NCLEX Secrets - Level of Cognitive Ability (Analysis 41-45)

NCLEX Secrets - Level of Cognitive Ability

41. A physician prescribes home health nurse visits for a child discharged with Reye's syndrome. During a home visit, a nurse instructs the parents about the residual effects of Reye's syndrome. Which statement, if made by the parents, indicates a need for further instruction?

a) we need to check for jaundiced skin and eyes everyday
b) we need to have the child nap during the day to provide rest
c) we need to decrease the stimuli at home to prevent increased intracranial pressure
d) we need to give frequent, small, nutritious meals to decrease the amount of vomiting

42. A nurse is reviewing the laboratory results for a child scheduled for tonsillectomy. The nurse determines that which laboratory value is most significant to review?

a) creatinine
b) prothrombin
c) sedimentation rate
d) blood urea nitrogen level

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NCLEX Review About The Aging Eye (16-20)

NCLEX Review About The Aging Eye

16. A nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions?

a) I will not sleep on my left side
b) I will not sleep on my right side
c) I will not sleep with my head elevated
d) I will not wear my glasses until my physician says it is okay

17. A day care nurse is observing a 2-year old child and suspects that the child may have strabismus. Which observation made by the nurse might indicate this condition?

a) the child has difficulty
b) the child consistently tills the head to see
c) the child consistently turns the head to see
d) the child does not respond when spoken to

18. The mother of a 6-year old child arrives at a clinic because the child has been experiencing scratchy, red, and swollen eyes. The nurse notes a discharge from the eyes and sends a culture to the laboratory for analysis. Chlamydial conjunctivitis is diagnosed. Based on this diagnosis, the nurse determines that which of the following requires further investigation?

a) possible trauma
b) possible sexual abuse
c) presence of an allergy
d) presence of a respiratory infection

19. A nurse prepares a teaching plan for a mother of a child diagnosed with bacterial conjunctivitis. Which of the following, if stated by the mother, indicates a need for further teaching?

a) I need to wash my hands frequently
b) I need to clean the eye as prescribed
c) it is okay to share towels and washcloths
d) I need to give the eye drops as prescribed

20. A nurse provides discharge instructions to the mother of a child after myringotomy with insertion of tympanostomy tubes. The nurse determines that the mother needs additional instructions if the mother states that:

a) swimming in deep water is prohibited
b) swimming in lake water needs to be avoided
c) she will place earplugs in the child's ears during baths and showers
d) she will be sure to give her child soft tissues to blow his nose




NCLEX Review About The Aging Eye:
ANSWERS AND RATIONALE

16) B
- after cataract surgery, the client should not sleep on the side of the body that was operated on. The client also should be placed in a semi-fowler's position to assist in minimizing edema and intraocular pressure. During the day, the client may wear glasses or a protective shield; at night, the protective shield alone is sufficient.

17) B
- Strabismus is a condition in which the eyes are not aligned because of lack of coordination of the extraocular muscles. The nurse may suspect strabismus in a child when the child complains of frequent headaches, squints, or tilts the head to see. Options A, C, and D are not indicative of this condition.

18) B
- Conjunctivitis is an inflammation of the conjunctiva. A diagnosis of chlamydial conjunctivitis in a child who is not sexually active should signal the health care provider to assess the child for possible sexual abuse. Allergy, infection, and trauma can cause conjunctivitis, but the causative organism is not likely to be chlamydia.

19) C
- Conjunctivitis is an inflammation of the conjunctiva. Bacterial conjunctivitis is highly contagious, and the nurse should teach infection control measures. These include good hand washing and not sharing towels and washcloths. Options A, B, and D are correct treatment measures.

20) D
- A myringotomy is the insertion of tympanoplasty tubes into the middle ear to equalize pressure and keep the ear aerated. Parents need to be instructed that the child should not blow his or her nose for 7 to 10 days. Bath and lake water are potential sources of bacterial contamination. Diving and swimming in deep water are prohibited. The child’s ears need to be kept dry. Options A, B, and C are appropriate instructions.



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NCLEX Reviewer Download about Pediatric Nursing (76-80)

NCLEX Reviewer Download about Pediatric Nursing

76. An emergency room nurse is performing an assessment on a child suspected of being sexually abused. Which assessment data obtained by the nurse most likely support this suspicion?

a) poor hygiene
b) fear of the parents
c) difficulty walking
d) bald spots on the scalp  

77. A nurse is performing an assessment of a 7-year old child who is suspected of having episodes of absence seizures. Which assessment question to the mother will assist in providing information that will identify the symptoms associated with this type of seizure?

a) does twitching occur in the face and neck?
b) does the muscle twitching occur on one side of the body?
c) does the muscle twitching occur on both sides of the body?
d) does the child have a blank expression during these episodes?

