Test Bank Safe Maternity and Pediatric Nursing Care 2nd Edition Linnard-Palmer

Test Bank Safe Maternity and Pediatric Nursing Care 2nd Edition Linnard-PalmerTable of Contents Chapter 1. Introduction to Maternity and Pediatric Nursing ......................................................... 2 Chapter 2. Culture.......................................................................................................................... 15 Chapter 3. Women’s Health Promotion Across the Life Span .................................................... 28 Chapter 4. Human Reproduction and Fetal Development...........................................................38 Chapter 5. Physical and Psychological Changes of Pregnancy ..................................................... 49 Chapter 6. Nursing Care During Pregnancy ................................................................................. 63 Chapter 7. Promoting a Healthy Pregnancy .................................................................................. 78 Chapter 8 Nursing Care of the Woman With Complications During Pregnancy ........................83 Chapter 9. Nursing Care During Labor and Childbirth ................................................................83 Chapter 10. Nursing Care of the Woman With Complications During Labor and Birth .......... 114 Chapter 11. Birth-Related Procedures ......................................................................................... 137 Chapter 12. Postpartum Nursing Care ........................................................................................ 159 Chapter 13. Postpartum Complications ....................................................................................... 171 Chapter 14. Physiological and Behavioral Adaptations of the Newborn.................................... 186 Chapter 15. Nursing Care of the Newborn .................................................................................. 196 Chapter 16. Newborn Nutrition ................................................................................................... 207 Chapter 17. Nursing Care of the Newborn at Risk ...................................................................... 218 Chapter 19. Health Promotion of the Toddler ............................................................................246 Chapter 20. Health Promotion of the Preschooler ..................................................................... 258 Chapter 21. Health Promotion of the School-Aged Child .......................................................... 268 Chapter 22. Health Promotion of the Adolescent ....................................................................... 277 Chapter 23. Nursing Care of the Hospitalized Child .................................................................. 287 Chapter 24. Acutely Ill Children and Their Needs ..................................................................... 301 Chapter 25. Adapting to Chronic Illness and Supporting the Family Unit ................................ 317 Chapter 26. The Abused Child..................................................................................................... 324 Chapter 27. Child With a Neurological Condition ...................................................................... 337 Chapter 28. Child With a Sensory Impairment ......................................................................... 348 Chapter 29. Child With a Mental Health Condition ................................................................... 363 Chapter 30. Child With a Respiratory Condition ....................................................................... 376 Chapter 31. Child With a Cardiac Condition ............................................................................... 395 Chapter 32. Child With a Metabolic Condition .......................................................................... 410 Chapter 33. Child With a Musculoskeletal Condition ................................................................ 419 1 | P a g eChapter 34. Child With a Gastrointestinal Condition ................................................................ 432 Chapter 35. Child With a Genitourinary Condition ....................................................................449 Chapter 36. Child With a Skin Condition ...................................................................................464 Chapter 37. Child With a Communicable Disease ..................................................................... 480 Chapter 38. Child With an Oncological or Hematological Condition ....................................... 490 Chapter 1. Introduction to Maternity and Pediatric Nursing MULTIPLE CHOICE 1. A patient chooses to have the certified nurse midwife (CNM) provide care during her pregnancy. What does the CNMs scope of practice include? a. Practice independent from medical supervision b. Comprehensive prenatal care c. Attendance at all deliveries d. Cesarean sections ANS: B The CNM provides comprehensive prenatal and postnatal care, attends uncomplicated deliveries, and ensures that a backup physician is available in case of unforeseen problems. DIF: Cognitive Level: Comprehension REF: Page 6 OBJ: 12 TOP: Advance Practice Nursing Roles KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. Which medical pioneer discovered the relationship between the incidence of puerperal fever and unwashed hands? a. Karl Cred b. Ignaz Semmelweis c. Louis Pasteur d. Joseph Lister ANS: B Ignaz Semmelweis deduced that puerperal fever was septic, contagious, and transmitted by the unwashed hands of physicians and medical students. DIF: Cognitive Level: Knowledge REF: Page 2 OBJ: 1 TOP: The Past KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 2 | P a g e3. A pregnant woman who has recently immigrated to the United States comments to the nurse, I am afraid of childbirth. It is so dangerous. I am afraid I will die. What is the best nursing response reflecting cultural sensitivity? a. Maternal mortality in the United States is extremely low. b. Anesthesia is available to relieve pain during labor and childbirth. c. Tell me why you are afraid of childbirth. d. Your condition will be monitored during labor and delivery. ANS: C Asking the patient about her concerns helps promote understanding and individualizes patient care. DIF: Cognitive Level: Application REF: Page 7-8 OBJ: 8 TOP: Cross-Cultural Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychological Adaptation 4. An urban area has been reported to have a high perinatal mortality rate. What information does this provide? a. Maternal and infant deaths per 100,000 live births per year b. Deaths of fetuses weighing more than 500 g per 10,000 births per year c. Deaths of infants up to 1 year of age per 1000 live births per year d. Fetal and neonatal deaths per 1000 live births per year ANS: D The perinatal mortality rate includes fetal and neonatal deaths per 1000 live births per year. DIF: Cognitive Level: Comprehension REF: Page 12, Box 1- 6 OBJ: 9 TOP: The Present-Child Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 5. What is the focus of current maternity practice? a. Hospital births for the majority of women b. The traditional family unit c. Separation of labor rooms from delivery rooms d. A quality family experience for each patient ANS: D Current maternity practice focuses on a high-quality family experience for all families, traditional or otherwise. 