NUR 1600 Reproduction Exam (acute pain, Correct Response, Passpoint, Lippincott) | Questions and Answer solutions | Already GRADED A.

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Reproduction Exam Question 1 See full question A nurse is caring for a client whose membranes ruptured prematurely 12 hours ago. When assessing this client, the nurse's highest priority is to eval... uate: You Selected: • maternal vital signs and fetal heart rate (FHR). Correct response: • maternal vital signs and fetal heart rate (FHR). Explanation: Remediation: Question 2 See full question A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for: You Selected: • hypotension. Correct response: • hypotension. Explanation: Remediation: Question 3 See full question A 23-year-old client diagnosed with schizophrenia cheerfully announces, "My mom and I are so excited that I am pregnant. She is willing to help us take care of the baby too." Which reason should cause the nurse to be concerned about this situation? You Selected: • Symptom management will be difficult in early pregnancy without medications. Correct response: • Symptom management will be difficult in early pregnancy without medications. Explanation: Remediation: Question 4 See full question Which of the following is a priority nursing diagnosis for the client presenting with pelvic inflammatory disease? You Selected: • Acute pain. Correct response: • Acute pain. Explanation: Remediation: Question 5 See full question A couple has completed testing and is a candidate for in vitro fertilization. The nurse is reviewing the procedure with them and realizes that further instruction is needed when the woman states: You Selected: • "The fertilization procedure can be done anytime during my cycle." Correct response: • "The fertilization procedure can be done anytime during my cycle." Explanation: Remediation: Question 6 See full question The nurse is teaching a 17-year-old girl who has a severe gonorrheal infection. The nurse realizes that the girl understands the implications of her disease when she tells the nurse: You Selected: • "I could have trouble getting pregnant." Correct response: • "I could have trouble getting pregnant." Explanation: Remediation: Question 7 See full question After the nurse instructs a client who is scheduled for in vitro fertilization (IVF) about the procedure, which statement by the client indicates to the nurse that the instructions have been successful? You Selected: • "After fertilization, three or four embryos will be transferred through the cervix." Correct response: • "After fertilization, three or four embryos will be transferred through the cervix." Explanation: Remediation: Question 8 See full question A multigravid client at 34 weeks’ gestation who is leaking amniotic fluid has just been hospitalized with a diagnosis of preterm premature rupture of membranes and preterm labor. The client’s contractions are 20 minutes apart, lasting 20 to 30 seconds. Her cervix is dilated to 2 cm. The nurse reviews prescriptions (see chart). Which prescription should the nurse initiate first? You Selected: • Initiate fetal and contraction monitoring. Correct response: • Initiate fetal and contraction monitoring. Explanation: Remediation: Question 9 See full question The nurse is assessing a client who is 4 hours postpartum. Based on the findings documented by the nurse, which action is most appropriate at this time? You Selected: • Notify the charge nurse of the assessment findings. Correct response: • Ask the client to empty her bladder. Explanation: Remediation: Question 10 See full question Which client would benefit most from information explaining the importance of receiving an annual Papanicolaou (PAP) test? You Selected: • A client infected with the human papillomavirus (HPV) Correct response: • A client infected with the human papillomavirus (HPV) Explanation: Question 1 See full question The nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be: You Selected: • red and moderate. Correct response: • red and moderate. Explanation: Remediation: Question 2 See full question A couple is inquiring about vasectomy as a permanent method of contraception. Which teaching statement would the nurse include in the teaching plan? You Selected: • "Another method of contraception is needed until the sperm count is 0." Correct response: • "Another method of contraception is needed until the sperm count is 0." Explanation: Remediation: Question 3 See full question A 20-year-old married client with a positive pregnancy test states, “Is it really true? I can not believe I am going to have a baby!” Which response by the nurse would be most appropriate at this time? You Selected: • "Yes it is true. How does that make you feel?" Correct response: • "Yes it is true. How does that make you feel?" Explanation: Remediation: Question 4 See full question On a client's second postpartum visit, a physician reviews the chart. What's the best term for the lochia described? You Selected: • Rubra Correct response: • Rubra Explanation: Remediation: Question 5 See full question A labor and birth nurse is caring for a client in labor. Which of the following does the nurse identify as a sign that the second stage of labor has begun? You Selected: • The client’s cervix cannot be felt during a vaginal examination. Correct response: • The client’s cervix cannot be felt during a vaginal examination. Explanation: Remediation: Question 6 See full question A primigravida client is admitted to the labor and birth area where the nurse evaluates her. Which of the following assessment findings would be a priority for the nurse to report to the healthcare provider? You Selected: • Fetal heart rate decelerating slightly with contractions Correct response: • Membranes ruptured with fetus at the –3 station Explanation: Remediation: Question 7 See full question A client in active labor asks the nurse why her blood pressure is being monitored so frequently. Which of the following is an appropriate response by the nurse? You Selected: • "Alterations in cardiovascular function affect the fetus." Correct response: • "Alterations in cardiovascular function affect the fetus." Explanation: Remediation: Question 8 See full question The nurse brings the infant to the new mother after obtaining assessment data and performing newborn interventions. Which of the following behaviors exhibited by the mother demonstrates that effective bonding is beginning to take place? You Selected: • The mother looks at the newborn with direct eye contact. Correct response: • The mother looks at the newborn with direct eye contact. Explanation: Remediation: Question 9 See full question During a prenatal visit, a health care provider decides to admit a client to the hospital. Based on the nurse’s progress note, which complication of pregnancy would the health care provider suspect? You Selected: • Hyperemesis gravidarum. Correct response: • Hyperemesis gravidarum. Explanation: Remediation: Question 10 See full question A nurse is caring for a client in the fourth stage of labor. Based on the nurse’s note, which postpartum complication has the client developed? You Selected: • Postpartum hemorrhage. Correct response: • Postpartum hemorrhage. Question 1 See full question A mother brings her 2-month-old infant to the clinic for a well-baby checkup. To best assess the interaction between the mother and infant, the nurse should observe them: You Selected: • as the mother feeds the infant. Correct response: • as the mother feeds the infant. Explanation: Remediation: Question 2 See full question A nurse is teaching a group of clients about birth control methods. When providing instruction about subdermal contraceptive implants, the nurse should cite which feature as the main advantage of this method? You Selected: • The implants provide effective, continuous contraception that isn't user dependent. Correct response: • The implants provide effective, continuous contraception that isn't user dependent. Explanation: Remediation: Question 3 See full question The nurse is admitting a primigravid client at 37 weeks' gestation who has been diagnosed with preeclampsia to the labor and birth area. Which client care rooms is most appropriate for this client? You Selected: • a darkened private room as close to the nurses' station as possible Correct response: • a darkened private room as close to the nurses' station as possible Explanation: Remediation: Question 4 See full question A primigravida, currently about 8 weeks pregnant, and her husband ask when they should begin the preparation for childbirth classes that discuss maternal nutrition during pregnancy. Which time would be most appropriate for the nurse to suggest that they begin the classes? You Selected: • now during the first trimester of pregnancy Correct response: • now during the first trimester of pregnancy Explanation: Remediation: Question 5 See full question A client is a long-distance runner and is 8 weeks pregnant with her first baby. The client tells the nurse that she would like to continue running throughout the pregnancy and asks the nurse if there are any safety risks. Which response by the nurse correctly identifies musculoskeletal changes in pregnancy that may be a safety risk to the client? You Selected: • “The joints of the pelvis relax.” Correct response: • “The joints of the pelvis relax.” Explanation: Question 6 See full question A client at 24 weeks gestation comes to the clinic for a prenatal check-up and informs the nurse that she has been “seeing double.” The nurse checks the urine and determines that there is 3+ proteinuria. What does the nurse determine is the potential priority problem? You Selected: • Gestational Diabetes Correct response: • Gestation hypertension Explanation: Remediation: Question 7 See full question The nurse is teaching pain management to a prenatal class. The nurse knows that the instruction has been effective when a participant says which of the following? You Selected: • “I will feel most of my pain in my pelvis during early labor.” Correct response: • “I will feel most of my pain in my pelvis during early labor.” Explanation: Remediation: Question 8 See full question A woman who delivered her last infant by caesarean section is admitted to the hospital at term with contractions every 5 minutes. The health care provider (HCP) intends to have her undergo “a trial labor.” The nurse explains to the client that: You Selected: • labor progress will be evaluated continually to determine appropriate progress for a vaginal delivery. Correct response: • labor progress will be evaluated continually to determine appropriate progress for a vaginal delivery. Explanation: Question 9 See full question When working the mother-baby unit which client would the nurse anticipate giving Rho(D) immune globulin (human) to: You Selected: • the Rh negative mother with an Rh positive baby. Correct response: • the Rh negative mother with an Rh positive baby. Explanation: Remediation: Question 10 See full question The nurse is caring for a female client who states, “I am having my menstrual period every two weeks and it lasts for one week. I am concerned because I want to get pregnant.” How should the nurse respond? Select all that apply. You Selected: • “You should schedule an exam with your health care provider.” • “Your health care provider should check your hormone levels.” Correct response: • “Your health care provider should check your hormone levels.” • “You should schedule an exam with your health care provider.” Explanation: Question 1 See full question The third stage of labor ends: You Selected: • after the delivery of the placenta. Correct response: • after the delivery of the placenta. Explanation: Remediation: Question 2 See full question A client is 9 days postpartum and breast-feeding her neonate. The client experiences pain, redness, and swelling of her left breast and is diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information? You Selected: • Wear a loose-fitting bra to avoid constricting the milk ducts. Correct response: • Use a warm moist compress over the painful area. Explanation: Remediation: Question 3 See full question The nurse is working with four clients on the obstetrical unit. Which client will be the highest priority for a cesarean section? You Selected: • client at 38 weeks' gestation with active herpes lesions Correct response: • client at 38 weeks' gestation with active herpes lesions Explanation: Remediation: Question 4 See full question After being examined and fitted for a diaphragm, a 24-year-old client receives instructions about its use. Which client statement indicates a need for further teaching? You Selected: • "If I gain or lose 20 lb (9 kg), I can still use the same diaphragm." Correct response: • "If I gain or lose 20 lb (9 kg), I can still use the same diaphragm." Explanation: Question 5 See full question A client who tells the nurse that she would like to use the basal body temperature method for family planning receives instructions about the method. Which client statement indicates to the nurse that the teaching has been successful? You Selected: • "It is important to take my temperature at about the same time every morning before arising.” Correct response: • "It is important to take my temperature at about the same time every morning before arising.” Explanation: Remediation: Question 6 See full question A 16-year-old primigravida at 36 weeks' gestation who has had no prenatal care experienced a seizure at work and is being transported to the hospital by ambulance. What should the nurse do upon the client’s arrival? You Selected: • Admit the client to a quiet, darkened room. Correct response: • Admit