HESI 101 Module 1 Exam_ HESI VN_LATEST 2021,100% CORRECT

HESI 101 Module 1 Exam_ HESI VN_LATEST 2021 Question 1 1 / 1 pts A nurse is providing information to a group of pregnant clients and their partners about the psychosocial development of an infant. Using Erikson’ ...

HESI 101 Module 1 Exam_ HESI VN_LATEST 2021 Question 1 1 / 1 pts A nurse is providing information to a group of pregnant clients and their partners about the psychosocial development of an infant. Using Erikson’s theory of psychosocial development, the nurse tells the group that infants have which developmental need? Correct! Need to rely on the fact that their needs will be met Must have needs ignored for short periods to develop a healthy personality Need to tolerate a great deal of frustration and discomfort to develop a healthy personality Need to experience frustration, so it is best to allow an infant to cry for a while before meeting his or her needs Rationale: According to Erikson’s theory of psychosocial development, infants struggle to establish a sense of basic trust rather than a sense of basic mistrust in their world, their caregivers, and themselves. If provided with consistent satisfying experiences that are delivered in a timely manner, infants come to rely on the fact that their needs are met and that, in turn, they will be able to tolerate some degree of frustration and discomfort until those needs are met. This sense of confidence is an early form of trust and provides the foundation for a healthy personality. Therefore the other options are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate the option that contains the closed-ended word “must.” Eliminate the comparable or alike options and indicate that experiencing frustration is necessary. Review Erikson’s theory of psychosocial development as it relates to the infant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Question 2 1 / 1 pts A nurse is weighing a breastfed 6-month-old infant who has been brought to the pediatrician’s office for a scheduled visit. The infant’s weight at birth was 6 lb 8 oz. The nurse notes that the infant now weighs 13 lb. The nurse should take which action? Correct! Tell the mother that the infant’s weight is increasing as expected. Tell the mother to decrease the daily number of feedings because the weight gain is excessive. Tell the mother that semisolid foods should not be introduced until the infant’s weight stabilizes. Tell the mother that the infant should be switched from breast milk to formula because the weight gain is inadequate. Rationale: Infants usually double their birth weight by 6 months and triple it by 1 year of age. If the infant is 6 lb 8 oz, at birth, a weight of 13 lb at 6 months of age is to be expected. Semisolid foods are usually introduced between 4 and 6 months of age. Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Recalling that infants double their weight by 6 months of age will direct you to the correct option. Review the growth rate of an infant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Question 3 1 / 1 pts The nurse is assisting with data collection on a well-baby examination. The nurse measures the head circumference, and it is the same as the chest circumference. On the basis of this measurement, the nurse should take which action? Report the presence of hydrocephalus to the health care provider. Suggest to the health care provider that a skull x-ray be performed. Tell the mother that the infant is growing faster than expected. Correct! Document these measurements in the infant’s health care record. Rationale: The head circumference growth rate during the first year is approximately 0.4 inch (1 cm) per month. By 10 to 12 months of age, the infant’s head and chest circumferences are equal. Therefore, suspecting the presence of hydrocephalus, telling the mother that the infant is growing faster than expected, and suggesting that a skull x-ray be performed are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that the infant has a physiological problem. Review the expected growth rate of an infant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Developmental Stages Question 4 1 / 1 pts A new mother asks the nurse, “I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?” Which statement should the nurse make in response to the mother? “Yes, your infant is protected from all infections.” "If you breastfeed, your infant is protected from infection." "The transfer of your antibodies protects your infant until the infant is 12 months old." Correct! "The immune system of an infant is immature, and the infant is at risk for infection." Rationale: Transplacental transfer of maternal antibodies supplements the infant’s weak response to infection until approximately 3 to 4 months of age. Although the infant begins to produce immunoglobulin (Ig) soon after birth, by 1 year of age, the infant has only approximately 60% of the adult IgG level, 75% of the adult IgM level, and 20% of the adult IgA level. Breast milk transmits additional IgA protection. The activity of T lymphocytes also increases after birth. Even though the immune system matures during infancy, maximal protection against infection is not achieved until early childhood. This immaturity places the infant at risk for infection. Test-Taking Strategy: Use the process of elimination. Eliminate the option containing the closed- ended word "all." Recalling that breastfeeding alone does not protect the infant from infection will assist you in eliminating the option that suggests breastfeeding protects the infant. From the remaining options, use the strategy of selecting the umbrella option to answer correctly. Review the physiological concepts related to the maturity of body systems in an infant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Developmental Stages Question 5 1 / 1 pts A nurse is assisting with data collection on the language development of a 9-month-old infant. Which developmental milestone does the nurse expect to note in an infant of this age? The infant babbles. Correct! The infant says "Mama." The infant smiles and coos. The infant babbles single consonants. Rationale: An 8- to 9-month-old infant can string vowels and consonants together. The first words, such as "Mama," "Daddy," "bye-bye," and "baby," begin to have meaning. A 1- to 3- month-old infant produces cooing sounds. Babbling is common in a 3- to 4-month-old. Single- consonant babbling occurs between 6 and 8 months of age. Test-Taking Strategy: Use the process of elimination and focus on the subject, the developmental milestone of a 9-month-old. Recalling the language development that occurs during infancy will direct you to the correct option. Remember that an 8- to 9-month-old infant can string vowels and consonants together. Review the developmental milestones related to language development in an infant if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Developmental Stages Question 6 1 / 1 pts The mother of a 9-month-old infant calls the nurse at the pediatrician’s office, tells the nurse that her infant is teething, and asks what can be done to relieve the infant’s discomfort. The nurse should provide which instruction? Schedule an appointment with a dentist for a dental evaluation. Rub the infant's gums with baby aspirin that has been dissolved in water. Obtain an over-the-counter (OTC) topical medication for gum-pain relief. Correct! Give the infant cool liquids or a Popsicle and hard foods such as dry toast. Rationale: Although sometimes asymptomatic, teething is often signaled by behavior such as nighttime awakening, daytime restlessness, an increase in nonnutritive sucking, excess drooling, and temporary loss of appetite. Some degree of discomfort is normal. It is unnecessary to obtain a dental evaluation, but a health care professional should further investigate any incidence of increased temperature, irritability, ear-tugging, or diarrhea. The nurse may suggest that the mother provide cool liquids and hard foods such as dry toast, Popsicles, or a frozen bagel for chewing to relieve discomfort. Hard, cold teethers and ice wrapped in cloth may also provide comfort for inflamed gums. OTC medications for gum relief should only be used as directed by the health care provider. Home remedies such as rubbing the gums with aspirin should be discouraged, but acetaminophen (Tylenol), administered as directed for the child’s age, can relieve discomfort. Test-Taking Strategy: Focus on the subject, teething and relieving the infant’s discomfort. First recall that it is unnecessary to consult with a dentist. Next, eliminate the comparable or alike options that involve administering medication to the infant. Review the measures that will relieve the discomfort of teething if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Question 7 1 / 1 pts A nurse is teaching the mother of an 11-month-old infant how to clean the infant’s teeth. The nurse tells the mother to take which action? Correct! Use water and a cotton swab and rub the teeth. Use diluted fluoride and rub the teeth with a soft washcloth. Use a small amount of toothpaste and a soft-bristle toothbrush. Dip the infant's pacifier in maple syrup so that the infant will suck. Rationale: Because the primary teeth are used for chewing until the permanent teeth erupt and because decay of the primary teeth often results in decay of the permanent teeth, dental care must be started in infancy. The mother can use cotton swabs or a soft washcloth to clean the teeth. Appropriate amounts of fluoride are necessary for the development of healthy teeth, but infants usually receive fluoride when formula and cereal are mixed with fluoridated water or through fluoride supplementation. Toothpaste is not recommended because infants tend to swallow it, possibly ingesting excessive amounts of fluoride. Dipping the infant's pacifier in maple syrup is unacceptable because of the risk of tooth decay. Test-Taking Strategy: Use the process of elimination and focus on the subject, cleaning the teeth. Recalling the risk associated with tooth decay will help eliminate the option that identifies the use of maple syrup. To select from the remaining options, noting that the client in the question is an infant will direct you to the correct option. Review the procedure for cleaning teeth in an infant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning A nurse provides information about feeding to the mother of a 6-month-old infant. Which statement by the mother indicates an understanding of the information? "I can mix the food in the my infant's bottle if he won't eat it." "Fluoride supplementation is not necessary until permanent teeth come in." Correct! "Egg white should not be given to my infant because of the risk for an allergy." "Meats are really important for iron, and I should start feeding meats to my infant right away." Rationale: Egg white, even in small quantities, is not given to the infant until the end of the first year of life because it is a common food allergen. Fluoride supplementation may be needed beginning at of 6 months, depending on the infant’s intake of fluoridated tap water. Foods are never mixed with formula in the bottle. It may be difficult for the infant to consume the formula, and it will also be difficult to determine the infant’s intake of the formula. Solid foods may be introduced into the diet when the infant is 5 to 6 months old. Rice cereal may be introduced first because of its low allergenic potential; or, depending on the health care provider’s recommendation, fruits and vegetables may be introduced first. Test-Taking Strategy: Read each option carefully and think about the subject, the principles associated with feeding and nutrition. Recalling that allergy is a concern will direct you to the correct option. Review the principles related to nutrition an infant if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation A nurse provides instructions to a mother of a newborn infant who weighs 7 lb 2 oz about car safety. The nurse provides the mother with which instructions? Correct! To secure the infant in the middle of the back seat in a rear-facing infant safety seat To place the infant in a booster seat in the front seat of the car with the shoulder and lap belts secured around the infant That it is acceptable to place the infant in the front seat in a rear-facing infant safety seat as long as the car has passenger-side air bags That because of the infant's weight it is acceptable to hold the infant as long as the mother and infant are sitting in the middle of the back seat of the car Rationale: Infants should not be restrained in the front seats of cars. If a passenger-side airbag is deployed, the airbag may severely jolt an infant safety seat, harming the infant. Infants weighing less than 20 lb and those younger than 1 year should always be in the middle of the back seat in a rear-facing car safety seat. An infant must be placed in an infant safety seat and is never to be held by another person when riding in a car. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that recommend placing the infant in the front seat. To select from the remaining options, keep safety in mind and remember that the infant should never be held and should be placed in an infant safety seat. Review car safety principles for an infant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Question 10 1 / 1 pts A nurse provides instructions to a mother about crib safety for her infant. Which statement by the mother indicates a need for further instructions? "I need to keep large toys out of the crib." "The drop side needs to be impossible for my infant to release." "Wood surfaces on the crib need to be free of splinters and cracks." Correct! "The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body." Rationale: The distance between slats must be no more than 2⅜ inches to prevent entrapment of the infant’s head and body. The mesh in a mesh-sided crib should have openings smaller than ¼ inch. The drop side must be impossible for the infant to release, and wood surfaces should be free of splinters, cracks, and lead-based paint. The mother should avoid placing large toys in the crib because an older infant may use them as steps to climb over the side, possibly resulting in serious injury. Test-Taking Strategy: Use the process of elimination and note the strategic words “need for further instructions” in the question. These words indicate a negative event query and the need to select the incorrect statement by the mother. Visualizing each of these options and keeping safety in mind will direct you to the correct option. Review crib safety instructions if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Question 11 1 / 1 pts The mother of a 2-year-old tells the nurse that she is very concerned about her child because he has developed "a will of his own" and "acts as if he can control others." The nurse provides information to the mother to alleviate her concern, recalling that, according to Erikson, a toddler is confronting which developmental task? Initiative versus guilt Trust versus mistrust Industry versus inferiority Correct! Autonomy versus doubt and shame Rationale: According to Erikson, the toddler is struggling with the developmental task of acquiring a sense of autonomy while overcoming a sense of shame and doubt. Toddlers discover that they have wills of their own and that they can control others. Asserting their will and insisting on their own way, however, often lead to conflict with those they love, whereas submissive behavior is rewarded with affection and approval. Toddlers experience conflict because they want to assert their will but do not want to risk losing the approval of loved ones. Trust versus mistrust is the developmental task of the infant. Initiative versus guilt is the developmental task of the preschool-age child. Industry versus inferiority is the developmental task of the school-age child. Test-Taking Strategy: Focus on the data in the question. Note the relationship between the words "a will of his own" and the word "autonomy" in the correct option. Review Erikson's developmental stages if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Question 12 1 / 1 pts A nurse is planning care for a hospitalized toddler. To best maintain the