3 | P a g eDIF: Cognitive Level: Comprehension REF: Page 6 OBJ: 7 TOP: The Present-Maternity Care KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance 6. Who advocated the establishment of the Childrens Bureau? a. Lillian Wald b. Florence Nightingale c. Florence Kelly d. Clara Barton ANS: A Lillian Wald is credited with suggesting the establishment of a federal Childrens Bureau. DIF: Cognitive Level: Knowledge REF: Page 4 OBJ: 1 | 2 TOP: The Past KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. What was the result of research done in the 1930s by the Childrens Bureau? a. Children with heart problems are now cared for by pediatric cardiologists. b. The Child Abuse and Prevention Act was passed. c. Hot lunch programs were established in many schools. d. Childrens asylums were founded. ANS: C School hot lunch programs were developed as a result of research by the Childrens Bureau on the effects of economic depression on children. DIF: Cognitive Level: Knowledge REF: Page 4 OBJ: 2 | 3 TOP: The Past KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care 8. What government program was implemented to increase the educational exposure of preschool children? a. WIC b. Title XIX of Medicaid c. The Childrens Charter d. Head Start ANS: D Head Start programs were established to increase educational exposure of preschool children. DIF: Cognitive Level: Knowledge REF: Page 3 OBJ: 5 TOP: Government Influences in Maternity and Pediatric Care KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4 | P a g e9. What guidelines define multidisciplinary patient care in terms of expected outcome and timeframe from different areas of care provision? a. Clinical pathways b. Nursing outcome criteria c. Standards of care d. Nursing care plan ANS: A Clinical pathways, also known as critical pathways or care maps, are collaborative guidelines that define patient care across disciplines. Expected progress within a specified timeline is identified. DIF: Cognitive Level: Knowledge REF: Page 12 OBJ: 14 TOP: Health Care Delivery Systems KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 10. A nursing student has reviewed a hospitalized pediatric patient chart, interviewed her mother, and collected admission data. What is the next step the student will take to develop a nursing care plan for this child? a. Identify measurable outcomes with a timeline. b. Choose specific nursing interventions for the child. c. Determine appropriate nursing diagnoses. d. State nursing actions related to the childs medical diagnosis. ANS: C The nurse uses assessment data to select appropriate nursing diagnoses from the NANDA-I list. Outcomes and interventions are then developed to address the relevant nursing diagnoses. DIF: Cognitive Level: Application REF: Page 11 OBJ: 13 TOP: Nursing Process KEY: Nursing Process Step: Nursing Diagnosis MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 11. A nursing student on an obstetric rotation questions the floor nurse about the definition of the LVN/LPN scope of practice. What resource can the nurse suggest to the student? a. American Nurses Association b. States board of nursing c. Joint Commission d. Association of Womens Health, Obstetric and Neonatal Nurses ANS: B The scope of practice of the LVN/LPN is published by the states board of nursing. DIF: Cognitive Level: Comprehension REF: Page 3, Legal and Ethical 5 | P a g eConsiderations OBJ: 18 TOP: Critical Thinking KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 12. What was recommended by Karl Cred in 1884? a. All women should be delivered in a hospital setting. b. Chemical means should be used to combat infection. c. Podalic version should be done on all fetuses. d. Silver nitrate should be placed in the eyes of newborns. ANS: D In 1884 Karl Cred recommended the use of 2% silver nitrate in the eyes of newborns to reduce the incidence of blindness. DIF: Cognitive Level: Knowledge REF: Page 2 OBJ: 1 TOP: Use of Silver Nitrate KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 13. What is the purpose of the White House Conference on Children and Youth? a. Set criteria for normal growth patterns. b. Examine the number of live births in minority populations. c. Raise money to support well-child clinics in rural areas. d. Promote comprehensive child welfare. ANS: D White House Conferences on Children and Youth are held every 10 years to promote comprehensive child welfare. DIF: Cognitive Level: Knowledge REF: Page 4 OBJ: 3 TOP: White House Conferences KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 14. How many hours of hospital stay does legislation currently allow for a postpartum patient who has delivered vaginally without complications? a. 24 b. 48 c. 36 d. 72 ANS: B 6 | P a g ePostpartum patients who deliver vaginally stay in the hospital for an average of 48 hours; patients who have had a cesarean delivery usually stay 4 days. DIF: Cognitive Level: Knowledge REF: Page 6 OBJ: 7 TOP: Hospital Terms for Postpartum Patients KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 15. How does the clinical pathway or critical pathway improve quality of care? a. Lists diagnosis-specific implementations b. Outlines expected progress with stated timelines c. Prioritizes effective nursing diagnoses d. Describes common complications ANS: B Critical pathways outline expected progress with stated timelines. Any deviation from those timelines is called a variance. DIF: Cognitive Level: Comprehension REF: Page 12 OBJ: 14 TOP: Critical Pathway KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 16. A patient asks the nurse to explain what is meant by gene therapy. What is the nurses best response? a. Gene therapy can replace missing genes. b. Gene therapy evaluates the parents genes. c. Gene therapy can change the sex of the fetus. d. Gene therapy supports the regeneration of defective genes. ANS: A Gene therapy can replace missing or defective genes. DIF: Cognitive Level: Knowledge REF: Page 8 OBJ: 7 TOP: Gene Therapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 17. The nurse is clarifying information to a patient regarding diagnosis-related groups (DRGs). What is the nurses best response when the patient asks how DRGs reduce medical care costs? a. By determining payment based on diagnosis 7 | P a g eb. By requiring two medical opinions to confirm a diagnosis c. By organizing HMOs d. By defining a person who will require hospitalization ANS: A DRGs determine the amount of payment and length of hospital stay based on the diagnosis. DIF: Cognitive Level: Comprehension REF: Page 8 OBJ: 11 TOP: DRGs KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 18. What is the best example of a Nursing Interventions Classification (NIC) intervention? a. Patient will ambulate in the hall independently for 10 minutes three times a day. b. Nurse will report temperature elevations to the charge nurse. c. Nurse will offer extra liquids at all meals. d. Patient will express pain relief after massage. ANS: C NIC is a guide to nursing actions. DIF: Cognitive Level: Comprehension REF: Page 12 | Page 14 OBJ: 15 TOP: NICs KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 19. How does electronic charting ensure comprehensive charting more effectively than handwritten charting? a. Provides a uniform style of chart b. Requires certain responses before allowing the user to progress c. All documentation is reflective of the nursing care plan d. Requires a daily audit by the charge nurse ANS: B Comprehensive electronic documentation is ensured by requiring specific input in designated categories before the user can progress through the system. DIF: Cognitive Level: Comprehension REF: Page 15-16 OBJ: 22 TOP: Computer Charting KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 20. The nurse reminds family members that the philosophy of family-centered care is to provide control to the family over health care decisions. What is the appropriate term for this type of control? 8 | P a g ea. Empowerment b. Insight c. Regulation d. Organizatio n ANS: A The term empowerment refers to the control a family has over its own health care decisions. DIF: Cognitive Level: Knowledge REF: Page 2 OBJ: 7 TOP: Empowerment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 21. A patient in the prenatal clinic is concerned about losing her job because of her pregnancy. The nurse instructs her that the Family Medical Leave Act (FMLA) allows an employee to be absent from work without pay. How many weeks does the FMLA allow a woman to recover from childbirth or care for a sick family member without loss of benefits or pay status? a. 4 b. 6 c. 10 d. 12 ANS: D The FMLA allows for employees to leave work for up to 12 weeks to recover from childbirth or to care for an ill family member without losing benefits or pay status. DIF: Cognitive Level: Knowledge REF: Page 3 OBJ: 5 TOP: FMLA KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 22. What term appropriately describes the nurse who is able to adapt health care practices to meet the needs of various cultures? a. Culturally aware b. Culturally sensitive c. Culturally competent d. Culturally adaptive ANS: C The nurse who is able to adapt health care to meet the needs of various cultures is said to be culturally competent. DIF: Cognitive Level: Knowledge REF: Page 7 OBJ: 8 9 | P a g eTOP: Cultural Competency KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 23. What is one major advantage to the application of critical thinking? a. Problem-free care b. Limitation of approaches to care c. Decreased need for assessment d. Problem prevention ANS: D Critical thinking results in problem prevention in designing nursing care. DIF: Cognitive Level: Comprehension REF: Page 14 OBJ: 19 TOP: Critical Thinking KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 24. Student practical nurses are discussing the North American Nursing Diagnosis Association International (NANDA-I) taxonomy in post conference on the acute care clinical setting. The students are aware that the role of the LPN with nursing diagnosis formulation is what? a. To initiate and identify nursing diagnosis specific to patient b. To update changes in nursing diagnosis as needed c. To have an understanding of nursing diagnosis terminology d. To accurately document nursing diagnosis on patient plan of care ANS: C The registered nurse is responsible to initiate, identify, update, and document nursing diagnoses. The licensed practical nurse is responsible to have an understanding of nursing diagnosis terminology. DIF: Cognitive Level: Comprehension REF: Page 14 OBJ: 17 TOP: NANDA-I taxonomy KEY: Nursing Process Step: Nursing Diagnosis MSC: NCLEX: Health Promotion and Maintenance: Data Collection Techniques MULTIPLE RESPONSE 25. What services are birthing centers able to provide? (Select all that apply.) a. Prenatal care b. Labor and delivery services c. Classes for new mothers d. Adoption referrals e. Family 10 | P a g eplanning ANS: A, B, C, E Birthing centers are capable of providing full-service obstetric care, classes for new mothers, and family planning. Birthing centers do not offer adoption services. DIF: Cognitive Level: Comprehension REF: Page 6 OBJ: 7 TOP: Birthing Centers KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care 26. What developments in the early 20th century encouraged women to seek hospitalization for childbirth? (Select all that apply.) a. Use of specialized obstetric instruments b. Use of anesthesia c. Physicians closer relationships with hospitals d. Focus on family-centered care e. Insurance coverage ANS: A, B, C In the early 1900s, the development of specialized obstetric instruments, better modes of anesthesia, and the physicians reliance on hospital services were instrumental in encouraging women to seek hospitalization for childbirth. DIF: Cognitive Level: Comprehension REF: Page 3 OBJ: 7 TOP: Hospitalization for Childbirth KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 27. What nonfamily-centered policies were prevalent in the 1960s? (Select all that apply.) a. Waiting room for fathers b. Sedation of mother during labor c. Delay of reunion of mother and infant d. Lenient visiting hours e. Restrictions of visitations by minor children ANS: A, B, C, E Hospital policies in the 1960s provided a separate waiting room for fathers while the mother went through labor in a sedated state. The reunion of mother and infant was delayed for several hours because of the sedation. Visiting hours were rigid and disallowed the visitation of minor children. DIF: Cognitive Level: Comprehension REF: Page 3 OBJ: 7 11 | P a g eTOP: Nonfamily-centered Practices KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 28. The nurse is aware that there is a legal responsibility to report certain diseases and conditions to county or state health authorities. Which would be included? (Select all that apply.) a. Tuberculosis b. Child abuse c. Industrial accidents d. Sexually transmitted diseases e. Food-borne infections ANS: A, B, D, E The nurse has a legal responsibility to report communicable diseases (such as tuberculosis and sexually transmitted diseases), food-borne infections, child abuse, and threats of suicide. DIF: Cognitive Level: Comprehension REF: Page 6, Legal and Ethical Considerations box OBJ: 6 TOP: Reportable Diseases KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 29. An inservice program at a long-term care facility is reviewing the Nursing Outcomes Classification (NOC) with nursing staff. After the presentation the nurses review resident care plans. Which of the following are found to be appropriately written outcomes? (Select all that apply.) a. Suction patient orally every 4 hours and as needed. b. Auscultate lung sounds every 2 hours. c. Provide Tylenol as ordered by health care