the client to a quiet, darkened room. Explanation: Remediation: Question 7 See full question A laboring client is experiencing increased pain and asks the nurse when she can have an epidural. Which of the following would be a priority intervention by the nurse to establish whether the client can have an epidural? You Selected: • Assess cervical dilation. Correct response: • Assess cervical dilation. Explanation: Remediation: Question 8 See full question The nurse is performing a newborn assessment on a neonate in the childbirth suite. The nurse notes epispadias. Which documentation of the defect would the nurse note You Selected: • B Correct response: • C Explanation: Question 9 See full question A pregnant woman at 39 weeks’ gestation comes to the labor and birth suite in early labor. The woman is a member of the local Muslim community. When developing the culturally appropriate plan of care for this client, which aspect would the nurse identify as the priority? You Selected: • protecting the client’s modesty Correct response: • protecting the client’s modesty Explanation: Remediation: Question 10 See full question A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days postmature. Which of the following physical findings contradicts the estimated gestational age of the newborn? You Selected: • Increased amounts of vernix Correct response: • Increased amounts of vernix Question 1 See full question A postpartum client's husband calls the nurse and says, "My wife feels funny." The nurse enters the room and notes blood gushing from the client's vagina, pallor, and a rapid, thready pulse. What should be the nurse's first intervention? You Selected: • Call the physician. Correct response: • Massage the fundus. Explanation: Remediation: Question 2 See full question The nurse, while shopping in a local department store, hears a multiparous woman say loudly, "I think the baby is coming." After asking someone to call 911, the nurse assists the client to give birth to a term neonate. While waiting for the ambulance, the nurse suggests that the mother initiate breastfeeding, primarily for what reason? You Selected: • to contract the mother's uterus Correct response: • to contract the mother's uterus Explanation: Remediation: Question 3 See full question Before advising a 24-year-old client desiring oral contraceptives for family planning, the nurse would assess the client for which signs and symptoms? You Selected: • hypertension Correct response: • hypertension Explanation: Remediation: Question 4 See full question A 15-year-old primigravid client at approximately 16 weeks’ gestation tells the nurse that she has been experiencing an occasional sharp pain from the fundus to her pubic bone on the left side. The nurse determines that the client is most likely experiencing which complication? You Selected: • round ligament pain Correct response: • round ligament pain Explanation: Remediation: Question 5 See full question A multigravid client at 34 weeks’ gestation who is leaking amniotic fluid has just been hospitalized with a diagnosis of preterm premature rupture of membranes and preterm labor. The client’s contractions are 20 minutes apart, lasting 20 to 30 seconds. Her cervix is dilated to 2 cm. The nurse reviews prescriptions (see chart). Which prescription should the nurse initiate first? You Selected: • Initiate fetal and contraction monitoring. Correct response: • Initiate fetal and contraction monitoring. Explanation: Remediation: Question 6 See full question The nurse is caring for a client who is in the transitional stage of labor. The client’s partner is concerned and asks, “What else can I do for my wife? She is so irritable.” Which of the following interventions would the nurse suggest? Select all that apply. You Selected: • “Encourage your wife to rest in between contractions.” • “Stay by your wife’s side. It is important that she know you are there to support her.” • “Continue to praise your wife and give her encouragement.” Correct response: • “Encourage your wife to rest in between contractions.” • “Continue to praise your wife and give her encouragement.” • “Stay by your wife’s side. It is important that she know you are there to support her.” Explanation: Remediation: Question 7 See full question The nurse is caring for a client in labor who has tested positive for gonorrhea. Which of the following will the nurse include in the client’s plan of care? You Selected: • Administer erythromycin eye drops to the infant after birth Correct response: • Administer erythromycin eye drops to the infant after birth Explanation: Remediation: Question 8 See full question The nurse is performing a vaginal examination on a client in labor.: You Selected: • -1 station. Correct response: • -1 station. Explanation: Remediation: Question 9 See full question A woman has just given birth to a stillborn baby at 39 weeks gestation. What is the mostappropriate response for the nurse to make at this time? You Selected: • “I am sorry for your loss.” Correct response: • “I am sorry for your loss.” Explanation: Question 10 See full question The nurse is performing Leopold’s maneuvers to determine fetal presentation and position. Which illustration shows the third maneuver? You Selected: • Correct response: • Explanation: Question 1 See full question When teaching a group of pregnant adolescents about reproduction and conception, the nurse is correct when stating that fertilization occurs: You Selected: • in the first third of the fallopian tube. Correct response: • in the first third of the fallopian tube. Explanation: Remediation: Question 2 See full question A nulliparous client says that she and her husband plan to use a diaphragm with spermicide to prevent conception. Which should the nurse include as the action of spermicides when teaching the client? You Selected: • destruction of spermatozoa before they enter the cervix Correct response: • destruction of spermatozoa before they enter the cervix Explanation: Question 3 See full question During a home visit on the fifth postpartum day, the client begins to cry and says that she is worried about her ability to care for her baby adequately. She tells the nurse, “I wish I could just get organized—I need 8 hours of sleep!” The nurse determines that she is experiencing which condition? You Selected: • Taking-hold phase of childbearing; she is feeling inadequate about neonatal care. Correct response: • Taking-hold phase of childbearing; she is feeling inadequate about neonatal care. Explanation: Remediation: Question 4 See full question A pregnant client at 26 weeks gestation walks a moderate distance to get to her prenatal class. When she gets to the class, she starts experiencing uterine cramping with no backache or bloody show. She is quite concerned about the cramping and asks the nurse what is happening. The most appropriate response from the nurse would be which of the following? You Selected: • Advise her to see her physician immediately for preterm labor. Correct response: • Advise the client to rest and drink fluids. Explanation: Remediation: Question 5 See full question The nurse is managing a pregnant client’s second stage of labor. The nurse should intervene when observing which action? You Selected: • closed glottis pushing Correct response: • closed glottis pushing Explanation: Remediation: Question 6 See full question Which client is the best candidate for a vaginal birth after a caesarean (VBAC)? You Selected: • client who had a breech presentation in her last pregnancy, and this pregnancy is a vertex pregnancy Correct response: • client who had a breech presentation in her last pregnancy, and this pregnancy is a vertex pregnancy Explanation: Question 7 See full question A client who had a hysterectomy 2 hours ago is returning to the postsurgical unit from the recovery room. The nurse is assessing the client. The vital signs are: temperature, 99° F (32° C); pulse, 98 bmp; respirations, 20 breaths/min; BP, 100/65 mm Hg. The urinary catheter is draining freely, and the client wants to try voiding without the catheter. The IV is infusing at 60 gtt/min. The perineal pad is saturated with bright red blood. The nurse reviews the progress notes from the recovery room (see notes). What should the nurse do first? You Selected: • Contact the surgeon. Correct response: • Contact the surgeon. Explanation: Remediation: Question 8 See full question A woman who has preeclampsia is receiving magnesium sulfate 20 grams per 500 mL of lactated Ringers via infusion pump. The prescribed rate of infusion is 2 grams/hour. How many mL/hour should the nurse set the infusion pump for? Record your answer using a whole number. Your Response: • 50 Correct response: • 50 Explanation: Question 9 See full question A client wants to avoid methods of birth control that contain estrogen. Which method would be the nurse recommend? You Selected: • etonogestrel/ethinyl estradiol vaginal ring Correct response: • depot medroxyprogesterone acetate injection Explanation: Question 10 See full question A pregnant client late in her first trimester comes to the clinic for a follow-up visit. The woman tells the nurse that she has been having morning sickness, but she "tried using this band on her wrist," and it helped cut down on the number of episodes she was having. The nurse interprets this therapy as an example of: You Selected: • meditation. Correct response: • acupressure. Question 1 See full question During the first 3 months, which hormone is most responsible for maintaining pregnancy? You Selected: • Human chorionic gonadotropin (hCG) Correct response: • Human chorionic gonadotropin (hCG) Explanation: Remediation: Question 2 See full question At what gestational age should a primigravida expect to start feeling quickening? You Selected: • 18 to 20 weeks Correct response: • 18 to 20 weeks Explanation: Remediation: Question 3 See full question On arrival at the emergency department, a client tells the nurse that she suspects that she may be pregnant but has been having a small amount of bleeding and has severe pain in the lower abdomen. The client's blood pressure is 70/50 mm Hg, and her pulse rate is 120 bpm. The nurse notifies the primary health care provider (HCP) immediately because of the possibility of: You Selected: • ectopic pregnancy. Correct response: • ectopic pregnancy. Explanation: Remediation: Question 4 See full question A nurse is caring for a 1-day postpartum client. The progress note below informs the nurse that the client is in which phase of the postpartum period? You Selected: • Letting go. Correct response: • Taking in. Explanation: Remediation: Question 5 See full question When preparing the room for admission of a multigravid client at 36 weeks’ gestation diagnosed with severe preeclampsia, which item is most important for the nurse to obtain? You Selected: • padding for the side rails Correct response: • padding for the side rails Explanation: Remediation: Question 6 See full question A client who is 5 cm dilated tells the nurse that she has the urge to push. Which of the following is the appropriate response by the nurse? You Selected: • Have client blow out breath to keep from pushing Correct response: • Have client blow out breath to keep from pushing Explanation: Remediation: Question 7 See full question A nurse is preparing to teach a client about fetal growth and development during the first 3 months of pregnancy. The nurse is assembling teaching aids by milestones. In ascending order, (month 1, month 2, month 3, and months 4 to 9), how would the nurse arrange the aids? All options must be used. You Selected: • Teeth and bones begin to appear, the kidneys start to function and, at the end of the month, gender is distinguishable. • The eyes, ears, nose, lips, tongue, and tooth buds develop; the umbilical cord has a definite form; and the external genitalia are present. • Internal and external fetal growth continues at a rapid rate, and the fetus stores the fats and minerals it needs to live outside the womb. • The embryo has a definite form; the head, trunk, and tiny buds for arms and legs develop; and the cardiovascular system begins to function. Correct response: • The embryo has a definite form; the head, trunk, and tiny buds for arms and legs develop; and the cardiovascular system begins to function. • The eyes, ears, nose, lips, tongue, and tooth buds develop; the umbilical cord has a definite form; and the external genitalia are present. • Teeth and bones begin to appear, the kidneys start to function and, at the end of the month, gender is distinguishable. • Internal and external fetal growth continues at a rapid rate, and the fetus stores the fats and minerals it needs to live outside the womb. Explanation: Remediation: Question 8 See full question A nurse is caring for a premenopausal client who had precancerous cells found during a routine papanicolaou (Pap) test. At which time during the menstrual cycle would the nurse schedule a cervical biopsy? You Selected: • One week after the end of the menstrual period Correct response: • One week after the end of the menstrual period Explanation: Question 9 See full question A nurse is caring for a primigravid client at 40 weeks gestation in active labor. Assessments include: cervix 5 cm dilated; 90% effaced; station 0; cephalic presentation, FHR baseline is 135 bpm and decreases to 125 bpm shortly after onset of 5 uterine contractions and returns to baseline before the uterine contraction ends. Based on this assessment what action should the nurse take first? You Selected: • Document findings on the woman’s medical record, and continue to monitor labor progress. Correct response: • Document findings on the woman’s medical