toddler’s sense of control and security and ease feelings of helplessness and fear, the nurse should perform which action? Spend as much time as possible with the toddler. Correct! Keep hospital routines as similar as possible to those at home. Allow the toddler to play with other children in the nursing unit playroom. Allow the toddler to select toys from the nursing unit playroom that can be brought into the toddler's hospital room. Rationale: The nurse can decrease the stress of hospitalization for the toddler by incorporating the toddler's usual rituals and routines from home into nursing care activities. Keeping hospital routines as similar to those of home as possible and recognizing ritualistic needs gives the toddler some sense of control and security and eases feelings of helplessness and fear. Spending as much time as possible with the toddler and allowing the toddler to play with other children and select the toys he would like to play with may be appropriate interventions, but keeping the hospital routine as similar as possible to the routine at home will best maintain the toddler's sense of control and security and ease feelings of helplessness and fear. Test-Taking Strategy: Note the strategic word "best" in the question. Use the process of elimination and focus on the subject, how to best maintain the toddler's sense of control and security and ease feelings of helplessness and fear. This will assist you in selecting the correct option. Review the psychosocial needs of the toddler with regard to hospitalization if you had difficulty with this question. Level of Cognitive Ability: Applying Content Area: Developmental Stages Question 13 1 / 1 pts A nurse in a day-care setting is planning play activities for 2- and 3-year-old children. Which toys are most appropriate for these activities? Correct! Blocks and push-pull toys Finger paints and card games Simple board games and puzzles Videos and cutting-and-pasting toys Rationale: Toys for the toddler should meet the child’s needs for activity and inquisitiveness. The toddler enjoys objects of different textures such as clay, sand, finger paints, and bubbles; push– pull toys; large balls; sand and water play; blocks; painting; coloring with large crayons; large puzzles; and trucks or dolls. Card games, simple board games, videos, and cutting-and-pasting toys are more appropriate play activities for the preschooler. Test-Taking Strategy: Focus on the subject, toys appropriate for 2- to 3-year-old children. Remember that all parts of an option need to be correct for the option to be correct. Focusing on the age of the child will direct you to the correct option. Review age-appropriate toys for the toddler if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Question 14 1 / 1 pts A mother of twin toddlers tells the nurse that she is concerned because she found her children involved in sex play and didn’t know what to do. The nurse should provide the mother with which advice? To separate her children during playtime That if the behavior continues, she will need to bring her children to a child psychologist Correct! That if she notes the behavior again, she should casually tell her children to dress and to direct them to another activity To tell her children that what they are doing is bad and that they will be punished if they are caught doing it again Rationale: Sex play and masturbation are common among toddlers. Parents should respect the toddler's curiosity as normal without judging the toddler as bad. Parents who discover children involved in sex play may casually tell them to dress and direct them to another play activity, thereby limiting sex play without producing feelings of shame or anxiety. Bringing the children to a child psychologist, separating them at play, and punishing them are all inappropriate. Test-Taking Strategy: Use the process of elimination and focus on the strategic word “toddlers.” Recalling that sex play and masturbation are common among toddlers will direct you to the correct option. Review psychosexual development in the toddler if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Question 15 0.5 / 1 pts A nurse is assisting with data collection regarding the motor development of a 24-month-old child. Which activities would the nurse expect the mother to report that the child can perform? Select all that apply. Put on and tie his shoes Correct! Align two or more blocks You Answered Dress himself appropriately Go to the bathroom without help Correct! Turn the pages of a book one at a time Question 16 1 / 1 pts A nurse is assisting with data collection regarding language development in a toddler from a bilingual family. The nurse expects which characteristic in the child’s language development? Correct! Is slower than expected Is developing as expected Is more advanced than expected Will require assistance from a speech therapist Rationale: Although the age at which children begin to talk varies widely, most can communicate verbally by the second birthday. The rate of language development depends on physical maturity and the amount of reinforcement the child has received. Children of bilingual families, twins, and children other than firstborns may have slower language development. A child from a development. Test-Taking Strategy: Use the process of elimination. Note that there are no data in the question to indicate that the child needs assistance from a speech therapist. When selecting from the remaining options, noting the word "bilingual" in the question and recalling the factors that affect language development will direct you to the correct option. Review the factors that affect language development if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Cultural Diversity Question 17 1 / 1 pts A mother asks the nurse when her child should have his first dentist visit. The nurse provide which response? At age 3 Just before beginning kindergarten Twelve months after the first primary tooth erupts Correct! Soon after the first primary tooth erupts, usually around 1 year of age Rationale: The child should see the dentist soon after the first primary tooth erupts at around 1 year of age. Therefore the remaining options are incorrect. Parents should be aware of the dental guidelines for children and should not delay necessary dental care. Test-Taking Strategy: Use the process of elimination and recall the subject, the importance of dental care. Answer correctly by selecting the option that provides dental care at the earliest age. Review dental care guidelines if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Developmental Stages Question 18 1 / 1 pts The mother of a toddler asks the nurse when she will know that her child is ready to start toilet training. The nurse tells the mother that which observation is a sign of physical readiness? The child has been walking for 2 years. The child can eat using a fork and knife. The child no longer has temper tantrums. Correct! The child can remove his or her own clothing. Rationale: Signs of physical readiness for toilet training include the following: The child can remove her own clothing; is willing to let go of a toy when asked; is able to sit, squat, and walk well; and has been walking for 1 year. Using a fork and knife, walking for 2 years, and an absence of temper tantrums are not signs of physical readiness. Test-Taking Strategy: Use the process of elimination. Noting the strategic words "physical readiness" in the question will assist you in eliminating the option that addresses temper tantrums. To select from the remaining options, visualize each to help direct you to the correct option. Review the signs of physical readiness for toilet training if you had difficulty with this Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Developmental Stages Question 19 1 / 1 pts The mother of a child who weighs 45 lb asks a nurse about car safety seats. The nurse tells the mother to place the child in which car safety seat? Booster seat in a rear-facing position in the front seat Correct! Booster seat with one of the car's seat belts placed over the child Car safety seat in the back seat in a face-forward position Car safety seat in a face-forward position in the front seat Rationale: A child needs to remain in a car safety seat until he or she weighs 40 lb. Once the child has outgrown the car safety seat, a booster seat is used. Booster seats are designed to raise the child high enough so that the restraining straps are correctly positioned over the child's chest and pelvis. The child should not be placed in the front seat. A car safety seat is used for the child who weighs less than 40 lb. These seats are placed in the middle of the back seat in a rear-facing position. Test-Taking Strategy: Use the process of elimination and note that the child weighs 45 lb. Keeping the subject of safety in mind and visualizing each of the options will direct you to the correct option. Review car safety measures if you had difficulty with this question. Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Question 20 1 / 1 pts The mother of a 5-year-old asks the nurse how often her child should undergo a dental examination. The nurse tells the mother that the child should have a dental examination how frequently? Once a year Every 3 months Correct! Every 6 months Whenever a new primary tooth erupts Rationale: Dental examinations for a 4- to 5-year-old child should be conducted every 6 months. Every 3 months, once a year, and whenever a new primary tooth erupts are all incorrect. Test-Taking Strategy: Knowledge of the subject, the schedule for dental examinations for a 5- year-old child is needed to answer this question. Recalling the general principles related to dental care and thinking about dental health care of an adult will help direct you to the correct option. Review dental-care principles for a child if you had difficulty with this question. Level of Cognitive Ability: Applying Content Area: Developmental Stages Question 21 1 / 1 pts A nurse, planning play activities for a hospitalized school-age child, uses Erikson’s theory of psychosocial development to select an appropriate activity. The nurse selects an activity that will assist the child in developing which developmental goal? Initiative Autonomy A sense of trust Correct! A sense of industry Rationale: According to Erikson, the central task of the school-age years is the development of a sense of industry. The school-age child replaces fantasy play with "work" at school, crafts, chores, hobbies, and athletics. Development of trust is the task of infancy. Development of autonomy is the task of toddlerhood. Development of initiative is the task of the preschooler. Test-Taking Strategy: Use knowledge regarding the subject, Erikson’s stages of psychosocial development, to answer the question. Focusing on the words “school-age child” will help direct you to the correct option. Review Erikson’s stages of psychosocial development if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Question 22 0 / 1 pts A nurse, assigned to care for a hospitalized child who is 8 years old, assists with planning care, taking into account Erik Erikson’s theory of psychosocial development. According to Erikson’s theory, which task represents the primary developmental task of this child? Correct Answer Mastering useful skills and tools Gaining independence from parents You Answered Developing a sense of trust in the world Developing a sense of control over self and body functions Rationale: According to Erikson's theory of psychosocial development, the school-age child's task is to master useful skills and tools of the culture (industry versus inferiority). Gaining independence from parents is the psychosocial task of the adolescent. Developing a sense of trust in the world is the psychosocial task of an infant. Developing a sense of control over self and body functions is the psychosocial task of the toddler. Test-Taking Strategy: Focus on the strategic words “8 years old” in the question and think about the developmental level of the child. Use knowledge of Erikson’s theory of psychosocial developmental to answer this question. Review Erikson’s theory of psychosocial development if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Question 23 0 / 1 pts A school nurse provides information to the parents of school-age children regarding appropriate dental care. The nurse tells the parents that their children should perform which action? You Answered Brush their teeth every morning and at bedtime Correct Answer Brush and floss their teeth after meals and at bedtime Brush and floss their teeth every morning and at bedtime Brush their teeth every morning and at bedtime and floss the teeth once a day, preferably at bedtime Rationale: School-age children are able to assume responsibility for their own dental hygiene. Good oral health habits tend to be carried into the adult years, helping prevent cavity formation for a lifetime. Thorough brushing with fluoride toothpaste followed by flossing between the teeth should be done after meals and before bedtime. It is important that parents set up a routine schedule for the child that promotes good daily oral hygiene and gives them responsibility for their own dental care. Test-Taking Strategy: Use the process of elimination. Use the process of elimination. Use the subject, general principles and guidelines related to dental care and select the option that provides the most frequent and thorough dental care. Review principles and guidelines of dental care if you had difficulty with this question. Level of Cognitive Ability: Applying Content Area: Developmental Stages Question 24 1 / 1 pts The parents of an adolescent tell the school nurse that they are frustrated because their daughter has become self-centered, lazy, and irresponsible. The nurse should provide which response to the parents? Correct! That this is normal behavior for an adolescent To restrict any social privileges until the behavior stops That this type of behavior is usually the result of parents' spoiling a child That their daughter will need to see a child psychologist if the behavior continues Rationale: Identity formation is the major developmental task of adolescence. Energy is focused within the self, and the adolescent is sometimes described as egocentric or self-absorbed. Frustrated parents often describe teenagers during this phase as self-centered, lazy, or irresponsible. In fact, the adolescent just needs time to think, concentrate on himself or herself, and determine who he or she is going to be. Erikson describes the conflict of this phase of psychosocial development as identity formation versus role confusion. The assertions that a psychologist is needed and that the behavior is the result of spoiling are incorrect. Restriction of social privileges will cause resentment and rebellion in the adolescent. Test-Taking Strategy: Focus on the adolescent’s behaviors described in the question. Recalling the subject, stages of psychosocial development according to Erikson will direct you to the correct option. Remember that identity formation is a major developmental task of adolescence. Review the psychosocial development of the adolescent if you had difficulty with this question. Level of Cognitive Ability: Applying Content Area: Developmental Stages Question 25 1 / 1 pts A nurse is preparing to care for a hospitalized teenage girl who is in skeletal traction. The nurse assists with planning care knowing that which is the most likely primary concern of the teenager? Correct! Body image Obtaining adequate nutrition Keeping up with schoolwork Obtaining adequate rest and sleep Rationale: Body image is of particular importance to an adolescent. Teenagers tend to be concerned about their weight, complexion, sexual development, and acceptance by their peers. They are not as concerned about obtaining adequate nutrition and tend to eat fast foods and junk foods and may experiment with weight-management techniques such as fasting, diet pills and laxatives, self-induced vomiting, and fad diets. Keeping up with schoolwork may be important to some teenagers, but it is not usually the primary concern. Along with engaging in increasingly independent activities, teenagers tend to stay up late and have difficulty waking