provider. d. Patient states Pain has decreased after medication administration. e. Patient blood pressure recorded as 120/72 after dressing change. ANS: D, E NOC was developed to identify outcomes of nursing care that are directly influenced by nursing actions. Outcomes are defined as the behaviors and feelings of the patient in response to the nursing care given. Suctioning patient, auscultating lung sounds, and providing Tylenol are nursing actions. DIF: Cognitive Level: Application REF: Page 12-14 OBJ: 16 TOP: Nursing Outcomes Classification (NOC) KEY: Nursing Process Step: Evaluation 12 | P a g eMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 30. Practical nursing students are using critical thinking skills to study for an upcoming test. What will these students include when studying? (Select all that apply.) a. Memorization of facts first b. Prioritizing information c. Relating facts to other facts d. Making assumptions e. Reviewing before the test ANS: B, C, E Using critical thinking when studying involves understanding facts before memorizing, prioritizing information to be memorized, relating facts to other facts, using all five senses, reviewing before tests, and reading critically. Critical thinking does not involve assumption as does general thinking. DIF: Cognitive Level: Comprehension REF: Page 15 OBJ: 20 TOP: Critical Thinking KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment 31. What factors have played a role in meeting the goals of Healthy People 2020 as it relates the goals for outcomes of pregnancy? (Select all that apply.) a. Early prenatal care b. Increased number of surgical births c. NICU care d. Use of prenatal glucocorticoids e. Fetal surgery ANS: A, C, D, E Early prenatal care, fetal surgery, use of prenatal glucocorticoids, technology, and NICU care have played a role in increasing the positive outcome of pregnancy, and the goals of Healthy People 2020 may well be met. Increase in surgical births and multiple gestations do not work toward meeting the goals of Healthy People 2020. DIF: Cognitive Level: Comprehension REF: Page 16-17 OBJ: 21 TOP: Healthy People 2020 KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection 32. A community health nurse is providing specialized care to patients in the home setting. What kind of specialized care may this nurse be providing? (Select all that apply.) a. Glucose monitoring b. Heparin therapy 13 | P a g ec. Family education d. Total parenteral nutrition e. Provision of referral services ANS: A, B, D Glucose monitoring, heparin therapy, and total parenteral nutrition are categorized as specialized care that may be provided by the community health nurse. Family education and provision of referral are categorized as therapeutic care. DIF: Cognitive Level: Application REF: Page 16-17 OBJ: 23 TOP: Community Health KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort COMPLETION 33. The nurse who is very conscientious about hand hygiene is following the concepts set out by and . ANS: Lister, Pasteur OR Pasteur, Lister Both Lister and Pasteur set out that handwashing could reduce incidence of infection by cross- contamination. DIF: Cognitive Level: Knowledge REF: Page 2 OBJ: 1 TOP: Handwashing KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control 34. The first White House Conference on Children and Youth was called by President . ANS: Theodore Roosevelt Theodore Roosevelt called the first White House Conference in 1909. DIF: Cognitive Level: Knowledge REF: Page 4 OBJ: 1 TOP: White House Conferences KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 35. The nurse reviewing the specific recovery goals set out on a clinical pathway observed that two goals were not met by their designated timeline. The nurse records a negative 14 | P a g efor these two goals. ANS: variance Using a clinical pathway model with goals and associated timelines, the nurse must record a negative variance when a timeline is not met and consider a new approach or an extended timeline. DIF: Cognitive Level: Comprehension REF: Page 12 OBJ: 14 TOP: Variances KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Management of Care 36. . is purposeful, goal-directed thinking based on scientific evidence rather than assumption or memorization. ANS: Critical thinking Critical thinking is purposeful and goal-directed thinking as oppo Chapter 2. Culture MULTIPLE CHOICE 1. The nurse is assessing a newborn. What sign of hypoglycemia does the nurse record? a. Increased nasal mucus b. Increased temperature c. Active muscle movements d. High-pitched cry ANS: D There are many signs of hypoglycemia in the newborn. One is a high-pitched cry. DIF: Cognitive Level: Comprehension REF: Page 219 OBJ: 9 TOP: Signs of Hypoglycemia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 2. What would the nurse expect to find when assessing the fundus of the uterus immediately after delivery? a. Well-contracted with its upper border at or just below the umbilicus b. Well-contracted with its upper border three or four fingerbreadths above the umbilicus 15 | P a g ec. Relaxed with its upper border level with the umbilicus d. Relaxed with its upper border two or three fingerbreadths below the umbilicus ANS: A Immediately after the placenta is expelled, the uterine fundus can be felt as a firm mass, about the size of a grapefruit, at the level of the umbilicus. DIF: Cognitive Level: Comprehension REF: Page 200 OBJ: 2 TOP: Fundus Assessment KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. What statement made by a new mother indicates she needs additional information about breastfeeding? a. I let the baby nurse 10 to 15 minutes on the first breast and then switch to the other breast. b. The baby needs to nurse at least 5 minutes on the breast to get the hindmilk. c. The baby has been nursing every 2 to 3 hours. d. If the baby gets fussy between feedings, I give her a bottle of water. ANS: D Supplemental feedings of formula or water should not be offered to a healthy newborn who is breastfeeding. DIF: Cognitive Level: Comprehension REF: Page 223- 227 OBJ: 14 TOP: BreastfeedingSupplemental Feedings KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. After delivery, the nurses assessment reveals a soft, boggy uterus located above the level of the umbilicus. What is the most appropriate nursing intervention? a. Notify the physician. b. Massage the fundus. c. Initiate measures that encourage voiding. d. Position the patient flat. ANS: B A poorly contracted uterus should be massaged until firm to prevent hemorrhage. DIF: Cognitive Level: Application REF: Page 202 OBJ: 9 TOP: Boggy Uterus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. What type of lochia will the nurse assess initially after delivery? 