Which contraceptive method is most appropriate for a woman whose history reveals two episodes of thrombophlebitis with her previous pregnancy, repeated Candida infections, and gestational diabetes and who wants to postpone pregnancy for at least 1 year? Oral contraceptive pill. Tubal ligation. Diaphragm. Intrauterine device. Of the family planning options presented, a diaphragm and jelly is the optimum choice for this woman. Answer 1 is incorrect because oral contraceptives are contraindicated with a history of thrombophlebitis. Answer 2 is incorrect because she is interested only in postponing pregnancy. Answer 4 is incorrect because use of intrauterine devices is contraindicated for women with impaired responses to infection, such as diabetics Select the option that is not a risk factor/contraindication with this woman's history. Which of the following identifies the basal body temperature (BBT) change characteristic of ovulation? Falls slightly, then increases by about 0.5°C. Rises slightly, then falls by about 0.5°C. Is affected by a surge of FSH. Is due to an estrogen surge. Basal body temperature falls slightly immediately before ovulation, then rises approximately 0.5°C. This characteristic finding aids women in identifying the fertile period of their cycle. Answer 2 is incorrect because the pattern described is reversed. Answers 3 and 4 are wrong because ovulation is related to an LH surge Remember the characteristic pattern: When calculating the 1-minute Apgar, the nurse adds the following assessment findings: heart rate—over 100; respiratory effort—slow and irregular; muscle tone—flaccid response to slap on soles of feet; weak cry; color—body pink, extremities blue. In view of these assessment findings, which Apgar score should the nurse record? 5 6 7 8 Heart rate—2; respiratory effort—1; muscle tone—0; reflex response—1; color—1. Total Apgar score is 5. Answers 2, 3, and 4 are incorrect because of inaccurate allocation of points for behaviors described Use the acronym APGAR to help remember the five areas for assessment: A—Appearance, P—Pulse, G—Grimace, A—Activity, R—Respiratory effort. A woman 36 weeks pregnant is admitted directly from clinic, with a blood pressure of 146/98, puffy face and hands, and "awful headaches and problems seeing." Admission note states: Admit stat for preeclampsia. Which nursing order should be questioned? Assess reflexes and amount and distribution of edema every shift. Up as desired. Admission and daily weight. Test urine for protein every 4 hours. If avoidable, women hospitalized for treatment of preeclampsia should be on bed rest in a quiet environment to minimize stimuli. Answer 1 is incorrect because the nurse should assess the amount and distribution of edema. Answer 3 is wrong because weight is an indicator of edema and diuresis and should be assessed in the preeclamptic woman. Answer 4 is wrong because I & O relationships and the presence and amount of protein in the urine are important indicators of her status This question asks for the wrong answer; three of the options are appropriate orders. Select the one that is not Objectives for the initial prenatal visit include determining a woman's present health status, validating pregnancy, and identifying factors that may affect or be affected by a pregnancy. Which assessment finding indicates a need for further evaluation? Urinary frequency, nausea, fatigue. Vital signs—'1' 98.2, P 92, R 20, BP 110/70. Urine—negative for sugar, trace of protein. Marked vaginal discharge with itching for the past few days. Marked vaginal discharge with itching for the past few days indicates a need for further assessment. Itching is most commonly associated with vaginal infections, and the cause should be identified and treated. Altered vaginal pH in pregnancy contributes to increased susceptibility to infection. Answer 1 is incorrect because urinary frequency, nausea, and fatigue are common complaints in early pregnancy. Answer 2 is wrong because vital signs are within normal limits. Answer 3 is wrong because normally increased vaginal discharge in pregnancy may contaminate voided urine and result in a nonpathological trace of protein Reword the question when the stem asks for "a need for further evaluation." The best answer will have an incorrect statement. Health teaching about over-the-counter pregnancy test kits should include which of the following information? False-negative tests may be due to dilute urine secondary to diuresis and inaccurate technique. Urine tests are classed as presumptive signs of pregnancy. Levels of progesterone from the corpus luteum are sufficient to diagnose pregnancy as early as the fourth week. Urine tests are classed as positive signs of pregnancy. The most common cause of false-negative findings in urine testing for signs of pregnancy (presence of HCG) is faulty technique; further, dilute urine secondary to diuresis may contain too little hormone to register in the routine over-the-counter (or office) pregnancy tests. Note: HCG levels peak approximately 50-60 days after conception. Answer 2 is incorrect because urine tests are classed as "probable" signs of pregnancy. Answer 3 is incorrect because pregnancy tests identify presence/levels of HCG (the biological marker for pregnancy). Answer 4 is wrong because urine tests are classed as "probable" signs of pregnancy Eliminate the two options that state that urine tests are presumptive and positive signs of pregnancy. Eliminate the incorrect marker of pregnancy (3). A woman appears excited, euphoric, and eager to learn about her labor status. Her behavior supports the nursing assessment that she is progressing through which phase of labor? Latent. Active. Transitional. Prodromal. These behaviors are typical of a woman during the latent phase of labor. Answer 2 is incorrect because, as labor progresses, internal stimuli demand more focus. Answer 3 is wrong because women in transitional phase are irritable and increasingly aware of their labor as contractions increase in strength, length, and discomfort. Answer 4 is wrong because, in the prodromal period of labor, contractions are mild and irregular and her major question may be "Am I really in labor?" A memory device to match expected behavior with correct phase of labor: latent = lively (i.e., excited, eager to learn). Thirty minutes after the birth of twins, a new mother's fundus is "boggy" and her lochial flow increased. After massage to firm the fundus, and while supporting the uterus with a hand above the symphysis, the nurse expresses several large clots. Which action should the nurse take next? Notify the physician because the site of her bleeding must be located. Notify the physician because she needs surgery. Administer oxytocin according to prn order. Reapply perineal pad and tell her to keep her thighs together. The most common cause of bleeding immediately post partum is uterine atony, and bleeding may be controlled with fundal massage and oxytocic stimulation. Answer 1 is incorrect because the patient has responded to the nursing measures. Answer 2 is wrong because her bleeding does not appear to be associated with lacerations that might require surgery. Answer 4 is wrong because perineal pressure is effective only in treating superficial tears Key word is "next" action. Eliminate the two options about notifying the MD when the problem is under control. Choose the only option that has a prn medication. While performing a newborn assessment, the nurse notes yellowish vernix. The nurse promptly calls this to the physician's attention because this may be a sign of: Rh or ABO incompatibility or maternal ingestion of sulfisoxazole (Gantrisin). An intrauterine gonorrheal infection. Maternal diabetes mellitus. Fetal postmaturity. Yellow vernix results from the breakdown of hemoglobin or bile pigments in meconium. Both maternal anti-Rh-antigen antibodies and ingestion of sulfisoxazole (Gantrisin) are implicated in hemolysis of fetal RBCs. Answer 2 is incorrect because gonorrheal infection is opaque, thick, and odorous without discoloring vernix. Answer 3 is wrong because diabetes does not have any effect on the color of vernix. Answer 4 is wrong because the postmature fetus does not have vernix Eliminate the three options that have no effect on the vernix. Which plan should the nurse recommend to a pregnant woman for morning nausea? Eat a high-protein snack at bedtime. Eat two dry crackers or toast before arising. Eat a high-protein breakfast. Drink a glass of orange juice immediately on awakening. Carbohydrates taken before arising seem to reduce symptoms of morning nausea; dry crackers may absorb stomach acid and raise blood sugar. Answer 1 is incorrect because high-protein snacks at bedtime appear to have no effect on nausea in the morning. Answer 3 is wrong because nausea is present before eating and may be severe enough to prevent eating. Answer 4 is wrong because orange juice on an empty stomach may precipitate emesis in a woman with "morning sickness." Key point is time-frame: before getting out of bed. Choose dry over acidic fluid. Which of the following best explains indigestion, heartburn, and constipation during pregnancy? Progesterone, produced by the placenta, causes reduced motility of smooth muscle, e.g., intestinal tract. Stress due to developmental tasks of pregnancy results in increased gastric acidity and reflux. Pressure from the growing uterus displaces the stomach and intestines. Increased pancreatic activity results in digestive-tract fat intolerance. The effects of progesterone on the GI tract include relaxation of the cardiac sphincter and delayed gastric emptying, which contribute to indigestion and heartburn, and slowed intestinal peristalsis, which increases water reabsorption and predisposes to constipation. Answer 2 is incorrect because the major cause of symptoms is described in Answer 1. Answer 3 is wrong because displacement due to pressure from the uterus is secondary to the effects of reduced smooth muscle tone. Answer 4 is wrong because increased pancreatic activity does not cause fat intolerance Select the option that explains hormonal influences. When preparing the room for a woman with preeclampsia which equipment items are most important to have ready? Suction and oxygen apparatus. Urinary retention catheter and drainage bag. Electronic blood pressure monitor. Padded tongue blade and airway. (1) is correct because the nurse's primary responsibility is to prepare for respiratory and cardiac support in case the woman experiences an eclamptic seizure. Answer 2 is incorrect because not all preeclamptic women require bladder catheterization. Answer 3 is incorrect because the nurse may monitor blood pressures using the standard sphygmomanometer and arm cuff. Answer 4 is incorrect because tongue blades are never used to manage seizures today Think airway first! A mother who just gave birth saturates her perineal pad in 15 minutes. Her fundus is firm and smooth, and there is a constant trickle of blood from the vagina. No clots can be expressed when the fundus is massaged. On the basis of these findings, what should the nurse suggest? Atonic bleeding. Traumatic bleeding. Retained placenta fragments. Inverted uterus. Traumatic bleeding (e.g., birth canal or cervical lacerations) is characterized by a firm, smooth uterus and a continuous trickle. Answer 1 is incorrect because the uterus remains well contracted. Answer 3 is wrong because bleeding from retained placental fragments occurs most commonly later in the postpartum period. Answer 4 is wrong because an inverted uterus is characterized by profuse vaginal bleeding and maternal collapse Narrow your choice by noting similarity in the use of the word "blood" in the stem and two of the options with "bleeding." Eliminate (1) because the fundus is not boggy, but firm. Which nursing action increases a woman's discomfort during a pelvic examination? Explaining why the examination is being done and what she may expect. Offering the nurse's hand for her to squeeze. Suggesting breathing techniques to help her relax. Asking her to empty her bladder before the examination. Offering your hand to squeeze encourages her to tense her muscles, including the pubococcygeus muscle of the pelvic floor increasing the discomfort of a pelvic examination. Answer 1 is incorrect because explaining that she may expect and the reasons for examination procedures is an appropriate nursing action designed to reduce her anxiety and tension. Answer 3 is wrong because suggesting and demonstrating breathing techniques is an appropriate nursing action designed to assist her to relax during the procedures. Answer 4 is wrong because asking her to empty her bladder is appropriate anticipatory guidance designed to reduce the stress of the pelvic examination Visualize what happens to the pelvic area when squeezing a hand; this may help you choose the best answer (i.e., what is helpful). Which finding is inconsistent with an 8-week gestation? Chadwick's sign. Hegar's sign. Goodell's sign. Ballottement. The finding of ballottement is more consistent with a pregnancy of 19 or more weeks. Answer 1 is incorrect because Chadwick's sign (bluish discoloration of the vagina) is usually present at 8 weeks of gestation. Answer 2 is wrong because Hegar's sign (softening of the lower uterine segment) is present by 8 weeks. Answer 3 is wrong because Goodell's sign (softening of the cervix) is usually present at this point in gestation Key words are "inconsistent" and "8 weeks of gestation." Three of the signs are present around 8 weeks; one is much later. Four hours after birth, a newborn begins to show signs of respiratory distress. This newborn's