record, and continue to monitor labor progress. Explanation: Question 10 See full question A nurse is evaluating a fetal monitoring strip to time the contractions of a client in labor. Identify the beginning of the contraction in the illustration. You Selected: • Your selection and the correct area, market by the green box. Question 1 See full question A nurse is teaching a client how to use a diaphragm. Which statement about using a diaphragm is appropriate? You Selected: • "Leave the diaphragm in place for at least 6 hours after intercourse." Correct response: • "Leave the diaphragm in place for at least 6 hours after intercourse." Explanation: Question 2 See full question 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 information would the nurse expect to include in the client's teaching plan? You Selected: • As ovulation approaches, cervical mucus is abundant and clear. Correct response: • As ovulation approaches, cervical mucus is abundant and clear. Explanation: Question 3 See full question During a preparation for parenting class, one of the participants asks the nurse, “How will I know if I am really in labor?” What should the nurse tell the participant about true labor contractions? You Selected: • "True labor contractions are felt first in the lower back, then the abdomen." Correct response: • "True labor contractions are felt first in the lower back, then the abdomen." Explanation: Remediation: Question 4 See full question 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 complication? You Selected: • congenital anomalies Correct response: • congenital anomalies Explanation: Question 5 See full question The nurse is performing an assessment of a client progressing through labor. Place the following findings in the order in which they occur. All options must be used. You Selected: • Uncontrollable urge to push • Mild contractions lasting 20 to 40 seconds • Strong Braxton Hicks contractions • Cervical dilation of 7 cm • 100% cervical effacement Correct response: • Strong Braxton Hicks contractions • Mild contractions lasting 20 to 40 seconds • Cervical dilation of 7 cm • 100% cervical effacement • Uncontrollable urge to push Explanation: Remediation: Question 6 See full question A primigravid client in early labor with abruptio placentae develops disseminated intravascular coagulation (DIC). Which agent should the nurse expect the health care provider (HCP) to prescribe? You Selected: • fresh-frozen platelets Correct response: • fresh-frozen platelets Explanation: Remediation: Question 7 See full question A couple seeks information about natural family planning. Which of the following should the nurse inform the couple about natural family planning? Select all that apply. You Selected: • Requires some period of abstinence. • Uses calculations of menstrual cycles. • Determines ovulation from basal body temperature. Correct response: • Requires some period of abstinence. • Uses calculations of menstrual cycles. • Determines ovulation from basal body temperature. Explanation: Remediation: Question 8 See full question A client thinks that she is 7 weeks pregnant. The nurse would explain that which assessment would best confirm pregnancy? You Selected: • Obtain a positive pregnancy test Correct response: • Obtain a positive pregnancy test Explanation: Remediation: Question 9 See full question A nurse is caring for a woman G1 P0 at 40 weeks gestation in active labor. Assessments include: cervix 5 cm dilated; 90% effaced; station 0; cephalic presentation; FHR baseline is 135 bpm and decreases to 125 bpm shortly after onset of 5 uterine contractions and returns to baseline before the uterine contraction ends. Based on this assessment, what action should the nurse take first? You Selected: • Document findings on the client’s chart, and continue to monitor labor progress. Correct response: • Document findings on the client’s chart, and continue to monitor labor progress. Explanation: Remediation: Question 10 See full question A pregnant African American woman at term comes to the labor and birth unit in early labor. When developing the plan of care for this client, the nurse would most likely expect which persons to be major sources of emotional support for the client? Select all that apply. You Selected: • client's mother • client's partner Correct response: • client's partner • client's father • client's mother Question 1 See full question The third stage of labor ends: You Selected: • after the delivery of the placenta. Correct response: • after the delivery of the placenta. Explanation: Remediation: Question 2 See full question A couple has completed testing and is a candidate for in vitro fertilization. The nurse is reviewing the procedure with them and realizes that further instruction is needed when the woman states: You Selected: • "The fertilization procedure can be done anytime during my cycle." Correct response: • "The fertilization procedure can be done anytime during my cycle." Explanation: Remediation: Question 3 See full question A client taking oral contraceptives is placed on a 10-day course of antibiotics for an infection. Which instruction should the nurse include in the teaching plan? You Selected: • "Use a barrier method of birth control for the rest of your cycle." Correct response: • "Use a barrier method of birth control for the rest of your cycle." Explanation: Question 4 See full question A client is a long-distance runner and is 8 weeks pregnant with her first baby. The client tells the nurse that she would like to continue running throughout the pregnancy and asks the nurse if there are any safety risks. Which response by the nurse correctly identifies musculoskeletal changes in pregnancy that may be a safety risk to the client? You Selected: • “The joints of the pelvis relax.” Correct response: • “The joints of the pelvis relax.” Explanation: Question 5 See full question A client is in the first stage of labor. She asks the nurse what the best physical position is to promote labor progression and efficient uterine contractions. Which of the following responses by the nurse is most appropriate? You Selected: • “Any position, but ensure infrequent position changes if possible.” Correct response: • “The best option at this stage is to ambulate.” Explanation: Remediation: Question 6 See full question A client returned to the recovery room after a dilatation and curettage has the postoperative medication prescriptions shown in the medical record. What should the nurse do next? You Selected: • Ask the client to rate the intensity of her pain on a scale of 1 to 10, and administer the analgesia according to the intensity of the pain. Correct response: • Ask the client to rate the intensity of her pain on a scale of 1 to 10, and administer the analgesia according to the intensity of the pain. Explanation: Remediation: Question 7 See full question The nurse brings the infant to the new mother after obtaining assessment data and performing newborn interventions. Which of the following behaviors exhibited by the mother demonstrates that effective bonding is beginning to take place? You Selected: • The mother looks at the newborn with direct eye contact. Correct response: • The mother looks at the newborn with direct eye contact. Explanation: Remediation: Question 8 See full question In caring for a pregnant client with hyperemesis gravidarum, which is the priority nursing intervention? You Selected: • reviewing dietary choices and food intake Correct response: • correction of fluid-electrolyte imbalance Explanation: Remediation: Question 9 See full question A woman who delivered her last infant by caesarean section is admitted to the hospital at term with contractions every 5 minutes. The health care provider (HCP) intends to have her undergo “a trial labor.” The nurse explains to the client that: You Selected: • labor will be stimulated with exogenous oxytocin until delivery. Correct response: • labor progress will be evaluated continually to determine appropriate progress for a vaginal delivery. Explanation: Question 10 See full question A nurse and an LPN are working in the labor and birth unit. Of the activities that must be done immediately, which should the nurse assign to the LPN? You Selected: • Increase the oxytocin rate on a laboring client. Correct response: • Perform a straight catheterization for protein analysis. Explanation: Remediation: Question 1 See full question A client and her spouse, both 25 years old, are having trouble conceiving. Infertility in this couple is defined as: You Selected: • the inability to conceive after 1 year of unprotected attempts. Correct response: • the inability to conceive after 1 year of unprotected attempts. Explanation: Remediation: Question 2 See full question A nurse is teaching a group of clients about birth control methods. When providing instruction about subdermal contraceptive implants, the nurse should cite which feature as the main advantage of this method? You Selected: • The implants provide effective, continuous contraception that isn't user dependent. Correct response: • The implants provide effective, continuous contraception that isn't user dependent. Explanation: Remediation: Question 3 See full question A 23-year-old client diagnosed with schizophrenia cheerfully announces, "My mom and I are so excited that I am pregnant. She is willing to help us take care of the baby too." Which reason should cause the nurse to be concerned about this situation? You Selected: • Symptom management will be difficult in early pregnancy without medications. Correct response: • Symptom management will be difficult in early pregnancy without medications. Explanation: Remediation: Question 4 See full question An anxious young adult is brought to the interviewing room of a crisis shelter, sobbing and saying that she thinks she is pregnant but does not know what to do. Which nursing intervention is most appropriate at this time? You Selected: • Recommend a pregnancy test after acknowledging the client's distress. Correct response: • Recommend a pregnancy test after acknowledging the client's distress. Explanation: Remediation: Question 5 See full question A client taking oral contraceptives is placed on a 10-day course of antibiotics for an infection. Which instruction should the nurse include in the teaching plan? You Selected: • "Use a barrier method of birth control for the rest of your cycle." Correct response: • "Use a barrier method of birth control for the rest of your cycle." Explanation: Question 6 See full question A menopausal woman with an intact uterus is taking a combined estrogen and progesterone replacement medication, conjugated estrogens/medroxyprogesterone acetate 0.625 mg/2.5 mg, for severe hot flashes. Combined hormonal therapy is given because estrogen alone: You Selected: • Would not be effective for hot flashes. Correct response: • Could be a risk factor for endometrial cancer. Explanation: Question 7 See full question While observing a new mother interact with her first baby, the nurse observes that the client appears hesitant to care for the neonate. Which action would be most important for the nurse to do? You Selected: • Continue to provide praise and support to the client. Correct response: • Continue to provide praise and support to the client. Explanation: Remediation: Question 8 See full question On a client's second postpartum visit, a physician reviews the chart. What's the best term for the lochia described? You Selected: • Rubra Correct response: • Rubra Explanation: Remediation: Question 9 See full question A 44-year-old client has been experiencing spotting, nausea, vomiting, and fatigue. A positive pregnancy test and an ultrasound confirm a 13 week gestation. The client had three prior miscarriages with no term births. What does the nurse recognize as the greatest risk factor for the client at this time? You Selected: • Pregnancy loss Correct response: • Pregnancy loss Explanation: Remediation: Question 10 See full question A client is in the first stage of labor. She asks the nurse what the best physical position is to promote labor progression and efficient uterine contractions. Which of the following responses by the nurse is most appropriate? You Selected: • “The best option at this stage is to ambulate.” Correct response: • “The best option at this stage is to ambulate.” Explanation: Remediation: Question 11 See full question The nurse is caring for a client in labor. Which of the following is how the nurse would report the frequency of each contraction? You Selected: • Measuring the length of time from the start of one contraction to the start of the next Correct response: • Measuring the length of time from the start of one contraction to the start of the next Explanation: Remediation: Question 12 See full question The nurse is teaching a G2P1 client about her upcoming labor. Which of the following responses would indicate to the nurse that further teaching is necessary? You Selected: • “I can wait until my contractions are every 2 minutes to contact the physician because my first labor was so long.” Correct response: • “I can wait until my contractions are every 2 minutes to contact the physician because my first labor was so long.” Explanation: Remediation: Question 13 See full question A nurse is assisting in the birthing room. The health care provider prepares to perform a midline episiotomy. On the illustration, identify the area where the health care provider makes the incision. You Selected: • Your selection and the correct area, market by the green box. Explanation: Remediation: Question 14 See full question The nurse is assessing a client who is 4 hours postpartum. Based on the findings documented