16 | P a g ea. Serosa b. Rubra c. Alba d. Vaginalis ANS: B The initial vaginal discharge after delivery is called lochia rubra. It is red and moderately heavy. Lochia rubra lasts for up to 3 days postpartum. DIF: Cognitive Level: Knowledge REF: Page 202 OBJ: 4 TOP: Lochia Rubra KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. A woman will be discharged 48 hours after a vaginal delivery. When planning discharge teaching, the nurse would include what information about lochia? a. Lochia should disappear 2 to 4 weeks postpartum. b. It is normal for the lochia to have a slightly foul odor. c. A change in lochia from pink to bright red should be reported. d. A decrease in flow will be noticed with ambulation and activity. ANS: C A return to bright red lochia rubra may indicate a late postpartum hemorrhage and must be reported. DIF: Cognitive Level: Application REF: Page 203 OBJ: 18 TOP: Hemorrhage KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. What instruction should the nurse teach the postpartum woman about perineal self-care? a. Perform perineal self-care at least twice a day. b. Cleanse with warm water in a squeeze bottle from front to back. c. Remove perineal pads from the rectal area toward the vagina. d. Use cool water to decrease edema of the perineum. ANS: B Cleansing from front to back prevents contamination from the rectal area. DIF: Cognitive Level: Application REF: Page 204 OBJ: 2 TOP: Perineal Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. A postpartum woman is not immune to rubella. What will the nurse expect? 17 | P a g ea. The rubella virus vaccine should be administered before discharge. b. The woman should receive the rubella virus vaccine at her 6-week postpartum checkup. c. The woman should be instructed not to get pregnant until she receives the rubella vaccine. d. No intervention is indicated at this time because the woman is not at risk for rubella. ANS: A The woman who is not immune to rubella is immunized in the immediate postpartum period because there is no danger of her being pregnant. DIF: Cognitive Level: Comprehension REF: Page 209 OBJ: 2 TOP: Rubella KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 9. Which statement indicates the new mother is breastfeeding correctly? a. I will alternate breasts when feeding the baby. b. I keep the baby on a 4-hour feeding schedule. c. I let the baby stay on the first breast only 5 minutes. d. I put only the nipple in the babys mouth when I am breastfeeding. ANS: A Alternating breasts for feeding increases milk production, particularly hindmilk, which has a higher protein and fat content. DIF: Cognitive Level: Comprehension REF: Page 224, Table 9-4 OBJ: 14 TOP: Breastfeeding KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. The nurse is counseling a lactating mother about diet. What would the nurse include with this information? a. Consume 500 more calories than her usual prepregnancy diet. b. Eat less meat and more fruits and vegetables. c. Drink 3 to 4 tall glasses of fluid daily. d. Eat 1000 more calories than her usual prepregnancy diet. ANS: A To maintain nutrient stores while breastfeeding, the mother needs 500 additional calories each day over her prepregnancy diet. DIF: Cognitive Level: Comprehension REF: Page 230 OBJ: 15 TOP: BreastfeedingMaternal Nutrition KEY: Nursing Process Step: Implementation 18 | P a g eMSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. A woman asks about resumption of her menstrual cycle after childbirth. What should the nurse respond? a. A woman will not ovulate in the absence of menstrual flow. b. Most nonlactating women resume menstruation about 2 months postpartum. c. Generally, a woman does not ovulate in the first few cycles after childbirth. d. The return of menstruation is delayed when a woman does not breastfeed. ANS: B Menstrual periods resume in about 6 to 8 weeks if the woman is not breastfeeding. DIF: Cognitive Level: Comprehension REF: Page 205 OBJ: 4 TOP: Return of Menses KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. In what situation will the physician order RhoGAM? a. An unsensitized Rh-negative mother has an Rh-positive infant. b. An Rh-negative mother becomes sensitized. c. A sensitized infant has a rising bilirubin level. d. An unsensitized infant exhibits no outward signs. ANS: A The Rh-negative woman should receive RhoGAM within 72 hours after the birth of an Rh- positive infant. DIF: Cognitive Level: Analysis REF: Page 209 OBJ: 4 TOP: RhoGAM KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 13. After birth, the nurse quickly dries and wraps the newborn in a blanket. How does this action prevent heat loss? a. Conduction b. Radiation c. Evaporation d. Convectio n ANS: C Newborns lose heat quickly after birth as fluid evaporates from their bodies. DIF: Cognitive Level: Comprehension REF: Page 216, Table 9-3 OBJ: 2 TOP: Thermoregulation KEY: Nursing Process Step: Implementation 19 | P a g eMSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. What will the nurses instructions for a new mother to care for the infants umbilical cord include? a. Keeping the area covered with a sterile dressing b. Dressing the stump with antibiotic ointment at every diaper change c. Fastening the diaper low to allow for air circulation d. Giving the newborn a daily tub bath until the cord falls off ANS: C Diaper placement below the umbilical stump allows for drying by air circulation. DIF: Cognitive Level: Application REF: Page 218-219, Skill 9-6 OBJ: 2 TOP: Umbilical Cord Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 15. A new mother states her preference to formula feed her newborn. What will the nurse planning discharge instructions tell her to help suppress lactation and promote comfort? a. Wear a well-fitting bra continuously for several days. b. Stand in a warm shower, letting the water spray over the breasts. c. Express small amounts of milk from the breasts several times a day. d. Massage the breasts when they ache. ANS: A When a mother does not wish to breastfeed, a snug bra worn around the clock can help alleviate discomfort from engorgement. DIF: Cognitive Level: Application REF: Page 230 OBJ: 18 TOP: Suppression of Lactation KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 16. On the second postpartum day, a mother bathed her newborn for the first time. She tells the nurse, I dont think I did it right. What postpartum psychological stage is this woman most likely in based on this comment? a. Taking in b. Taking hold c. Letting go d. Settling 20 | P a g edown ANS: B In phase 2, taking hold, the mother begins to initiate action and becomes interested in caring for the infant. In doing so, she may become critical of her performance. DIF: Cognitive Level: Analysis REF: Page 212, Table 9-2 OBJ: 6 TOP: Postpartum Psychological Stages KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Physiological Adaptation 17. A primipara tells the nurse, My afterpains get worse when I am breastfeeding. What is the most appropriate nursing response? a. Ill get you some aspirin to relieve the cramping that you feel. b. Afterpains are more intense with your first baby. c. Breastfeeding releases a hormone that causes your uterus to contract. d. A change of position when youre breastfeeding might help. ANS: C Breastfeeding mothers may have more afterpains because infant suckling causes the posterior pituitary to release oxytocin, which is a hormone that contracts the uterus. DIF: Cognitive Level: Application REF: Page 201 OBJ: 2 TOP: Afterpains with Breastfeeding KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. A new mother has decided not to breastfeed her newborn. What information will the nurse include when planning to teach the mother about formula feeding? a. Positioning the bottle so that the nipple is full of formula during the entire feeding b. Heating the infant formula in a microwave c. Burping the infant after 4 ounces and again when the bottle is empty d. Propping a bottle for a feeding ANS: A The nipple of the bottle should be kept full of formula to reduce the amount of air the infant swallows. DIF: Cognitive Level: Comprehension REF: Page 232, Skill 9-7 OBJ: 17 TOP: Formula Feeding KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 19. In the recovery room, the nurse checks the newly delivered womans fundus following a cesarean section. How would the nurse proceed with this assessment? 