78. A nurse has provided discharge instructions to the parents of an infant who has had a ventriculoperitoneal shunt procedure performed for the treatment of hydrocephalus. Which statement, if made by the parents, indicates an accurate understanding of the presence of a shunt complication?

a) I should call my doctor if my infant refuses baby food
b) if my infant has a high-pitched cry, I should call the doctor
c) my infant will pass urine more often now that the shunt is in place
d) I should position my infant on the side with the shunt when sleeping

79. A nurse is performing an admission assessment on a newborn infant with a diagnosis of spina bifida (myelomeningocele). A priority nursing assessment for this newborn is:

a) pulse rate
b) palpation of the abdomen
c) specific gravity of the urine
d) head circumference measurement

80. A mother arrives in an emergency room with her 5-year old child and the mother states that the child fell off a bunk bed. A head injury is suspected, and a nurse is assessing the child continuously for signs of increased intracranial pressure (ICP). Which of the following is a late sign of increased ICP in this child?

a) nausea
b) bradycardia
c) bulging fontanel
d) dilated scalp veins





NCLEX Reviewer Download about Pediatric Nursing:
ANSWERS AND RATIONALE

76) C
- the most likely assessment findings in sexual abuse include difficulty walking or sitting; torn, stained, or bloody underclothing; pain, swelling, or itching of the genitals; and bruises, bleeding, or lacerations in the genitals, or anal area. Poor hygiene may indicate physical neglect. Bald spots on the scalp and fear of the parents most likely are associated with physical abuse.

77) D
- Absence seizures are brief episodes of altered awareness. No muscle activity occurs except eyelid fluttering or twitching. The child has a blank facial expression. These seizures last only 5 to 10 seconds, but they may occur one after another several times a day. Myoclonic seizures are brief random contractions of a muscle group that can occur on one or both sides of the body. Simple partial seizures consist of twitching of an extremity, face, or neck, or the sensation of twitching or numbness in an extremity or face or neck.

78) B
- If the shunt is broken or malfunctioning, the fluid from the ventricle part of the brain will not be diverted to the peritoneal cavity. The cerebrospinal fluid will build up in the cranial area. The result is increased intracranial pressure, which then causes a high-pitched cry in the infant. The infant should not have pressure placed on the shunt side. Skin breakdown and possible compressions to the apparatus could result. This type of shunt affects the gastrointestinal system, not the genitourinary system. Option A is only a concern if the infant becomes malnourished or dehydrated, which then could raise the body temperature. Otherwise, the infant’s refusing baby food has no direct relationship to the shunt functioning.

79) D
- Newborn infants with spina bifida (myelomeningocele type) are at risk for hydrocephalus; therefore, the head circumference should be measured to obtain a baseline. Options A, B, and C are incorrect because pulse rate will not be affected with this disorder, the specific gravity can indicate hydration status but it is not priority at this time, and abdominal masses do not occur with this disorder.

80) B
- Late signs of increased intracranial pressure (ICP) include a significant decrease in level of consciousness, bradycardia, and fixed and dilated pupils. A bulging fontanel and dilated scalp veins are early signs of increased ICP and would be noted in an infant, not a 5-year-old child. Nausea is an early sign of increased ICP. 


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Pediatric Nurse Education (71-75)

Pediatric Nurse Education Questions 71-75

71. A clinic nurse provides instructions to a parent of a toddler experiencing physiological anorexia. Which statement if made by the parent indicates a need for further instructions?

a) I will not force-feed my child
b) I will be feed my child if she will not eat
c) I will limit the juice intake to less than 12 ounces per day
d) At mealtime, I will offer less than my child may eat and let my child ask for more  

72. A child with autism is being admitted to the hospital for diagnostic tests. The nurse should assign this child to a:

a) private room
b) semiprivate room
c) four-bed ward room
d) contact isolation room

73. A nurse is assigned to care for an 8-year old child with basilar skull fracture. The nurse reviews the physician's orders and contacts the physician to question which order?

a) obtain daily weight
b) suction as needed
c) provide clear liquid diet
d) maintain a patent intravenous line