by the nurse, which action is most appropriate at this time? You Selected: • Straight-catheterize the client immediately. Correct response: • Ask the client to empty her bladder. Explanation: Remediation: Question 15 See full question The nurse is working in the labor and child birth unit when a mother with active herpes simplex virus-Type 2 (HSV-2) appears in active labor. Which adjustment in the plan of care is anticipated? You Selected: • Prepare the mother for a cesarean section Correct response: • Prepare the mother for a cesarean section Explanation: Question 16 See full question The nurse would question the prescription for a fetal scalp electrode on which client? You Selected: • client with late decelerations Correct response: • client with an HIV infection Explanation: Remediation: Question 17 See full question A nurse and an LPN are working in the labor and birth unit. Of the activities that must be done immediately, which should the nurse assign to the LPN? You Selected: • Perform a straight catheterization for protein analysis. Correct response: • Perform a straight catheterization for protein analysis. Explanation: Remediation: Question 18 See full question Which client would benefit most from information explaining the importance of receiving an annual Papanicolaou (PAP) test? You Selected: • A client infected with the human papillomavirus (HPV) Correct response: • A client infected with the human papillomavirus (HPV) Explanation: Remediation: Question 19 See full question Which client would benefit most from information explaining the importance of receiving an annual Papanicolaou (PAP) test? You Selected: • A client infected with the human papillomavirus (HPV) Correct response: • A client infected with the human papillomavirus (HPV) Explanation: Remediation: Question 20 See full question The nurse is caring for a female client who states, “I am having my menstrual period every two weeks and it lasts for one week. I am concerned because I want to get pregnant.” How should the nurse respond? Select all that apply. You Selected: • “You should schedule an exam with your health care provider.” • “Your health care provider should check your hormone levels.” Correct response: • “Your health care provider should check your hormone levels.” • “You should schedule an exam with your health care provider.” Question 1 See full question A client is 9 days postpartum and breast-feeding her neonate. The client experiences pain, redness, and swelling of her left breast and is diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information? You Selected: • Use a warm moist compress over the painful area. Correct response: • Use a warm moist compress over the painful area. Explanation: Remediation: Question 2 See full question The health care provider (HCP) has determined that a preterm labor client at 34 weeks' gestation has no fetal fibronectin present. Based on this finding, the nurse would anticipate that within the next week: You Selected: • the client will not develop preterm labor. Correct response: • the client will not develop preterm labor. Explanation: Remediation: Question 3 See full question A client has obtained levonorgestrel 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 statement? You Selected: • "I can wait up to 4 days after intercourse to start taking these to prevent pregnancy." Correct response: • "I can wait up to 4 days after intercourse to start taking these to prevent pregnancy." Explanation: Question 4 See full question A couple is inquiring about vasectomy as a permanent method of contraception. Which teaching statement would the nurse include in the teaching plan? You Selected: • "Another method of contraception is needed until the sperm count is 0." Correct response: • "Another method of contraception is needed until the sperm count is 0." Explanation: Remediation: Question 5 See full question A 39-year-old multigravid client asks the nurse for information about female sterilization with a tubal ligation. Which client statement indicates effective teaching? You Selected: • "My fallopian tubes will be tied off through a small abdominal incision." Correct response: • "My fallopian tubes will be tied off through a small abdominal incision." Explanation: Remediation: Question 6 See full question A nulliparous client says that she and her husband plan to use a diaphragm with spermicide to prevent conception. Which should the nurse include as the action of spermicides when teaching the client? You Selected: • destruction of spermatozoa before they enter the cervix Correct response: • destruction of spermatozoa before they enter the cervix Explanation: Question 7 See full question The nurse is performing a health history for a woman in her first trimester of pregnancy who lives alone with two cats. What education should the nurse provide so that the client may protect herself from illness? You Selected: • The client should wear disposable gloves and wash hand with soap and warm water after cat litter exposure. Correct response: • The client should wear disposable gloves and wash hand with soap and warm water after cat litter exposure. Explanation: Remediation: Question 8 See full question A parent brings her 2-month-old infant to the clinic for a well-baby checkup. To assess the interaction between parent and infant, in which of the following settings should the nurse should observe the parent and infant? You Selected: • As the parent feeds the infant Correct response: • As the parent feeds the infant Explanation: Question 9 See full question During a prenatal visit, a health care provider decides to admit a client to the hospital. Based on the nurse’s progress note, which complication of pregnancy would the health care provider suspect? You Selected: • Pregnancy-induced hypertension. Correct response: • Hyperemesis gravidarum. Explanation: Remediation: Question 10 See full question The nurse determines that teaching about the warning signs of preterm labor has been successful when the client states that she will call the health care provider if she has which symptom? You Selected: • abdominal cramps with diarrhea Correct response: • abdominal cramps with diarrhea Question 1 See full question A mother brings her 2-month-old infant to the clinic for a well-baby checkup. To best assess the interaction between the mother and infant, the nurse should observe them: You Selected: • as the mother feeds the infant. Correct response: • as the mother feeds the infant. Explanation: Remediation: Question 2 See full question A client has expressed her desire to give birth with minimal intervention. She is now moving into the active phase of labor. What intervention by the nurse would be the priority of care? You Selected: • Offering support by reviewing the short-pant form of breathing Correct response: • Offering support by reviewing the short-pant form of breathing Explanation: Remediation: Question 3 See full question A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for: You Selected: • hypotension. Correct response: • hypotension. Explanation: Remediation: Question 4 See full question The nurse is working with four clients on the obstetrical unit. Which client will be the highest priority for a cesarean section? You Selected: • client at 38 weeks' gestation with active herpes lesions Correct response: • client at 38 weeks' gestation with active herpes lesions Explanation: Remediation: Question 5 See full question Which of the following is a priority nursing diagnosis for the client presenting with pelvic inflammatory disease? You Selected: • Acute pain. Correct response: • Acute pain. Explanation: Remediation: Question 6 See full question The nurse is teaching a young woman about using oxcarbazepine to control seizures. The nurse determines teaching is effective when the client states: You Selected: • "I will use one of the barrier methods of contraception." Correct response: • "I will use one of the barrier methods of contraception." Explanation: Remediation: Question 7 See full question A multigravid client at 34 weeks’ gestation who is leaking amniotic fluid has just been hospitalized with a diagnosis of preterm premature rupture of membranes and preterm labor. The client’s contractions are 20 minutes apart, lasting 20 to 30 seconds. Her cervix is dilated to 2 cm. The nurse reviews prescriptions (see chart). Which prescription should the nurse initiate first? You Selected: • Initiate fetal and contraction monitoring. Correct response: • Initiate fetal and contraction monitoring. Explanation: Remediation: Question 8 See full question A client comes to the clinic stating that she is pregnant with her first child. After the pregnancy is confirmed, which of the following is the priority intervention by the nurse? You Selected: • Providing prenatal education Correct response: • Providing prenatal education Explanation: Remediation: Question 9 See full question A woman who has preeclampsia is receiving magnesium sulfate 20 grams per 500 mL of lactated Ringers via infusion pump. The prescribed rate of infusion is 2 grams/hour. How many mL/hour should the nurse set the infusion pump for? Record your answer using a whole number. Your Response: • 10 Correct response: • 50 Explanation: X = 500mL/20grams x 2grams/hour. X = 50 mL/hour. Question 10 See full question A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days postmature. Which of the following physical findings contradicts the estimated gestational age of the newborn? You Selected: • Increased amounts of vernix Correct response: • Increased amounts of vernix Question 1 See full question A postpartum client's husband calls the nurse and says, "My wife feels funny." The nurse enters the room and notes blood gushing from the client's vagina, pallor, and a rapid, thready pulse. What should be the nurse's first intervention? You Selected: • Massage the fundus. Correct response: • Massage the fundus. Explanation: Remediation: Question 2 See full question A client scheduled for a vasectomy asks the nurse how soon after the procedure he can have sexual intercourse without using an alternative birth control method. How should the nurse respond? You Selected: • "You can safely have unprotected intercourse when your sperm count indicates sterilization." Correct response: • "You can safely have unprotected intercourse when your sperm count indicates sterilization." Explanation: Remediation: Question 3 See full question A 15-year-old primigravid client at approximately 16 weeks’ gestation tells the nurse that she has been experiencing an occasional sharp pain from the fundus to her pubic bone on the left side. The nurse determines that the client is most likely experiencing which complication? You Selected: • round ligament pain Correct response: • round ligament pain Explanation: Remediation: Question 4 See full question When preparing the room for admission of a multigravid client at 36 weeks’ gestation diagnosed with severe preeclampsia, which item is most important for the nurse to obtain? You Selected: • padding for the side rails Correct response: • padding for the side rails Explanation: Remediation: Question 5 See full question The nurse is caring for a 15-year-old adolescent mother after childbirth. The adolescent lives at home with her parents and has a boyfriend who is also 15 years old. Neither is currently working, and they both have plans for higher education. When addressing the psychosocial issues that may occur after the birth of the child, which of the following would be the most important for the nurse to include in his/her teaching? You Selected: • Increased stress for new mothers Correct response: • Increased stress for new mothers Explanation: Remediation: Question 6 See full question A client thinks that she is 7 weeks pregnant. The nurse would explain that which assessment would best confirm pregnancy? You Selected: • Obtain a positive pregnancy test Correct response: • Obtain a positive pregnancy test Explanation: Remediation: Question 7 See full question A client asks why she feels so much variability in fetal activity each day. The nurse explains that fetal movement is affected by which factors? Select all that apply. You Selected: • time of day • barometric pressure • cigarette smoking Correct response: • fetal sleep • blood glucose • time of day • cigarette smoking Explanation: Remediation: Question 8 See full question A primigravid client at 38 weeks’ gestation comes to the labor room because “my water broke.” The health care provider (HCP) asks the nurse to verify spontaneous rupture of membranes using nitrazine paper. The nurse observes that the nitrazine paper turns bright blue. The nurse’s next action should be to: You Selected: • document the findings of the nitrazine test. Correct response: • notify the HCP that the membranes are ruptured. Explanation: Remediation: Question 9 See full question The nurse is performing a vaginal examination on a client in labor. The nurse finds the fetal presenting part 1 cm above the ischial spines. The nurse should chart the station as: You Selected: • -1 station. Correct response: • -1 station. Explanation: Remediation: Question 10 See full question A nurse is caring for a woman G1 P0 at 40 weeks gestation in active labor. Assessments include: cervix 5 cm dilated; 90% effaced; station 0; cephalic presentation; FHR baseline is 135 bpm and decreases to 125 bpm shortly after onset of 5 uterine contractions and returns to baseline before the uterine contraction ends. Based on this assessment, what action should the nurse take first? You Selected: • Notify the health care provider (HCP) immediately, and prepare for emergency caesarean section. Correct response: • Document findings