21 | P a g ea. Palpate from the midline to the side of the body. b. Palpate from the symphysis to the umbilicus. c. Palpate from the side of the uterus to the midline. d. Massage the abdomen in a circular motion. ANS: C The fundus is checked gently by walking the fingers from the side of the uterus to the midline. DIF: Cognitive Level: Application REF: Page 209 OBJ: 5 TOP: Postpartum Cesarean Assessment KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 20. The nurse instructed a postpartum woman about storing and freezing breast milk. What statement by the woman leads the nurse to determine that the teaching was effective? a. I can thaw frozen breast milk in the microwave. b. Ill put enough breast milk for one day in a container. c. Breast milk can be stored in glass containers. d. Breast milk can be kept in the refrigerator for up to 3 months. ANS: C Breast milk can be safely stored in glass or clear hard plastic containers. DIF: Cognitive Level: Comprehension REF: Page 229 OBJ: 14 TOP: Storing Breast Milk KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 21. What should the nurse implement for security purposes when bringing the infant from the nursery to the mother? a. Ask, Is this your band number? b. Confirm room number of mother. c. Ask the mother to identify herself verbally. d. Check the band number of the infant with that of the mother. ANS: D The nurse should check the band number of the infant with that of the mother by asking the mother to verbally read the number. DIF: Cognitive Level: Application REF: Page 216-217 OBJ: 8 TOP: Security Identification Procedure KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 22 | P a g e22. Below what blood glucose level is the newborn considered hypoglycemic? a. Below 70 mg/dL b. Below 60 mg/dL c. Below 50 mg/dL d. Below 40 mg/dL ANS: D A blood glucose level of less than 40 mg/dL is considered hypoglycemic. If the screening sample is below 40 mg/dL, a venous sample will be drawn. After the blood has been drawn, the infant should be fed to prevent a further drop. DIF: Cognitive Level: Comprehension REF: Page 219 OBJ: 8 TOP: Hypoglycemia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 23. The nurse is caring for a woman of Middle Eastern descent on the first postpartum day. Education is provided regarding instruction on use of a sitz bath. What documentation best indicates that the woman has understood the provided instruction? a. Patient correctly performed return demonstration. b. Patient indicated understanding by nodding head with instruction. c. Patient verbalizes I understand. d. Family member indicates patient understands procedure. ANS: A The nurse may need an interpreter to understand and provide optimal care to the woman and her family. If possible, when discussing sensitive information the interpreter should not be a family member, who might interpret selectively. The interpreter should not be of a group that is in social or religious conflict with the patient and her family, an issue that might arise in many Middle Eastern cultures. It is also important to remember that an affirmative nod from the woman may be a sign of courtesy to the nurse rather than a sign of understanding or agreement. DIF: Cognitive Level: Application REF: Page 200 OBJ: 3 TOP: Cultural Influences KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Cultural Awareness 24. A woman has given birth to an unresponsive newborn that NICU staff are attempting to revive. The patient and her husband are grief stricken and request the child be baptized immediately. What is the nurses most appropriate action? 23 | P a g ea. Contact the hospital chaplain. b. Request the couples clergy. c. Baptize the newborn. d. Ask the physician to baptize the newborn. ANS: C If the condition of a newborn is poor, the parents may wish to have a baptism performed. The minister or priest is notified. However this is an emergency, so the nurse may perform the baptism by pouring water on the infants forehead while saying, I baptize you in the name of the Father, and of the Son, and of the Holy Spirit. If there is any doubt as to whether the infant is alive, the baptism is given conditionally: If you are capable of receiving baptism, I baptize you in the name of the Father, and of the Son, and of the Holy Spirit. The physician is attending to the patients immediate health needs. DIF: Cognitive Level: Application REF: Page 213 OBJ: 7 TOP: Grieving Parents KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Grief and Loss 25. A woman required a cesarean section for safe delivery of her newborn. She is planning to breastfeed and verbalized concern about pain. What is the best suggestion by the nurse? a. Consider formula feeding for the first few days. b. Pumping breast milk would be best for now. c. Take pain medication 30 to 40 minutes prior to nursing. d. Use the football hold when breastfeeding. ANS: D The best answer is to encourage use of the football hold to decrease pressure on the operative site. There is no indication for the woman to formula feed or pump. Some pain medications should not be taken when breastfeeding. DIF: Cognitive Level: Application REF: Page 224-225, Figure 9-10 OBJ: 12 TOP: Breastfeeding KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort MULTIPLE RESPONSE 26. Which assessments would lead the nurse to determine the gestational age of the infant as preterm? (Select all that apply.) 