74. A lumbar puncture is performed on a child suspected of having bacterial meningitis and cerebrospinal fluid (CSF) is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis?

a) clear CSF, elevated protein and deceased glucose level
b) clear CSF, decreased pressure and elevated protein level
c) cloudy CSF, elevated protein and decrease glucose level
d) cloudy CSF, decreased protein and decreased glucose level

75. A clinic nurse is observing a child diagnosed with autistic disorder. The nurse would expect to observe which characteristic of this disorder?

a) normal social play
b) lack of social interaction
c) normal responses to sensory stimuli
d) normal verbal but abnormal nonverbal communication




Pediatric Nurse Education:
ANSWERS AND RATIONALE

71) B
- a toddler has the skills required to feed himself or herself. The parent needs to be instructed not to feed children who can feed themselves and not to force-feed a child. To increase nutritious intake at mealtime, juice intake needs to be limited to less than 12 oz per day. At mealtime, the best option is to offer less than the toddler may eat and let the child ask for more food.

72) A
- autistic disorder is a complex childhood disorder that involves abnormalities in behavior, social interactions, and communication. Autistic children are unable to relate to persons or to respond to social and emotional cues. Characteristically, these children engage in repetitive behaviors, including head banging, twirling in circles, biting themselves, and flapping their hands or arms. Abnormal communication patterns include verbal and nonverbal communication. A child with autism needs deceased stimulation, with limited visual and auditory distractions. A private room would be the best environment, allowing for control of visual and auditory distractions. The semiprivate and four-bed ward rooms would be too stimulating for the child with autism. Autism is not a disorder that requires contact isolation.

73) B
- nasotracheal suctioning is contraindicated in a child with a basilar skull fracture. Because of the nature of the injury, there is a high risk of secondary infection and the probability of the catheter entering the brain through the fracture. Fluid balance is monitored closely by daily weight, intake and output measurement, and serum osmolality, determination to detect early signs of water retention, excessive dehydration, and states of hypertonicity or hypotonicity. The child is maintained on an NPO status or restricted to clear fluids until it is determined that vomiting will not occur. An intravenous line is maintained to administer fluids or medications if necessary.

74) C
- meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. Meningitis is diagnosed by testing cerebrospinal fluid obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure, turbid or cloudy cerebrospinal fluid and elevated leukocyte, elevated protein, and decreased glucose levels

75) B

 - Autistic disorder is a complex childhood disorder that involves abnormalities in behavior, social interactions, and communication. Autistic children are unable to relate to persons or to respond to social and emotional cues. Characteristically, these children engage in repetitive behaviors, including head banging, twirling in circles, biting themselves, and flapping their hands or arms. Abnormal communication patterns include verbal and nonverbal communication.





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Pediatric Nurse Education (66-70)

Pediatric Nurse Education Questions 66-70

66. A nurse is evaluating the developmental level of a 2-year old child. Which of the following does the nurse expect to observe?

a) use fork to eat
b) uses a cup to drink
c) pours own milk into a cup
d) uses a knife for cutting food  

67. The parents of a 2-year old child arrive at a hospital to visit their child. The child is in the playroom when the parents arrive. When the parents enter the playroom, the child does not readily approach the parents. The nurse interprets this behavior as indicating that:

a) the child is withdrawn
b) this is a normal pattern
c) the child is self-centered
d) the child has adjusted to the hospital setting

68. A clinic nurse provides information to the mother of a toddler regarding toilet training. Which statement by the mother indicates a need for further information regarding the toilet training?

a) bladder control usually is achieved before bowel control
b) the child should not be forced to sit on the potty for long periods
c) the ability of the child to remove clothing is a sign of physical readiness
d) the child will not be ready to toilet train until the age of about 18 to 24 months

69. A clinic nurse assesses the communication patterns of a 5-month old infant. The nurse determines that the infant is demonstrating the highest level of developmental achievement expected if the infant:

a) coos when comforted
b) links syllables together
c) uses monosyllabic babbling
d) uses simple words such as "mama"

70. A 2-year old child is treated in the emergency room for a burn to the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicates an understanding of measures to provide safely in the home?

a) we will be sure not to leave hot liquids unattended
b) I guess my children need to understand what the word hot means
c) we will be sure that the children stay in their rooms when we work in the kitchen
d) We will install a safely gate as soon as we get home so the children cannot get into the kitchen




Pediatric Nurse Education:
ANSWERS AND RATIONALE
66) B
- by age 2-years, the child can use a cup and spoon correctly but with some spilling. By age 3 to 4, the child begins to use fork. By the end of the preschool period, the child should be able to pour milk into a cup and begin to use a knife for cutting.