in the morning. Obtaining adequate rest and sleep is not teenagers’ primary concern. Test-Taking Strategy: Note the strategic word "primary." Thinking about the psychosocial development of the teenager (adolescent) will direct you to the correct option. Review psychosocial development of the adolescent if you had difficulty with this question. Level of Cognitive Ability: Applying Content Area: Developmental Stages Question 26 1 / 1 pts The mother of an adolescent calls the clinic nurse and reports that her daughter wants to have her navel pierced. The mother asks the nurse about the dangers associated with body piercing. The nurse provides which information to the mother? Hepatitis B is a concern with body piercing Infection always occurs when body piercing is done Correct! Body piercing is generally harmless as long as it is performed under sterile conditions It is important to discourage body piercing because of the risk of contracting human immunodeficiency virus (HIV) Rationale: Generally body piercing is harmless if the procedure is performed under sterile conditions by a qualified person. Some of the complications that may occur are bleeding, infection, keloid formation, and the development of allergies to metal. The area needs to be cleaned at least twice a day (more often for a tongue piercing) to prevent infection. HIV and hepatitis B infections are not associated with body piercing; however, they are a possibility with tattooing. Test-Taking Strategy: Use the process of elimination. Eliminate the option containing the closed- ended word "always." The fact that HIV and hepatitis B are not associated with body piercing will help you eliminate these options. Review the complications associated with body piercing if you had difficulty with this question. Level of Cognitive Ability: Applying Content Area: Safety Question 27 1 / 1 pts A sexually active adolescent asks the school nurse about the use of latex condoms and the reduction of the risk of sexually transmitted infections (STIs). The nurse provides which information to the adolescent? Correct! Use of a latex condom can reduce the risk of transmission of STIs. The only way to reduce the risk of transmission of STIs is abstinence. Use of a latex condom is a good method for preventing pregnancy. A spermicide needs to be used along with a condom to prevent transmission of STIs. Rationale: Use of a condom during intercourse can reduce the risk of STI transmission. Abstinence is not the only way to reduce the risk of STI transmission. A spermicide used along with a condom will help prevent pregnancy, not an STI. One disadvantage of condoms is that they may fail to prevent pregnancy. Also, using a latex condom to prevent pregnancy is unrelated to preventing the transmission of STIs. Test-Taking Strategy: Use the process of elimination and focus on the subject, reduction of the risk of transmission of an STI. Eliminate the option using the closed-ended word “only.” Focusing on the subject will help you select the correct option from the remaining options. Review the methods of reducing the risk of transmission of STIs if you had difficulty with this question. Level of Cognitive Ability: Applying Content Area: Infection Control Question 28 1 / 1 pts A nurse helps a young adult conduct a personal lifestyle assessment. The nurse carefully reviews the assessment with the young adult for which reason? Yong adults are at risk for a serious illness. Young adults are unable to afford health insurance. Young adults are exposed to hazardous substances. Correct! Young adults may ignore physical symptoms and postpone seeking health care. Rationale: Young adults are usually quite active, experience severe illnesses less commonly than members of older age groups, tend to ignore physical symptoms, and often postpone seeking health care. Clients in this developmental stage may benefit from a personal lifestyle assessment. A personal lifestyle assessment can help the nurse and client identify habits that increase the risk for cardiac, pulmonary, renal, malignant, and other chronic diseases. Young adults are not at risk for serious illness. The young adult may or may not be exposed to hazardous substances and may or may not be able to afford health insurance. Test-Taking Strategy: Use the process of elimination. Focusing on the subject, a characteristic of young adults, will direct you to the correct option. Review the characteristics associated with the young adult if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Question 29 1 / 1 pts A nurse is conducting a psychosocial assessment of a young adult. Which observations would lead the nurse to determine that the client is demonstrating a sign of emotional health? Select all that apply. The young adult is sensitive to criticism. The young adult verbalizes unrealistic fears. The young adult verbalizes disappointment with life. Correct! The young adult verbalizes satisfaction with friendships. Correct! The young adult has a sense of meaning and direction in life. Rationale: Most young adults have the physical and emotional resources and support systems to meet the many challenges, tasks, and responsibilities they face. Signs of emotional health in the young adult include a sense of meaning and direction in life, successful negotiation of transitions, absence of feelings of being cheated or disappointed by life, attainment of several long-term goals, satisfaction with personal growth and development, reciprocated feelings of love for a partner, satisfaction with social interactions and friendships, a generally cheerful attitude, no sensitivity to criticism, and no unrealistic fears. Test-Taking Strategy: Focus on the subject, a sign of emotional health. Select the options that use positive words such as “satisfaction” and “meaning and direction.” Review the signs of emotional health in the young adult if you had difficulty with this question. Level of Cognitive Ability: Analyzing Content Area: Health Assessment/Physical Exam Question 30 0 / 1 pts According to Erik Erikson’s developmental theory, which choice is a developmental task of the middle adult? Redefining self-perception and capacity for intimacy Correct Answer Providing guidance during interactions with his children Verbalizing readiness to assume parental responsibilities You Answered Making decisions concerning career, marriage, and parenthood Rationale: According to Erikson’s developmental theory, the primary developmental task of the middle adult is to achieve generativity. Generativity is the willingness to care for and guide others. Middle adults can achieve generativity with their own children or the children of close friends or through guidance in social interactions with the next generation. Making decisions concerning career, marriage, and parenthood; redefining self-perception and capacity for intimacy; and verbalizing readiness to assume parental responsibilities are all developmental tasks of the young adult. Test-Taking Strategy: Use the process of elimination. Eliminate comparable or alike options that relate to marriage and parenting. Also, focusing on the subject, a middle adult, will direct you to the correct option. Review the developmental tasks of the middle adult if you had difficulty with this question. Integrated Process: Nursing Process/Assessment Content Area: Developmental Stages Question 31 1 / 1 pts A nurse is participating in a planning conference to improve dietary measures for an older client who is experiencing dysphagia. Which action should the nurse suggest including in the plan of care? Encouraging the client to feed herself Ensuring that most of the diet consists of liquids Correct! Monitoring the client during meals to ensure that food is swallowed Consulting with the physician regarding feeding through an enteral tube Rationale: Clients with dysphagia must be assisted during meals, and the nurse should carefully observe the client to ensure that foods are successfully swallowed instead of being trapped in the mouth. The diet should be nutritionally balanced and consist of both solids and liquids. Aspiration of liquids or solids is possible and may lead to aspiration pneumonia. Thickeners can be added to liquids because thin liquids are most difficult to swallow for clients with dysphagia. Clients with severe dysphagia may require enteral tube feedings, but there is no information in the question to indicate that the dysphagia is severe. Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation. This will direct you to the correct option. Remember that one risk that exists with dysphagia is aspiration. Review nutritional measures for the older client with dysphagia and dysphagia precautions if you had difficulty with this question. Integrated Process: Nursing Process/Planning Content Area: Safety Question 32 1 / 1 pts An older client reports that she has been awakening during the night, awakens early in the morning and is unable to fall back to sleep, and feels sleepy during the daytime. On the basis of these reported data, the nurse should take which action? Report the findings to the registered nurse. Correct! Document the findings in the medical record. Ask the registered nurse to obtain a prescription for a nighttime sedative. Encourage the client to consume stimulants such as caffeinated coffee or tea during the daytime hours. Rationale: Age-related changes in sleep include reduced sleep efficiency, increased incidence of nocturnal awakening, increased incidence of early-morning awakening, and increased daytime sleepiness. Because the reported data are normal age-related changes, the nurse would document the findings. There is no reason to report the findings to the registered nurse. Sedatives should be avoided. The consumption of caffeinated beverages is likely to increase disruption of sleep patterns. Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Recalling the age-related changes related to sleep patterns and remembering that those described in the question are normal will direct you to the correct option. Review age-related sleep pattern changes if you had difficulty with this question. Integrated Process: Nursing Process/Implementation Content Area: Developmental Stages Question 33 1 / 1 pts A nurse is assisting with developing a plan of care for an older client that will help maintain an adequate sleep pattern. Which action should the nurse suggest be included in the plan? Encouraging at least one daytime nap Discouraging the use of a nightlight at bedtime Correct! Encouraging bedtime reading or listening to music Discouraging social interaction, particularly at bedtime Rationale: Measures that will help maintain an adequate sleep pattern include balancing daytime activities with rest, discouraging daytime naps, promoting social interactions, and encouraging bedtime reading or listening to music. The use of a nightlight will foster an environment that is both helpful and safe. Test-Taking Strategy: Use the process of elimination. Thinking about the safety needs of the older client will assist you in eliminating the option of discouraging the use of a nightlight. To select from the remaining options, focusing on the subject, maintaining an adequate sleep pattern, will direct you to the correct option. Review measures that will maintain an adequate sleep pattern if you had difficulty with this question. Level of Cognitive Ability: Applying Content Area: Developmental Stages Question 34 1 / 1 pts A nurse is assisting with data collection on an older client who will be seen by a physician in a health care clinic. When the nurse asks the client about sexual and reproductive function, the client reports concern about sexual dysfunction. Which should be the nurse’s next action? Report the client’s concern to the health care provider. Correct! Ask the client about medications he is taking. Document the client’s concern in the medical record. Tell the client that sexual dysfunction is a normal age-related change. Rationale: Sexual dysfunction is not a normal process of aging. The prevalence of chronic illness and medication use is higher among older adults than in the younger population. Illnesses and medications can interfere with the normal sexual function of older men and women. Although the nurse may report the client’s concern and document the concern in his medical record, the next action is to ask the client about the medications he is taking. Test-Taking Strategy: Use the steps of the nursing process to answer the question. This will direct you to the correct option, which is the only option related to data collection. Review the causes of sexual dysfunction in the older client if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Question 35 1 / 1 pts A community health nurse is providing information to a group of older clients about measures to decrease the risk of contracting influenza during peak flu season. The nurse should provide which information? It is best to do grocery shopping and other errands late in the day. Clients must stay in the house and ask a neighbor or family member to run their errands. Drinking eight 8-oz glasses of fluid each day will reduce the risk of contracting influenza. Correct! Clients should wash their hands frequently and keep hands away from the face, especially during peak flu season. Rationale: During peak influenza season, older clients should avoid crowds to decrease the risk of contracting influenza. The nurse should encourage clients to do their shopping and other errands early in the morning, when crowds are smaller, or to have someone else shop for them. Frequent hand hygiene is the best means of avoiding transmission of the flu virus. Drinking eight 8-oz glasses of fluid a day will not reduce the risk of contracting influenza; however, it will prevent dehydration if illness occurs. Test-Taking Strategy: Use the process of elimination. Eliminate the option containing the closed- ended word “must.” Also eliminate the option that uses the words “late in the day.” To select from the remaining options, focusing on the subject of the question, how to decrease the risk of contracting influenza, will direct you to the correct option. Review interventions used to decrease the risk of contracting influenza if you had difficulty with this question. Level of Cognitive Ability: Applying Content Area: Infection Control Question 36 1 / 1 pts A nurse is caring for an older client who has a bronchopulmonary infection. The nurse monitors the client’s ability to maintain a patent airway because of which factor involved in the normal aging process? Increased production of surfactant Increased respiratory system compliance Correct! Decreased older client’s ability to clear secretions Decreased number of alveoli and increased function of those remaining Rationale: Respiratory changes related to the normal aging process decrease an older adult’s ability to clear secretions and protect the airway. In healthy older adults, the number of alveoli does not change or reduce significantly; their structure, however, is altered. Respiratory system compliance decreases with advancing age because of a progressive loss of elastic recoil of the lung parenchyma and conducting airways and reduced elastic recoil of the lung and opposing forces of the chest wall. Production of surfactant in the lung does not usually decrease with aging, nor does it increase. However, the production of alveolar cells responsible for surfactant production is diminished. Test-Taking Strategy: Use knowledge of the subject, normal age-related changes in the older client. Note the relationship between the words “maintain a patent airway” in the question and “ability to clear secretions” in the correct option. Review the normal age-related changes of the respiratory system if you had difficulty with this question. Level of Cognitive Ability: Applying Content Area: Adult Health/Respiratory Question 37 1 / 1 pts An older female client asks a nurse why her hair has turned gray. Which response is most appropriate for the nurse to make to the client? "It is caused by hereditary factors." Correct! "A loss of melanin occurs in the normal aging process." "The skin on the scalp becomes thin, causing moisture to escape." "The number of sweat glands and blood vessels decreases in the normal aging