history includes 42 weeks of gestation and two episodes of late FHR decelerations during labor. Which of the following should the nurse suspect? Aspiration syndrome. RDS. Oxygen toxicity. Bronchopulmonary dysplasia. Aspiration syndrome occurs commonly among post-term newborns, especially if they are postmature. Hypoxia accompanies progressive placental insufficiency (evidenced by late FHR decelerations) with advancing gestational age. Physiological response to hypoxia is relaxation of the anal sphincter, with release of meconium into amniotic fluid, and the fetal gasp reflex. Answer 2 is incorrect because RDS is associated most commonly with prematurity and insufficient pulmonary surfactant. Answer 3 is wrong because oxygen toxicity occurs after a period of oxygen therapy. Answer 4 is wrong because bronchopulmonary dysplasia (BPD) is associated with prolonged administration of oxygen at high concentrations; the time since birth is too short for the baby to develop BPD The key element is a time factor: 42 weeks = postmaturity. Plans to minimize symptoms of physiologic adaptations to pregnancy include suggesting which of the following? High-carbohydrate diet and decreased fluid intake, to stimulate peristalsis. Pelvic rock-and-tilt exercises, to increase tone of her abdominal muscles. Symptomatic relief by over-the-counter antacids and mild laxatives. Increased fluid intake and small, frequent, high-bulk meals. Increasing fluid and roughage intake will reduce symptoms of constipation. Answer 1 is incorrect because a high-carbohydrate diet and reduced fluid intake may make constipation worse. Answer 2 is wrong because exercise does not counteract the effects of progesterone. Answer 3 is wrong because many over-the-counter antacids contain sodium and frequent use of laxatives may result in further loss of tone, leading to constipation Because constipation is a common discomfort of pregnancy, focus on (1) and (4), which relate to diet. Next, eliminate (1) because of decreased fluid. Which theory provides the basis for the nurse's explanation and teaching regarding gestational diabetes? There is an anti-insulin effect of human placental lactogen (HPL). There is a proinsulin effect of HPL. Increased maternal tissue sensitivity to insulin. Diabetes is unrelated to pregnancy; size and production of the islets of Langerhans are unaffected. The anti-insulin effects of the placental hormone HPL (a growth hormone) and reduced maternal tissue sensitivity to insulin often may result in development of gestational diabetes in women who previously had no symptoms of diabetes. Answer 2 is wrong because the effect of HPL is antagonistic to insulin, not proinsulin. Answer 3 is wrong because there is decreased maternal tissue sensitivity to insulin. Answer 4 is wrong because the size and production of the islets of Langerhans increase during pregnancy Understand the mechanisms and risks for glucose intolerance/insulin resistance in pregnancy. To help remember the insulin requirements in pregnancy, use the following memory aid: trimester one:?-; trimester two: ?; trimester three: ?;postpartum:?; A new mother wants to breastfeed. She has had no previous experience or instruction. Which of the following should the nurse include in teaching her about good nipple care? Washing nipples and breasts every day with soap and water to prevent infection. Keeping nipples clean with warm water and then air-drying to reduce irritation. Applying dilute alcohol solution to nipples after each feeding, to toughen them. Covering the nipples with a plastic-lined breast shield to protect clothing. Nipples cleansed with plain water and air-dried carefully are less likely to develop fissures. Answer 1 is incorrect because soap is drying and removes natural oils. Answer 3 is incorrect because alcohol would be too drying and promotes fissure development. Answer 4 is wrong because a plastic shield would retain body heat and moisture, irritating nipples Three options have incorrect information. Eliminate the two options that may be too drying (soap, alcohol). Go for "water and air." A woman in labor is becoming more serious, evidences a malar flush, and tends to hyperventilate with contractions. These signs occur most commonly during which phase? Latent. Active. Transitional. Pushing. These behaviors are characteristic of the active phase of the first stage of labor, at about 5 cm dilation. Answer 1 is wrong because women are more excited and relaxed during the latent phase when labor is less uncomfortable. Answer 3 is wrong because behaviors during transition reveal the woman's focus on completing the process rapidly; irritability is common. Answer 4 is wrong because the woman uses sustained inhalations to increase the force of her pushing Recall stages and phases of labor and expected patient behaviors: latent—more relaxed, less uncomfortable; active—hyperventilation, flushed; transitional— irritable. A newborn who weighed 7 lb at birth now weighs 6 lb 8 oz. Implementing health teaching, the nurse tells the mother the percentage of birthweight usually lost by normal, healthy babies. Which of the following represents the maximum amount of normal weight loss for this newborn? 6oz(170g). 8oz(227g). 11 oz(317g). 16oz(454g). Term infants may lose 5-10% of their birth weight. Arithmetic: 7 X 16 oz = 112 oz; 10% of 112 = 11.2 oz (317.5 g). Answers 1,2, and 4 are wrong because of inaccurate computation Accurate multiplication (16 oz = 1 pound) is the key. Remember that 5-10% loss is OK. For which reason must a preeclamptic woman be carefully assessed for fluid intake and urine output? Oliguria is a grave sign. Daily intake should never exceed 2000 mL. Sudden diuresis can precipitate convulsion. If urine output is less than 100 mL/4 hr, repeat dose of magnesium sulfate is needed. Oliguria is an ominous sign in preeclampsia. Answer 2 is incorrect because daily intake is individualized for the preeclamptic woman. Answer 3 is wrong because sudden diuresis is a good prognostic sign. Answer 4 is wrong because urinary output must equal or exceed 120 mL/4 hr before magnesium sulfate, if needed, can be given again Scanty urine is a critical finding; lots of urine (diuresis) is a good sign (3). A new mother saturates her perineal pad in 15 minutes. Her fundus is firm and smooth, and there is a constant trickle of blood from the vagina. No dots can he expressed when the fundus is massaged. Which action should the nurse take immediately? Notify the physician because she needs surgery. Notify the physician because the site of her bleeding must be located. Administer oxytocin according to prn order. Reapply perineal pad and evaluate bleeding in 15 minutes. The laceration must be located and treated before bleeding will stop. Answer 1 is incorrect because, if the laceration is accessible, bleeding may be controlled by insertion of vaginal packing. Answer 3 is wrong because bleeding is not related to uterine atony. Answer 4 is wrong because perineal pressure would be ineffective with a vaginal laceration Choose the answer that would be the first action; think assessment (by the MD) as the priority (i.e., "must be located"). If a pregnant woman's vaginal discharge is thick, white, cheeselike, and pruritic, the nurse's therapeutic and educational actions should be based on which of the following? No action needed. This is normal leukorrhea of pregnancy. Metronidazole (Flagyl) is the drug of choice to treat this condition. Even if untreated, this condition presents no hazard to the neonate. This condition is more likely to occur in women who are pregnant or taking oral contraceptives or antibiotics or who are diabetic. Her discharge is characteristic of a monilial (yeast) infection. This infection is more common in women whose vaginal pH has changed because of pregnancy or diabetes or who are taking oral contraceptives. Antibiotic therapy is also associated with increased risk for developing an infection by Candida albicans. Answer 1 is incorrect because normal leukorrhea associated with pregnancy is thin, colorless, and nonpruritic. Answer 2 is wrong because mycostatin (Nystatin) is the drug of choice for treating vaginal yeast infections; metronidazole (Flagyl) is used in treating trichomonal infections. Answer 3 is wrong because, if present during the baby's birth, this organism causes neonatal thrush Because these are the signs and symptoms of monilial infection, you can eliminate the first three options; this is not normal (1). The drug in Answer 2 is incorrect, and there is a hazard to the neonate (3). If a pregnant woman's last normal menstrual period started August 5, her EDB is: May 12. May 30. June 8. June 12. Using Nägele's rule to calculate the EDB, the correct date is arrived at by taking the date of the first day of the last menstrual period (LMP) and subtracting 3 months and adding 7 days. Answer 2 is wrong because 7 days have been subtracted from her LMP. Answer 3 is wrong because calculations have erroneously included August as one of 3 months, and only 3 days have been added to the date of LMP. Answer 4 is wrong because, although calculations added 7 days, August was again erroneously included as one of the 3 months subtracted Use the memory aid for Nägele's formula: EDB = LMP - 3 months + 7 days. A pregnant woman complains, "I waddle like a duck, and after even a short walk, my back and legs ache. Why? What can I do about that?" Which of the following provides the basis for appropriate health teaching? Relaxation of pelvic joint articulations and strain on supporting muscles due to the growing uterus cause these symptoms. An increased metabolic rate in pregnancy results in excess production of lactic acid in back muscles. Progesterone causes striated muscle stretching and pain on motion. Decreased venous return from the legs and the pressure of the heavy uterus cause waddling and discomfort. Shitting the center of gravity to compensate for the weight of the growing uterus places strain on supporting musculature and contributes to low-back ache during pregnancy; relaxation of joint articulations is responsible for the waddling gait. Answer 2 is wrong because vigorous exercise contributes to the production of lactic acid; the increased metabolic rate during pregnancy has no effect. Answer 3 is wrong because progesterone affects smooth muscle. Answer 4 is wrong because decreased venous return and pressure from the growing uterus contribute to development of varicosities Only (1) and (4) address both the "waddle" and back leg discomfort. Eliminate (4) because the explanation is for varicosities. Which action should the nurse recommend to reduce normal discomforts of pregnancy such as duck-waddle walk and back and leg ache? Avoid walking whenever possible; get bed rest in side-lying Sims' position several times daily. Perform pelvic tilt-and-rock exercises; get rest whenever possible, legs elevated. Wear a maternity girdle to provide support. Increase calcium intake, perform stretching exercises, and rest frequently during the day. Exercises like the pelvic tilt slide and rock strengthen the abdominal and back muscles, which support the mother in an erect position—and the growing uterus; rest while elevating the legs reduces stress on these muscles and the legs and decreases symptoms. Answer 1 is incorrect because walking is an excellent mild exercise recommended for the pregnant woman. Answer 3 is wrong because a girdle may contribute to decreased venous return from the extremities. Answer 4 is wrong because symptoms are due to strain on supporting muscles and are unrelated to the level of circulating calcium Choose the option that results in muscle strengthening. A new mother is distressed because her baby looks a little yellow. She says, "The other nurse said she has 'physical' jaundice. What's that? Is it bad?" The nurse's explanation is based on knowledge of the normal physiological changes of the newborn. Which of the following is responsible for a newborn's physiologic jaundice? Liver immaturity and fetal polycythemia. Oliguria and kidney immaturity. Infection. Dehydration. Physiologic jaundice is related to inability of the liver to conjugate bilirubin liberated by normal hemolysis of fetal RBCs and polycythemia. Answer 2 is incorrect because jaundice associated with kidney immaturity is pathological. Answer 3 is wrong because jaundice occurring secondary to infection is also pathological. Answer 4 is wrong because, although dehydration may be associated with the jaundice, it also is pathological Identify physiologic vs. pathologic jaundice. Pathological is not normal. Note the words in the stem: "normal" physiological. Liver immaturity is not pathological, hut oliguria, infection, and dehydration are. When discussing common complaints arising from normal maternal adaptations to pregnancy, which normal physiologic change has greater implications for the woman with a history of diabetes mellitus and requires more teaching about warning signs and symptoms needing prompt medical evaluation? Increased venous pressure in lower extremities. Placental production of HPL (human placental lactogen). Increased cardiac output. Relaxation of the cardiac sphincter. Human placental lactogen (HPL) is an insulin antagonist and may complicate management of diabetes during pregnancy. Answer 1 is incorrect because fatigue and varicosities are common complaints associated with decreased venous return from the lower extremities. Answer 3 is wrong because increased cardiac output places additional work on the heart. Answer 4 is wrong because relaxation of the cardiac sphincter is associated with heartburn and gastric reflux By understanding the functions of