67) B
- the phrases through which young children progress when separated from their parents include protest, despair, and denial or detachment. In the stage of protest, when the parents return, the child readily goes to them. In the stage of despair, the child may not approach them readily or may cling to a parent. In denial or detachment, when the parents return, the child becomes cheerful, interested in the environment and new persons (seemingly unaware of the lost parents), friendly with the staff, and interested in developing superficial relationships. Options A, C,A and D are incorrect interpretations of the child's behavior.

68) A
- bowel control usually is achieved before bladder control. The child should not be forced to sit for long periods. The ability to remove clothing is one of the physical signs of readiness. The physical ability to control the anal and urethral sphincters is achieved some time after the child is walking, probably between the age of 18 and 24 months.

69) C
- using monosyllabic babbling occurs between 3 and 6 months of age. Using simple words such as "mama" occurs between 9 and 12 months of age. Linking syllables together when communicating occurs between 6 and 9 months of age. Cooing begins at birth and continues until 2 months of age.

70) A
- toddler's, with their increased mobility and development of motor skills, can reach hot water or hot objects placed on counters and stoves and can reach open fires or stove burners above their eye level. The nurse should encourage parents to remain in the kitchen when preparing a meal, use the back burners of the stove, and turn pot handles inward and toward the middle of the stove. Hot liquids should never be supervised. The statements in option B, C, and D do not indicate an understanding of the principles of safety.


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Test Prep for Nursing Exam about Pediatric Nursing (61-65)

61. A nurse is planning care for a newborn of a diabetic mother. A priority nursing diagnosis for this infant:

a) hyperthermia related to excess fat and glycogen
b) risk for injury related to low blood glucose levels
c) risk for delayed development related to excessive size
d) risk for aspiration related to impaired suck and swallow  

62. A nursing instructor asks a nursing student to describe the procedure for administering erythromycin (0.5% Ilotycin) ointment on the eyes of a neonate. The instructor determines that the student needs to research this procedure further if the student state that:

a) I will flush the eyes after instilling the ointment
b) I will cleanse the neonate's eyes before instilling the ointment
c) administration of the eye ointment is within 1 hour after delivery
d) I will instill the eye ointment into each of the neonate's conjunctival sacs

63. Which statement would indicate the "law and order orientation" found in level two of Kohlberg's theory of moral development?

a) If I skip down the hall, will the teacher be mad at me?
b) We will spend time talking about the activities for the week
c) I don't like it when you yell while I am talking to my friend. Here are some activities to do until I am finished talking
d) If you do all of your class work today without bothering others in the class, you will get an extra seed for your good garden.

64. A home health nurse visits a 70-year old woman weekly. At each visit, the client reminisces about pas t life experiences in a positive way. Using Erickson's psychosocial development theory, the home health nurse interprets this behavior as:

a) a mental status alteration
b) a normal psychosocial response
c) requiring a psychiatric consultation
d) a sensory deficit requiring social activities

65. Which of the following car safety devices should be used for a child who is 8-years old and is 4 feet tall?

a) seat belt
b) booster seat
c) rear-facing convertible seat
d) front-facing convertible seat



ANSWERS AND RATIONALE

61) B
- the neonate born to a diabetic mother is at risk for hypoglycemia so risk for injury related to low blood glucose levels would be priority nursing diagnosis. The infant would also be at risk for hyperbilirubinemia, respiratory distress, hypocalcemia, and congenital anomalies. Hyperthermia, risk for delayed development, and risk for aspiration are not expected problems.

62) A
- eye prophylaxis protects the neonate against Neisseria gonorrhoeae and Chlamydia tranchomatis. The eyes are not flushed after instillation of the medication because the flush will wash away the administered medication. Option B, C and D are correct statements regarding the procedure for administering eye medication to the neonate.

63) A
- in the law and order orientation of Kohlberg's theory, the child has more concern with society as a whole and emphasis is on obeying laws to maintain social order. The child wants to be considered "good" by persons whose opinions matter to them. Option A is the only option that reflects these criteria. Option B, C, and D are unrelated to the law and order orientation.