on the client’s chart, and continue to monitor labor progress. Question 1 See full question During an annual checkup, a client tells the nurse that she and her partner have decided to start a family. Ideally, when should the nurse plan for childbirth education to begin and end? You Selected: • It should begin before conception and end 3 months after childbirth. Correct response: • It should begin before conception and end 3 months after childbirth. Explanation: Remediation: Question 2 See full question A nurse is providing discharge teaching to a postpartum client. Which instruction is the priority to include in her teaching? You Selected: • "If you have excessive vaginal bleeding, massage your fundus and call the physician." Correct response: • "If you have excessive vaginal bleeding, massage your fundus and call the physician." Explanation: Remediation: Question 3 See full question A primigravid client in a preparation for parenting class asks how much blood is lost during an uncomplicated vaginal birth. The nurse should tell the woman: You Selected: • "The minimum blood loss considered within normal limits is 1,000 ml." Correct response: • "The maximum blood loss considered within normal limits is 500 ml." Explanation: Remediation: Question 4 See full question A young female client is receiving chemotherapy and mentions to the nurse that she and her husband are using a diaphragm for birth control. Which information is most important for the nurse to discuss? You Selected: • body changes related to hormones Correct response: • infection control Explanation: Remediation: Question 5 See full question The nurse is caring for a client that has been in labor for 6 hours. When does the nurse document that the client has ended the third stage of labor? You Selected: • When the placenta has been birthed Correct response: • When the placenta has been birthed Question 1 See full question Before advising a 24-year-old client desiring oral contraceptives for family planning, the nurse would assess the client for which signs and symptoms? You Selected: • hypertension Correct response: • hypertension Explanation: Remediation: Question 2 See full question When conducting a health history with a female client with thyrotoxicosis, the nurse should ask about which change in the menstrual cycle? You Selected: • oligomenorrhea Correct response: • oligomenorrhea Explanation: Remediation: Question 3 See full question A primigravid client in early labor with abruptio placentae develops disseminated intravascular coagulation (DIC). Which agent should the nurse expect the health care provider (HCP) to prescribe? You Selected: • fresh-frozen platelets Correct response: • fresh-frozen platelets Explanation: Remediation: Question 4 See full question A woman with preeclampsia is receiving magnesium sulfate via infusion pump at 1 gram/hour. The nurse’s assessment includes: temperature 36.7° C; pulse 78; respirations 12/minute; B/P 128/82; urinary output 90 mLs in last 4 hours via Foley catheter; patellar-tendon reflex absent; ankle clonus absent; fetal heart rate 120 beats per minute; cervix 4 cm dilated, 80% effaced, station –1. You Selected: • Document findings and continue to monitor her progress in labor. Correct response: • Discontinue the magnesium sulfate infusion and notify the health care provider (HCP). Explanation: Remediation: Question 5 See full question A nurse is caring for a premenopausal client who had precancerous cells found during a routine papanicolaou (Pap) test. At which time during the menstrual cycle would the nurse schedule a cervical biopsy? You Selected: • One week after the end of the menstrual period Correct response: • One week after the end of the menstrual period Question 1 See full question When teaching a group of pregnant adolescents about reproduction and conception, the nurse is correct when stating that fertilization occurs: You Selected: • in the first third of the fallopian tube. Correct response: • in the first third of the fallopian tube. Explanation: Remediation: Question 2 See full question After surgery to remove a ruptured fallopian tube, a multigravid client receives discharge instructions about potential complications to report to her physician. Which of the following, if stated by the client as a complication, indicates a need for additional teaching? You Selected: • Headache. Correct response: • Headache. Explanation: Question 3 See full question The nurse is teaching a young woman about using oxcarbazepine to control seizures. The nurse determines teaching is effective when the client states: You Selected: • "I will use one of the barrier methods of contraception." Correct response: • "I will use one of the barrier methods of contraception." Explanation: Remediation: Question 4 See full question The nurse is caring for a client in labor who is worried about having an episiotomy. Which of the following interventions will the nurse include in the client’s plan of care? Select all that apply. You Selected: • Encouraging a gradual expulsion of the infant • Avoiding side-lying position for pushing • Encouraging immediate pushing after epidural placement Correct response: • Avoiding the lithotomy position while pushing • Placing warm or hot compresses on the perineum • Encouraging a gradual expulsion of the infant Explanation: Remediation: Question 5 See full question A nurse is caring for a primigravid client at 40 weeks gestation in active labor. Assessments include: cervix 5 cm dilated; 90% effaced; station 0; cephalic presentation, FHR baseline is 135 bpm and decreases to 125 bpm shortly after onset of 5 uterine contractions and returns to baseline before the uterine contraction ends. Based on this assessment what action should the nurse take first? You Selected: • Perform vaginal exam to rule out umbilical cord prolapse. Correct response: • Document findings on the woman’s medical record, and continue to monitor labor progress. Explanation: Question 1 See full question The nurse, while shopping in a local department store, hears a multiparous woman say loudly, "I think the baby is coming." After asking someone to call 911, the nurse assists the client to give birth to a term neonate. While waiting for the ambulance, the nurse suggests that the mother initiate breastfeeding, primarily for what reason? You Selected: • to begin the parental-infant bonding process Correct response: • to contract the mother's uterus Explanation: Remediation: Question 2 See full question The charge nurse is preparing for the day shift on the labor and birth unit. Which would be included in the responsibilities for this position? Select all that apply. You Selected: • Follow up with the primary nurse after a birth. • Admit the new labor patient sent from the triage area. • Review the current status of each labor patient with the primary nurse. Correct response: • Review the current status of each labor patient with the primary nurse. • Follow up with the primary nurse after a birth. • Complete report of unit with the oncoming charge nurse. Explanation: Question 3 See full question 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 information would the nurse expect to include in the client's teaching plan? You Selected: • As ovulation approaches, cervical mucus is abundant and clear. Correct response: • As ovulation approaches, cervical mucus is abundant and clear. Explanation: Question 4 See full question A nurse observes a deceleration on the fetal heart tracing of a woman in labor. The nurse anticipates that which of the following is causing an early deceleration? You Selected: • Umbilical cord compression Correct response: • Fetal head compression Explanation: Remediation: Question 5 See full question A nurse is preparing to teach a client about fetal growth and development during the first 3 months of pregnancy. The nurse is assembling teaching aids by milestones. In ascending order, (month 1, month 2, month 3, and months 4 to 9), how would the nurse arrange the aids? All options must be used. You Selected: • Teeth and bones begin to appear, the kidneys start to function and, at the end of the month, gender is distinguishable. • The embryo has a definite form; the head, trunk, and tiny buds for arms and legs develop; and the cardiovascular system begins to function. • Internal and external fetal growth continues at a rapid rate, and the fetus stores the fats and minerals it needs to live outside the womb. • The eyes, ears, nose, lips, tongue, and tooth buds develop; the umbilical cord has a definite form; and the external genitalia are present. Correct response: • The embryo has a definite form; the head, trunk, and tiny buds for arms and legs develop; and the cardiovascular system begins to function. • The eyes, ears, nose, lips, tongue, and tooth buds develop; the umbilical cord has a definite form; and the external genitalia are present. • Teeth and bones begin to appear, the kidneys start to function and, at the end of the month, gender is distinguishable. • Internal and external fetal growth continues at a rapid rate, and the fetus stores the fats and minerals it needs to live outside the womb. Question 1 See full question Which information would the nurse include in the teaching plan for a 32-year-old female client requesting information about using a diaphragm for family planning? You Selected: • Diaphragms should not be used if the client develops acute cervicitis. Correct response: • Diaphragms should not be used if the client develops acute cervicitis. Explanation: Question 2 See full question A client is planning to be treated for infertility with the zygote intrafallopian transfer (ZIFT) method. Which information should the nurse include when teaching the client about this type of treatment method? You Selected: • Fertilization takes place outside of the body. Correct response: • Fertilization takes place outside of the body. Explanation: Question 3 See full question A 15-year-old primigravid client at approximately 16 weeks’ gestation tells the nurse that she has been experiencing an occasional sharp pain from the fundus to her pubic bone on the left side. The nurse determines that the client is most likely experiencing which complication? You Selected: • round ligament pain Correct response: • round ligament pain Explanation: Remediation: Question 4 See full question A primiparous client who is bottle-feeding her neonate at 12 hours after birth asks the nurse, “When will my menstrual cycle return?” Which response by the nurse would be most appropriate? You Selected: • “It will probably be 6 to 10 weeks before it starts again.” Correct response: • “It will probably be 6 to 10 weeks before it starts again.” Explanation: Question 5 See full question On arrival at the emergency department, a client tells the nurse that she suspects that she may be pregnant but has been having a small amount of bleeding and has severe pain in the lower abdomen. The client's blood pressure is 70/50 mm Hg, and her pulse rate is 120 bpm. The nurse notifies the primary health care provider (HCP) immediately because of the possibility of: You Selected: • ectopic pregnancy. Correct response: • ectopic pregnancy. Explanation: Remediation: Question 6 See full question The nurse is caring for a client in labor who has tested positive for gonorrhea. Which of the following will the nurse include in the client’s plan of care? You Selected: • Administer erythromycin eye drops to the infant after birth Correct response: • Administer erythromycin eye drops to the infant after birth Explanation: Remediation: Question 7 See full question A nurse is caring for a client who is anxious to know her baby’s due date. The nurse instructs the client on how to determine the baby’s due date according to Nägele’s rule. The client is correct to state which of the following when discussing the use of the rule. Select all that apply. You Selected: • “I need to know the date of intercourse.” • “Nägele’s rule provides a good approximation of the due date.” • “I will add seven days to the first day of my last menstrual period and count back 3 months.” • “Nägele’s rule may be used in conjunction with other assessment findings.” Correct response: • “Nägele’s rule provides a good approximation of the due date.” • “I will add seven days to the first day of my last menstrual period and count back 3 months.” • “Nägele’s rule may be used in conjunction with other assessment findings.” Explanation: Remediation: Question 8 See full question A nurse is monitoring the contractions of a client in the first stage of labor. Order the phases of a uterine contraction from the beginning of contraction to its conclusion. All options must be used. You Selected: • Acme. • Relaxation. • Decrement. • Increment. Correct response: • Increment. • Acme. • Decrement. • Relaxation. Explanation: Remediation: Question 9 See full question ? You Selected: • "I plan to get pregnant again next year.” Correct response: • "I know the placenta caused problems, and my baby died in my uterus." Explanation: Question 10 See full question The nurse is working in the labor and child birth unit when a mother with active herpes simplex virus-Type 2 (HSV-2) appears in active labor. Which adjustment in the plan of care is anticipated? You Selected: • Prepare the mother for a cesarean section Correct response: • Prepare the mother for a cesarean section Explanation: Question 1 See full question At what gestational age should a primigravida expect to start feeling quickening? You Selected: • 18 to 20 weeks Correct response: • 18 to 20 weeks Explanation: Remediation: Question 2 See full question A young female client is receiving chemotherapy and mentions to the nurse that she and her husband are