process." Rationale: The number of melanocytes, which provide pigment and hair color, decreases with age, giving older adults less protection from ultraviolet rays, paler skin color, and graying hair. Although the skin becomes thinner with the aging process and the number of sweat glands and blood vessels decreases, these changes are unrelated to graying hair. Heredity factors influence when the process of graying begins but do not cause the graying of hair. Test-Taking Strategy: Use knowledge of the subject, and recall the normal process of aging. Note the relationship between the words “turned gray” in the question and “loss of melanin” in the correct option. Review the age-related changes related to the hair if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Question 38 1 / 1 pts A nurse provides instructions to an older adult about measures to prevent heatstroke. Which statement by the client indicates a need for further instruction? "I should drink extra fluids during the summer." "I should wear cool, light clothing in warm weather." "I need to wear a hat with a wide brim when I go outdoors." Correct! "I need to wear additional antiperspirant and deodorant in warm weather." Rationale: As an individual ages, the number of sweat glands decreases, resulting in reduced body odor and reduced evaporative heat loss because of decreased sweating. The need for antiperspirants and deodorants is decreased. However, older adults are at a greater risk of heatstroke as a result of a compromised cooling mechanism; they should therefore avoid heat exposure over long periods and in areas of high humidity. The older adult should wear a hat with a wide brim and cool, lightweight, light-colored clothing when outdoors. It is also important that the older adult maintain adequate hydration, particularly during the summer and in hot climates. Test-Taking Strategy: Focus on the subject, heatstroke, and note the strategic words “need for further instruction.” These words indicate a negative event query and the need to select the incorrect option. Recall that with aging, bodily changes occur, including a decrease in the number of sweat glands. This will help direct you to the correct option. Review these age-related changes to the skin if you had difficulty with this question. Level of Cognitive Ability: Evaluating Content Area: Developmental Stages Question 39 1 / 1 pts A nurse is interviewing an older adult while assisting with data collection. Which client comment regarding vision requires immediate discussion with the health care provider? Correct! “It looks like I have a blank spot in the middle of what I’m trying to see.” “I have to hold my newspaper farther and farther away from me when I read.” “If I go from a very bright room to a very dark room, I have some trouble adjusting.” “I have a little trouble telling if my same-colored shirts and blouses actually match; the colors seem the same to me.” Rationale: Seeing blank spots in the middle of an object is loss of central vision, a symptom of macular degeneration, which would require an immediate discussion with the health care provider. Having to hold close objects farther away is presbyopia, a normal finding with aging. With normal aging, the lens of the eye loses the ability to quickly adjust to changes in lighting. Slight changes in color perception are common with aging. Test-Taking Strategy: Use knowledge of the subject, visual changes with aging, to assist with answering this question. Losing central vision (or any actual loss of vision) is not normal and would warrant an immediate discussion with the health care provider. Review expected changes in vision with aging if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Question 40 1 / 1 pts A nurse is reviewing the medical record of an older client with presbycusis. Which finding would the nurse expect to note in the client’s record? Unilateral conductive hearing loss Difficulty hearing low-pitched tones Correct! Difficulty hearing whispered words in the voice test Improved hearing ability during conversational speech Rationale: Presbycusis, a sensorineural hearing loss, is the most common form of hearing loss in older adults. Typically the loss is bilateral, resulting in difficulty hearing high-pitched tones. The condition is revealed when the client has difficulty hearing whispered words in the voice test and difficulty hearing consonants during conversational speech. Test-Taking Strategy: Use knowledge of the subject, hearing changes in older adults. Eliminate the option containing the words “increased hearing.” Recalling that the hearing loss in presbycusis is bilateral will assist you in eliminating the option containing the word “unilateral.” For you to select from the remaining options, it is necessary to know that the client has difficulty hearing high-pitched tones (not low-pitched tones). Review age-related changes in hearing if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Question 41 0 / 1 pts A nurse is assisting with data collection regarding skin and peripheral vascular findings on a client in later adulthood. Which observation would the nurse expect to note as an age-related finding? You Answered Thin, ridged toenails Thick skin on the lower legs Bounding dorsalis pedis pulse Correct Answer Loss of hair on the lower legs Rationale: In later adulthood, the dorsalis pedis and posterior tibial pulses may become more difficult to find. They would not be bounding. Trophic changes associated with arterial insufficiency (thin, shiny skin; thick, ridged nails; loss of hair on the lower legs) also occur normally with aging. Test-Taking Strategy: Use knowledge of the subject, changes related to aging in the skin and peripheral vascular systems. Recalling the age-related changes in the skin and cardiovascular system and noting the words “loss of hair” will direct you to the correct option. Review age- related changes in the skin and peripheral vascular systems if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Question 42 1 / 1 pts The nurse notes that a client in later adulthood has tremors of the hands. On the basis of this finding, the nurse should take which action? Correct! Document the findings. Notify the registered nurse immediately. Obtain a prescription for a muscle relaxant. Ask the registered nurse about referring the client to a neurological specialist. Rationale: Senile tremors are occasionally noted in clients in later adulthood. These benign tremors include intentional tremor of the hands, head-nodding (as if saying “yes”), and tongue protrusion. Because this finding is an age-related occurrence, obtaining a prescription for a muscle relaxant, notifying the registered nurse immediately, and asking about referring the client to a neurological specialist are unnecessary and incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate contact with the registered nurse. Review age-related changes of the neurological system if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation A nurse observes a nursing assistant communicating with a hearing-impaired client in later adulthood. The nurse should intervene if the nursing assistant performs which action? Uses short sentences Correct! Overarticulates words Uses facial expressions or gestures Speaks at a normal rate and volume Rationale: Hearing-impaired clients must supplement hearing with lip-reading. The client needs to be able to see the speaker's face and lips. The nurse would watch to see that the nursing assistant avoided situations in which there is a glare or shadows on the client's field of vision. The nurse would also remind the assistant to reduce or eliminate background noise, speak at a normal rate and volume, and refrain from overarticulating or shouting. The assistant should use short sentences and pause at the end of each sentence and should use facial expressions or gestures to give useful clues. Test-Taking Strategy: Note the strategic word “intervene” in the question. This word indicates that you need to select the option that indicates an incorrect action by the nursing assistant. Visualize each of the options to help direct you to the correct one. Review strategies to improve communication when a client has hearing loss if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation A nurse is assisting with gathering subjective data from a client during a health assessment and plans to ask the client about the medical history of the client’s extended family. About which family members would the nurse ask the client? Wife and wife's parents Foster children and their parents Wife's children from a previous marriage Correct! Aunts, uncles, grandparents, and cousins Rationale: The extended family includes relatives (aunts, uncles, grandparents, and cousins) in addition to the nuclear family. The nuclear family consists of a husband and a wife and perhaps one or more children. A blended family is formed when parents bring unrelated children from prior or foster-parenting relationships into a new joint living situation. Test-Taking Strategy: Use the process of elimination. Focusing on the strategic words "extended family" in the question will direct you to the correct option. Review family structures if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Data Collection/Physical Exam Question 45 1 / 1 pts from the hospital. Which family member does the nurse ensure is present when teaching the client about his prescribed medications? The client's son The client's father Correct! The client's mother The client's grandson Rationale: African American families are oriented around women. Within the African American family structure, the wife/mother is often charged with the responsibility of protecting the health of family members. The African American woman is expected to assist each family member in maintaining good health and in determining the course of treatment if a family member becomes ill. The nurse must recognize the importance of the African American woman in disseminating information and in assisting the client in making decisions. Although the African American man may be included in the decision-making process, the African American family is often matrifocal, so the nurse ensures that the woman is present. Therefore the other options are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that identify male members of the family. Review the characteristics of the African American family system if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Cultural Diversity Question 46 1 / 1 pts A female client asks a nurse about the advantages of using a female condom. The nurse discusses which advantage with the client? That it can be used along with a male condom That it is 100% safe in preventing pregnancy Correct! That it offers protection against sexually transmitted infections (STIs) That it does not have to be discarded after use and can be used several times before a new one must be obtained Rationale: A female condom is a loose-fitting tubular polyurethane pouch that is anchored over the labia and cervix. The condom, which is prelubricated, is available without a prescription. It cannot be combined with a male condom and should be used just once, then discarded. Like the male condom, the female condom provides protection against STIs. The pregnancy failure rate with typical use is approximately 21%.. Test-Taking Strategy: Use the process of elimination. Noting the strategic word “condom” in the question and recalling that one advantage of using a male condom is the prevention of STIs will direct you to the correct option. Review the advantages and disadvantages of the female barrier device if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Reproductive Question 47 A nurse provides information to a client about the use of a diaphragm. Which statement indicates to the nurse that the client needs further information on how to use the diaphragm? "I need to reapply spermicidal cream with repeated intercourse." "The diaphragm needs to be filled with spermicidal cream before insertion." "The diaphragm can be inserted as long as 6 hours before intercourse." Correct! "I can leave the diaphragm in place as long as I want after intercourse." Rationale: The diaphragm may be inserted as long as 6 hours before intercourse and must remain in place for at least 6 hours after. Because of the risk of toxic shock syndrome, the diaphragm must not remain in place for more than 24 hours. The diaphragm must be filled with spermicidal cream or jelly before insertion, and the spermicide must be reapplied before intercourse is repeated. Test-Taking Strategy: Use the process of elimination and note the strategic words “needs further information.” These words indicate a negative event query and the need to select the incorrect client statement. Recalling that the risk of toxic shock syndrome exists with the use of a diaphragm and noting the words “as long as I want” will direct you to the correct option. Review client instructions for use of a diaphragm if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Reproductive Question 48 0 / 1 pts use. On which major factor that will provide the motivation needed for consistent implementation of a birth control method should the nurse focus? Correct Answer Personal preference Family planning goals Work and home schedules You Answered Desire to have children in the future Rationale: Personal preference is a major factor in providing the motivation needed for consistent implementation of a birth control method. The nurse should educate the client about the various contraceptive methods available so that expressions of preference may be based on understanding. The desire to have children in the future, work and home schedules, and family planning goals may affect the choice of birth control method but are not motivating factors. Test-Taking Strategy: Focus on the subject, the major factor that will provide motivation. This will direct you to the correct option. Review factors to consider when helping a client choose a birth control method if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Reproductive Question 49 1 / 1 pts A sexually active married couple, discussing birth control methods with the nurse, expresses the need for a method that is convenient. Because the couple has told the nurse that family- planning goals have been met, which method of birth control does the nurse suggest? Diaphragm Spermicide Correct! Sterilization Male condom Rationale: If family planning goals have already been met, sterilization of the male or female partner may be desirable. When sexual activity is limited, use of a spermicide, condom, or diaphragm may be most appropriate. Test-Taking Strategy: Focus on the data in the question, and note that the couple is sexually active and is seeking a method of birth control that is convenient. Eliminate the comparable or alike options that involve the application of a contraceptive method. Review family planning and methods of birth control if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Reproductive Question 50 1 / 1 pts A nurse is assisting with gathering subjective data from a client who is seeking a prescription for an oral contraceptive. To identify risk factors associated with the use of an oral contraceptive, which question does the nurse ask? "Are you dieting?" "Do you smoke cigarettes?" "Do you engage in strenuous exercise such as jogging?" "Do you normally have menstrual cramps with your periods?" Rationale: Oral contraceptives have been associated with venous and arterial thromboembolism, pulmonary embolism, myocardial infarction, and thrombotic stroke. The risk of thromboembolic phenomena is increased in the presence of other risk factors, especially heavy smoking and a history of thrombosis. Additional risk factors include hypertension, cerebrovascular disease, coronary artery disease, and surgery in which postoperative thrombosis might be expected. Dieting, menstrual cramping, and strenuous exercise are not risk factors associated with the use of oral contraceptives. Test-Taking Strategy: Use the process of elimination and note that the question addresses the use of an oral contraceptive. Focusing on the subject, identification of risk factors, will direct you to the correct option. Review the risks associated with