24 | P a g ea. Thin, transparent skin b. Vernix only in the body creases c. Folded ear springs back slowly d. Breast tissue under the nipple e. Creases over entire sole ANS: A, C The only signs of preterm are the thin skin and the slowly responding ear. DIF: Cognitive Level: Application REF: Page 217 OBJ: 2 TOP: Gestational Age Assessment KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 27. The nurse is giving a shower to a patient who had a cesarean section 2 days previously. What interventions should be included before, during, and after the shower? (Select all that apply.) a. Leave abdominal dressing open to air. b. Position patient with back to water stream. c. Cover infusion site with rubber glove. d. Provide a shower chair. e. Confirm ambulation ability. ANS: B, C, D, E The patient should be evaluated for ambulatory ability, and the abdominal dressing and infusion site should be covered with a waterproof cover. The patient should be provided a shower chair and positioned with her back to the water stream. DIF: Cognitive Level: Application REF: Page 209-211 OBJ: 5 TOP: Postpartum Shower KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 28. What postpartum exercises should the nurse teach a patient who had a vaginal delivery yesterday? (Select all that apply.) a. Abdominal tighteners b. Head lift c. Pelvic tilt d. Kegel exercises e. Leg lifts ANS: A, B, C, D Exercises for postpartum involution such as abdominal tighteners, head lifts, pelvic 25 | P a g etilts, and Kegel exercises are acceptable. Leg lifts are too strenuous early in the postpartum period. DIF: Cognitive Level: Comprehension REF: Page 208 OBJ: 18 TOP: Postpartum Exercises KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 29. While instructing a new mother on formula preparations, the nurse would include what types? (Select all that apply.) a. Ready-to-feed formula b. Concentrated liquid formula c. Powdered formula d. Cows milk e. Canned evaporated milk ANS: A, B, C Formula choices are ready-to-use, concentrated liquid formula that will be diluted according to the infants needs and powdered formula that is mixed as needed. Cows milk and canned evaporated milk are unsuitable because they are nutritionally inadequate and stress the kidneys. DIF: Cognitive Level: Comprehension REF: Page 231 OBJ: 17 TOP: Formula Choices KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 30. The nurse is instructing a woman at 6 months postpartum on weaning her infant from breastfeeding. What interventions will the nurse suggest? (Select all that apply.) a. Omit newborns favorite feeding first. b. Eliminate one feeding at a time. c. Expect the need for comfort feeding. d. Formula will need to be provided to substitute for feeding. e. Pump breasts in place of eliminated feeding. ANS: B, C, D When weaning a newborn from breastfeeding, the mother should eliminate the favorite feeding last. One feeding should be eliminated at a time, and the need for comfort feeding should be expected. In younger infants formula will need to be substituted. The mother should not be instructed to pump in place of eliminated feeding or the breasts will continue to produce milk. DIF: Cognitive Level: Comprehension REF: Page 230 OBJ: 16 26 | P a g eTOP: Weaning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort COMPLETION 31. The nurse assesses a 6-inch stain of lochia rubra on a pad that was worn for 2 hours. The nurse would document this as a(n) amount of lochia. ANS: moderate A 6-inch stain on a pad worn for 2 hours is regarded as a moderate amount of lochia discharge. DIF: Cognitive Level: Application REF: Page 202, Skill 9-2 OBJ: 2 TOP: Estimating Lochia Discharge KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 32. The nurse explains that the three infections that are contraindications to breastfeeding are , , and . ANS: human immunodeficiency virus (HIV), hepatitis B, hepatitis C Mothers who are HIV positive should not breastfeed because the virus can be transmitted through breast milk, as can the viruses that cause hepatitis B and C. DIF: Cognitive Level: Comprehension REF: Page 222 OBJ: 13 TOP: Contraindication for Breastfeeding KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 33. The hormone responsible for milk production is . ANS: prolactin During pregnancy, the woman secretes high levels of prolactin, the hormone that causes milk production. Following delivery, increased levels of prolactin lead to lactation. DIF: Cognitive Level: Knowledge REF: Page 223 OBJ: 11 TOP: Prolactin KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 27 | P a g e34. The hormone responsible for milk let-down or ejection from the breasts is . ANS: oxytocin The milk let-down reflex is caused by the hormone oxytocin. DIF: Cognitive Level: Knowledge REF: Page 223 OBJ: 11 TOP: Oxytocin KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 35. refers to changes that the reproductive organs, particularly the uterus, undergo after birth to return to their prepregnancy size and condition. ANS: Involution Chapter 3. Women’s Health Promotion Across the Life Span MULTIPLE CHOICE 1. A woman who is 7 weeks pregnant tells the nurse that this is not her first pregnancy. She has a 2-year-old son and had one previous spontaneous abortion. How would the nurse document the patients obstetric history using the TPALM system? a. Gravida 2, para 20120 b. Gravida 3, para 10011 c. Gravida 3, para 10110 d. Gravida 2, para 11110 ANS: C Refer to Box 4-1 in the textbook for the TPALM system of identifying gravida and para. DIF: Cognitive Level: Application REF: Page 48, Box 4-1 OBJ: 1 TOP: Definition of Terms KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. A woman calls her health care provider to schedule prenatal visits in an uncomplicated pregnancy. How frequently will the nurse assist the patient to schedule these appointments? 28 | P a g ea. Every 3 weeks until the 6th month, then every 2 weeks until delivery b. Every 4 weeks until the 7th month, after which appointments will become more frequent c. Monthly until the 8th month d. Every 2 to 3 weeks for the entire pregnancy ANS: B Monthly visits are scheduled up to 28 weeks, and then visits increase to every 2 to 3 weeks through 36 weeks. From 36 weeks until delivery, visits are weekly. DIF: Cognitive Level: Application REF: Page 46 OBJ: 2 | 3 TOP: Prenatal Visits KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. During the physical examination for the first prenatal visit, it is noted that Chadwicks sign is present. What is Chadwicks sign? a. Bluish or purplish discoloration of the vulva, vagina, and cervix b. Presence of early fetal movements c. Darkening of the areola and breast tenderness d. Palpation of the fetal outline ANS: A Chadwicks sign is the purplish or bluish discoloration of the cervix and vagina. DIF: Cognitive Level: Knowledge REF: Page 49 OBJ: 7 TOP: Normal Physiological Changes in Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. After the examination is completed, the patient asks the nurse why Chadwicks sign occurs during pregnancy. What would the nurse explain as the cause of Chadwicks sign? a. Enlargement of the uterus b. Progesterone action on the breasts c. Increasing activity of the fetus d. Vascular congestion in the pelvic area ANS: D Chadwicks sign is caused by increased vascular congestion in the cervical and vaginal area. DIF: Cognitive Level: Comprehension REF: Page 49 OBJ: 6 | 7 TOP: Normal Physiological Changes in Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 29 | P a g e5. The nurse has explained physiological changes that occur during pregnancy. Which statement indicates that the woman understands the information? a. Blood pressure goes up toward the end of pregnancy. b. My breathing will get deeper and a little faster. c. Ill notice a decreased pigmentation in my