HPL, you can see the connection with diabetes. Answers 3 and 4 deal with cardiac problems, not diabetes Close observation and continuous nursing assessment of a woman with severe preeclampsia are necessary to facilitate prompt identification and management of which of the following? Abruptio placentae. Placenta previa. Hydramnios. Hyperemesis gravidarum. Abruptio placentae may be a complication of severe preeclampsia and places both mother and fetus in jeopardy. Answer 2 is incorrect because placenta previa is due to low implantation, not pathophysiological changes in preeclampsia. Answer 3 is wrong because hydramnios is most commonly associated with maternal diabetes, and although it may coexist with preeclampsia, it is not a contributing factor. Answer 4 is wrong because hyperemesis gravidarum occurs earlier in pregnancy and is not associated with development or progression of preeclampsia By recalling the definition of the four terms, identify the condition for which severe preeclampsia is a risk factor. A pregnant woman is admitted for evaluation of her cardiac status at 24 weeks of gestation. During the evening, she complains of dyspnea and shortness of breath while ambulating. She has a moist cough. Her physician orders complete bed rest. Which nursing intervention is most appropriate to prevent further deterioration of her cardiac condition? Place her in Trendelenburg position to encourage venous return to the heart. Assist her with activities of daily living to reduce energy expenditures. Encourage frequent coughing and deep breathing to prevent pulmonary complications of immobility. Initiate a regimen of lower-limb exercises to prevent venous stasis and leg thrombosis. Activities of daily living increase energy expenditures and may contribute to further cardiac decompensation. Answer 1 is incorrect because dyspnea and shortness of breath will be exacerbated in Trendelenburg position. Answer 3 is incorrect because any activity that causes her to perform a Valsalva maneuver (coughing) will cause a sudden increase in blood return to the heart, which is contraindicated in cardiac disease. Answer 4 is incorrect because the major goal of care is to reduce all energy expenditures Look at the verbs: "place," "assist," "encourage," "initiate." Choose "assist" for preventing further cardiac decompensation. A new mother tells the nurse she is breastfeeding because she can't stand the thought of the baby being vaccinated. Which response demonstrates effective health teaching? That's great. Vaccinations aren't needed if you breastfeed him. Oh, you still need to have him vaccinated against DPT, measles, and polio before he is 6 months old. You can only give temporary protection to the infant against the diseases you have had yourself. The most protection comes from colostrum just after birth. Unfortunately, you didn't start feeding him right away. Only disease-specific antibodies produced by the mother in response to that infection can be produced through breast milk to the baby. Answer 1 is incorrect because vaccinations would be needed to develop active immunity. Answer 2 is wrong because measles vaccination is not effective if given before 1 year of age. Answer 4 is wrong because maternal antibodies confer only short-lived passive immunity Understand the effects of antibodies on the infant who is breastfeeding. When a question asks for effective health teaching, three of the answers will not be accurate information. Choose the one that is. A woman says, "My doctor says I'm 5 months (20 weeks) pregnant. What does my baby look like now?" The nurse's response is based on knowledge of normal fetal development. Which of the following describes the average fetus at 20 weeks of gestation? Viable, able to survive outside of the uterus with minimal assistance. About 10 inches long, weight about 10 oz, and covered with fine, downy hair and vernix. Beginning sex differentiation, kidney function, and detectable movements. Shedding lanugo and vernix, growing rapidly, weighs about 1 1/2 pounds. These are the characteristics of the fetus at 20 weeks of gestation (22 menstrual weeks). Answer 1 is incorrect because, although 20 weeks has been identified as viability, most such fetuses are too immature to survive independent extrauterine existence successfully. Answer 3 is wrong because sex differentiation begins at conception and is discernible at 12 weeks, and kidneys begin secreting urine at 11 weeks. Answer 4 is wrong because the fetus begins to exhibit these characteristics at 31 weeks Remember: 10 inches, 10 oz at 20 weeks. Review fetal development by trimester of pregnancy In discussing "dos and don'ts," which health teaching aspect should be emphasized as important for health maintenance during pregnancy? Keeping appointments for prenatal visits, remembering to ask questions when necessary, and following the medical/nursing recommendations. Making preparation for childbirth classes. Moderate exercise, high-carbohydrate diet, and adequate rest. Taking multivitamins and iron, drinking six glasses of milk daily, and minimizing physical exertion. The most important factor in reducing morbidity and mortality associated with pregnancy is close health supervision and prompt management of emerging problems and complications. Answer 2 is incorrect because the primary goal of prenatal classes is to prepare the couple for labor and birth. Answer 3 is wrong because high-protein diets are recommended during pregnancy to reduce the possibility of preeclampsia. Answer 4 is wrong because the pregnant woman should drink 1 quart of milk and increase her intake during lactation The best option relates to goals during pregnancy, not specifically for labor and delivery, as in (2), for reduction of morbidity and mortality. When an answer has multiple points, be sure to read each of these carefully because not all points in the option are correct, such as (3) and (4), making the option only partially accurate. Which response is appropriate to give to a pregnant woman who is worried about having urinary frequency? Placental progesterone causes irritability of the bladder sphincter. Your symptoms will go away after the baby comes. Frequency is due to bladder irritation from concentrated urine and is normal in pregnancy. Increase your daily fluid intake to 3000 mL. Pregnant women urinate frequently to get rid of fetal wastes. Limit fluids to 1000 mL daily. Try using Kegel (perineal) exercises and limiting fluids before bedtime. If you have frequency associated with fever, pain on voiding, or blood in the urine, call your doctor/nurse-midwife. Progesterone also reduces smooth muscle motility in the urinary tract and predisposes the pregnant woman to urinary tract infections. Women should contact their doctors if they exhibit signs of infection. Kegel exercises will help strengthen the perineal muscles; limiting fluids at bedtime reduces the possibility of being awakened by the necessity of voiding. Answer 1 is incorrect because progesterone does not cause irritability of the bladder sphincter. Answer 2 is wrong because frequency in early and late pregnancy is due to pressure on the bladder from the growing uterus. Answer 3 is wrong because hydration is important in maintaining normal digestion and nutrient transport to body cells, removing wastes, and regulating body temperature. During pregnancy, eight 8 oz glasses of fluid daily are recommended When the question asks for an appropriate response, eliminate the theoretically incorrect responses first. Understand the effects of progesterone on smooth muscle (specifically the bladder). As a woman progresses through labor, she becomes increasingly irritable with her partner, complaining of lower-backpain and fatigue. Which nursing intervention is most appropriate now? Have the woman turn on her side and give her a back rub. Ask her if she would like the nurse to get an order for something for her discomfort. Reassure the partner that irritability is normal, and teach the partner to apply sacral pressure with contractions. Send the partner for a coffee break, and encourage the woman to try to get some rest. Reassurance that her behavior is normal for this point in labor helps reduce the partner's feelings of guilt and help lessness and fosters the sense of a mutual, shared experience; sacral pressure reduces her discomfort. Answer 1 is wrong because it does not address the partner's feelings. Answer 2 is wrong because it does not facilitate the shared experience and may result in feelings of failure in some women. Answer4 is wrong because she is progressing well and needs/wants her partner's support Note the pattern in the answers: three options do not involve the partner; one option does. In this case, choose the option that is different. At 37 weeks, a pregnant woman calls the office to say she awakened in a pool of blood and is dizzy and nauseated. She denies any abdominal pain or cramping. On the basis of this assessment, the nurse suggests she go to the hospital immediately. The nurse established a nursing diagnosis of high risk for fluid volume deficit associated with which of the following? Placenta previa. Abruptio placentae. Preeclampsia. Uterine rupture. Painless vaginal bleeding is associated with placenta previa. Answer 2 is wrong because abdominal pain and a tense abdomen are signs of possible abruptio placentae. Answer 3 is wrong because painless vaginal bleeding is not indicative of preeclampsia. Answer 4 is wrong because the uterine rupture is characterized by sudden sharp abdominal pain, signs of internal bleeding, and shock The key point is painless. Recall the differences between signs and symptoms of placenta previa and abruptio placentae. Answers 2 and 4 involve pain and can be eliminated, and for one condition (3) pain is not relevant. An expectant father says, "My wife is a heavy smoker—three packs a day. She won't listen to me. Will you talk to her?" Which nursing approach is appropriate to this problem? Tell the woman that, if she continues to smoke that much, the baby will be small and have a greater chance of childhood respiratory infections. Teach the woman to substitute snacking on cheese, dried apricots, or raisins to curb her desire to smoke. Discuss current thoughts about the effects of smoking during pregnancy with the woman, and ask her if she can think of ways to cut down. Ask the woman how she plans to cut down to 10 cigarettes daily. Encouraging her to consider ways to reduce her smoking implies your respect for her ability to deal with the problem and encourages her active participation in her own pregnancy-related care. Answer 1 is incorrect because such comments generate guilt and may threaten her self-image. Answer 2 is wrong because telling her to substitute even "good foods" implies lark of respect for her judgment and assumes that she will comply with your choices for her behavior. Answer 4 is wrong because it implies she has no choice in the matter; patient goals are best established mutually "Discuss" is better than "tell" or "teach" in this case. Which signs and symptoms require immediate medical evaluation during pregnancy? Excessive saliva, "bumps" around the areolae, and increased vaginal mucus. Fatigue, nausea, and urinary frequency at any time during pregnancy. Ankle edema, enlarging varicosities, and heartburn. Severe abdominal pain or fluid discharge from the vagina. Severe abdominal pain may indicate complications of pregnancy such as abortion, ectopic pregnancy, or abruption placentae; fluid discharge from the vagina may indicate pre-mature rupture of the membranes. Answer 1 is incorrect because ptyalism, elevated Montgomery tubercles, and leukorrhea are normal physiological responses during pregnancy. Answer 2 is wrong because fatigue, nausea, and frequency are normal in early pregnancy. Answer 3 is wrong because ankle edema, varicosities, and heartburn are normal during pregnancy Select "severe pain" as the most critical finding. Know the signs of the most serious complications during pregnancy. Which signs and symptoms during pregnancy should the nurse teach as possible warning signs of potential problems? Edema of the lower extremities, vulvar varices, and copious, clear vaginal discharge. Heartburn, shortness of breath, change in appetite. Leg cramps, back pain, and increased pigmentation over the bridge of the nose and the cheeks. Headache, visual disturbances, or feeling of fullness in face and hands. Headache and feeling of fullness in face and hands may indicate preeclampsia. Answer 1 is wrong because pedal edema, varicosities, and vaginal discharge are related to decreased venous return and increased vascularity in pregnancy. Answer 2 is wrong because heartburn, shortness of breath, and change in appetite are normal responses in pregnancy. Answer 3 is wrong because leg cramps, low-backache, and chloasma are associated with normal physiological changes of pregnancy Distinguish between common normal discomforts of pregnancy and more serious complications. Prioritize critical findings. The pregnant woman who would likely be given a "trial of labor" for vaginal birth after cesarean (VBAC) is one who had a first: Cesarean through a classic uterine incision because of severe fetal distress. Low transverse cesarean for breech presentation; this pregnancy is in vertex presentation. Cesarean for fetopelvic disproportion. Low transverse cesarean for active vaginal/perineal herpes infection; culture at 39 weeks this pregnancy was positive for herpes. The reason for the first cesarean was a breech presentation, and that is not present in this pregnancy. Also, a low transverse uterine incision presents only a very slight risk for uterine