64) B
- according to Erickson, late adulthood is the period of old age. The adult reminisces about past life experiences, viewing them in a positive way. The adult needs to feel good about accomplishments, see successes in life, and feel that he or she has made a contribution to society. Option A, C, and D are incorrect interpretations.

65) B
- children should remain in a booster seat until the are 8 to 12 years old and at least 4 feet, 9 inches tall. An infant should ride in a car in a semi reclined, rear-facing position in an infant-only seat or a convertible seat until they weigh at least 20 lb and are at least 1 year of age. The transition point for switching to the forward-facing position is defined by the manufacturer of the convertible car safety seat bu is generally at a body weight of 9 kg (20lb) and 1 year of age. Convertible car safety seats are used until the child weighs at least 40 lb. 


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Online Nursing Practice Test about Pharmacology (71-75)

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71. A nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which of the following is part of the plan for preparation and administration of the potassium?

a) obtaining a controlled IV infusion pump
b) monitoring urine output during administration
c) diluting in appropriate amount of normal saline
d) preparing the medication for bolus administration  

72. A client is brought to the emergency room stating that he has accidentally been taking two times his prescribed dose of warfarin (Coumadin) for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to do which of the following next?

a) prepares to administer the antidote
b) draws a sample for type crossmatch and transfuse the client
c) draws a sample for an activated partial thromboplastin (aPTT)
d) draws a sample for prothrombin (PT) and international normalized ration (INR) level

73. Methylergonovine (Methergine) is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, the priority nursing assessment is to check the:

a) uterine tone
b) blood pressure
c) amount of lochia
d) deep tendon reflexes

74. A nurse is preparing to administer beractant (survanta) to a premature infant who has respiratory distress syndrome. The nurse plans to administer the medication by which of the following routes?

a) intradermal
b) intratracheal
c) subcutaneous
d) intramuscular

75. A nurse is caring for a client who is receiving oxytocin (Pitocin) to induce labor. The nurse discontinuous the oxytocin infusion if which of the following is noted on assessment of the client?

a) fatigue
b) drowsiness
c) uterine hyperstimulation
d) early decelerations of the fetal heart rate




ANSWERS AND RATIONALE

71) D
- potassium chloride administered intravenously must always be diluted in IV fluid and infused via a pump or controller. The usual concentration of IV potassium chloride is 20 to 40 mEq/L. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. Dilution in normal saline is recommended, but dextrose solution is avoided because this type of solution increases intracellular potassium shifting. The IV bag containing the potassium chloride is always gently agitated before hanging. The IV site is monitored closely because potassium chloride is irritating to the veins and the risk of phlebitis exists.

72) D
- the next action is to draw a sample for PT and INR level to determine the client's anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client if an antidote (vitamin K) or blood transfusion is needed. The aPTT monitors the effects of heparin therapy.

73) B
- methylergonovine, an ergot alkaloid, is an agent that is used to prevent or control postpartum hemorrhage by contracting the uterus. Methylergonovine causes continuous uterine contractions and may elevate blood pressure. A priority assessment before the administration of the medication is to check the blood pressure. The physician should be notified if hypertension is present. Although options A, C, and D may be components of postpartum assessment, option B, blood pressure, is related specifically to the administration of this medication.

74) B
- respiratory distress is common in a premature neonates and may be due to lung immaturity as a result of surfactant deficiency. The mainstay of treatment is the administration of exogenous surfactant, which is administered by the intratracheal route. Option A, C, and D are not routes of administration for this medication.

75) C
- oxytocin stimulates uterine contractions and is a common pharmacological method to induce labor. An adverse reaction associated with administration of this medication is hyperstimulation of uterine contractions. Therefore, oxytocin infusion must be stopped when any signs of uterine hyperstimulation are present. Drowsiness and fatigue may be caused by the labor experience. Early decelerations of the fetal heart rate are reassuring sign and do not indicate fetal distress.