skin. d. There will be a curvature in the upper spine area. ANS: B The pregnant woman breathes more deeply, and her respiratory rate may increase slightly. DIF: Cognitive Level: Comprehension REF: Page 52 OBJ: 7 | 13 TOP: Normal Physiological Changes in Pregnancy KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. A woman reports that her last normal menstrual period began on August 5, 2013. What is this womans expected delivery date using Ngeles rule? a. April 30, 2014 b. May 5, 2014 c. May 12, 2014 d. May 26, 2014 ANS: C To determine the expected date of delivery, count backward 3 months from the first day of the last menstrual period, then add 7 days and change the year if necessary. DIF: Cognitive Level: Analysis REF: Page 48, Box 4-2 OBJ: 5 TOP: Determining Estimated Date of Delivery KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. During the second prenatal visit, the nurse attempts to locate the fetal heartbeat with an electronic Doppler device. How early might fetal heart tones be detected with an electronic Doppler device? a. 4 weeks b. 8 weeks c. 10 weeks d. 14 weeks ANS: C The fetal heartbeat can be detected as early as 10 weeks of pregnancy using a Doppler device. 30 | P a g eDIF: Cognitive Level: Knowledge REF: Page 50 OBJ: 3 | 7 TOP: Normal Physiological Changes in Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. In a routine prenatal visit, the nurse examining a patient who is 37 weeks pregnant notices that the fetal heart rate (FHR) has dropped to 120 beats/min from a rate of 160 beats/min earlier in the pregnancy. What is the nurses first action? a. Ask if the patient has taken a sedative. b. Notify the physician. c. Turn the patient to her right side. d. Record the rate as a normal finding. ANS: D The FHR at term ranges from a low of 110 to 120 beats/min to a high of 150 to 160 beats/min. This should be recorded as normal. The FHR drops in the late stages of pregnancy. DIF: Cognitive Level: Application REF: Page 50 OBJ: 3 TOP: Assessing Fetal Heart Tone KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. A womans prepregnant weight is determined to be average for her height. What will the nurse advise the woman regarding recommended weight gain during pregnancy? a. 10 to 20 pounds b. 15 to 25 pounds c. 25 to 35 pounds d. 28 to 40 pounds ANS: C The recommended weight gain for a woman of normal weight before pregnancy is 25 to 35 pounds. DIF: Cognitive Level: Knowledge REF: Page 57 OBJ: 8 TOP: Nutrition in Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. When the nurse tells a pregnant woman that she needs 1200 mg of calcium daily during pregnancy, the woman responds, I dont like milk. What dietary adjustments 31 | P a g ecould the nurse recommend? a. Increase intake of organ meats. b. Eat more green leafy vegetables. c. Choose more fresh fruits, particularly citrus fruits. d. Include molasses and whole-grain breads in the diet. ANS: B For women who do not like milk, other sources of calcium include enriched cereals, legumes, nuts, dried fruits, green leafy vegetables, and canned salmon and sardines that contain bones. DIF: Cognitive Level: Application REF: Page 60 OBJ: 8 | 13 TOP: Nutrition for Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 11. A pregnant woman is experiencing nausea in the early morning. What recommendations would the nurse offer to alleviate this symptom? a. Eat three well-balanced meals per day and limit snacks. b. Drink a full glass of fluid at the beginning of each meal. c. Have crackers handy at the bedside, and eat a few before getting out of bed. d. Eat a bland diet and avoid concentrated sweets. ANS: C The nurse can recommend eating dry toast or crackers before getting out of bed in the morning to alleviate nausea during pregnancy. DIF: Cognitive Level: Application REF: Page 65, Table 4-6 OBJ: 10 TOP: Common Discomforts in Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. The patient who is 28 weeks pregnant shows a 10-pound weight gain from 2 weeks ago. What is the nurses initial action? a. Assess food intake. b. Weigh the patient again. c. Take the blood pressure. d. Notify the physician. ANS: C The marked weight gain may be an indication of gestational hypertension. The blood pressure should be assessed before notifying the physician. 32 | P a g eDIF: Cognitive Level: Application REF: Page 53 OBJ: 4 TOP: Gestational Hypertension KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. The patient remarks that she has heard some foods will enhance brain development of the fetus. The nurse replies that foods high in docosahexaenoic acid (DHA) are thought to enhance brain development. What food can the nurse recommend? a. Fried fish b. Olive oil c. Red meat d. Leafy green vegetables ANS: C Foods rich in DHA are red meat, flounder, halibut, and soybean and canola oil. Frying fish negatively alters the DHA. DIF: Cognitive Level: Application REF: Page 55 OBJ: 8 TOP: Nutrition in Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 14. The nurse encourages adequate intake of folic acid for women of childbearing age before and during pregnancy. What is folic acid thought to decrease the incidence of in fetal development? a. Structural heart defects b. Craniofacial deformities c. Limb deformities d. Neural tube defects ANS: D Folic acid can reduce the incidence of neural tube defects such as spina bifida and anencephaly. DIF: Cognitive Level: Knowledge REF: Page 45 | Page 61 OBJ: 8 TOP: Nutrition for Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 15. A woman tells the nurse that she is quite sure she is pregnant. The nurse recognizes which as a positive sign of pregnancy? a. Amenorrhea b. Uterine enlargement 33 | P a g ec. HCG detected in the urine d. Fetal heartbeat ANS: D Positive indications are caused only by the developing fetus and include fetal heart activity, visualization by ultrasound, and fetal movements felt by the examiner. DIF: Cognitive Level: Knowledge REF: Page 50 OBJ: 6 | 7 TOP: Physiological Changes During Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. At her initial prenatal visit a woman asks, When can I hear the babys heartbeat? At what gestational age can the fetal heartbeat be auscultated with a specially adapted stethoscope or fetoscope? a. 4 weeks b. 12 weeks c. 18 weeks d. 24 weeks ANS: C The fetal heartbeat can be heard with a fetoscope between the 18th and 20th weeks of pregnancy. DIF: Cognitive Level: Knowledge REF: Page 50 OBJ: 7 TOP: Physiological Changes During Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 17. A woman pregnant for the first time asks the nurse, When will I begin to feel the baby move? What is the nurses best response? a. You may notice the baby moving around the 4th or 5th month. b. Quickening varies with every woman. c. Youll feel something by the end of the first trimester. d. The baby will be big enough for you to feel in your 8th month. ANS: A Quickening, fetal movement felt by the mother, is first perceived at 16 to 20 weeks of gestation. DIF: Cognitive Level: Knowledge REF: Page 49 OBJ: 7 TOP: Physiological Changes During Pregnancy 34 | P a g e