Test 2 NUR 160 Questions With
Complete Solutions
A 12-hour-old infant is receiving IV fluids for polycythemia.
For which complication should a nurse monitor this client?
1. hypotension
2. decreased level of consciousness
3. tachycardia
4. fluid overload Correct Answers 4. fluid overload
The possibility of fluid overload is increased and must be
considered by a nurse when administering IV therapy to a
newborn. IV therapy does not significantly increase heart rate or
change blood pressure, as well as the level of consciousness,
unless fluid overload occurs.
A 26-year old mother of three children tells the nurse at her
annual check-up that she does not want to have any more
children; however, her religion forbids the use of contraceptive
devices. Which of the following methods would be the best
option for this client?
1. rhythm method
2. diaphragm
3. hormonal method
4. intrauterine device Correct Answers 1. rhythm method
Fertility awareness methods (FAMs) include the rhythm method,
which involves limiting sexual intercourse to the time during the
,woman's menstrual cycle when she is most likely to be infertile.
This method does not involve contraceptive devices. Barrier
methods such as diaphragms and IUDs interfere with conception
by physically preventing sperm from fertilizing ova. Barriers
work through mechanical and chemical means. Hormonal
methods of birth control alter a woman's normal hormone level
to prevent ovulation and thus the chances for conception.
A 38-year-old client wishes to discontinue use of oral
contraceptive pills (OCPs) and attempt to conceive. The client
says to the nurse, "I know a lot of women who have waited later
to have children and became pregnant easily." How will the
nurse respond?
1. "As soon as you stop taking the pill, you should be able to
conceive. There are no age-related problems with you becoming
pregnant."
2. "Women in their late 30s who use oral contraceptive pills may
face a delay in conception, as the body takes a few months to be
able to conceive."
3. "The age of a woman does not matter when trying to
conceive, but you have been on birth control for a long time,
thus it may take you longer."
4. "You should be off of oral contraceptive pills for at least 1
year before trying, and then you may or may not be able to
become pregnant." Correct Answers 2. "Women in their late
30s who use oral contraceptive pills may face a delay in
conception, as the body takes a few months to be able to
conceive."
,Age impacts the ability to conceive. The chance of subfertility
increases with age. Because of this gradual decline in fertility,
women who defer pregnancy to their late 30s are apt to have
more difficulty conceiving than their younger counterparts.
Clients using oral, injectable, or implanted hormones for
contraception may have difficulty becoming pregnant for several
months after discontinuing these medications as the body needs
time to restore normal functioning.
A breastfeeding mother wants to know how to help her 2-week-
old newborn gain the weight lost after birth. Which action
should the nurse suggest as the best method to accomplish this
goal?
1. Recommend that the mother pump her breast milk and
measure it before feeding.
2. Add cereal to the newborn's feedings twice a day.
3. Breastfeed the infant every 2 to 4 hours on demand.
4. Weigh the infant daily to ensure that she is gaining 1.5 to 2
ounces (42.5 to 57 grams) per day. Correct Answers 3.
Breastfeed the infant every 2 to 4 hours on demand.
A client at 34 weeks' gestation has recently been diagnosed with
human immunodeficiency virus (HIV). The client asks how HIV
would be transmitted to the newborn. Which statement would be
the nurse's best response?
1. It is recommended to formula-feed your newborn as it is
transmitted through your breast milk."
2. "It is only transmitted through the birth canal so a cesarean
birth will be scheduled."
, 3. "The risk of your newborn being infected with HIV infection
is about 1%."
4. "It is not transmitted to your newborn as it is protected in the
uterus." Correct Answers 1. It is recommended to formula-feed
your newborn as it is transmitted through your breast milk."
An infected mother can transmit HIV infection to her newborn
before or during birth and through breastfeeding. The risk of
perinatal transmission of HIV from an infected mother to her
newborn is about 25%. This risk falls to less than 1% if the
mother receives antiretroviral therapy during pregnancy. HIV
can be spread to the infant through breastfeeding. HIV-infected
mothers should be counseled to avoid breastfeeding and use
formula instead.
A client diagnosed with pelvic organ prolapse is being taught
how to perform pelvic floor muscle exercises. During the
teaching session, the client asks the nurse, "How do these
exercises help?" Which response by the nurse would be most
appropriate?
1. "The exercises help you to establish regular bowel elimination
patterns so you don't strain so much."
2. "They help to increase the volume of your muscles, which
leads to stronger muscle contraction."
3. "They help to move the pelvic floor upward so that your
symptoms eventually decrease."
4. "The exercises increase the amount of blood that your
muscles receive, making them less relaxed." Correct Answers
2. "They help to increase the volume of your muscles, which
leads to stronger muscle contraction."
