestation C. Between 21 and 23 weeks' gestation D. Between 24 and 26 weeks' gestation A pregnant woman usually can detect fetal movement (quickening) between 16 and 20 weeks' gestation. Before 16 weeks, the fetus is not developed enough for the woman to detect movement. After 20 weeks, the fetus continues to gain weight steadily, the lungs start to produce surfactant, the brain is grossly formed, and myelination of the spinal cord begins. A pregnant client is receiving magnesium sulfate therapy for the control of preeclampsia. A nurse discover that the client is encountering toxicity from the medication in which of the following assessment? A. Urine output of 25 ml/hr. B. The presence of deep tendon reflex. C. Respirations of 10 breaths per minute. D. Serum magnesium level of 7 mEq/L. - C. Respirations of 10 breaths per minute. Magnesium sulfate is a central nervous system depressant and anticonvulsant. It can cause smooth muscle relaxation. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, decreased urine output, loss of deep tendon reflexes, hypotension and a decrease maternal and fetal heart rate. Option A: Urine output should be maintained at 25-30ml/hr. Option B: Deep tendon reflexes must be present. Option D: Normal range for magnesium is between 4-7 mEq/L Rho(D) immune globulin (RhoGAM) is given to a pregnant woman after delivery and the nurse is giving information to the patient about the indication of the medication. The nurse determines that the patient understands the purpose of the medication if the patient tells that it will protect her baby from which of the following? A. Developing German Measles. B. Developing Pernicious anemia. C. Developing Rh incompatibility. D. Having an RH+ blood - C. Developing Rh incompatibility. Rh incompatibility can develop when a Rh-negative mother becomes sensitized to the RH antigen. Sensitization may occur when a Rh-negative woman becomes pregnant with a fetus who is Rh positive. Blood cells from the baby may cross the maternal bloodstream, which can happen during pregnancy, labor, and delivery, causing the mother's immune system to form antibodies, against Rh-positive blood. Administration of the Rhogam prevents the mother from developing antibodies against Rh-positive blood by providing passive antibody protection against the Rh antigen. Options A and B are not related to the Rh incompatibility. Option D is not indicated for the administration of Rhogam. A nurse is assigned to a patient who is receiving Oxytocin (Pitocin) to induce labor. The nurse terminates the oxycotin infusion if which of the following is noted on the assessment of the client? A. Early decelerations of the fetal heart rate. B. Backache. C. Fatigue. D. Uterine hyperstimulation - D. Uterine hyperstimulation Oxytocin is used to induce labor by stimulating uterine contraction. Oxytocin infusion must be discontinued if any signs of uterine stimulation are present. Option A: Eary decelerations of the fetal heart rate are a reassuring sign, but it does not indicate fetal distress. Options B and C are probably caused by the labor experience itself. ..................