oral contraceptives if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Question 51 0 / 1 pts A nurse reviews the health history of a client who will be seeing the health care provider to obtain a prescription for a combination oral contraceptive (estrogen and progestin). Which finding in the health history would cause the nurse to determine that use of a combination oral contraceptive is contraindicated? The client has type 2 diabetes mellitus. You Answered The client is being treated for hypertension. Correct Answer The client has been treated for breast cancer. Rationale: Combination oral contraceptives contain both estrogen and progestin and are contraindicated during pregnancy and for women who have (or have a history of) the following disorders: thrombophlebitis, thromboembolic disorders, cerebrovascular disease, coronary artery disease, myocardial infarction, known or suspected breast cancer, known or suspected estrogen-dependent neoplasm, benign or malignant liver tumors, and undiagnosed abnormal genital bleeding. They are used with caution in women with diabetes mellitus, women who smoke heavily, women with risk factors for cardiovascular disease (hypertension, obesity, hyperlipidemia), and women anticipating elective surgery in which thrombosis might be expected. Test-Taking Strategy: Focus on the subject, a contraindication of a combination oral contraceptive. Recalling that a combination oral contraceptive contains estrogen will direct you to the correct option, breast cancer. Review the contraindications combination oral contraceptive if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Question 52 1 / 1 pts Clomiphene is prescribed for a female client to treat infertility. The nurse is providing information to the client and her spouse about the medication and provides the couple with which information? The couple should engage in coitus once a week during treatment. The physician should be notified immediately if breast engorgement occurs. If the oral tablets are not successful, the medication will be administered intravenously. Correct! Multiple births occur in a small percentage of clomiphene-facilitated pregnancies. Rationale: Multiple births (usually twins) occur in a small percentage (8%–10%) of clomiphene- facilitated pregnancies, and the couple should be informed of this. The medication is available in 50-mg tablets for oral use. There is no available intravenous form. Breast engorgement is a common side effect of the medication that reverses after medication withdrawal. When ovulation does occur as a result of use of clomiphene, it is usually within 5 to 10 days after the last dose. The couple is instructed to engage in coitus at least every other day during this time. Test-Taking Strategy: Use knowledge of the subject, use of clomiphene. Note the relationship between the words “treat infertility” in the question and “multiple births” in the correct option. Review use of clomiphene if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Reproductive Question 53 1 / 1 pts A nurse is reviewing the medical notes of a client seen by the physician to determine whether the client is pregnant. The nurse determines that pregnancy was confirmed if which finding is documented? Amenorrhea Correct! Palpable fetal movement Thinning of the cervix Positive result on home urine test for pregnancy Rationale: The positive indicators of pregnancy include auscultation of fetal heart sounds, fetal movement felt by the examiner, and visualization of the fetus with sonography. Amenorrhea is a presumptive sign of pregnancy because it is experienced and reported by the woman. Presumptive signs are not reliable indicators of pregnancy, because they may be caused by conditions other than pregnancy. Thinning of the cervix (the Hegar sign) and a positive pregnancy test result are probable indicators of pregnancy. A false-positive pregnancy test result may occur as a result of an error in reading, the presence of protein or blood in the urine, a recent pregnancy, a recent first-trimester abortion, or medications the client is taking. Test-Taking Strategy: Use the process of elimination. Noting the strategic word "confirmed" will assist you in selecting the correct option. Recalling the presumptive, probable, and positive signs of pregnancy will also assist you in answering correctly. Review the positive signs of pregnancy if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Question 54 1 / 1 pts A nurse is preparing to assess the fetal heart rate (FHR) of a client who is 14 weeks pregnant. Which piece of equipment does the nurse use to assess the FHR? Fetoscope Stethoscope Correct! Doppler transducer Pulse oximetry on the client and a fetoscope Rationale: Fetal heart sounds can be heard with a fetoscope by 20 weeks of gestation. The Doppler transducer amplifies fetal heart sounds so that they are audible by 10 to 12 weeks of gestation. Fetal heart sounds cannot be heard with a stethoscope. Pulse oximetry is not used to auscultate fetal heart sounds. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that involve a fetoscope. To select from the remaining options, note the week of gestation of the client, which will direct you to the correct option. Review the equipment used for auscultating fetal heart sounds if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Question 55 1 / 1 pts A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats/min. With this information, what should be the nurse’s next action? Correct! Document the findings. Notify the registered nurse of the finding. Wait 15 minutes and then recheck the FHR. Tell the client that the FHR is faster than normal but that it is nothing to be concerned about at this time. Rationale: The normal fetal heart depends on gestational age (usually higher in the first trimester) and is generally in the range of 120 to 160 beats/min. An FHR of 160 beats/min is within the normal range, so documentation is the only action indicated. Test-Taking Strategy: Recalling that the normal FHR is in the range of 120 to 160 beats/min will direct you to the correct option, documenting the findings. Also note that the incorrect options are comparable or alike options, in that they indicate concern over the FHR finding. Review the normal FHR if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum Question 56 1 / 1 pts A nurse is preparing to auscultate a fetal heart rate (FHR). The nurse performs the Leopold maneuvers to determine the position of the fetus and then places the fetoscope over which part of the fetus? Chest of the fetus Correct! Back of the fetus Carotid artery in the neck of the fetus Brachial area of one extremity of the fetus Rationale: The nurse would use the Leopold maneuvers to identify the position of the fetus and to determine the location of the fetal back. The FHR is most easily heard through the fetal back because it usually lies closest to the surface of the maternal abdomen. Because of the position of the fetus in the maternal abdomen (fetal position), auscultation of the FHR over the chest, carotid artery, or brachial area is not possible. Test-Taking Strategy: Use knowledge of the subject, location of the FHR, and visualize each of the options. Recalling the position of the fetus in the maternal abdomen will direct you to the correct option. Review the procedure for auscultating the FHR and the Leopold maneuvers if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Question 57 1 / 1 pts A nurse is determining the fetal heart rate (FHR) and places the fetoscope on the mother’s abdomen to count the FHR. The nurse simultaneously palpates the mother’s radial pulse and notes that it is synchronized with the sounds heard through the fetoscope. Which action should the nurse take? Ask the mother to lie still while both the FHR and the radial pulse rate are counted. Correct! Move the fetoscope to another area on the mother's abdomen to locate the fetal heart. Count the FHR for 30 seconds and then count the radial pulse rate of the mother for 30 seconds. Count the FHR for 60 seconds, ensuring that it is synchronized consistently with the mother's radial pulse. Rationale: When auscultating the fetal heart rate, the nurse would place the fetoscope on the maternal abdomen, over the fetal back. The nurse would then palpate the mother’s radial pulse. If her pulse is synchronized with the sounds from the fetoscope, the nurse would move the fetoscope to another area on the mother’s abdomen to locate the FHR. The nurse needs to be sure that the FHR is what is actually being heard. Other sounds that may be heard are the funic souffle (blood flowing through the umbilical cord) and the uterine souffle (blood flowing through the uterine vessels). The funic souffle is synchronized with the FHR; the uterine souffle is synchronized with the mother’s pulse. Test-Taking Strategy: Focus on the data in the question. Noting that the sounds heard through the fetoscope are synchronized with the mother’s radial pulse will help direct you to the correct option. Also note that the incorrect options are comparable or alike options in that they indicate continuing with the counting of the heart rate. Review the procedure for auscultating the FHR if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Question 58 1 / 1 pts A nurse is determining a fetal heart rate (FHR) and notes accelerations from the baseline rate when the fetus is moving. The nurse interprets this finding as: A reassuring sign A nonreassuring sign An indication of fetal distress An indication of the need to contact the physician Rationale: When determining the FHR, the nurse determines that the findings are reassuring or whether further steps should be taken to clarify data or correct problems. Reassuring signs include an average rate between 120 and 160 beats/min at term; a regular rhythm or a rhythm with slight fluctuations; accelerations from the baseline rate, often occurring with fetal movement; and the absence of decreases from the baseline rate. A nonreassuring sign suggests fetal distress, warranting immediate intervention and indicating the need to contact the physician. Test-Taking Strategy: Use the process of elimination. Note that the incorrect options are comparable or alike options, indicating a problem and the need for immediate intervention. Review reassuring signs during monitoring of the FHR if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Maternity/Intrapartum Question 59 1 / 1 pts A nurse-midwife, performing a vaginal examination of a client who suspects that she is pregnant, documents the presence of the Chadwick sign. The nurse reads the client’s record and interprets this sign as indicating which situation? A positive sign of pregnancy That cervical softening is present Correct! That the cervix was seen to be violet Rationale: One probable sign of pregnancy is the Chadwick sign—violet coloration of the cervix, which is normally pink. The color change, which also extends into the vagina and labia, occurs because of increased vascularity of the pelvic organs. Thinning of the cervix is termed the Hegar sign, and softening of the cervix is called the Goodell sign. These are both probable signs of pregnancy. Test-Taking Strategy: Focus on the subject, the Chadwick sign. Recalling that the Chadwick sign is the name given to violet coloration of the cervix, which is normally pink, and that this is a probable sign of pregnancy will direct you to the correct option. Review the presumptive, probable, and positive signs of pregnancy if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Question 60 1 / 1 pts A client is pregnant for the sixth time. She tells the nurse that she has had three elective first- trimester abortions and that she has a son who was born at 40 weeks' gestation and a daughter who was born at 36 weeks' gestation. In calculating the gravidity and para (parity), the nurse determines that the client is: Gravida 6, para 2 Gravida 2, para 6 Gravida 2, para 2 Gravida 3, para 6 Rationale: The term gravida refers to the number of pregnancies, of any duration, that a woman has had. Parity (para) refers to the number of pregnancies that have progressed past 20 weeks at delivery. Therefore this client is gravida 6 (pregnant for the sixth time), para 2 (has a son and a daughter). Pregnancy outcomes may also be described with the GTPAL acronym: gravida (G), term births (T), preterm births (P), abortions (A), and live births (L). The GTPAL for this client would be G = 6, T = 1, P = 1, A = 3, L = 2. Test-Taking Strategy: Knowledge regarding the subject, calculation of gravida and para, is needed to answer this question. Recalling that gravida refers to the number of pregnancies and para refers to the number of pregnancies that have progressed past 20 weeks at delivery will direct you to the correct option. Review gravida and para as a component of the obstetric history if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Question 61 1 / 1 pts A nurse is determining the estimated date of delivery for a pregnant client using Nagele’s rule and notes documentation that the date of the client’s last menstrual period was August 30, 2013. The nurse determines the estimated date of delivery to be which date? July 6, 2014 May 6, 2014 Correct! June 6, 2014 May 30, 2014 Rationale: Nagele’s rule is often used to establish the estimated date of delivery. This method involves subtracting 3 months and adding 7 days to the date of the first day of the last normal menstrual period, then correcting the year. Subtracting 3 months from August 30, 2013, brings the date to May 30, 2013; adding 7 days brings it to June 6, 2013. Finally, the year is corrected, bringing the estimated date of delivery to June 6, 2014. Test-Taking Strategy: Recalling the subject, Nagele’s rule, will assist you in answering this question. (Remember when you calculate the date for this client that there are 31 days in May.) Review Nagele’s rule if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Question 62 1 / 1 pts A rubella titer is performed on a pregnant client, and the results indicate a titer of less than 1:8. The nurse provides the client with which information? The test results are normal. She has developed immunity to the rubella virus. Correct! The test will need to be repeated during the pregnancy. She must have been exposed to the rubella virus at some point in her life. Rationale: A client is not immune to rubella if the titer is 1:8 or less. If the client is not immune, retesting will be performed during the pregnancy. Additionally, rubella immunization is required after delivery if the client is not immune. Therefore telling the client that she has developed immunity to the rubella virus, telling her that she may have been exposed to rubella, and telling her that the test results are normal are all incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that the results are normal or that the woman has developed immunity. Review rubella titer testing and the result that indicates immunity to rubella if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Laboratory Values Question 63 1 / 1 pts A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the client’s blood. On the basis of this finding, the nurse makes which determination? The results are negative. The client needs to receive the hepatitis B series of vaccines. The results indicate that the mother does not have hepatitis B. Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth. Rationale: A hepatitis B screen is performed to determine the presence of antigens in maternal blood. If they are present, the newborn will need to receive hepatitis immunoglobulin and vaccine soon after birth. Therefore noting that the results are negative, noting that the client needs to receive the hepatitis B series of vaccines, and noting that the results indicate that the mother does not have hepatitis B are all incorrect interpretations. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that the results are negative and that the mother does not have hepatitis B. To select from the remaining options, recall the significance of antigens in maternal blood, which will direct you to the correct option. Review the significance of the hepatitis B screen during pregnancy if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Laboratory Values Question 64 1 / 1 pts A multigravida pregnant woman asks the nurse when she will start to feel fetal movements. Around which week of gestation does the nurse tell the mother that fetal movements are first noticed? 