Related Topics:

• Online Nursing Practice Test about Pharmacology (76-80)
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Test Prep for Nursing Exam about Pediatric Nursing (56-60)

56. A nurse on the pediatric unit is caring for four clients and is preparing to do rounds. Which client should the nurse see first?

a) a client being discharged who needs to receive an immunization
b) a client who has returned from the recovery room and is restless
c) a client scheduled for an upper GI series
d) a client with ear tubes that came out spontaneously

57. A nurse in a newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs, if noted in the newborn infant, would alert the nurse to the possibility of this syndrome?

a) tachypnea and retractions
b) acrocyanosis and grunting
c) hypotension and bradycardia
d) presence of a barrel chest with acrocyanosis  

58. A nurse in a newborn nursery is caring for a neonate. On assessment, the infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The nurse prepares to administer this therapy by:

a) intravenous injection
b) subcutaneous injection
c) intramuscular injection
d) instillation of the preparation into the lung through an endotracheal tube

59. A nurse is assessing a newborn infant who was born to a mother who is addicted to drugs. Which of the following assessment findings would the nurse expect to note during the assessment of this newborn?

a) lethargy
b) sleepiness
c) incessant crying
d) cuddles when being held

60. A nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn infant on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with fetal alcohol syndrome?

a) length of 19 inches
b) abnormal palmar creases
c) birth weight of 6 lb. 14 oz
d) head circumference appropriate for gestational age




ANSWERS AND RATIONALE
56) B
- the client with unstable condition should be given first priority by the nurse. Restlessness after surgery may indicate bleeding, shock, or hypoxia.

57) A
- the newborn infant with respiratory distress syndrome may present with clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. Acrocyanosis is the bluish discoloration of the hands and feet, is associated with immature peripheral circulation, and is not uncommon in the first few hours of life. Options B, C, and D do not indicate clinical signs of respiratory distress syndrome.

58) D
- the aim of therapy in respiratory distress syndrome is to support the disease until the disease runs its course, with the subsequent development of surfactant. The infant may benefit from surfactant replacement therapy. In this therapy, an exogenous surfactant preparation is instilled into the lungs through an endotracheal tube. Option A, B, and C identify incorrect methods of administering surfactant.

59) C
- a newborn infant born to a woman using drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and be difficult to console. The infant would hyperextend and posture rather than cuddle when being held.

60) B
- features of newborn infants diagnosed with fetal alcohol syndrome include craniofacial abnormalities, intrauterine growth retardation, cardiac abnormalities, abnormal palmar creases, and respiratory distress. Option A, C, and D are normal assessment findings in the full-term newborn infant.


Related Topics:

• Test Prep for Nursing Exam about Pediatric Nursing (61-65) 
• Or go back to Test Prep for Nursing Exam about Pediatric Nursing (1-5) to start the practice test from the beginning.

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NCLEX Review about Obstetrical Malpractice (96-100)

NCLEX Review about Obstetrical Malpractice

96. A nurse is performing an assessment on a client diagnosed with placenta previa. Which of these assessment findings would the nurse expect to note? Select all that apply

a) uterine rigidity
b) uterine tenderness
c) severe abdominal pain
d) bright red vaginal bleeding
e) soft, relaxed, nontender uterus
f) fundal height may be greater than expected fro gestational age

97. A nurse is caring for four 1-day postpartum clients. Which client has an abnormal finding that would require further intervention?

a) the client with mild after pains
b) the client with a pulse rate of 60 bpm
c) the client with colostrum discharge from both breast
d) the client with lochia that is red and has foul-smelling odor  

98. A nursing student is preparing to perform a cardiovascular assessment on a postpartum client. A nursing instructor asks the student about the procedure to elicit Homan's sign. Which response by the nursing student would indicate an understanding of this assessment technique?

a) I will ask the client to raise her legs up to her waist and then to lower her legs slowly
b) I will ask the client to raise her legs and to try to lower them against pressure from my hand
c) I will ask the client to extend her legs flat on the bed, and I will grasp her foot gently dorsiflex it forward
d) I will ask the client to extend her legs flat on the bed, and I will grasp her foot and sharply extend it backward

99. A nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client had a midline episiotomy and has several hemorrhoids. What is the priority nursing diagnosis for this client?

a) acute pain
b) disturbed body image
c) impaired urinary elimination
d) risk for imbalanced fluid volume

100. A nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which of the following statements? Select all that apply.

a) I will use soap to wash my breasts often
b) drinking alcohol can affect my milk supply
c) the use of caffeine can decrease my milk supply
d) I will start my estrogen birth control pills again as soon as I get home
e) I know if my breasts get engorged I will limit my breast-feeding and supplement the baby
f) I plan on having bottled water available in the refrigerator so I can get additional fluids easily




NCLEX Review about Obstetrical Malpractice:
ANSWERS AND RATIONALE

96) D, E, F
- painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. The client will have a soft, relaxed, nontender uterus, and the fundal height may be more than expected for gestational age. In abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. Additionally, in abruptio placentae, the abdomen will feel hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability.