rupture with subsequent VBAC deliveries. Answer 1 is incorrect because the classic vertical incision through the uterus (and subsequent scar) is considered to weaken the uterus and compromise its ability to withstand stretching and contracting. Answer 3 is incorrect because the original cause (fetopelvic disproportion) remains. Answer 4 is incorrect because an infant may acquire herpes during passage through an infected birth canal Visualize the common uterine incision used and why it would pose the greatest risk for uterine rupture. Eliminate Answer 3 because the same condition exists again and eliminate Answer 4 because there is maternal infection now. Review the risks of cesarean birth, and specifically the risks of a vaginal birth after a previous cesarean. A woman with a history of diabetes may require hospitalization during her pregnancy for treatment of any problems associated with her pregnancy or for diagnostic tests. When asked to verbalize her understanding of the discussion, which of this woman's responses indicates a need for further health teaching? Pregnancy may change the amount of insulin 1 need for regulation of my diabetes. I may need to be hospitalized to evaluate how well my placenta is functioning. If this awful morning sickness keeps up, the doctor may put me in to control it. The doctor may need to take a sample of my water (amniocentesis) to see if the baby has the gene for diabetes. Amniocentesis does not show whether the fetus is a potential diabetic, but it may be performed on diabetic women to test for fetal lung maturity. Answer 1 is wrong because her statement indicates understanding of the inter relationship between her pregnancy and her diabetes. Answer 2 is wrong because pregnant diabetics may be hospitalized for testing for placental function. Answer 3 is wrong because nausea and vomiting in the pregnant diabetic may lead to acidosis When a question asks for "need for further health teaching," the best answer will have an incorrect statement. Review the goals of care for a pregnant diabetic. Assessment findings at 16 weeks of gestation include marked chloasma and secondary pigmented areolae; in addition, the woman's umbilicus is flush with her skin. During which trimester are these physical changes of pregnancy commonly found? First. Second. Third. Fourth. Chloasma, secondary pigmented areolae, and umbilicus flush with the skin are characteristic changes in the second trimester. Answer 1 is wrong because these signs are not present during the normal first trimester. Answer 3 is wrong because, although present during the third trimester, these changes begin during the second. Answer 4 is wrong because these signs diminish during the fourth trimester Think skin (chloasma, pigmented areola) = second. Note the word "secondary" in the stem is similar to "second" in (2). A new mother tells the nurse, "I am afraid the baby will have something wrong with her because I was bad while I was carrying her. Is she really okay?" If observed, which of the following would the nurse note as unusual in a newborn girl? Enlarged breasts and some pink drainage from the baby's vagina. A dark line between the baby's umbilicus and symphysis. Little "blackheads" covering her nose and chin. A dark discoloration over her sacrum and lower back. (3) is unusual because milia (unopened sebaceous glands) look like whiteheads. Answer 1 is typical because enlarged breasts and pink spotting (pseudomenstruation) are effects of high circulating levels of maternal hormones. Answer 2 is typical because the linea nigra is evident due to maternal hormones. Answer 4 is typical because "mongolian spots" are found on the lower back and sacrum of darker-skinned people Look for what is not typical after recalling normal assessment findings for a full-term neonate girl. An infertility assessment begins with a thorough health history. Which factor is likely to be implicated in female infertility? Moderate alcohol intake. Menstrual cycle of 26 to 28 days. History of PID. Past use of diaphragm and spermicide for contraception. PID is associated with adhesions and blockage of the fallopian tubes, preventing transport and joining of the ovum and sperm. Answer 1 is incorrect because moderate alcohol intake is not implicated in female infertility. Answer 2 is incorrect because a normal menstrual cycle is not associated with infertility. Answer 4 is incorrect because use of a diaphragm and spermicidal jelly is not implicated in infertility Look for the risk factor that is a common cause of female infertility. Which nursing intervention is most likely to be included in the plan of care for a woman with heart disease during the first postpartum day? Push oral and IV fluid to stimulate diuresis and prevent fluid volume overload. Encourage early ambulation and exercise to reduce the risk of thrombophlebitis. Monitor vital signs, skin color, and pulmonary status to identify cardiac decompensation. Encourage her to defer breastfeeding on the first day to reduce the cardiac workload. (3)is correct because major cardiovascular changes that occur with the termination of pregnancy can result in sudden cardiac decompensation in the first postpartum day. Answer 1 is incorrect because pushing fluids can result in fluid volume overload and cardiac decompensation. Answer 2 is incorrect because the postpartum woman with heart disease is encouraged to rest on the first day to minimize cardiac stressors while major cardiovascular changes occur. Answer 4 is incorrect because breastfeeding is not contraindicated The emphasis is on a time factor: first postpartum day and the risks caused by heart disease during pregnancy and lactation. The nursing assessment of a newborn reveals a lump on one side of the head that does not cross suture lines. Which of the following should the nurse tell the mother is the cause of the lump? Bleeding between the periosteum and parietal bone occurred due to pressure against the bony pelvis during birth. Edema of the scalp occurred due to pressure of the vertex against the cervix during the first stage of labor. Intracranial hemorrhage occurred due to pressure from the forceps during birth. Simple swelling of a common hemangioma occurred due to prolonged pushing in the second stage of labor. Cephalohematoma is caused by subperiosteal bleeding, and the "lump" is limited by the suture lines. Answer 2 is incorrect because edema of the scalp is caput succedaneum. Answer 3 is wrong because a cephalohematoma is outside the skull. Answer 4 is wrong because hemangiomas are benign blood vessel tumors In this question, choose the answer that gives information but does not diagnose, for example, Answers 3 and 4. Recall where the problem is (i.e., outside of the skull and whether it crosses the suture line) to help focus on the difference between cephalohematoma and caput succedaneum. Assessing for the normal psychological changes in the third trimester, the nurse would expect a pregnant woman to exhibit which normal behavior? Ambivalence about the pregnancy. Eagerness to begin Lamaze classes. Fantasizing about her child. Withdrawal from other relationships. During the third trimester, the mother becomes ready to begin learning techniques for her use during labor. Answer 1 is wrong because ambivalence about the pregnancy is usually seen in early pregnancy. Answer 3 is wrong because fantasizing is most typical during the second trimester. Answer 4 is wrong because the period of introspection and introversion occurs in the second trimester Time-frame is the clue: third trimester. Three of the options occur earlier. Choose "eagerness" over "fantasizing." Note that the other two options, "ambivalence" (1) and "withdrawal" (4) are problematic. "Eagerness" comes through in the end (third trimester). In reviewing with a pregnant woman those symptoms that require prompt medical evaluation, which of the following would the nurse include? Increasing pedal edema. Feelings of dizziness on arising. Epigastric pain. Spotting within 24 hours of vaginal examination. Epigastric pain is associated with edema of the liver capsule in preeclampsia. Answer 1 is incorrect because dependent edema is common in late pregnancy, due to reduced venous return from the lower extremities. Answer 2 is wrong because orthostatic hypotension may be a common occurrence during the third trimester. Answer 4 is wrong because brown spotting is a normal finding within 24 hours of vaginal examination, due to the increased friability of the cervix during pregnancy Think "most critical findings." "Prompt" = urgent. Pain is critical and urgent because of the signs/symptoms of preeclampsia. A pregnant woman's history reveals a pregnancy at age 15 that was terminated by elective abortion at 10 weeks, birth of twin girls at 37 weeks, and a spontaneous abortion at 12 weeks last year. Analyzing these data, the nurse selects which of the following to describe her present gravidity and parity? Gravida 5 para 2. Gravida 5 para 1. Gravida 4 para 2. Gravida 4 para 1. Gravidity is defined as the number of pregnancies; she has been pregnant three previous times and is now pregnant for the fourth time. Parity is defined as the number of pregnancies carried to viability (20 weeks since conception; 22 menstrual weeks). The woman has had two pregnancies terminated before viability (abortions) and has carried one pregnancy, which resulted in viable twin girls. Answer 1 is incorrect because this counts the twins as two pregnancies carried to viability. Answer 2 is wrong because, although it correctly identifies the twins as one parity, it counts them as two pregnancies. Answer 3 is wrong because, although it correctly identifies the woman as gravida 4, it counts the twins twice Know definitions of gravida and para and how to determine a woman's obstetric history. Use the acronym GTPAL: G—-Gravida; T—Term; P—Para; A— Abortions; L—living children. The postovulation rise in BBT is due to the high blood level of which hormone? Follicle-stimulating hormone (FSH). Human placental lactogen (HPL). Estrogen. Progesterone. High circulating levels of progesterone released by the corpus luteum are thought to be responsible for the immediate postovulation rise in body temperature. Answer 1 is wrong because FSH is responsible for maturation of the follicle before ovulation. Answer 2 is wrong because HPL is produced by the placenta and is not present at this time. Answer 3 is wrong because estrogen is not implicated in the rise in body temperature postovulation Think P's: postpovulation = progesterone. Recall female hormones and their functions related to the menstrual cycle. Nursing assessment of a woman in labor notes marked introspection, irritability, and inability to focus. She is diaphoretic, and cries, "I can't take it!" These behaviors are characteristic of which stage or phase of labor? Active phase. Transitional phase. Second stage. Third stage. These behaviors are characteristic of the transitional phase of labor, approaching 10 cm dilation. Answer 1 is incorrect because the woman shows a more intense, serious demeanor and may hyperventilate with contractions in the active phase. Answer 3 is incorrect because the second stage of labor is characterized by expulsive efforts. Answer 4 is incorrect because in the third stage the placenta is expelled and the woman is euphoric and focuses on the infant The three Ts (introspection, irritability, inability to...) are indicative of transition. Recall the phases and stages of labor and expected patient responses. During the last month of pregnancy, a pregnant woman comments, "I am sick and tired of this whole thing. I can hardly wait for it to be over." Comparing her statement to the normal psychological responses of other pregnant women during the last trimester, the nurse responds appropriately with which statement? I think you should see the psychiatric social worker. You should be feeling more positive about the baby by now. I know exactly how you feel. I've seen it a thousand times. It'll pass. Well, sounds like you're ready for labor. Do you have any questions about your coming labor? Your pregnancy is getting a bit tiresome and the time is dragging? She does need support for her feelings at this point in pregnancy and validation that they are normal. Answer 1 is incorrect because she is evidencing only normal responses to late pregnancy. Answer 2 is wrong because such statements tend to inhibit further exploration of her feelings and convey that such feelings are unimportant to the nurse. Answer 3 is wrong because it neither validates the normalcy of her feelings nor encourages any further ventilation Choose the most open-ended communication approach. The goal is to be supportive of expected psychological changes in the third trimester. A 16-year-old, single woman wants to give her baby up for adoption. Which plan will be of most help to her? Provide a safe environment, encourage ventilation of her feelings, give no answers or direction so that she makes her own decisions. Provide the information she needs to understand the situation, place it in perspective in terms of her life goals, and begin to plan for the future. Support her choice whatever her decision. Help her see ways of not making the same error again so she can grow in self-esteem and self-respect. (2) is correct because the nurse can best fulfill the role of advocate by providing all essential information the adolescent needs to make informed decisions; this allows opportunity for introspection and growth. Answer 1 is incorrect because adolescents require and desire some guidance or assistance with major life decisions from supportive adults. Answer 3 is incorrect