6 weeks 8 weeks 12 weeks 16 weeks Rationale: Fetal movements (quickening) are first noticed by the multigravida pregnant woman at 16 to 20 weeks of gestation and gradually increase in frequency and strength. The other options are incorrect. Test-Taking Strategy: Knowledge of the subject regarding quickening is required to answer this question. In this situation, it is best to select the option that identifies the longest duration of gestation. Review the process of quickening if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum Question 65 1 / 1 pts The nurse provides information to a pregnant client who is experiencing nausea and vomiting about measures to relieve the discomfort. Which statement by the mother indicates the need for further information? "I need to avoid eating fried or greasy foods." Correct! "I need to be sure to drink adequate fluids with my meals." "I should eat five or six small meals a day rather than three full meals." "I should keep dry crackers at my bedside and eat them before I get out of bed in the morning." Rationale: To alleviate nausea and vomiting, the client should avoid drinking fluids with meals. The client should keep dry crackers at her bedside, avoid fried foods, and eat smaller meals. Additionally, the client should eat dry crackers every 2 hours to prevent an empty stomach and avoid spicy foods and foods with strong odors, such as onion and cabbage. Test-Taking Strategy: Use the process of elimination, noting the strategic words “need for further information.” These words indicate a negative event query and the need to select the incorrect statement. Use knowledge of general principles related to nutrition and the measures to alleviate nausea and vomiting to direct you to the correct option. Review the measures that will alleviate nausea and vomiting if you had difficulty with this question. Level of Cognitive Ability: Evaluating Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Maternity/Antepartum Question 66 1 / 1 pts A pregnant client asks a nurse about the use of noninvasive acupressure as a complementary alternative therapy to relieve nausea. The nurse provides which instruction? Complementary alternative therapies should not be used during pregnancy. Correct! Devices that apply pressure alone are available over the counter. The physician or nurse-midwife needs to provide a prescription for acupressure. It is all right to try any type of complementary alternative therapy to relieve the nausea. Rationale: As a complementary alternative therapy, acupressure over the Neiguan acupuncture point (approximately three fingers’ width above the wrist crease on the inner arm) is performed with the use of electrical impulses or with a device that applies pressure alone. Devices that apply an electrical impulse over this point require a prescription from a physician or nurse- midwife. Devices that apply pressure alone are available over the counter. Certain types (those that are noninvasive and are not harmful) may be acceptable for use during pregnancy. Not all types of complementary alternative therapies can be used during pregnancy, because some may be harmful to the mother, fetus, or both. Test-Taking Strategy: Use the process of elimination. Noting the strategic word “noninvasive acupressure” will help direct you to the correct option. Review complementary alternative therapies to relieve nausea and those that are safe during pregnancy if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Maternity/Antepartum Question 67 1 / 1 pts A nurse is telling a pregnant client about the signs that must be reported to the health care provider. The nurse tells the client that the health care provider should be contacted if which occurs? Morning sickness Breast tenderness Urinary frequency Correct! Puffiness of the face Rationale: Danger signs in pregnancy include swelling of the fingers (rings become tight); puffiness of the face or around the eyes; vaginal bleeding, with or without discomfort; rupture of the membranes; a continuous pounding headache; visual disturbances; persistent or severe abdominal pain; chills or fever; painful urination; persistent vomiting; and a change in the frequency or strength of fetal movements. Morning sickness, breast tenderness, and frequent urination are common occurrences during pregnancy and do not warrant contacting the physician or nurse-midwife. Test-Taking Strategy: Use the process of elimination and focus on the subject, a sign that should be reported. Eliminate the comparable or alike options that indicate common occurrences during pregnancy. Review the danger signs in pregnancy if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Maternity/Antepartum Question 68 1 / 1 pts A pregnant client tells the nurse that she has a 2-year-old child at home and expresses concern about how the toddler will adapt to a newborn infant’s being brought into the home. Which statement is the most appropriate response for the nurse to make to the client? "Don’t be concerned; any 2-year-old would welcome a newborn.” "If your 2-year-old becomes angry or jealous, you should have the child seen by a child psychologist." "A 2-year-old toddler will be more concerned about exploring the environment, so there’s no reason to be concerned.” Correct! "Even though a 2-year-old may have little perception of time, if any changes in sleeping arrangements need to be made for the newborn they should be carried out several weeks before birth." Rationale: Sibling adaptation to the birth of an infant depends largely on age and developmental level. Very young children (2 years or younger) are unaware of the maternal changes occurring during pregnancy and are unable to understand that a new brother or sister is going to be born. Even though toddlers have little perception of time, if any changes in sleeping arrangements need to be made they should be carried out several weeks before the birth of the new baby. Until a child feels secure in the affection of his or her parents, expecting a 2-year-old to welcome a new “stranger” is unrealistic. The parents can be taught to accept strong feelings such as anger, jealousy, and frustration without judgment and to continue to reinforce the child’s feelings of being loved. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that are nontherapeutic and avoid addressing the client’s concern. To select from the remaining options, recall that anger and jealousy are expected feelings in a toddler, which will assist you in eliminating this option. Review the concepts related to sibling adaptation if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Content Area: Maternity/Antepartum Question 69 1 / 1 pts A Muslim woman and her husband are seen in the health care clinic because the woman suspects that she is pregnant. When planning for the physical assessment of the woman, the nurse ensures that which occurs? Correct! A female health care provider examines the woman. The woman's husband remains in the examining room at all times. The woman is examined without any other people in the examining room. Written permission is obtained from the woman to obtain subjective health data. Rationale: Fear, modesty, and a desire to avoid examination by men may keep some women from seeking health care during pregnancy. In many cultures (e.g., Muslim, Hindu, Latino), exposure of a woman’s genitals to men is considered demeaning. Nurses must remember that the reputations of women from these cultures depend on their demonstrated modesty. It is best for a female health care practitioner to perform the examination. If this is not possible, the woman should be carefully draped, with her legs completely covered. A female nurse should remain with the woman at all times. Obtaining permission from the husband may be necessary before an examination or treatment can be performed. Test-Taking Strategy: Focus on the subject, a Muslim client. Recalling that modesty is a cultural characteristic of a Muslim woman will direct you to the correct option. Review these cultural characteristics of a Muslim client if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Cultural Diversity Question 70 1 / 1 pts A nurse is teaching a pregnant client about nutrition and food sources that are high in folic acid. Which food item does the nurse tell the client contains the highest amount of folic acid? Lettuce Oranges Broccoli Correct! Pinto beans Rationale: Foods high in folic acid include beans (black, kidney, pinto, refried), peanuts, orange juice and oranges, asparagus, peas, broccoli, lettuce, and spinach. Pinto beans contain 294 mcg per 1-cup serving. An orange contains 44 mcg per 1-cup serving, lettuce contains 60 mcg per 1- cup serving, and broccoli contains 78 mcg per 1-cup serving. Test-Taking Strategy: Note the strategic words “highest amount” in the question. These words indicate that all of the items in the options contain folic acid but also that you need to select the item that contains the greatest amount. You need to recall that beans are high in folic acid to answer correctly. Review foods high in folic acid if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Nutrition Question 71 1 / 1 pts A pregnant client is scheduled to undergo a transabdominal ultrasound, and the nurse provides information to the client about the procedure. The nurse provides which information? The procedure takes about 2 hours. She will be positioned on her back for the procedure. A probe coated with gel will be inserted into the vagina. Correct! She may need to drink fluids before the test and may not void until the test has been completed. Rationale: For a transabdominal ultrasound, the woman is positioned on her back, with her head elevated, but is turned slightly to one side to prevent supine hypotension. A wedge or rolled blanket is placed under one hip to help her maintain this position comfortably. If a full bladder is necessary, the woman is instructed to drink several glasses of clear fluid 1 hour before the test and told that she should not void until the test has been completed. Warm mineral oil or transmission gel is spread over her abdomen, and the sonographer slowly moves a transducer over the abdomen to obtain a picture. The procedure takes 10 to 30 minutes. For transvaginal ultrasonography, a transvaginal probe is inserted into the vagina. Test-Taking Strategy: Use the process of elimination. Note the strategic word “transabdominal” in the question, and eliminate the option that contains the words “inserted into the vagina.” Recalling that the pregnant client is at risk for supine hypotension will help you eliminate the option that involves positioning the client on her back. To select from the remaining options, visualize this procedure and eliminate the option stating that the test will take 2 hours, because this is a lengthy period. Review the procedure for transabdominal ultrasound if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum Question 72 0 / 1 pts An amniocentesis is scheduled for a pregnant client who is in the third trimester of pregnancy. The nurse tells the client that the most common indication for amniocentesis during the third trimester is which reason? Correct Answer Determination of fetal lung maturity Checking the amniotic fluid for intrauterine infection Checking the fetal cells for chromosomal abnormalities You Answered Determination of whether alpha-fetoprotein (AFP) is present in the amniotic fluid Rationale: The most common indications for amniocentesis in the third trimester are determination of fetal lung maturity and evaluation of the fetus’ condition when the woman has Rh isoimmunization. The most common purpose for midtrimester amniocentesis is to examine fetal cells in the amniotic fluid to identify chromosomal abnormalities. Midtrimester amniocentesis is also performed to evaluate the fetus’ condition when the woman is sensitized to Rh-positive blood, to diagnose intrauterine infection, and to investigate amniotic-fluid AFP and acetylcholinesterase when the maternal serum AFP concentration is increased. Test-Taking Strategy: Use the process of elimination. Noting the words “third trimester” in the question will help direct you to the option that addresses fetal lung maturity. Use of the ABCs— airway, breathing, and circulation—will also direct you to the correct option. Review the indications for performing an amniocentesis in the third trimester if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum Question 73 0 / 1 pts A nurse is explaining a nonstress test to a pregnant client. The nurse explains that the results are nonreactive if which finding is noted on the electronic monitoring recording strip? Correct Answer Absence of accelerations after fetal movement Accelerations without fetal movement with fetal heart rate (FHR) increases of 15 beats/min for 15 seconds You Answered Acceleration of the FHR by 25 to 30 beats/min for at least 15 seconds in response to fetal movement Two fetal heart accelerations within a 20-minute period, peaking at 15 beats/min above baseline and lasting 15 seconds from baseline to baseline Rationale: In a nonreactive (nonreassuring) stress test, the monitor recording would not demonstrate the required characteristics of a reactive (reassuring) recording within a 40-minute period. In a reactive (reassuring) recording, at least two fetal heart accelerations, with or without fetal movement detected by the woman, occur within a 20-minute period, peak at least 15 beats/min above the baseline, and last 15 seconds from baseline to baseline. Test-Taking Strategy: Use knowledge of the subject, nonstress testing. Note the relationship between the word “nonreactive” in the question and “absence” in the correct option. Review interpretation of the results of a nonstress test if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Maternity/Antepartum Question 74 1 / 1 pts A nurse is taking the vital signs of a pregnant client who has been admitted to the labor unit. The nurse notes that the client’s temperature is 100.6°F, the pulse rate is 100 beats/min, and respirations are 24 breaths/min. On the basis of these findings, what is the most appropriate nursing action? Recheck the vital signs in 1 hour. Correct! Notify the registered nurse of the findings. Continue collecting subjective and objective data. Document the findings in the client’s medical record. Rationale: The woman’s temperature should range from 98°F to 99.6°F. The pulse rate should be 60 to 90 beats/min, and respirations should be 12 to 20 breaths/min. A temperature of 100.4°F or higher, especially in the presence of an increased pulse rate and faster respirations, suggests infection, and the registered nurse should be notified. Although the findings would be documented, the nurse would most appropriately contact the registered nurse. Once the nurse has contacted the registered nurse, the nurse would continue assisting with data collection. Vital signs would be rechecked as prescribed or in accordance with agency protocol. Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Noting that the vital signs are elevated above normal range will help direct you to the correct option. Review normal maternal vital signs in the intrapartum period if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum rupture of the membranes. On inspecting the amniotic fluid, the nurse notes that it is clear, with creamy white flecks. What is the most appropriate action for the nurse to take on the basis of this finding? Correct! Document the findings. Check the client's temperature. Report the findings to the nurse-midwife. Obtain a sample of the amniotic fluid for laboratory analysis. Rationale: Amniotic fluid should be clear and may include bits of vernix, the creamy white fetal skin lubricant. Therefore the nurse would most appropriately document the findings. Checking the client’s temperature, reporting the findings to the nurse-midwife, and obtaining a sample of the amniotic fluid for laboratory analysis are not necessary. Cloudy, yellow, or foul-smelling amniotic fluid suggests infection. Green fluid indicates that the fetus passed meconium before birth. If abnormalities are noted, the nurse should notify the nurse-midwife. Test-Taking Strategy: Use knowledge of the subject, appearance of normal amniotic fluid. Noting the word “clear” in the question will help direct you to the correct option. Review the expected findings of amniotic fluid if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum discomfort does the nurse encourage the mother to assume? Prone Supine Standing Correct! Hands and knees Rationale: "Back labor," in which the back of the fetal head puts pressure on the woman’s sacral promontory (occiput posterior position), is common. The discomfort of back labor is difficult to relieve with medication alone. Positions that encourage the fetus to move away from the sacral promontory are the hands-and-knees position and leaning forward over a birthing ball (a sturdy ball similar to a beach ball). These positions reduce back pain and enhance the internal-rotation mechanism of labor. It would be difficult for the woman to assume a prone position. The supine position places the client at risk for supine hypotension. A standing position might increase pressure, worsening the woman’s backache. Test-Taking Strategy: Focus on the subject of the question, relieving back discomfort, and note the strategic word “best” in the question. Visualizing each of the positions in the options will direct you to the correct option. Review the measures for relieving back discomfort if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Question 77 A nurse monitoring a client in labor notes this fetal heart rate pattern (see figure) on the electronic fetal monitoring strip. Which is the most appropriate nursing action? Stop the oxytocin (Pitocin) infusion. Notify the registered nurse of the findings. Administer oxygen with a face mask at 8 to 10 L/min. Correct! Continue to monitor the client and fetal heart rate patterns. Rationale: Early decelerations are not associated with fetal compromise and require no intervention. They occur during contractions as the fetal head presses against the woman’s pelvis or soft tissues, such as the cervix. Early decelerations have a gradual rather than an abrupt decrease from baseline. They have a consistent appearance in that one early deceleration looks similar to others. Early decelerations mirror the contraction, beginning near its onset and returning to the baseline by the end of the contraction, with the low point of the deceleration occurring near the contraction’s peak. The rate at the lowest point of the deceleration usually remains greater than 100 beats/min. Test-Taking Strategy: Knowledge regarding of the subject, the appearance and significance of early decelerations, is needed to answer this question. Recalling that early decelerations are not associated with fetal compromise will help you answer correctly. Review the appearance and significance of early decelerations if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Question 78 1 / 1 pts A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. The nurse should immediately perform which action? Notify the registered nurse. Perform a vaginal examination on the mother. Correct! Position the mother so that her hips are elevated. Insert a gloved finger into the mother's vagina to feel for cord compression. Rationale: Conditions that restrict blood flow through the umbilical cord may result in variable decelerations. If cord compression is suspected, the mother is immediately repositioned. She may be turned to her side, or her hips may be elevated to shift the fetal presenting part toward her diaphragm. A hands-and-knees position may also reduce compression of a cord that is trapped behind the fetus. Several position changes may be required before the pattern improves or resolves. The nurse may need to contact the registered nurse, but this would not be the immediate action. Although the nurse may check the woman’s vaginal area for the presence of the umbilical cord, a vaginal examination is not performed because of the possibility of further compromise of blood flow through the umbilical cord. Because of this risk, the nurse would not insert a gloved finger into the vagina to feel for the cord. Test-Taking Strategy: Note the strategic word “immediately” in the query of the question and use the ABCs—airway, breathing, and circulation—to answer the question. The only action that would provide circulation is positioning the mother so that her hips are elevated, which would relieve cord compression. Review the immediate nursing measures when cord compression is suspected if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Question 79 1 / 1 pts A woman in labor whose cervix is not completely dilated is pushing strenuously during contractions. Which method of breathing should the nurse encourage the woman to perform to help her overcome the urge to push? Cleansing breaths Correct! Blowing repeatedly in short puffs Holding her breath and using the Valsalva maneuver Deep inspiration and expiration at the beginning and end, respectively, of each contraction Rationale: If a woman pushes strenuously before the cervix is completely dilated, she risks injury to the cervix and the fetal head. Blowing prevents closure of the glottis and breath-holding, helping overcome the urge to push strenuously. The woman would be encouraged to blow repeatedly, using short puffs, when the urge to push is strong. Cleansing breaths (deep inspiration and expiration at the beginning and end of each contraction) are encouraged during the first stage of labor to provide oxygenation and reduce myometrial hypoxia and to promote relaxation. The woman would not be encouraged to hold her breath or perform the Valsalva maneuver, which is a bearing-down maneuver. Test-Taking Strategy: Use the process of elimination. Eliminate comparable or alike options; cleansing breaths include deep inspiration and expiration at the beginning and end of each contraction. Recalling that the Valsalva maneuver is a bearing-down maneuver will help you eliminate this option. Review breathing techniques during labor if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Content Area: Maternity/Intrapartum Question 80 1 / 1 pts A woman receives a subarachnoid (spinal) block for a cesarean delivery. For which adverse effect of the block does the postpartum nurse monitor the woman? Pruritus Vomiting Correct! Headache Hypertension Rationale: The adverse effects associated with a subarachnoid block include maternal hypotension, bladder distention, and postdural headache. Postdural headache occurs as a result of cerebrospinal fluid leakage at the site of dural puncture. A spinal headache is postural, worsening when the woman is upright and possibly disappearing when she is lying flat. Bed rest with oral or intravenous hydration helps relieve the headache. Nausea, vomiting, and pruritus are adverse effects associated with the use of intrathecal opioids. Test-Taking Strategy: Use the process of elimination. Noting the word “spinal” in the question and focusing on the subject, an adverse effect, will help direct you to the correct option. Review the adverse effects of a subarachnoid block if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Question 81 1 / 1 pts A nurse is monitoring a woman who is receiving oxytocin to induce labor. Which action should the nurse, on suddenly noting the presence of late decelerations on the fetal heart rate (FHR) monitor, take first? Correct! Stopping the oxytocin infusion Notifying the registered nurse Checking the woman's blood pressure and pulse Increasing the intravenous (IV) rate of the nonadditive solution Rationale: Oxytocin stimulates uterine smooth muscle, resulting in increased strength, duration, and frequency of uterine contractions. The nurse monitors the client who is receiving oxytocin closely and, if uterine hypertonicity or a nonreassuring FHR pattern such as late decelerations occurs, intervenes to reduce uterine activity and increase fetal oxygenation. The nurse would first stop the oxytocin infusion. The nurse would next increase the IV rate of the nonadditive solution, place the woman in a side-lying position, and administer oxygen through a snug face mask at a rate of 8 to 10 L/min. The nurse would then notify the nurse-midwife or physician of the adverse reaction, the nursing interventions taken, and the response to interventions. The nurse would monitor the woman’s vital signs while she is receiving oxytocin, but this would not be the first action in this situation. Test-Taking Strategy: Use the process of elimination and note the strategic word “first.” Noting that the question indicates that the client is receiving oxytocin and recalling the adverse effects of oxytocin will direct you to the correct option. Review the adverse effects of oxytocin and the associated nursing interventions if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Content Area: Delegating/Prioritizing Question 82 1 / 1 pts Immediately after delivery, the nurse assesses the woman's uterine fundus. At what location does the nurse expect to be able to palpate the fundus? In the pelvic cavity Two centimeters above the umbilicus At the level of the umbilicus Correct! Midway between the symphysis pubis and umbilicus Rationale: Immediately after delivery, the uterus is about the size of a large grapefruit or softball. The fundus may be palpated midway between the symphysis pubis and the umbilicus but then rises to a level just above the umbilicus and then sinks to the level of the umbilicus, where it remains for about 24 hours. After 24 hours, the fundus begins to descend by approximately 1 cm, or one finger’s breadth, per day. By the 10th to 14th day, the fundus is in the pelvic cavity and cannot be palpated abdominally. Test-Taking Strategy: Knowledge regarding the descent of the uterine fundus is required to answer this question. Noting the strategic words “immediately after delivery” will help direct you to the correct option. Review the expected findings in the immediate postpartum period related to involution if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Question 83 1 / 1 pts A nurse is taking the vital signs of a woman who delivered a healthy newborn 1 hour ago. The nurse notes that the woman’s radial pulse rate is 55 beats/min. On the basis of this finding, which action by the nurse is most appropriate? Correct! Documenting the finding Helping the woman get out of bed and walk Performing active and passive range-of-motion exercises Reporting the finding to the registered nurse immediately Rationale: After delivery, bradycardia (pulse rate 50–70 beats/min) may occur. The lower pulse rate reflects the large amount of blood returning to the central circulation after delivery of the placenta. The increase in central circulation results in increased stroke volume and permits a slower heart rate to provide adequate maternal circulation. It is not necessary to notify the registered nurse immediately because a pulse rate of 55 beats/min is a normal finding. The client should remain on bed rest in the immediate postpartum period. Although range-of-motion exercises are important for the client on bed rest, this action is unrelated to the data in the question. Therefore the most appropriate nursing action is to document the finding. Test-Taking Strategy: Use knowledge of the subject, expected vital signs in the immediate postpartum period. Recalling the physiological alterations that occur in the woman after delivery will direct you to the correct option. Remember that after delivery bradycardia may occur and that it is a normal finding. Review the expected vital sign measurements in the immediate postpartum period if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Question 84 1 / 1 pts A nurse is monitoring the amount of lochia drainage on a perineal pad in a woman who is 1 hour postpartum and notes a 5-inch bloodstain (see figure). How does the nurse report the amount of lochial flow? Scant Light Correct! Moderate Heavy Rationale: Lochia is the discharge from the uterus, consisting of blood from the vessels of the placental site and debris from the decidua, that occurs during the postpartum period. Use the following guide to determine the amount of flow: scant = less than 2.5 cm (1 inch) on menstrual pad in 1 hour; light = less than 10 cm (4 inches) on menstrual pad in 1 hour; moderate = less than 15 cm (6 inches) on menstrual pad in 1 hour; heavy = saturated menstrual pad in 1 hour; and excessive = menstrual pad saturated in 15 minutes. Test-Taking Strategy: Focus on the data in the question and the figure. Noting the words “5-inch bloodstain” and the use of guidelines to determine the amount of lochial flow will direct you to the correct option. If you had difficulty with this question, review postpartum assessment of the amount of lochial flow. Level of Cognitive Ability: Understanding Content Area: Maternity/Postpartum Question 85 0 / 1 pts A woman who delivered a healthy newborn 6 hours earlier complains of discomfort at the episiotomy site. Which action by the nurse is the most appropriate? Correct Answer Applying an ice pack to the perineum Contacting the registered nurse You Answered Administering an intravenous (IV) opioid analgesic Assisting the woman in taking a warm sitz bath Rationale: Ice causes vasoconstriction and is most effective if applied to the perineal area soon after birth to prevent edema and numb the area. Ice is used for the first 12 to 24 hours after a vaginal birth. Sitz baths, which provide continuous circulation of water, cleanse and comfort the traumatized perineum. Warm water is most effective after 24 hours have elapsed since delivery. An IV opioid analgesic is not necessary. Rather, an anesthetic spray that will decrease surface discomfort may be used. It is not necessary to notify the registered nurse. Test-Taking Strategy: Use the process of elimination and focus on the subject, the woman’s complaint. Recalling that episiotomy pain is to be expected will assist in eliminating the option that involves contacting the registered nurse. An IV medication is not required to relieve the discomfort, so eliminate this option. To select from the remaining options, recall the effects of heat and cold and note that the client gave birth 6 hours ago. Review measures to relieve perineal discomfort in the postpartum period if you had difficulty with this question. Level of Cognitive Ability: Applying Content Area: Maternity/Postpartum Question 86 0 / 1 pts A nurse provides information to a new mother who is being discharged from the maternity unit about signs and symptoms that should be reported to her health care provider. Which statement by the mother indicates a need for further information? "My temperature needs to remain within a normal range." Correct Answer "Frequent urination and burning when I urinate are expected." You Answered "Feelings of pelvic fullness or pelvic pressure are a sign of a problem." "I will call my nurse-midwife if I get any redness, swelling, or tenderness in my legs." Rationale: The new mother is instructed to notify the nurse-midwife or physician if any of the following occurs: fever; localized areas of redness, swelling, or pain in either breast that is not relieved by support or analgesics; persistent abdominal tenderness; feelings of pelvic fullness or pressure; persistent perineal pain; frequency, urgency, or burning on urination; a change in the character of lochia (increased amount, resumption of bright-red color, passage of clots, foul odor); localized tenderness, redness, swelling, or warmth of the legs; and swelling, redness, drainage from, or separation of an abdominal incision. Test-Taking Strategy: Use the process of elimination and note the strategic words “need for further information.” These words indicate a negative event query and the need to select the incorrect statement. Recalling the signs of a urinary tract infection will direct you to the correct option. Review the postpartum signs and symptoms that should be reported if you had difficulty with this question. Integrated Process: Teaching and Learning Content Area: Maternity/Postpartum Question 87 1 / 1 pts A nurse, monitoring a client in the fourth stage of labor, checks the client’s vital signs every 15 minutes. The