97) D
- lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor or an odor similar to menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. The other options are normal findings for 1-day postpartum client.

98) C
- to elicit Homan's sign, the nurse asks the client to extend her legs flat on bed. The nurse grasps the foot and dorsiflexes it forward. If this causes any discomfort or resistance, the nurse should notify the physician or midwife that Homan'ss sign is present. Option A, B, and D are incorrect descriptions of this assessment technique.

99) A
- the priority nursing diagnosis for a client who delivered 2 hours ago and who has a midline episiotomy and hemorrhoids is acute pain. Most clients have some degree of discomfort during the immediate postpartum period. There is no data in the question that indicate the presence of Disturbed body image, Impaired urinary elimination, Risk for imbalanced fluid volume.

100) B, C, F
- breast-feeding client should increase their daily fluid intake; therefore, having bottled water available indicates that the postpartum client understands the importance of increasing fluids. If engorgement occurs, the client should not limit breast-feeding, but should breast-feed frequently. Oral contraceptives containing estrogen are not recommended fro breast-feeding mothers and soap should not be used on the breasts because it tends to remove natural oils, which increases the chance of cracked nipples. Common causes of decreased milk supply include formula use, inadequate rest or diet, smoking by the mother or others in the home, and use of caffeine, alcohol, or other medications.

Related Topics:

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NCLEX Review about Obstetrical Malpractice (91-95)

NCLEX Review about Obstetrical Malpractice

91. A nurse in labor room is assisting with the vaginal delivery of a newborn infant. The nurse would monitor the client closely for risk of uterine rupture if which of the following occurred?

a) forcep delivery
b) schultz presentation
c) hypotonic contractions
d) weak bearing-down efforts

92. A clinic nurse is performing a prenatal assessment on a pregnant client. The nurse would implement teaching related to the risk of abruptio placentae if which of the following information was obtained on assessment?

a) the client is 28 years of age
b) this is the second pregnancy
c) the client has a history of hypertension
d) the client performs moderate exercise on a regular daily schedule  

93. A nurse is performing an initial assessment on a client who has just been told that pregnancy test is positive. Which assessment finding would indicate that the client is at risk of preterm labor?

a) the client is a 35-year old primigravida
b) the client has history of cardiac disease
c) the client's hemoglobin level is 13.5 g/dL
d) the client is a 20-year old primigravida of average weight and height

94. A nurse in labor room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which of the following assessment findings would alert the nurse to compromise?

a) maternal fatigue
b) coordinated uterine contractions
c) progressive changes in the cervix
d) persistent nonreassuring fetal heart rate

95. A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of slowing labor. The nurse is reviewing the physician's orders and would expect to note which of the following prescribed treatments for this condition?

a) increased hydration
b) oxytocin (Pitoxin) infusion
c) medication that will provide sedation
d) administration of a tocolytic medication



NCLEX Review about Obstetrical Malpractice : ANSWERS AND RATIONALE

91) A
- excessive fundal pressure, forcep delivery, violent bearing-down efforts, tumultuous labor, and shoulder dystocia can place a client at risk for traumatic uterine rupture. Hypotonic contractions and weak bearing-down efforts do not add to the risk of rupture because they do not add to the stress on the uterine wall. Schultz presentation is the expulsion of the placenta with the fetal side presenting first and is not associated with uterine rupture.

92) C
- abruptio placentae is associated with conditions characterized by poor uteroplacental circulation, such as hypertension, smoking, and alcohol or cocaine abuse. The condition is also associated with physical and mechanical factors, such as overdistention of the uterus, which occurs with multiple gestation or polyhydramios. In addition, a short umbilical cord, physical trauma, and increased maternal age and parity are risk factors.

93) B
- several factors are associated with preterm labor. These include the history of medical conditions, present and past obstetric problems, social and environmental factors, and demographic factors such as race and age. Other risk factors include a multifetal pregnancy, which contributes to overdistention of the uterus, anemia, which decreases oxygen supply to the uterus, and age younger than 18 years or first pregnancy older than the age of 40.

94) D
- signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium. Maternal exhaustion and infection can occur if the labor is prolonged but do not indicate fetal or maternal compromise. Progressive changes in the cervix and coordinated uterine contractions are a reassuring pattern in labor.

95) B
- therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows. A cesarean birth will be performed if no progress in labor occurs. Option A, C, and D identify therapeutic measures for a client with hypertonic dysfunction.