using a diaphragm for birth control. Which information is most important for the nurse to discuss? You Selected: • infection control Correct response: • infection control Explanation: Remediation: Question 3 See full question A nurse is caring for a newborn exposed to drugs while in utero. Which of the following behaviors will the nurse expect the newborn to exhibit? Select all that apply. You Selected: • Tachypnea with excessive secretions • Hyperactivity and increased muscle tone • Sensitive gag reflex Correct response: • Tachypnea with excessive secretions • Sensitive gag reflex • Hyperactivity and increased muscle tone Explanation: Remediation: Question 4 See full question The nurse is caring for four clients in labor. Which client is at most risk for a postpartum hemorrhage? You Selected: • a client who is a gravida 4 para 3 with a history of polyhydramnios with this pregnancy Correct response: • a client who is a gravida 4 para 3 with a history of polyhydramnios with this pregnancy Explanation: Remediation: Question 5 See full question A client at 32 weeks of gestation has mild preeclampsia. She is discharged home with instructions to remain in bed rest. She would also be instructed to call her health care provider if she experiences which of the following symptoms? Select all that apply. You Selected: • Headache • Epigastric pain • Severe nausea and vomiting • Blurred vision Correct response: • Headache • Blurred vision • Epigastric pain • Severe nausea and vomiting Question 1 See full question During the first 3 months, which hormone is most responsible for maintaining pregnancy? You Selected: • Human chorionic gonadotropin (hCG) Correct response: • Human chorionic gonadotropin (hCG) Explanation: Remediation: Question 2 See full question 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 complication? You Selected: • congenital anomalies Correct response: • congenital anomalies Explanation: Question 3 See full question A nurse is caring for a client who is in the third stage of labor. Which characteristic behaviors does the nurse anticipate at this stage? Select all that apply. You Selected: • The client is apprehensive about the process. Correct response: • The client is focused on the neonate’s condition. • The client states she has discomfort from uterine contractions. Explanation: Remediation: Question 4 See full question A primigravid client at 38 weeks’ gestation comes to the labor room because “my water broke.” The health care provider (HCP) asks the nurse to verify spontaneous rupture of membranes using nitrazine paper. The nurse observes that the nitrazine paper turns bright blue. The nurse’s next action should be to: You Selected: • notify the HCP that the membranes are ruptured. Correct response: • notify the HCP that the membranes are ruptured. Question 1 See full question A postpartum client visits her physician to discuss contraception. After a thorough discussion, the client decides to use hormonal contraceptives. The physician orders ethinyl estradiol-ethynodiol diacetate, one tablet by mouth daily, followed by 7 days without a dose before beginning the next cycle of tablets. Which type of combination hormonal contraceptive is ethinyl estradiol-ethynodiol diacetate? You Selected: • Progestin-dominant triphasic Correct response: • Monophasic Explanation: Ethinyl estradiol-ethynodiol diacetate is a monophasic oral contraceptive agent. Remediation: Question 2 See full question A client has obtained levonorgestrel 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 statement? You Selected: • "I can wait up to 4 days after intercourse to start taking these to prevent pregnancy." Correct response: • "I can wait up to 4 days after intercourse to start taking these to prevent pregnancy." Explanation: Levonorgestrel can reduce the chance of pregnancy if taken within 72 hours of unprotected intercourse, but 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. Levonorgestrel works by preventing ovulation or fertilization depending on where a client is the menstrual cycle. Common side effects include nausea, breast tenderness, vertigo, and stomach pain. Question 3 See full question A client taking oral contraceptives is placed on a 10-day course of antibiotics for an infection. Which instruction should the nurse include in the teaching plan? You Selected: • "Use a barrier method of birth control for the rest of your cycle." Correct response: • "Use a barrier method of birth control for the rest of your cycle." Explanation: Antibiotics may decrease the effectiveness of oral contraceptives. The client should be instructed to continue the contraceptives and use a barrier method as a backup method of birth control until the next menstrual cycle. The client should not stop taking her oral contraceptives, and there is no indication for or benefit to taking the antibiotic 2 hours after the contraceptive. There is no incidence of the adverse effects of increased hunger and fluid retention with the interaction of antibiotic therapy and oral contraceptives. Question 4 See full question A client diagnosed with testicular cancer expresses concerns about fertility. The client and his spouse desire to eventually have a family, and the nurse discusses the option of sperm banking. The nurse should inform the couple that sperm banking would need to be performed: You Selected: • before treatment is started. Correct response: • before treatment is started. Explanation: Because of the high risk of infertility with chemotherapy, pelvic irradiation, and retroperitoneal lymph node dissection that may follow an orchiectomy, cryopreservation of sperm is completed before treatment is started and should be discussed with the client. Remediation: Question 5 See full question A client two days postpartum was given a shot of RhoGAM. At the postpartum home visit, the client asks the nurse why she needed RhoGAM. Which of the following is the most appropriate response by the nurse? You Selected: • “RhoGAM suppresses antibody formation in women with Rh positive blood after giving birth to an Rh negative baby.” Correct response: • “RhoGAM suppresses antibody formation in women with Rh negative blood after giving birth to an Rh positive baby.” Explanation: RhoGAM is indicated to suppress antibody formation in women with Rh negative blood after giving birth to an RH positive baby. It is also given to Rh negative women after miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, and amniocentesis. Remediation: Question 6 See full question A client is a gravida 2 para 1 and is currently 12 weeks gestation. She states that she drank beer throughout her last pregnancy. The client asks the nurse if it is okay to have a few drinks during this current pregnancy. Which of the following responses by the nurse would be most appropriate? You Selected: • “It is not safe to consume alcohol during pregnancy.” Correct response: • “It is not safe to consume alcohol during pregnancy.” Explanation: Complete abstinence from alcohol use during pregnancy is recommended. A safe level of alcohol consumption during pregnancy has not yet been established. Conclusive evidence surrounding the effects of either social or moderate drinking on the fetus, regardless of trimester or gestation, are not available. The best answer is to advise the pregnant women to abstain from all alcohol usage. Remediation: Question 7 See full question A client at 37 weeks gestation is at a prenatal visit and states that she sometimes feels dizzy when lying directly on her back. Which of the following is the nurse’s best response? You Selected: • “Do you have a family history of cardiac-related illnesses?” Correct response: • “This may be due to the uterus putting pressure on a blood vessel.” Explanation: During pregnancy, the uterus enlarges, and if the client is lying in a supine position, the uterus may put pressure on the vena cava, causing supine hypotensive syndrome. This pressure on the vena cava causes a decrease in blood flow and a decrease in blood pressure. Often the client will describe symptoms of dizziness, pallor, and clamminess. Instruct the client to lie on her left side to avoid this type of episode. This is not a normal occurrence, but rather a common experience, given the client’s description, and warrants discussion. It would be inappropriate to assume that this is due to low hemoglobin. Asking the client of any family cardiac history may imply the nurse’s assumption of cardiac complication and may not be the most appropriate response given the client’s description of what is being experienced. Remediation: Question 8 See full question The nurse is assessing a client who is 4 hours postpartum. Based on the findings documented by the nurse, which action is most appropriate at this time? You Selected: • Notify the charge nurse of the assessment findings. Correct response: • Ask the client to empty her bladder. Explanation: A full bladder may displace the uterine fundus to the left or right of the abdomen. A straight catheterization is unnecessarily invasive if the client can urinate on her own. Nursing interventions would be completed before notifying the primary health-care provider or charge nurse in a nonemergency situation. Raising the head of the bed is not helpful to change the position of the uterus. Remediation: Question 9 See full question The nurse is performing a newborn assessment on a neonate in the childbirth suite. The nurse notes epispadias. Which documentation of the defect would the nurse note You Selected: • C Correct response: • C Explanation: Question 10 See full question At an initial prenatal visit the client tells the nurse that her last menstrual period started on April 14th. Using Naegele’s rule, the nurse determines the woman’s estimated due date is when? You Selected: • January 21 Correct response: • January 21 Explanation: Naegele’s rule is a mathematical equation that uses a woman’s last menstrual period (LMP) to estimate a pregnant client’s dues date. The formula is LMP + 7 days ? 3 months. Here the LMP is: April 14th + 7 days = April 21st; April 21st ? 3 months = January 21st. Question 1 See full question A nurse visits a client at home on the 10th postpartum day. When assessing the client's uterus, which finding requires further evaluation? You Selected: • Lochia alba Correct response: • A fundus palpable at the umbilicus Explanation: A fundus palpable at the umbilicus 10 days postpartum is abnormal. The fundus is typically at this level 1 hour after delivery. By the 10th day postpartum, the uterus should no longer be palpable. Lochia alba is normal at 10 days postpartum. Minimal afterpains when nursing is a normal finding. Remediation: Question 2 See full question A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for: You Selected: • hypotension. Correct response: • hypotension. Explanation: When a client receives an epidural anesthetic, sympathetic nerves are blocked along with the pain nerves, possibly resulting in vasodilation and hypotension. Other adverse effects include bladder distention, prolonged second stage of labor, nausea and vomiting, pruritus, and delayed respiratory depression for up to 24 hours after administration. Diaphoresis and tremors are not usually associated with the administration of epidural anesthesia. Headache, a common adverse effect of many drugs, also is not associated with administration of epidural anesthesia. Remediation: Question 3 See full question The health care provider (HCP) has determined that a preterm labor client at 34 weeks' gestation has no fetal fibronectin present. Based on this finding, the nurse would anticipate that within the next week: You Selected: • the client will not develop preterm labor. Correct response: • the client will not develop preterm labor. Explanation: The absence of fetal fibronectin in a vaginal swab between 22 and 37 weeks’ gestation indicates there is less than 1% risk of developing preterm labor in the next week. Fetal fibronectin is an extra cellular protein normally found in fetal membranes and deciduas and has no correlation with preeclampsia, fetal lung maturation, or gestational diabetes. Remediation: Question 4 See full question The nurse is working with four clients on the obstetrical unit. Which client will be the highest priority for a cesarean section? You Selected: • client at 38 weeks' gestation with active herpes lesions Correct response: • client at 38 weeks' gestation with active herpes lesions Explanation: Herpes simplex virus can be transmitted to the infant during a vaginal birth. The neonatal effects of herpes are severe enough that a cesarean birth is warranted if active lesions—primary or secondary—are present. A client with a primary infection during pregnancy sheds the virus for up to 3 months after the lesion has healed. The client carrying an infant weighing 8 lb (3,629 g) will be given a trial of labor before a cesarean. The client with a fetus in the right occiput posterior position will have a slow labor with increased back pain but can give birth vaginally. The fetus in a breech position still has many weeks to change positions before being at term. At 7 months’ gestation, the breech position is not a concern. Remediation: Question 5 See full question A 39-year-old multigravid client asks the nurse for information about female sterilization with a tubal ligation. Which client statement indicates effective teaching? You Selected: • "My fallopian tubes will be tied off through a small abdominal incision." Correct response: • "My fallopian tubes will be tied off through a small abdominal incision." Explanation: Tubal ligation, a female sterilization procedure, involves ligation (tying off) or cauterization of the fallopian