nurse notes that the client’s pulse rate has increased from 70 to 100 beats/min. On the basis of this finding, which priority action should the nurse take? Correct! Checking the client's uterine fundus Notifying the registered nurse immediately Documenting the vital signs in the client's medical record Continuing to check the client's vital signs every 15 minutes Rationale: During the fourth stage of labor, the woman’s vital signs should be assessed every 15 minutes during the first hour. An increasing pulse rate is an early sign of excessive blood loss, because the heart pumps faster to compensate for reduced blood volume. The blood pressure decreases as the blood volume diminishes, but this is a later sign of hypovolemia. The most common reason for excessive postpartum bleeding is that the uterus is not firmly contracting and compressing open vessels at the placental site. Therefore the nurse should check the client’s uterine fundus for firmness, height, and positioning. Notifying the registered nurse immediately is not necessary unless the nurse is unable to determine the cause of bleeding and is unable to correct it. Continuing to check the client’s vital signs every 15 minutes will delay necessary intervention. Although the findings will need to be documented, the priority action is to determine if the client is bleeding. Test-Taking Strategy: Note the strategic words “priority action.” Noting that the pulse rate has increased and recalling the signs of bleeding and shock will help direct you to the correct option. Also note that the correct option addresses assessment of the cause for bleeding. Review the Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Question 88 1 / 1 pts A nurse calculates a newborn infant’s Apgar score 1 minute after birth and determines that the score is 6. The nurse should take which most appropriate action? Recheck the score in 5 minutes. Initiate cardiopulmonary resuscitation. Provide no action except to support the infant's spontaneous efforts. Correct! Gently stimulate the infant by rubbing his back while administering oxygen. Rationale: The Apgar score is a method of rapid evaluation of an infant’s cardiorespiratory adaptation after birth. The nurse scores the infant at 1 minute and 5 minutes in five areas: heart rate, respiratory effort, muscle tone, reflex response, and color. The infant is assigned a score of 0 to 2 in each of the five areas, and the scores are totaled. If the score ranges from 8 to 10, no action is needed other than support of the infant’s spontaneous efforts and continued observation. If the score falls between 4 and 7, the nurse gently stimulates the infant by rubbing his back while administering oxygen. The nurse also determines whether the mother received opioids, which may have depressed the infant’s respirations. If the score is between 1 and 3, the infant needs resuscitation.. Test-Taking Strategy: Focus on the data in the question, the Apgar score. Recalling that the score Apgar score if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Question 89 1 / 1 pts A nurse monitoring a newborn infant notes that the infant’s respirations are 40 breaths/min. On the basis of this finding, what is the most appropriate action for the nurse to take? Correct! Documenting the findings Contacting the registered nurse Placing the infant in an oxygen tent Wrapping an extra blanket around the infant Rationale: The normal respiratory rate of a newborn infant is 30 to 60 breaths/min (average 40). The nurse would document the findings. Contacting the registered nurse, placing the infant in an oxygen tent, and wrapping an extra blanket around the infant are all unnecessary actions. Test-Taking Strategy: Knowledge regarding the normal respiratory rate in a newborn infant is needed to answer this question. Eliminate the comparable or alike options that indicate action must be taken for an abnormal finding. Focus on the data in the question, and recall that 40 breaths/min is normal. Review normal newborn vital signs if you had difficulty with this question. Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Newborn Question 90 1 / 1 pts A nurse in the newborn nursery, assisting with data collection for a newborn, prepares to measure the chest circumference. The nurse places the tape measure around the infant at which location? In the axillary area Correct! At the level of the nipples Two inches below the nipples At the level of the umbilicus Rationale: The chest circumference of the infant is measured at the level of the nipples. It is usually 2 to 3 cm smaller than the head’s circumference. The average circumference of the chest is 30.5 to 33 cm (12–13 inches). (If molding of the head is present, the head and chest measurements may be equal at birth.) The other options are incorrect anatomical areas for measuring chest circumference. Test-Taking Strategy: Focus on the subject, measuring chest circumference. Visualizing each of the options will help direct you to the correct one. Review the procedure for measuring chest circumference in a newborn infant if you had difficulty with this question. Level of Cognitive Ability: Applying Integrated Process: Nursing Process/Data Collection Content Area: Newborn Question 91 0 / 1 pts A nurse in the health care provider’s office is checking the Babinski reflex in a 3-month-old infant. The nurse determines that the infant’s response is normal if which finding is noted? The infant turns to the side that is touched. The fingers curl tightly and the toes curl forward. Correct Answer The toes flare, and the big toe is dorsiflexed. You Answered There is extension of the extremities on the side to which the head is turned, with flexion on the opposite side. Rationale: To elicit the Babinski reflex, the nurse strokes the lateral sole of the foot from the heel to across the base of the toes. In the expected response, the toes flare, and the big toe dorsiflexes. The Babinski reflex disappears at 12 months of age. Turning to the side that is touched is the expected response when the rooting reflex is elicited. Tight curling of the fingers and forward curling of the toes is the expected response when the grasp reflex (palmar and plantar) is elicited. Extension of the extremities on the side to which the head is turned with flexion on the opposite side is the expected response when the tonic neck reflex is elicited. Test-Taking Strategy: Knowledge regarding the subject, the method of testing and the expected response of the Babinski reflex, is needed to answer this question. Recalling that to elicit Babinski reflex the nurse would stroke the lateral sole of the foot will direct you to the correct option. Review the procedure for testing the Babinski reflex in an infant and the expected response if you had difficulty with this question. Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Newborn Question 92 1 / 1 pts Intramuscular (IM) phytonadione (vitamin K) 0.5 mg is prescribed for a newborn. After the medication is prepared, in which anatomic site does the nurse administer it? Gluteal muscle Deltoid muscle Rectus femoris muscle Correct! Vastus lateralis muscle Rationale: Vitamin K is administered to the newborn infant in the hour after birth to help prevent hemorrhagic disease. The best site for intramuscular injection is the infant’s vastus lateralis muscle, although, if necessary, the rectus femoris muscle may be used. The large vastus lateralis muscle is located away from the sciatic nerve, as well as the femoral artery and vein. The rectus femoris muscle is nearer these structures, and an injection there is more hazardous. The deltoid muscle is not used to administer intramuscular injections in the newborn infant. The gluteal muscles are never used until a child has been walking for at least a year. These muscles are poorly developed and dangerously near the sciatic nerve. Test-Taking Strategy: Use knowledge of the subject, the anatomic site for an IM injection. Visualizing the anatomic location of each of the muscles identified in the options will direct you to the correct option. Review the procedure for administering vitamin K to a newborn if you had difficulty with this question. Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Newborn Question 93 1 / 1 pts A newborn infant's blood glucose level is analyzed by the laboratory. The laboratory staff calls the nurse and reports that the blood glucose level is 40 mg/dL. On the basis of this result, which action should the nurse take first? Hold the next scheduled feeding. Correct! Contact the registered nurse. Document the results in the newborn's medical record. Ask the laboratory to draw another blood sample in 2 hours and repeat the test. Rationale: The blood glucose level for a newborn infant should remain greater than 40 mg/dL. If glucose is not constantly available to the brain, permanent damage may occur. The nurse would most appropriately contact the registered nurse to obtain prescriptions regarding feeding the infant with a low blood glucose. The nurse would also follow agency policy regarding feeding infants with a low blood glucose level if such a policy exists. A common practice is to feed the infant if the glucose level is 40 mg/dL or less. Holding the next scheduled feeding is harmful. Although the nurse would document the laboratory result, this is not the most appropriate initial action. Another blood sample may need to be drawn if it is prescribed, but asking the laboratory to repeat the test in 2 hours is not the appropriate action. Test-Taking Strategy: Note the strategic word “first” in the query of the question. Recalling the normal blood glucose level for a newborn and recalling the danger associated with a low blood glucose level will direct you to the correct option. Review nursing interventions for maintaining a safe blood glucose level in the newborn if you had difficulty with this question. Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Newborn Question 94 1 / 1 pts A nurse demonstrates the procedure for bathing a newborn to a new mother. The next day, the nurse watches as the mother bathes the infant. The nurse determines that the mother is performing the procedure correctly if the mother performs which action? Washes the diaper area first Washes the infant's chest first Correct! Uncovers only the body part being washed Uses a cotton-tipped swab to carefully clean inside the infant's nose Rationale: Bathing should start with the eyes and face, usually the cleanest areas. Next, the external ear and the areas behind the ears are cleansed. The infant’s neck should be washed because formula, lint, or breast milk often accumulates in the folds of the neck. The hands and arms are then washed. Next, the infant’s legs are washed, and the diaper area is washed last. The person administering the bath should keep the infant warm by uncovering only the area being washed. Cotton-tipped swabs are not used to clean the infant’s ears or nose because injury could occur if the infant were to move suddenly. Test-Taking Strategy: Use the process of elimination. Remembering the subject, the basic techniques of bathing a client, will assist you in answering this question. Always start with the cleanest area of the body first and proceed to the dirtiest area. Also, recalling that cotton-tipped swabs can cause injury will assist you in eliminating this option. Review the procedure for Level of Cognitive Ability: Evaluating Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Newborn Question 95 1 / 1 pts The mother of a newborn who was circumcised before discharge from the hospital calls the nurse at the pediatrician’s office and tells the nurse that she is concerned because she has noticed a yellow crust over the circumcision site. The nurse provides which information to the mother? To bring the infant to the pediatrician's office to be checked Correct! That the crust is to be expected as a normal part of healing To remove the crust, using a warm, wet face cloth and a mild soap That it could indicate a sign of an infection and the infant’s temperature should be checked every 2 hours Rationale: After circumcision, a yellow crust may form over the circumcision site. This crust is a normal part of healing and should not be removed. The mother should be told to expect this occurrence. Yellow crusting or discharge is not a sign of infection, and the pediatrician does not need to be notified, because the finding is to be expected. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that a complication exists. To select from the remaining options, recall the normal process of healing. This will help you answer correctly. Review the expected findings after Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Newborn Question 96 1 / 1 pts A new mother who is breastfeeding her newborn calls the nurse at the pediatrician’s office and reports that her infant is passing seedy, mustard-yellow stools. The nurse provides the mother with which information? Correct! That this is normal for breastfed infants To decrease the number of feedings by two per day That the stools should be solid and pale yellow to light brown To monitor the infant for infection and, if a fever develops, to contact the pediatrician Rationale: Breastfed infants pass very soft, seedy, mustard-yellow stools. Formula-fed infants excrete stools that are more solid and pale yellow to light brown. Decreasing the number of feedings might be harmful to the newborn. Because this finding is an expected occurrence in a breastfed infant, infection is not a concern. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that the infant’s stools are abnormal. Remember, breastfed infants pass very soft, seedy, mustard-yellow stools. Review the expected elimination patterns in a breastfed infant if you had difficulty with this question. Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Newborn Question 97 1 / 1 pts A nurse is monitoring a newborn infant for jaundice. Which step should the nurse take to determine the presence of jaundice in the infant? Squeeze the infant's nail beds. Squeeze the infant's brachial area. Apply pressure with a finger over the umbilical area. Correct! Apply pressure with a finger on the infant's forehead. Rationale: To assess an infant for jaundice, pressure is applied with a finger over a bony area such as the nose, forehead, or sternum for several seconds to empty all capillaries in that spot. If jaundice is present, the blanched area will appear yellow before the capillaries refill. Jaundice is first noticeable in the head and then progresses gradually toward the abdomen and extremities because of the newborn infant’s circulatory pattern. Squeezing the infant’s nail beds and brachial area and applying pressure with a finger over the umbilical area are all incorrect methods of assessing for jaundice. Assessing for jaundice in natural light is recommended because artificial lighting and reflection from nursery walls may distort the actual skin color. Visual assessment of jaundice does not, however, provide an accurate assessment of the level of serum bilirubin. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that contain the word “squeeze.” To select from the remaining options, recall that jaundice is first noticeable in the head; this will direct you to the correct option. Review the procedure for determining the presence of jaundice in a newborn if you had difficulty with this question. Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Newborn Question 98 1 / 1 pts A prescription is written to administer hepatitis B vaccine to a newborn infant. Before administering the vaccine, the nurse should perform which action? Check the infant for jaundice. Check the infant's temperature. Correct! Obtain parental consent to administer the vaccine. Request that a hepatitis blood screen be performed on the infant. Rationale: Hepatitis B vaccine is for immunization against infection caused by all known subtypes of hepatitis B virus. The usual recommended schedule is to administer the vaccine at birth, at 1 month of age, and again at 6 months of age. Parental consent must be obtained before the vaccine is administered. Checking the infant’s temperature, checking for jaundice, and requesting that a hepatitis blood screen be performed on the infant are all unnecessary.