because it may not be appropriate or ethical to support some decisions the adolescent makes. Answer 4 is incorrect because such actions are judgmental, tend to destroy rapport, and nullify possible growth Select the answer that describes the advocacy role of the nurse in patient decision making (i.e., providing information for informed decision making by the patient). The physician determines that a woman's inability to conceive is due to anovulatory cycles and discusses treatment options. An expected emotional response to this diagnosis and possible treatment indicating that the woman understands the underlying problem would be: Guilt for past sexual behaviors. Grief because she will never be able to conceive. Fears regarding the need for corrective surgery. Anxiety regarding the side effects of clomiphen citrate (Clomid). (4) is correct because clomiphen citrate (Clomid) is used in infertility caused by anovulatory cycles. It increases the secretion of FSH and LH and stimulates ovulation. Side effects include vasomotor flushes, bloating, nausea, vomiting, headache, hair loss, and visual disturbances. Answer 1 is incorrect because anovulatory cycles are not caused by past patterns of sexual behavior. Answer 2 is incorrect because many women who experience anovulatory cycles may successfully conceive after treatment. Answer 3 is incorrect because anovulatory cycles are not treated with surgical intervention The key word is treatment option. Narrow your focus to (3) or (4) because they are possible treatments for female infertility. Eliminate (3) because it is not a treatment for anovulatory cycles. A couple has been unable to conceive; the man is being evaluated for possible problems. A semen analysis is ordered. Which instruction regarding collection of a sperm specimen is appropriate? Collect specimen at night, refrigerate, and bring to clinic the next morning. Collect specimen in the morning after 24 hours of abstinence and bring to clinic immediately. Collect specimen after 48 to 72 hours of abstinence and bring to clinic within 2 hours. Collect a specimen at the clinic, place in iced container, and give to laboratory personnel immediately. (3) is correct because semen analysis requires that a freshly masturbated specimen be obtained after a rest (abstinence) period of 48 to 72 hours. Answer 1 is incorrect because an accurate sperm count and evaluation of motility require that the specimen be examined within 2 hours. Refrigeration will kill sperm. Answer 2 is incorrect because 24 hours of abstinence is insufficient for adequate production of sperm. Answer 4 is incorrect because ice will reduce motility and kill sperm Think: best is more rest (abstinence). Note the answer is time related: when in relation to abstinence, and how—that is, avoid ice, refrigeration as in Answers 1 and 4. In health teaching for women who desire "natural child birth," which statement should the nurse explain is a myth? Medication may be used to reduce tension and pain during labor. Labor and birth under Lamaze techniques are almost painless. Labor is easier for women who are self assured, relaxed, and cooperative during the process. Preparation for childbirth may include body-building exercises, breathing techniques, and comfort aids. Lamaze techniques, although helpful, do not guarantee freedom from discomfort throughout the labor process. Answer 1 is incorrect because medication may be used to assist the woman in controlling her response to the child-bearing process and to facilitate a successful experience. Answer 3 is wrong because labor is easier for the woman who understands what is happening and is able to relax and cooperate. Answer 4 is wrong because many preparation-for-childbirth courses use these aids. When the question asks which one is a myth, choose the incorrect answer. A pregnant woman is told to increase her intake of foods high in iron. Which of the following foods should the nurse suggest as being the best source of iron? Lean red meat. Nuts. Shellfish. Dairy products. Red meats, egg yolks, and organ meats are the best sources of iron. Answers 2,3, and 4 are incorrect because they do not contain as much iron as red meat Knowing the best (highest) food sources of iron will help you choose the best answer. Health teaching during the prenatal period should emphasize that expectant primigravida mothers should go to the hospital when which pattern is evident? Contractions are 2-3 minutes apart, lasting 90 seconds, and membranes have ruptured. Contractions are 3-5 minutes apart, accompanied by rectal pressure and bloody show. Contractions are 5 minutes apart, lasting 60 seconds, and increasing in intensity. Contractions are 5-10 minutes apart, lasting 30 seconds, and are felt as strong menstrual cramps. Although instructions vary among birth centers, primi-gravidas should seek care when regular contractions are felt about 5 minutes apart, becoming longer and stronger. Answer 1 is incorrect because she should have sought care earlier. Answer 2 is incorrect because she should have sought care earlier. Rectal pressure may be a sign of impending birth. Answer 4 is incorrect because this pattern may reflect "false labor" or very early latent phase labor Think time factor: when, how long, "too late" vs. "too soon." Be aware of how to distinguish between false and true labor. Assessment findings of Leopold's maneuvers reveal a soft, rounded mass in the fundus, irregular nodules on the rightside, and a hard prominence on the right, just above the symphysis. Which of the following accurately describes the fetal presentation and position? Right sacrum posterior (RSP). Left sacrum anterior (LSA). Right occiput posterior (ROP). Left occiput anterior (LOA). Of the choices given, if the breech is in the fundus, the occiput must be the presenting part; if the irregular nodules (elbows, knees, feet) are on the right side, the fetal back is to the maternal left. Answer 1 is incorrect because the "S" refers to the fetal sacrum and describes a breech presentation. Answer 2 is wrong because this also describes a breech presentation. Answer 3 is wrong because the fetal back is on the maternal left side, as is the occiput Visualize the fetal position described to help you choose the answer with the head (occiput) presenting. If the fetus is LOA, in which maternal location should the nurse anticipate finding the fetal heart tones (FHTs)? Below the umbilicus on the left side. Below the umbilicus on the right side. Above the umbilicus on the left side. Above the umbilicus on the right side. FHR is heard best through the fetal back, which, in LOA presentations, is below the umbilicus on the maternal left side. Answer 2 is incorrect because the fetal back is on the maternal left. Answer 3 is wrong because, in a vertex presentation, the heart tones are more audible below the umbilicus. Answer 4 is wrong because it describes the placement of FHTs in breech presentations Visualize LOA fetal position and presentation. Think left side (1 and 3) for left occiput anterior (LOA). Which normal assessment finding can the nurse expect in the 34th week of pregnancy? Braxton-Hicks contractions, joint hypermobility, and backache. Dysuria, constipation, hemorrhoids, and lightening. Feeling of tranquility and heightened introspection. Morning sickness, breast tenderness. Braxton-Hicks contractions, hypermobility of joints, and backache are all normal findings at this point in pregnancy. Answer 2 is incorrect because complaints of dysuria should be explored due to the tendency to urinary tract infection in pregnancy. Answer 3 is wrong because a feeling of tranquility and heightened introspection are common in the second trimester. Answer 4 is wrong because these symptoms are most common in the first trimester The clues in the stem are normal and third trimester. Match time-frame (later in pregnancy) with findings (contractions occur later in pregnancy). Which suggestion by the nurse may relieve a pregnant woman's heartburn symptoms? Eat dry bread products before rising. Bend at the knees when reaching down, not at the waist. Eat fewer, larger meals and avoid nibbling. Do pelvic-rock exercise. Bending at the waist facilitates movement of food out of the stomach through a relaxed cardiac sphincter. Answer 1 is incorrect because this is the treatment for morning sickness. Answer 3 is wrong because this tends to aggravate heart burn. Answer 4 is wrong because the pelvic rock relieves backache, not heartburn Eliminate the two options about food and eating. Picture bending from the knees and the effect on cardiac sphincter/diagnosis. A new mother complains of severe lower abdominal cramping after breastfeeding. Which would be the first action taken by the nurse to reduce her discomfort? Administer pain medication as per order. Have her lie on her abdomen with a rolled towel at the level of her fundus. Ask her to walk around for a few minutes. Ask her to empty her bladder. A full bladder may be the major source of her discomfort. Answer 1 is incorrect because medication should be given for minor discomforts only after trying other comfort measures. Answer 2 is wrong because this measure would be used only after she has voided. Answer 3 is wrong because walking does not relieve afterpains First eliminate the two options about position/activity because they are secondary measures. The question asks for the FIRST action. Because the discomfort is felt in the abdomen, choose the option with bladder, which is felt abdominally. In assessing a new mother's response to her son's birth on the first postpartum day, which behavior should the nurse expect to find present? Talkativeness, dependency, passivity. Autonomy and independence. Disinterest in her own body functions. Interest in learning to bathe the baby. Talkativeness, dependency, and passivity are all signs of the "taking-in" phase of the postpartum. Answer 2 is incorrect because the mother needs to have her needs for nurturing and positive reinforcement met at this time. Answer 3 is wrong because she is most interested in her own body functions, her return to normal, and her ability to void and defecate. Answer 4 is wrong because she is not ready to "take hold." Taking-in phase (1) is before taking-hold phase (4). Answers 2 and 3 are theoretically incorrect (according to Reva Rubin's theories) because the opposite of these behaviors occur. Also note two options that are contradictory: dependency (1) vs. independence (2). "Dependency" goes with taking-in. Which technique should the nurse use to assess the frequency, duration, and intensity of uterine contractions? Spread fingers of one hand lightly over the fundus. Move the fingers of one hand over the uterus, pressing into the muscle. Hold fingers and palm of one hand over the area just below the umbilicus. Indent the uterus in several places, during and between contractions. The frequency, duration, and intensity of uterine contractions are assessed by light palpation of the contractile part, i.e., the fundus. Answer 2 is incorrect because moving the hand over the uterus may reduce the accuracy of perceiving contractions; pressure into the muscle may contribute to uterine dysfunction due to manipulation. Answer 3 is wrong because the most contractile part of the uterus is the fundus, not the corpus. Answer 4 is wrong because uterine manipulation between contractions may contribute to uterine dysfunction Picture the actions (the position of the hands). Eliminate Answers 2 and 4 because they may be harmful. Ongoing evaluation of a woman with severe preeclampsia reveals 4 plus deep-tendon patellar reflexes with two beats of clonus. The most appropriate nursing diagnosis related to her current status would be: Pain related to hyperreflexia and clonus. Risk for injury related to possible eclamptic seizures. Impaired physical mobility related to alterations in lower limbs. Sensory/perceptual alterations related to sensory overload. (2)is correct because deep-tendon reflexes indicate the degree of CNS irritability and the potential for seizure activity. Answer 1 is incorrect because hyperreflexia and clonus are not associated with pain or discomfort. Answer 3 is incorrect because hyperreflexia and clonus do not interfere with motor activity in the lower extremities. Answer 4 is incorrect because women with preeclampsia are placed in environments with reduced stimuli to decrease the risk of seizure activity Note the term preeclampsia in the stem and same term "eclamptic" in the correct option (2). Following a birth, after the physician or midwife has cut the cord, and before the baby is given to the mother, which should the nurse do first? Confirm identification of the infant and apply bracelets to mother and infant. Examine the infant for any observable abnormalities. Wrap the infant in a prewarmed blanket and cover the head. Instill prophylactic medication in the infant's eyes. The first priority (beside maintaining a newborn's patent airway) is body temperature. Answer 1 is incorrect because, although important, identification of the newborn may be delayed until after the infant's status is stable. Answer 2 is wrong because the second priority is to note any abnormalities. Answer 4 is wrong because eye prophylaxis may be instilled 2 hours later This question asks you to rank order of priority when all options are correct. Review protocols for newborn care immediately after birth. Which of the following should elicit the Moro reflex in healthy newborns? Sudden or loud noises. Stroking the soles of the feet. Turning a newborn's head to one side. Stroking a newborn's cheek. The Moro reflex occurs in response to sudden stimulation of the newborn's CNS by