tubes through a small abdominal incision (laparotomy). Reversal of a tubal ligation is not easily done, and the pregnancy success rate after reversal is about 30%. After a tubal ligation, the client may engage in intercourse 2 to 3 days after the procedure. The ovaries are not generally removed during a tubal ligation. An oophorectomy involves removal of one or both ovaries. Remediation: Question 6 See full question A client has stress incontinence. Which data from the client's history contributes to the client's incontinence? You Selected: • the client's history of three full-term pregnancies Correct response: • the client's history of three full-term pregnancies Explanation: The history of three pregnancies is most likely the cause of the client’s current episodes of stress incontinence. The client’s fluid intake, age, or history of swimming would not create an increase in intra-abdominal pressure. Remediation: Question 7 See full question The nurse is admitting a primigravid client at 37 weeks' gestation who has been diagnosed with preeclampsia to the labor and birth area. Which client care rooms is most appropriate for this client? You Selected: • a darkened private room as close to the nurses' station as possible Correct response: • a darkened private room as close to the nurses' station as possible Explanation: A primigravid client diagnosed with preeclampsia has the potential for developing seizures (eclampsia). This client should be in a room with the least amount of stimulation possible to reduce the risk of seizures and as close to the nurses’ station as possible in case the client requires immediate assistance. Bright lighting and sunshine can be a stimulant, possibly increasing the risk of seizures, as can being in a semiprivate room with roommate, visitors, conversation, and noise. Remediation: Question 8 See full question A client in labor is given 25 mg of intravenous (IV) meperidine for labor pain. The nurse should monitor the client for which adverse effects of the drug? Select all that apply. You Selected: • Tachycardia • Respiratory depression • Nausea and vomiting Correct response: • Nausea and vomiting • Respiratory depression • Tachycardia Explanation: Adverse effects of meperidine include hypotension (not hypertension), nausea, vomiting, respiratory depression, urinary retention (not urinary incontinence), tachycardia, sedation, drowsiness, and decreased uterine activity. Remediation: Question 9 See full question The nurse is teaching a G2P1 client about her upcoming labor. Which of the following responses would indicate to the nurse that further teaching is necessary? You Selected: • “I can wait until my contractions are every 2 minutes to contact the physician because my first labor was so long.” Correct response: • “I can wait until my contractions are every 2 minutes to contact the physician because my first labor was so long.” Explanation: Although a woman having her second baby (gravida 2) may have a shorter labor than her first labor, she should still contact the healthcare provider when the contractions are every 5 minutes apart for at least 1 hour. Waiting until the contractions are every 2 minutes is too late. Braxton Hicks contractions do not cause cervical dilation and may stop when the client ambulates or hydrates. As a woman’s cervix begins to efface, she may experience a blood-tinged mucus, known as a bloody show. Remediation: Question 10 See full question A woman who delivered her last infant by caesarean section is admitted to the hospital at term with contractions every 5 minutes. The health care provider (HCP) intends to have her undergo “a trial labor.” The nurse explains to the client that: You Selected: • labor progress will be evaluated continually to determine appropriate progress for a vaginal delivery. Correct response: • labor progress will be evaluated continually to determine appropriate progress for a vaginal delivery. Explanation: A trial labor in this context means that the woman is allowed to go into labor, and her progress is assessed by cervical dilation and effacement as well as fetal descent evaluated to determine whether to allow the labor to progress to delivery. If there are indications that labor is not progressing, other means of delivery are considered. Labor stimulation is used cautiously and may not be safe. The presence of contractions every 5 minutes indicates true labor. If fetal distress is noted and an emergency cesarean section cannot be done immediately, tocolytic agents may be considered to stop contractions. Question 1 See full question A client has expressed her desire to give birth with minimal intervention. She is now moving into the active phase of labor. What intervention by the nurse would be the priority of care? You Selected: • Offering support by reviewing the short-pant form of breathing Correct response: • Offering support by reviewing the short-pant form of breathing Explanation: By helping the client use the pant form of breathing, the nurse can help the client manage her contractions. This is appropriate because the client has expressed a desire to deliver with minimal intervention. The client may elect to have opiod analgesia or epidural anesthesia at some point, but this is not the priority at this time. The nurse will observe for ruptured membranes, but this is not the priority. Remediation: Question 2 See full question Normal lochial findings in the first 24 hours after birth include: You Selected: • bright red blood. Correct response: • bright red blood. Explanation: Bright red blood is a normal lochial finding in the first 24 hours after birth. Lochia should never contain large clots, tissue fragments, or membranes. A foul odor or absence of lochia may signal infection. Remediation: Question 3 See full question The nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be: You Selected: • red and moderate. Correct response: • red and moderate. Explanation: During the first 3 days, the lochia will be red (lochia rubra) with moderate flow. Note, however, that the client shouldn't be soaking more than one pad every hour. A continuous flow of moderately clotted blood from the vagina isn't normal and should be reported. Clots may indicate retained pieces of placenta. Lochia changes to pink or brown (lochia serosa) after 3 to 10 days. By day 10, the lochia should be white (lochia alba) and continue for several weeks. Remediation: Question 4 See full question A couple has completed testing and is a candidate for in vitro fertilization. The nurse is reviewing the procedure with them and realizes that further instruction is needed when the woman states: You Selected: • "The fertilization procedure can be done anytime during my cycle." Correct response: • "The fertilization procedure can be done anytime during my cycle." Explanation: Remediation: Question 5 See full question A nulliparous client says that she and her husband plan to use a diaphragm with spermicide to prevent conception. Which should the nurse include as the action of spermicides when teaching the client? You Selected: • destruction of spermatozoa before they enter the cervix Correct response: • destruction of spermatozoa before they enter the cervix Explanation: Spermicidal agents work by destroying the spermatozoa before they enter the cervix. In addition, some spermicides alter the vaginal pH to a strong acidic environment, which is not conducive to survival of spermatozoa. Spermicides do not prevent the spermatozoa from entering the uterus, but the diaphragm or condom is a barrier. Question 6 See full question Four hours after cesarean birth of a neonate weighing 8 lb, 13 oz (4,000 g), the primiparous client asks, “If I get pregnant again, will I need to have a cesarean?” When responding to the client, the nurse should base the response to the client about vaginal birth after cesarean (VBAC) on which standard of practice? You Selected: • VBAC may be possible if the client has not had a classic uterine incision. Correct response: • VBAC may be possible if the client has not had a classic uterine incision. Explanation: VBAC can be attempted if the client has not had a classic uterine incision. This type of incision carries a danger of uterine rupture. A health care provider (HCP) must be available, and a cesarean birth must be possible within 30 minutes. A history of rapid labor is not a criterion for VBAC. A low transverse incision is not a contraindication for VBAC. A classic (vertical) incision is a contraindication because the client has a greater possibility for uterine rupture. Estimated fetal weight greater than 4,000 g by itself is not a contraindication if the mother is not diabetic. Remediation: Question 7 See full question A primigravida, currently about 8 weeks pregnant, and her husband ask when they should begin the preparation for childbirth classes that discuss maternal nutrition during pregnancy. Which time would be most appropriate for the nurse to suggest that they begin the classes? You Selected: • now during the first trimester of pregnancy Correct response: • now during the first trimester of pregnancy Explanation: Remediation: Question 8 See full question A laboring client is experiencing increased pain and asks the nurse when she can have an epidural. Which of the following would be a priority intervention by the nurse to establish whether the client can have an epidural? You Selected: • Assess cervical dilation. Correct response: • Assess cervical dilation. Explanation: It is imperative that the epidural be administered when the woman is in active labor and at a cervical dilation of 4-5 cm to receive optimal effect. The nurse would first assess whether the client is eligible for an epidural before consulting anesthesia. Measuring the intensity of the client’s contraction would not give the nurse the information needed to make a clinical judgment. The client’s response to IV morphine would not determine the client’s eligibility to an epidural. Remediation: Question 9 See full question A client in labor received an epidural for pain management. Before receiving the epidural, the client’s blood pressure was 124/76 mm Hg. Ten minutes after receiving the epidural, the client’s blood pressure is 98/56 mm Hg, and the mother is vomiting. Before calling the health care provider (HCP), the nurse should: You Selected: • turn the client to her side. Correct response: • turn the client to her side. Explanation: The nurse should turn the client to the side to reduce pressure on the abdominal aorta. The IV fluid rate would be increased, not decreased. There is no information indicating the client has a full bladder or requires a vaginal examination. Remediation: Question 10 See full question The nurse is caring for a client who has a history of gastric bypass surgery and is now being seen for her first prenatal visit. Which interventions should be included in the plan of care? Select all that apply. You Selected: • Check urine at each visit for protein and glucose. • Take a prenatal vitamin with 400 mcg of folic acid. • Refer the client to a registered dietician. Correct response: • Take a prenatal vitamin with 400 mcg of folic acid. • Refer the client to a registered dietician. • Check urine at each visit for protein and glucose. Question 1 See full question A postpartum client's husband calls the nurse and says, "My wife feels funny." The nurse enters the room and notes blood gushing from the client's vagina, pallor, and a rapid, thready pulse. What should be the nurse's first intervention? You Selected: • Massage the fundus. Correct response: • Massage the fundus. Explanation: Postpartum hemorrhage results in excessive vaginal bleeding and signs of shock, such as pallor and a rapid, thready pulse. Placental separation causes a sudden gush or trickle of blood from the vagina, rise of the fundus in the abdomen, increased umbilical cord length at the introitus, and a globe-shaped uterus. Uterine involution causes a firmly contracted uterus, which cannot occur until the placenta is delivered. Cervical lacerations produce a steady flow of bright red blood in a client with a firmly contracted uterus. The priority measure to correct postpartum hemorrhage is to massage the fundus. Packing the uterus with sterile gauze is contraindicated. The physician will have to be called but the nurse must first intervene. Remediation: Question 2 See full question A client scheduled for a vasectomy asks the nurse how soon after the procedure he can have sexual intercourse without using an alternative birth control method. How should the nurse respond? You Selected: • "You can safely have unprotected intercourse when your sperm count indicates sterilization." Correct response: • "You can safely have unprotected intercourse when your sperm count indicates sterilization." Explanation: After a vasectomy, sterilization isn't ensured until the client's sperm count measures zero. This usually requires 6 to 36 ejaculations. Having intercourse immediately after the procedure or as soon as discomfort disappears may lead to pregnancy. Remediation: Question 3 See full question A young female client is receiving chemotherapy and mentions to the nurse that she and her husband are using a diaphragm for birth control. Which information is most important for the nurse to discuss? You Selected: • infection control Correct response: • infection control Explanation: The risk of becoming neutropenic during chemotherapy is very high. Therefore, an inserted foreign object such as a diaphragm may be a nidus for infection. Although the nurse may wish to inform the client about the ease with which various contraceptive modalities may be used, the focus of this discussion should be on preventing an