Complete Solutions
A 12-hour-old infant is receiving IV fluids for polycythemia.
For which complication should a nurse monitor this client?
1. hypotension
2. decreased level of consciousness
3. tachycardia
4. fluid overload Correct Answers 4. fluid overload
The possibility of fluid overload is increased and must be
considered by a nurse when administering IV therapy to a
newborn. IV therapy does not significantly increase heart rate or
change blood pressure, as well as the level of consciousness,
unless fluid overload occurs.
A 26-year old mother of three children tells the nurse at her
annual check-up that she does not want to have any more
children; however, her religion forbids the use of contraceptive
devices. Which of the following methods would be the best
option for this client?
1. rhythm method
2. diaphragm
3. hormonal method
4. intrauterine device Correct Answers 1. rhythm method
Fertility awareness methods (FAMs) include the rhythm method,
which involves limiting sexual intercourse to the time during the
,woman's menstrual cycle when she is most likely to be infertile.
This method does not involve contraceptive devices. Barrier
methods such as diaphragms and IUDs interfere with conception
by physically preventing sperm from fertilizing ova. Barriers
work through mechanical and chemical means. Hormonal
methods of birth control alter a woman's normal hormone level
to prevent ovulation and thus the chances for conception.
A 38-year-old client wishes to discontinue use of oral
contraceptive pills (OCPs) and attempt to conceive. The client
says to the nurse, "I know a lot of women who have waited later
to have children and became pregnant easily." How will the
nurse respond?
1. "As soon as you stop taking the pill, you should be able to
conceive. There are no age-related problems with you becoming
pregnant."
2. "Women in their late 30s who use oral contraceptive pills may
face a delay in conception, as the body takes a few months to be
able to conceive."
3. "The age of a woman does not matter when trying to
conceive, but you have been on birth control for a long time,
thus it may take you longer."
4. "You should be off of oral contraceptive pills for at least 1
year before trying, and then you may or may not be able to
become pregnant." Correct Answers 2. "Women in their late
30s who use oral contraceptive pills may face a delay in
conception, as the body takes a few months to be able to
conceive."
,Age impacts the ability to conceive. The chance of subfertility
increases with age. Because of this gradual decline in fertility,
women who defer pregnancy to their late 30s are apt to have
more difficulty conceiving than their younger counterparts.
Clients using oral, injectable, or implanted hormones for
contraception may have difficulty becoming pregnant for several
months after discontinuing these medications as the body needs
time to restore normal functioning.
A breastfeeding mother wants to know how to help her 2-week-
old newborn gain the weight lost after birth. Which action
should the nurse suggest as the best method to accomplish this
goal?
1. Recommend that the mother pump her breast milk and
measure it before feeding.
2. Add cereal to the newborn's feedings twice a day.
3. Breastfeed the infant every 2 to 4 hours on demand.
4. Weigh the infant daily to ensure that she is gaining 1.5 to 2
ounces (42.5 to 57 grams) per day. Correct Answers 3.
Breastfeed the infant every 2 to 4 hours on demand.
A client at 34 weeks' gestation has recently been diagnosed with
human immunodeficiency virus (HIV). The client asks how HIV
would be transmitted to the newborn. Which statement would be
the nurse's best response?
1. It is recommended to formula-feed your newborn as it is
transmitted through your breast milk."
2. "It is only transmitted through the birth canal so a cesarean
birth will be scheduled."
, 3. "The risk of your newborn being infected with HIV infection
is about 1%."
4. "It is not transmitted to your newborn as it is protected in the
uterus." Correct Answers 1. It is recommended to formula-feed
your newborn as it is transmitted through your breast milk."
An infected mother can transmit HIV infection to her newborn
before or during birth and through breastfeeding. The risk of
perinatal transmission of HIV from an infected mother to her
newborn is about 25%. This risk falls to less than 1% if the
mother receives antiretroviral therapy during pregnancy. HIV
can be spread to the infant through breastfeeding. HIV-infected
mothers should be counseled to avoid breastfeeding and use
formula instead.
A client diagnosed with pelvic organ prolapse is being taught
how to perform pelvic floor muscle exercises. During the
teaching session, the client asks the nurse, "How do these
exercises help?" Which response by the nurse would be most
appropriate?
1. "The exercises help you to establish regular bowel elimination
patterns so you don't strain so much."
2. "They help to increase the volume of your muscles, which
leads to stronger muscle contraction."
3. "They help to move the pelvic floor upward so that your
symptoms eventually decrease."
4. "The exercises increase the amount of blood that your
muscles receive, making them less relaxed." Correct Answers
2. "They help to increase the volume of your muscles, which
leads to stronger muscle contraction."