noise, falling, or jolting. Answer 2 is incorrect because this action elicits the Babinskireflex. Answer 3 is wrong because this action elicits the tonic neck reflex. Answer 4 is wrong because this elicits rooting Match common neurological reflexes of the newborn with the action described in each of the four options. Which assessment of a woman in labor can be determined by vaginal examination? Fetal weight. Cervical dilation. Strength of contractions. Fetal head circumference. Cervical dilation is determined by vaginal examination. Answer 1 is incorrect because fetal weight can only be indirectly estimated by fundal height measurement and sonography. Answer 3 is incorrect because strength of contractions is evaluated by palpation of the uterine fundus. Answer 4 is incorrect because head circumference cannot be determined until after birth Note the relationship between the word "vaginal" in the stem and the correct answer, "cervical." The decision is made to encourage a woman in early labor to walk around the unit for a while, and to then reassess her status. Which assessment distinguishes between true and false labor? Confirmation of spontaneous rupture of membranes. Signs and symptoms of increasing discomfort. Evidence of cervical dilation. Presence of copious bloody vaginal discharge. The criterion used to distinguish true from false labor is evidence of cervical change. Answer 1 is incorrect because spontaneous rupture of membranes can occur before initiation of labor. Answer 2 is incorrect because women who are not in true labor may experience increasing pain due to obstetric complications. Answer 4 is incorrect because copious bloody vaginal discharge can occur without labor (placental problems) True Labor = Cervical Changes (TL = CC). Which of the following should he emphasized as the most important factor in safeguarding cardiac function during pregnancy, for a woman with rheumatic heart disease (RHD)? Adequate exercise. Adequate rest. Low-salt diet. Ferrous sulfate. The most important single factor in maintaining good health for the pregnant woman with heart disease is adequate rest. The woman should have approximately 8-10 hours rest each night and should lie down for 30 minutes after each meal. Answer 1 is incorrect because reduced activity reduces fatigue and supports preservation of cardiac reserve. Answer 3 is wrong because moderate sodium intake (2000 mg) is allowable for the average class I cardiac; nutritional counseling focuses on increasing dietary intake of iron, protein, and essential nutrients to meet the increased demands of pregnancy. Answer 4 is wrong because ferrous sulfate is prescribed to meet the increased demands for hemoglobin synthesis and to combat nutritional anemia Note that two options are contradicting: exercise vs. rest. Think "rest the heart." Late in pregnancy, which of the following is the most likely cause of groin pain that seems worse on the right side? Bladder infection. Constipation. Tension on the round ligament. Beginning of labor. Tension on round ligaments occurs because of the erect human posture and pressure exerted by the growing uterus. Answer 1 is incorrect because bladder infection is accompanied by frequency and dysuria. Answer 2 is wrong because discomfort from constipation is accompanied by other symptoms, and the location of the discomfort differs. Answer 4 is wrong because groin pain is not characteristic of beginning labor The key is time and place. Note that the stem states late pregnancy and location is on the right. A pregnant woman's history reveals one pregnancy, terminated by elective abortion at 10 weeks; birth of twins at 37 weeks; and a spontaneous abortion at 12 weeks. According to the TPAL system, which of the following describes her present parity? 0-2-2-2. 2-0-2-2. 0-1-2-2. 1-0-2-2. 0-1-2-2 describes her present status. She has not carried a pregnancy to term (T); one pregnancy terminated in the preterm (P) birth of twins, two pregnancies ended in abortion (A), and she has two living children (L). Answer 1 is incorrect because only one was a preterm pregnancy. Answer 2 is incorrect because it describes her as having delivered two term infants and no preterm infants. Answer 4 is wrong because it describes her as having carried one pregnancy to term and having no preterm infants Be able to determine an obstetric history using the TPAL system: T—Term; P—Preterm; A— Abortion; L—Living children. Which of the following influences the planning and implementation of postpartum care for a woman who has been diagnosed as severely preeclamptic? Even if she has had no convulsions during the antepartal and intrapartal periods, she remains at risk for convulsions for the first 48 hours postpartum. Preeclampsia is associated only with pregnancy. Once die baby has been born, she is cured. The woman should be advised she may be left with chronic renal damage. Since subsequent pregnancy is extremely hazardous, family planning should be implemented as soon as possible. The possibility of postpartum eclampsia, while high, is often overlooked. Nursing care is planned to maintain ongoing status assessments and minimize environmental stimuli. Answer 2 is wrong because, although the risk decreases subsequent to birth, eclamptic convulsions have been known to occur in the postpartum. Answer 3 is wrong because chronic renal disease is not a sequel to preeclampsia. Answer 4 is wrong because preeclampsia does not necessarily occur in subsequent pregnancies Narrow the choice to two contradictory options: "at risk" (1) vs. "cured" (2). Reduction of risk in the immediate postpartum period is the goal. For which complication of pregnancy is an Rh-negative woman at risk? Spontaneous abortion. Preeclampsia. Maternal anemia. Erythroblastosis fetalis. Even Rh-negative women during their first pregnancy are at some risk for Rh incompatibility; erythroblastosis fetalis results from hemolysis of fetal cells by maternal anti bodies. Answers 1 and 2 are wrong because the Rh-negative woman is not more prone to spontaneous abortion or preeclampsia. Answer 3 is wrong because fetal, not maternal, anemia results from Rh incompatibility The focus should be on the potential risk for the fetus. Understand the pathophysiology of Rh isoimmunization. Which assessment findings indicate 20 weeks of gestation? Lightening, FHR audible by fetoscope, fundus palpable at the umbilicus. Braxton-Hicks contractions, ballottement, and fundus at umbilicus. Quickening noted, FHR audible by fetoscope, fundus at or just below the umbilicus. Goodell's, Hegar's, and Chadwick's signs present, fundus halfway between symphysis and umbilicus. Quickening, audible FHR with fetoscope, and fundal height at just below the umbilicus are present in most women by the 20th week of pregnancy. Answer 1 is wrong because lightening usually occurs at 36-38 weeks of gestation. Answer 2 is wrong because Braxton-Hicks contractions are palpable around the 30th week. Answer 4 is wrong because Goodell's, Hegar's, and Chadwick's signs are first noted at 6-8 weeks of pregnancy, and this fundal height is consistent with the 16th week of gestation The best answer is derived from the correct time-frame—(1) and (2) occur later than 20 weeks; (4) occurs earlier. A new mother tells the nurse she is planning to breastfeed her son until he is 2 years old so she won't have to worry about getting pregnant. Which response demonstrates appropriate health teaching? Lactation does suppress ovulation, so you'll be pretty safe. You are safe only as long as you don't menstruate. It's best to use some other form of birth control. You may not menstruate, hut you may ovulate and could get pregnant. You'll find you won't be interested in intercourse until you wean your baby. Although lactation does suppress ovulation, time of ovulation varies widely, making this an unreliable birth control method (bottle-feeding mothers have ovulated as early as 36 days postpartum; breastfeeding mothers, as early as 39 days postpartum). Answer 1 is incorrect because of unpredictability of the time of inhibition of ovulation. Answer 2 is wrong because the mother may have anovulatory or ovulatory menses or may ovulate in the absence of menstruation. Answer 4 is wrong because the woman may desire to resume intercourse when lochia stops When a question asks which plan is appropriate, identify and eliminate the inappropriate statements first. Nursing assessments during the fourth stage of labor following placenta previa will include close monitoring for signs of hemorrhage. This nursing decision is based on which rationale? Placenta was implanted in lower uterine segment, where there are fewer muscle fibers to contract the placental site. The area under an abrupted placenta never contracts as strongly as when there is no premature separation. Since the placenta was surgically removed, the uterine muscle does not contract as efficiently. The woman lost 250 mL of blood during the third stage of labor. The lower uterine segment does not contract as effectively as the fundus. Postpartum bleeding is more common in women with placenta previa. Answer 2 is incorrect because the woman did not have abruptio placentae. Answer 3 is wrong because surgical removal of the placenta does not inhibit uterine contraction. Answer 4 is wrong because a loss of 250 mL during the third stage is within normal limits The question is asking why hemorrhage may occur with placenta previa. Answers 2 and 4 can be eliminated because they do not answer this question. A woman in labor using the Lamaze technique is examined and found to be in transition. Which breathing pattern used at this time would indicate a need for nursing intervention? Rapid, shallow chest breathing. Slow, deep, abdominal breathing. Use of intercostal muscles with diaphragm relaxed. Beginning and ending each contraction with two cleansing breaths. (2)is the best answer because intervention is needed. The breathing technique recommended for transition is rapid, shallow chest breathing. Answer 1 is not the choice because rapid, shallow chest breathing is advised. Answer 3 is not the choice because the use of intercostal muscles with a relaxed diaphragm is recommended. Answer 4 is not the choice because each contraction should begin and end with two cleansing breaths in the Lamaze method Look for the inadvisable breathing patterns. Narrow the choice to two contradictory breathing options: rapid and shallow chest vs. slow and deep abdominal. Note also that the question asks for transition phase breathing, not for latent and early active phase, where Answer 2 would be appropriate. Which of these normal physiological changes has greater implications for the woman with a history of rheumatic fever at age 8, and requires more teaching about warning signs and symptoms needing prompt medical evaluation? Increased venous pressure in lower extremities. Placental production of HPL. Increased cardiac output. Relaxation of the cardiac sphincter. Increased cardiac output has greater implications because her heart has been compromised by rheumatic fever. She should understand and be able to recognize signs of complications associated with her heart function. Answer 1 is wrong because increased venous pressure in the lower extremities presents little more than an annoyance. Answer 2 is wrong because placental production of HPL presents a greater problem for a woman with diabetes. Answer 4 is wrong because relaxation of the cardiac results in minor complaints Recall that the potential risk of rheumatic fever is cardiac problems. Following an amniotomy, the nurse remains alert for any signs of complications. In addition to the FHR, which of the following may indicate fetal distress? Crowning and increased fetal activity. Crowning and hypotonic contractions. Increased fetal activity and meconium-stained amniotic fluid. Baseline variability on the monitor strip. Significantly increased fetal activity and meconium-stained amniotic fluid are signs of fetal distress. Answer 1 is incorrect because crowning is followed rapidly by birth and because any fetal distress can be treated promptly. Answer 2 is wrong because crowning is shortly followed by birth. Answer 4 is wrong because baseline variability is a normal fetal pattern Choose the abnormal fetal and amniotic fluid signs. A woman in labor insists on remaining in a supine position in bed. Which response should the nurse make regarding this behavior? It's best for the baby if you lie on your side. These two pillows under your knees will be good for the baby and more comfortable for you. You will get nauseated and light-headed if you stay in that position. This rolled-up towel under your hip will do the job just as well. Tilting the hip moves the heavy uterus off the major blood vessels (the vena cava and aorta), preventing supine hypotension, reduced placental perfusion, and fetal bradycardia. Answer 1 is incorrect because the statement denies the need for comfort at this time. Answer 2 is wrong because the pillows may increase her comfort but will not prevent supine hypotension. Answer 3 is wrong because the statement may be perceived as a threat and does not recognize the woman's need for comfort and emotional support In positioning a patient, decide what you are trying to prevent or promote. Understand the effects of vena caval syndrome and preventive position changes. Which of the following would the nurse note as a deviation from the normal characteristics of the term neonate? Head circumference larger than chest circumference. Diaphragmatic breathing. Passage of meconium stool. Epicanthal folds and simian line. Epicanthal folds and simian lines are associated with a diagnosis of Down