infection, which can be fatal for the neutropenic client. There are no data to suggest the client is at risk for acquiring a sexually transmitted disease. The client will not be experiencing body changes directly related to hormonal changes. Remediation: Question 4 See full question A 16-year-old primigravida at 36 weeks' gestation who has had no prenatal care experienced a seizure at work and is being transported to the hospital by ambulance. What should the nurse do upon the client’s arrival? You Selected: • Position the client in a supine position. Correct response: • Admit the client to a quiet, darkened room. Explanation: Because of her age and report of a seizure, the client is probably experiencing eclampsia, a condition in which convulsions occur in the absence of any underlying cause. Although the actual cause is unknown, adolescents and women older than 35 years are at higher risk. The client’s environment should be kept as free of stimuli as possible. Thus, the nurse should admit the client to a quiet, darkened room. Clients experiencing eclampsia should be kept on the left side to promote placental perfusion. In some cases, edema of the lungs develops after seizures and is a sign of cardiovascular failure. Because the client is at risk for pulmonary edema, breath sounds should be monitored every 2 hours. Vital signs should be monitored frequently, at least every hour. Remediation: Question 5 See full question The antenatal clinic nurse is educating a client with gestational diabetes soon after diagnosis. Evaluation for this client session will include which outcome? Select all that apply. You Selected: • The client describes her planned walking program while pregnant. • The client will strive to maintain a hemoglobin A1C less than 6%. • The client will continue her prenatal vitamins, iron, and folic acid. Correct response: • The client states the need to maintain blood glucose levels between 70 to 110 mg/dL (3.9 to 6.2 mmol/L). • The client describes her planned walking program while pregnant. • The client will strive to maintain a hemoglobin A1C less than 6%. • The client will continue her prenatal vitamins, iron, and folic acid. Explanation: The gestational diabetic needs to maintain blood glucose levels as close to “normal” as the nondiabetic pregnant woman. Walking is an excellent form of exercise for anyone and works well for pregnant diabetics as it burns calories, accelerates the heart rate, and as a result maintains the blood sugar at a lower level. During pregnancy continuously high blood glucose levels measured by a hemoglobin A1C of greater than 6 mg/dL (60 g/L) carry risks for the dyad. The suggested diet for a gestational diabetic is 1,800 to 2,400 cal/day to avoid the body breaking down maternal fat to maintain blood glucose levels. Continuing prenatal vitamins, iron, and folic acid (800 mcg/day) are general nutritional recommendations for pregnancy. Remediation: Question 6 See full question A woman’s breasts undergo anatomic and physiologic changes during pregnancy and lactation. Which of the following is true? You Selected: • The alveolar cells being to secrete colostrum. Correct response: • The alveolar cells being to secrete colostrum. Explanation: During the second half of pregnancy, the alveolar cells may begin to secrete colostrum. During pregnancy, the nipples expand and darken, and the sebaceous glands in the areola hypertrophy. Colostrum that contains important nutrients for the newborn is produced during the second half of pregnancy. Remediation: Question 7 See full question The nurse brings the infant to the new mother after obtaining assessment data and performing newborn interventions. Which of the following behaviors exhibited by the mother demonstrates that effective bonding is beginning to take place? You Selected: • The mother looks at the newborn with direct eye contact. Correct response: • The mother looks at the newborn with direct eye contact. Explanation: Successful bonding occurs when the mother looks at her newborn’s face, with direct eye contact (termed an en face position) and is a sign that the mother is beginning effective bonding. Touching the newborn through the blanket and touching with one fingertip occurs before bonding takes place. Remediation: Question 8 See full question The nurse performs a routine prenatal assessment on a woman at 35 weeks gestation and finds vital signs: blood pressure 138/88 mm Hg, pulse 82/min, respirations 18/min, temperature 99.1° F (37.3°C). Which statement is most appropriate for the nurse to make at this time? You Selected: • “Your blood pressure is slightly high. I will check it again before you leave.” Correct response: • “Your blood pressure is slightly high. I will check it again before you leave.” Explanation: A blood pressure reading of 138/88 mm Hg is nearing hypertension range and could be a sign of developing gestational hypertension. Conversely, the client may be experiencing “white coat” syndrome or could be anxious during the prenatal visit. In order to obtain an accurate blood pressure reading, the nurse should allow the woman to rest for a period of time and recheck the blood pressure in the same arm and while the woman is in the same position. This blood pressure is considered approaching high. All other vitals are within normal range. Question 9 See full question A woman is diagnosed with complete molar pregnancy. The nurse understands that the woman requires more teaching when she makes which statement? You Selected: • "I know the placenta caused problems, and my baby died in my uterus." Correct response: • "I know the placenta caused problems, and my baby died in my uterus." Explanation: Although the woman shows signs and symptoms typical of early pregnancy, in gestational trophoblastic disease, or molar pregnancy, gestational tissue exists but the pregnancy is not viable. The woman must have follow-up human chorionic gonadotropin (HCG) levels for the remaining 12 months to ensure remaining tissue does not turn malignant. Due to the risks of developing malignancy, the woman must avoid pregnancy for at least one year following gestational trophoblastic disease. In a complete molar pregnancy, the villi swell and form cysts, and the woman is at risk for choriocarcinoma, which is a rapidly spreading malignancy. Question 10 See full question A pregnant client late in her first trimester comes to the clinic for a follow-up visit. The woman tells the nurse that she has been having morning sickness, but she "tried using this band on her wrist," and it helped cut down on the number of episodes she was having. The nurse interprets this therapy as an example of: You Selected: • acupressure. Correct response: • acupressure. Explanation: The band on the wrist described by the client is an example of acupressure. Biodfeedback involves conncection to electrical sensors provide the person with information about the body so that the person can then focus actions to make small changes in the body to achieve the goal. Meditation involves deep thinking and reflection to focus the mind and body. Aromatherapy involves the use of essential oils to promote well-being Question 1 See full question When teaching a group of pregnant adolescents about reproduction and conception, the nurse is correct when stating that fertilization occurs: You Selected: • in the first third of the fallopian tube. Correct response: • in the first third of the fallopian tube. Explanation: Fertilization occurs in the first third of the fallopian tube. After ovulation, an ovum is released by the ovary into the abdominopelvic cavity. It enters the fallopian tube at the fimbriated end and moves through the tube on the way to the uterus. Sperm cells "swim up" the tube and meet the ovum in the first third of the fallopian tube. The fertilized ovum then travels to the uterus and implants. Nurses must know where fertilization occurs because of the risk of an ectopic pregnancy. Remediation: Question 2 See full question A client is using the rhythm (calendar-basal body temperature) method of family planning. In this method, the unsafe period for sexual intercourse is indicated by: You Selected: • 3 full days of elevated basal body temperature and clear, thin cervical mucus. Correct response: • 3 full days of elevated basal body temperature and clear, thin cervical mucus. Explanation: Ovulation (the period when pregnancy can occur) is accompanied by a basal body temperature increase of 0.7° F to 0.8° F (.39° C to .44° C) and clear, thin cervical mucus. A return to the preovulatory body temperature indicates a safe period for sexual intercourse. A slight rise in basal temperature early in the cycle isn't significant. Breast tenderness and mittelschmerz aren't reliable indicators of ovulation. Remediation: Question 3 See full question After being examined and fitted for a diaphragm, a 24-year-old client receives instructions about its use. Which client statement indicates a need for further teaching? You Selected: • "If I gain or lose 20 lb (9 kg), I can still use the same diaphragm." Correct response: • "If I gain or lose 20 lb (9 kg), I can still use the same diaphragm." Explanation: The client would need additional instructions when she says that she can still use the same diaphragm if she gains or loses 20 lb (9 kg). Gaining or losing more than 15 lb (7 kg) can change the pelvic and vaginal contours to such a degree that the diaphragm 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 childbirth because weight changes and physiologic changes of 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. Question 4 See full question A 28-year-old female client is prescribed danazol for endometriosis. The nurse should instruct the client to report: You Selected: • hair loss. Correct response: • headaches. Explanation: Adverse effects of danazol include headaches, dizziness, irritability, and decreased libido. Masculinization effects, such as deepened voice, facial hair, and weight gain, also may occur. Question 5 See full question A primigravida experiences spontaneous rupture of the membranes. What should the nurse do? Select all that apply. You Selected: • Assess maternal temperature. • Monitor the fetal heart rate and pattern. • Perform a nitrazine test to confirm that the membranes are ruptured. Correct response: • Perform a nitrazine test to confirm that the membranes are ruptured. • Monitor the fetal heart rate and pattern. • Assess maternal temperature. Explanation: When membranes rupture, the nurse should immediately check fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. He or she should also perform a nitrazine test to confirm that the membranes are ruptured. Maternal temperature should be assessed every 1 to 2 hours so infection can be identified early. Membranes may rupture any time during labor. In some cases, 24 hours may pass between rupture and onset of labor, so the nurse does not need to prepare for childbirth at this time. Remediation: Question 6 See full question The nurse is caring for a 15-year-old adolescent mother after childbirth. The adolescent lives at home with her parents and has a boyfriend who is also 15 years old. Neither is currently working, and they both have plans for higher education. When addressing the psychosocial issues that may occur after the birth of the child, which of the following would be the most important for the nurse to include in his/her teaching? You Selected: • Increased stress for new mothers Correct response: • Increased stress for new mothers Explanation: Remediation: Question 7 See full question The nurse is preparing a laboring client for internal electronic fetal monitoring (EFM). Which finding requires nursing intervention? You Selected: • The cervix is fully dilated. Correct response: • The membranes are intact. Explanation: Internal EFM can be used only after the client's membranes rupture, when the cervix is dilated at least 2 cm and when the presenting part is at least at –1 station. Anesthesia is not required for internal EFM. Remediation: Question 8 See full question A 17-year-old client confides in the school nurse that he/she is interested in understanding safe sex practices. In instructing the client on how to correctly use a condom, which information would be stressed? Select all that apply. You Selected: • Leave a 1/2 inch space at the end of the condom. • Condoms should be stored in a cool, dry place to prevent damage. • The condom would be applied on an erect penis. • Never reuse a condom. Correct response: • Condoms should be stored in a cool, dry place to prevent damage. • Leave a 1/2 inch space at the end of the condom. • Never reuse a condom. • The condom would be applied on an erect penis. Explanation: Condoms can be a reliable method of birth control offered with proper instruction. Condoms would be stored in a cool, dry place to prevent heat damage. A 1/2 inch space would be left at the tip of the condom to allow for collection of the ejaculate and to prevent tearing of the condom. A condom is applied after the penis is erect. A condom would not be reused. Question 9 See full question The nurse is performing a vaginal examination on a client in labor. The nurse finds the fetal presenting part 1 cm above the ischial spines. The nurse should chart the station as: You Selected: • -1 station. Correct response: • -1 station. Explanation: Remediation: Question 10 See full question When working the mother-baby unit which client would the nurse anticipate giving Rho(D) immune globulin (human) to: You Selected: • the Rh negative mother with an Rh positive baby. Correct response: • the Rh negative mother with an Rh positive baby. [Show More]

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