syndrome. Answer 1 is incorrect because the head is the largest part of the newborn's body and is larger than the chest. Answer 2 is wrong because diaphragmatic breathing is the normal newborn pattern of respiration. Answer 3 is wrong because passage of meconium stool immediately following birth is within the normal pattern for newborns Deviation from normal" means look for what is not normal. The reason the nurse keeps the neonate in a neutral thermal environment is that when a newborn becomes too cool, he or she requires: Less oxygen, and the newborn's metabolic rate increases. More oxygen, and the newborn's metabolic rate decreases. More oxygen, and the newborn's metabolic rate increases. Less oxygen, and the newborn's metabolic rate decreases. When cold, the infant requires more oxygen and there is an increase in the newborn's metabolic rate. Nonshivering thermogenesis is a complex process that increases the metabolic rate and rate of oxygen consumption; therefore the newborn increases its heat production. Answer 1 is incorrect because more oxygen is needed, not less. Answer 2 is incorrect because the metabolic rate increases, not decreases. Answer 4 is incorrect because both oxygen needs and metabolic rate increase You can eliminate the two options with "less oxygen" first, because of the physiological responses of the newborn to thermoregulation. Recall complications associated with cold stress. A mother is in the third stage of labor. The nurse is observing for signs of separation of the placenta, which include which of the following? The uterus becomes globular. The fundus appears at the introitus. The umbilical cord is shortened. Mucoid discharge is increased. Signs of placental separation include a change in the shape of the uterus from ovoid to globular. Answer 2 is incorrect because the placenta appears at the introitus, not the fundus of the uterus. Answer 3 is incorrect because the umbilical cord lengthens with placental separation, not shortens. Answer 4 is incorrect because there is often an increase in bloody discharge, not mucoid Picture what happens to the shape of uterus as the placenta separates from it. Immediately after a woman's membranes have ruptured, the first priority of nursing care is to: Take the woman's temperature. Time the woman's contractions. Check the fetal heart rate. Check the woman' s blood pressure. Fetal heart rate is of primary concern, because the environment for the fetus has changed. There is an increased risk for prolapse of the umbilical cord immediately after rupture of membranes, especially if the presenting part is not engaged. Answer 1 is incorrect because this is a secondary priority. The woman may develop an elevated temperature later because of increased risk of infection. Answer 2 is incorrect because this is a secondary priority. Answer 4 is incorrect because the woman's blood pressure will probably not change in response to the rupture of her membranes Think heart rate first! Study tip: Review the assessment and nursing interventions for the emergency condition of prolapse of the umbilical cord. A woman in the postpartum stage has a low rubella titer and receives a rubella virus vaccine. Because she is being immunized, which instruction is most important for the nurse to include in health teaching? Have your titers checked in two weeks. Do not eat products that contain eggs for the next twenty-four hours. Do not become pregnant for three months. Expect to have a slight rash in a day or two. Women who receive live rubella virus vaccine should be advised not to become pregnant for 3 months because of the potential risk to the fetus (congenital measles syndrome). Answer 1 is incorrect because immunity is not established fully by 2 weeks. Answer 2 is incorrect because dietary restrictions are not necessary following rubella vaccine. Answer 4 is incorrect because mild symptoms may occur 11-20 days after vaccination, and are usually mild and transient. Breastfeeding is not contraindicated following vaccination. Focus on the two options about what not to do, and choose the one that deals with prevention of risk to the fetus. A nurse's aide reports to the RN that a multigravida who is 6 hours postpartum has not voided and has not ambulated yet. The patient says she has no desire to void and says that with her last infant she needed to be catheterized. The RN should instruct the nurse's aide to: Ask the woman if she is bleeding heavily. Find out how much fluid the woman has consumed in the last 6 hours. Not be concerned because this is normal for this patient. Assist the woman to the bathroom. If a woman has not voided by 6 hours after delivery, she should be encouraged to ambulate to the bathroom, This may assist her in voiding. Catheterization may need to be done, but only after she is given the opportunity to void. Answer 1 is incorrect because she should be encouraged to empty her bladder, and then her fundus should be assessed for firmness and position. Women who have distended bladders, however, may be at risk for uterine atony and increased bleeding. Answer 2 is incorrect because her fluid intake is not likely to have an impact on her ability to void at this point in the postpartum period. Urinary retention is probably caused from birth trauma and effects of anesthesia. Answer 3 is incorrect because a woman should void and empty her bladder within 6 hours postpartum. Women will begin to diurese in the postpartum period, and there is an increased risk of postpartum bleeding and rupture of the bladder Choose the answer that delegates activities to LPN/LVN for stable patients with predictable outcomes, not assessment activities (1,2). A woman had previously used a diaphragm for contraception before her pregnancy. Now at 6 weeks postpartum, she asks the nurse if she needs to have her diaphragm refitted. The best response is: Yes, it should be refitted after a pregnancy. No, it is not necessary. Once involution is completed, it should fit as it did before. It isn't advisable to use a diaphragm after giving birth to a baby. Yes, but you should wait until you are 3 months postpartum. A diaphragm should be refitted after each pregnancy around 6 weeks postpartum. It should also be refitted it the woman loses or gains a significant amount of weight (15-20 lb) or has uterine or vaginal surgery. Answer 2 is incorrect because a pregnancy can change the shape and size of the cervix and vagina. Answer 3 is incorrect because women may use a diaphragm for postpartum contraception once involution is completed. Answer 4 is incorrect because she does not need to wait until 3 months postpartum. Usually 6 weeks is sufficient It is a "yes" answer, but eliminate the option with the specific time frame (i.e., 3 months). The nurse should teach the parents' group that Chlamydiatrachomatis is not only an intracellular bacterium that causes neonatal conjunctivitis, but it also can cause: Discoloration of baby and adult teeth. Snuffles and rhagades in the newborn. Pneumonia in the newborn. Central hearing defects in infancy. Newborns can get pneumonia (tachypnea, mild hypoxia, cough, eosinophilia) and conjunctivitis from Chlamydia. Answer 1 is incorrect because discolored teeth are caused by tetracycline. Answer 2 is incorrect because snuffles is seen with congenital syphilis. Rhagades refers to circumoral radiating scars that result from cracked, rough mucocutaneous lesions of the lips. Answer 4 is incorrect because congenital rubella causes central and peripheral hearing defects in infancy Eliminate two of the options that are congenital (2, 4), and (1), which is caused by a medication. A 13-year-old girl just delivered an infant who needs emergency surgery. The consent form should be signed by: The mother of the baby. The grandmother of the baby. The RN. The MD. Even though the mother is a minor, she is legally able to sign consent for her own child. Answer 2 is incorrect because the baby's mother is able to give consent. The exception might be if the mother is unable and the baby's grandmother has power of attorney for her daughter. Answer 3 is incorrect because the RN should not sign a consent form for treatment or surgery. Answer 4 is incorrect because the physician cannot sign a consent form for treatment or surgery Eliminate who should not sign the consent form (i.e., all but the patient should not). The nurse manager on a maternity unit is informed that a woman who is 36 weeks pregnant with severe preeclampsia is to be admitted to the unit. Which bed assignment is the best choice? Bed in a double room 50 feet from the nurse's station with a roommate who has rheumatic heart disease. Bed in a double room next to the nurse's station with a roommate who is a drug addict with withdrawal symptoms. Bed in a four-bed unit with all other women who are postpartum. Bed in a four-bed unit with other women who have pyelonephritis, diabetes, and premature rupture of membranes. A quiet room close to the nurse's station provides the best environment for treatment (observation and decreased stimulation). A private room is ideal, but of these choices, Answer 1 is the best. Answers 2,3, and 4 are incorrect because too much noise or stimulation can precipitate eclamptic seizures. All of these environments could be too noisy and too stimulating Because of severe preeclampsia, choose the least stimulating environment (i.e., I noise, 1 number of people). The nurse analyzes the following data: A woman in labor has remained at 6 cm dilation, — 1 station (vertex presentation), with molding of the baby's head at +2 station for 3 hours. The baby's FHR has increased from a baseline of 140 to 170. The physician orders Pitocin augmentation of labor. The nurse's correct action would be to: Add Pitocin to the IV and label it correctly. Start the Pitocin drip using an IV pump. Accurately chart the Pitocin infusion. Refuse to carry out the order for Pitocin augmentation. The data indicate that the woman has an arrest of her labor (potentially cephalopelvic disproportion), and the fetus is developing a tachycardia (fetal distress). It would be contraindicated to augment labor under these circumstances. The nurse should emphasize the assessment findings to the physician. Answers 1,2, and 3 arc incorrect because augmentation of labor is contraindicated with the current situation Because of the risk of hyperstimulation of the uterus, choose the one answer that does not give it. Think of patient safety, and think of the legal responsibility of the RN. When forceps are used for the birth of an infant's head, the newborn should be assessed for: Torticollis. Facial paralysis. Fractured clavicle. Cephalhematoma. Facial paralysis can occur when the forcep blades compress cranial nerve VII (facial) anterior to the ears. It is usually mild and temporary, lasting only a few days. Answer 1 is incorrect. Torticollis, or wry neck, is caused by a shortened sternocleidomastoid muscle on one side of the fetal neck. Answer 3 is incorrect. Fractured clavicle is usually caused when the shoulders are being born, when the infant is large, or when the mother's pelvis is small. Answer 4 is incorrect. Cephalhematoma is not caused by properly placed forceps. This bleeding between the periosteum and one or more of the cranial bones (especially the parietal) is secondary to pressure from the maternal pelvis Choose the one option that is related to nerve damage. Less than 24 hours after being discharged, a new postpartum mother calls the nurse on the mother/baby unit. She reports that she has very heavy, bright-red bleeding. What would be the best advice to give her? Don't worry about it; it is normal. Lie down for about an hour. Check your bleeding then, and if it is still as heavy, call me back. Lie down, massage your uterus (lower abdomen). If it does not firm up and your bleeding does not decrease, come to the hospital immediately. Call your doctor and ask what to do. This is subinvolution of the uterus and may cause postpartum hemorrhage. The uterus should firm up with massage. If it does not, or the bleeding continues to be heavy, she should go to the hospital immediately; she might need oxytocin and perhaps a D&C. She should also be checked for retained tissue, birth canal lacerations, or infection. Answer 1 is incorrect because this is too much bleeding, and a return to bright-red, heavy bleeding postpartum, after the flow has decreased, is not normal. Answer 2 is not correct because the woman could be hemorrhaging. She should not wait an hour for intervention. Answer 4 is incorrect because the nurse's role after early discharge is to triage problems over the phone and prioritize which ones need immediate medical attention Consider time sequence when advising patients (e.g., when is this taking place?). Of the following findings in a full-term newborn, which is not an expected outcome of maternal hormone influence, and therefore should be reported? Witch's milk. Slight vaginal bleeding. Undescended testicles. Linea nigra. Undescended testicles are a condition unrelated to maternal hormonal influence. By 36-38 weeks of gestation, they should be descending through the inguinal canal and into the scrotal sac. Answers 1,2, and 4 are incorrect. They are all a result of maternal hormonal influences and are considered normal findings in the full-term neonate Eliminate the three options that are related to maternal hormone influence. Key concept is time related (i.e., at term, not at 36 weeks of gestation or earlier). The plan of care developed by nurses for parents of a drug-dependent baby includes: Recommendations for minimal contact between parents and the infant. Ways to encourage parent-infant bonding and any positive parental responses to the baby. Discouraging attachment between the parents and baby. Acknowledgment that drug-dependent parents are less likely to be interested in their babies. Positive parent-infant bonding and responses to the baby are encouraged; this may help motivate parents to enter drug rehabilitation. Answer 1 is incorrect. Positive parental contact should be encouraged. Answer 3 is incorrect. Positive parental contact should be encouraged. Answer 4 is incorrect. The nurse cannot assume that drug-dependent parents are less likely to be interested in their babies Choose the option that would reflect the nurse's advocacy role in fostering the well-being of the family. Because Answers 1 and 3 are really saying the same thing, they cannot be correct. Answer 2 is the opposite of the incorrect options (1 and 3). Choose the option that is different from the others. The nurse is to assign a nurse's aide on the postpartum unit to care for patients. The aide has a cold that day, but no other problems. Which patient would the nurse not want to assign to this nurse's aide? Woman in renal failure. Woman who has hypertension. Woman who had a prolonged labor. Woman who has AIDS. The woman with AIDS has compromised immunity. The nurse should not assign this patient to a health care provider who has a viral or infectious illness. Answers 1, 2, and 3 are incorrect. It would not be as great a risk for patients with renal failure, hypertension, or a prolonged labor to have contact with a health care provider who has a cold Consider the nurse's role in delegation of care, and think about patient safety as the priority when there is a risk of exposure to infectious or viral agents for patients with compromised immunity. When teaching a woman about fertility awareness, the nurse should emphasize that the basal body temperature: Is the average temperature taken each morning. Should be recorded each morning before any activity. Has a lower degree of accuracy in predicting ovulation than the cervical mucus test. Can be done with a mercury thermometer but not a digital one. The basal body temperature (BBT) is the lowest body temperature of a healthy person that is taken immediately after waking and before getting out of bed. The BBT usually varies from 36.2CC to 36.3°C during menses and for about 5-7 days afterward. About the time of ovulation, a slight drop in temperature (approximately 0.05°C) may be seen; after ovulation, in concert with the increasing progesterone levels of the early luteal phase, the BBT rises 0.2°-0./loC. This elevation remains until 2-3 days before menstruation, or if pregnancy has occurred. Answer 1 is incorrect. The BBT is not an average temperature, but must be taken every day to assess for slight fluctuations. Answer 3 is incorrect. Cervical mucus assessment is only one of the signs of approaching ovulation. Many things, such as semen, contraceptive gels, vaginal discharge from infection, and sexual arousal, can affect the amount and consistency of cervical mucus. Other factors, such as illness, can affect the BBT as well. Answer 4 is incorrect. Either a mercury or digital thermometer may be used to accurately measure BBT; it is advisable that a woman uses the same thermometer the entire month, however, because the readings might vary slightly The key is when (i.e., each morning before activity). A teaching plan to use in presenting information to parents about fetal development should include the fact that the embryonic membrane closest to the uterine lining, and the first to form, is called the: Amnion. Amniotic sac. Chorion. Mesoderm. At the time of implantation, two fetal membranes, which will surround the developing embryo, begin to form. The chorion develops from the trophoblast and contains chorionic villi on its surface. The villi burrowing into the deciduas increase in size and complexity as the vascular processes develop into the placenta. The villi eventually atrophy and degenerate, leaving a smooth chorionic membrane. Answer 1 is incorrect because the amnion is the other embryonic membrane, the inner cell membrane that develops from the interior cells of the blastocyst. The amnion eventually becomes the covering of the umbilical cord and covers the chorion on the fetal surface of the placenta. Answer 2 is incorrect because the amniotic sac is the fluid-filled sac inside the membranes surrounding the embryo/fetus. Answer 4 is incorrect because the mesoderm is a primary germ layer that develops into fetal bones, teeth, and muscles The correct answer is based on knowing when the development of the embryo, including membranes, amniotic sac, and fluid, occurs. The amniotic fluid cushions the embryo/fetus against mechanical injury, controls the embryo/fetus' temperature, and: Creates adherence of the amnion. Provides for fetal respiration and metabolism. Provides a means of nutrient exchange for the embryo/fetus. Allows freedom of movement so the embryo/fetus can change position. Amniotic fluid allows freedom of movement for musculoskeletal development of the fetus, in addition to the other functions mentioned. Answer 1 is incorrect because the amnion and chorion are formed and adhered before the development of the fluid. Answer 2 is incorrect because the placenta provides for oxygen and carbon dioxide exchange. Answer 3 is incorrect because one of the metabolic functions of the placenta is nutrient exchange Visualize the fetus moving around in the fluid. Eliminate the two options that are functions of the placenta. During a prenatal exam a patient asks the nurse, "How does my baby breathe inside?" The nurse's best response is: The lungs of the fetus carry out respiratory gas exchange in utero. The placenta assumes the function of the fetal lungs by supplying oxygen and allowing the excretion of carbon dioxide into your bloodstream. The blood from the placenta is carried through the umbilical artery, which penetrates the abdominal wall of the fetus. The fetus is able to obtain sufficient oxygen due to the fact that your hemoglobin concentration is 50% greater during pregnancy. Oxygen diffuses from the maternal blood across the placental membranes into the fetal blood, and carbon dioxide diffuses in the opposite direction. In this way, the placenta functions as lungs for the fetus. Answer 1 is incorrect because respiratory gas exchange does not occur in the fetal lung while in utero. Answer 3 is incorrect because blood from the placenta is carried through the umbilical vein, not artery, to the fetus. Answer 4 is incorrect because it is not the mother's hemoglobin that assists the baby to breathe; the placenta functions as the fetal lungs until birth Remember—placenta = fetal "lungs." The hematocrit decreases an average of 7-10% during pregnancy. This is referred to as physiologic anemia of pregnancy. Which mechanism best explains this decrease? The total erythrocyte count increases about 30%; the plasma volume increases about 50%. The total erythrocyte count increases about 50%; the plasma volume decreases 30%. The total erythrocyte count decreases 30%; the plasma volume increases about 50%. The erythrocyte count remains the same; the plasma volume increases 50%. Both red blood cells (RBCs) and plasma increase in pregnancy; but because the plasma increase exceeds the increase in RBC production, there is a decrease in both Hct and Hgb due to hemodilution. Answers 2, 3, and 4 are incorrect because the increases are not correct. Neither erythrocyte nor plasma volume decreases during pregnancy The increases in both are a protective mechanism for both mother and fetus. Assessment data indicate an abnormality at 20 weeks of gestation when: The fundal height measurement is at 4 fingers below the umbilicus. Fetal movements are felt faintly on the right side of the abdomen. The woman complains of backache and fatigue. The fetal heart rate is 140 and sometimes is difficult to count. The height of the fundus (single pregnancy) should measure about 20 cm at 20 weeks (at the umbilicus). A measurement less than that might indicate inadequate fetal growth or an error in calculation of gestational age. Answers 2,3 and 4 are all findings that would be considered normal during the second trimester of pregnancy The key point is when that is, when prenatal assessment findings are not normal during the second trimester. During the postpartum period, the nurse should advise the breastfeeding adult woman to: Increase her calories by about 600 kcal/day over her pregnancy requirements. Return to prepregnancy requirements for protein. Increase her calories by about 500 kcal/day over her prepregnancy requirements. Decrease the amount of calcium that was consumed during pregnancy. The suggested RDA is an increase of 500 kcal more than the adult woman's nonpregnant intake. It is recommended that lactating women consume at least 1800 kcal/day because it becomes difficult to obtain adequate nutrients for the maintenance of lactation at levels below that. Answer 1 is incorrect because this exceeds kcal requirements. It is recommended to increase 300 kcal/day for pregnancy and an additional 200 kcal/day (total 500 kcal) during lactation. Answer 2 is incorrect because protein requirements increase in both pregnancy and lactation. RDA for magnesium, vitamin C, zinc, and protein is slightly to moderately higher than during pregnancy. Answer 4 is incorrect because it is especially important that the calcium intake be adequate during pregnancy and lactation First, decide if the RDA in the correct answer relates to nonpregnancy time period or during pregnancy. Next, you can eliminate Answers 1 and 4 because they relate to the time during pregnancy. Select Answer 3 rather than (2) because of need to increase calories. Remember: T calories, T protein over prepregnancy requirements. When responding to a question from a new mother about producing enough milk for the baby as the baby grows and needs more milk at each feeding, the nurse should explain that: The mother's milk supply will increase as the infant demands more at each feeding. The breast milk will gradually become richer to supply additional calories. Early addition of solid baby foods will ensure an infant's nutritional needs. As the infant requires more milk, feedings should be supplemented with cow's milk. As milk is removed from the breast, more is produced. Answers 2,3, and 4 are incorrect because as the infant requires more milk with each feeding, the woman's breasts will meet the demands with adequate nutrition and volume if there is adequate maternal nutrition and hydration. Also, early introduction of solids (Answer 3) may make the infant more prone to food allergies. Regular feeding of solids may also lead to decreased intake of breast milk and has been associated with early cessation of breastfeeding Remember the concept that milk production during lactation is a supply-demand system. Which woman would be at highest risk for preterm labor? The pregnant woman who is working full-time at a sedentary job. The woman who is pregnant with twins. The woman who has gained 35 lb by 36 weeks of gestation. The woman who is pregnant with her first baby. The considerable uterine distention involved with multiple gestation can place the woman at risk for premature contractions, cervical dilation, and delivery. If there are risk factors for preterm birth, abstinence from orgasm, nipple stimulation, and increased rest during the last trimester maybe recommended to avoid preterm labor. Answers 1,3, and 4 do not necessarily place a woman at increased risk for preterm labor. Inadequate weight gain is a risk factor, not extra weight gain. A history of preterm labor must always be considered a high-risk factor Visualize what happens to the uterus with twins and what that can lead to. A woman gave birth to her second daughter. She tells the nurse, "I'm concerned my two-year-old daughter will not accept the new baby." The nurse should suggest that: The older daughter not have much interaction with the baby at the hospital, because she may harm her new sibling. The older daughter stay with her grandmother for a few days until the parents and new baby are settled at home. The older daughter be given more responsibility and assure her "that she is a big girl now, and doesn't need Mommy as much." The woman spend time alone with her older daughter when the baby is sleeping. The introduction of a baby into a family with one or more children challenges parents to promote acceptance of the baby by siblings. The parents' attitudes toward the arrival of the baby can set the stage for the other children's reactions. Spending time with the older siblings alone will also reassure them of their place in the family, even though the older children will have to eventually assume new positions within the family hierarchy. Answer 1 is incorrect because direct sibling contact does not place healthy newborns at risk for exposure to pathogenic organisms or for physical harm from siblings. It may facilitate the adjustment to the addition of a new family member. Answer 2 is incorrect because parents need to assume the task of caring for a new child while not neglecting the others. A temporary separation might be necessary while the mother recovers, but involvement of the whole family is important. Answer 3 is incorrect because the older child's goal is to maintain the lead position in a family. If the parents threaten that position even more by changing that child's status, it may delay adjustment to the new sibling. Allowing the older child to help with the new baby is positive It is about the mother and 2-year-old first. Focus on the age-appropriate answer about reducing sibling rivalry.