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Sample NCLEX about Obstetrics Nursing (86-90)

--> Sample NCLEX about Obstetrics Nursing

86.A nurse is reviewing the physician's orders for a client admitted for premature rupture of membranes. Gestational age of the fetus is determined to be 37 weeks. Which physician's order should the nurse question?

a) perform a vaginal examination every shift
b) monitor maternal vital signs every 4 hours
c) monitor fetal heart rate (FHR) continuously
d) administer ampicillin 1gm as an intravenous piggyback (IVPB) every 6 hours

87. A nurse is providing emergency measures to a client in labor who has been diagnosed with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which of the following nursing diagnosis would be most appropriate for this client at this time?

a) fear
b) fatigue
c) powerlessness
d) ineffective coping

88. A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa?

a) infection
b) hemorrhage
c) chronic hypertension
d) disseminated intravascular coagulation

89. A maternity nurse is caring for a client with abruptio placentae and is monitoring the client for disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with DIC?

a) prolonged clotting times
b) decreased platelet count
c) swelling of the calf of one leg
d) petechiae, oozing from injection sites, and hematuria

90. A nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present?

a) a soft abdomen
b) uterine tenderness
c) absence of abdominal pain
d) painless, bright red vaginal bleeding





Sample NCLEX about Obstetrics Nursing
ANSWERS AND RATIONALE

86) A
- vaginal examinations should not be done routinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect to administer an antibiotic, monitor maternal vital signs, and monitor the FHR.

87) A
- the mother is anxious and frightened, and the most appropriate nursing diagnosis for the client at this time is fear. No data in the question support a nursing diagnosis of powerlessness, ineffective coping, or fatigue, although these nursing diagnoses may be considered for this client at some point during the hospitalization experience.

88) B
- because the placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding. Option A, C, and D are not risks that are related specifically to placenta previa.

89) C
- disseminated intravascular coagulation (DIC) is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Platelets are decreased because they are consumed by the process, coagulation studies show no clot formation (and are thus normal to prolonged), and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area. The presence of petichiae, oozing from injection sites, and hematuria are signs associated with DIC. Swelling and pain in the calf of one leg are more likely associated with thrombophlebitis.

90) B
- painless, bright red vaginal bleeding in the second trimester of pregnancy is a sign of placenta previa. In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitor often reveals increased uterine resting tone, caused by failure of the uterus to relax in attempt to constrict blood vessels and control bleeding

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Sample NCLEX about Obstetrics Nursing (81-85)

Sample NCLEX about Obstetrics Nursing

81. A nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a Doppler ultrasound device. The nurse accurately determines that the fetal heart sounds are heard by:

a) Noting whether the heart rate is greater than 140 bpm
b) placing the diaphragm of the Doppler on the mother's abdomen
c) palpating the maternal radial pulse while listening to the fetal heart rate
d) Performing Leopold's maneuver first to determine the location of the fetal heart

82. A nurse is caring for a client in labor who is receiving oxytoxin (Pitocin) by intravenous infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued?

a) increased urinary output
b) a fetal heart rate of 90 bpm
c) three contractions occurring within a 10-minute period
d) adequate resting tone of the uterus palpated between contractions

83. A nurse is reviewing the record of a client in the labor room and notes that the nurse-midwife has documented that the fetus is at negative 1 (-1) station. The nurse determines that the fetal presenting part is:

a) 1 inch below the coccyx
b) 1 inch below the iliac crest
c) 1 cm above the ischial spine
d) 1 fingerbreath below the symphysis pubis

84. nurse is monitoring a client in labor. The nurse suspects umbilical cord compression. If which of the following is noted on the external monitor tracing during a contraction?

a) late decelerations
b) early decelerations
c) short-term variability
d) variable decelerations

85. A labor and delivery room nurse has just received report on four clients. The nurse should assess which client first?
a) a primiparous client in the active stage of labor
b) a multiparous client who was admitted for induction of labor
c) a client who is not contracting but has suspected premature rupture of the membranes
d) a client who has just received an Iv loading dose of magnesium sulfate to stop preterm labor





Sample NCLEX about Obstetrics Nursing:
ANSWERS AND RATIONALE

81) C
- the nurse must simultaneously palpate the maternal radial or carotid pulse and auscultate the fetal heart rate (FHR) to differentiate the two. If the fetal and maternal heart rates are similar, the nurse may mistake the maternal heart rate for the FHR. Noting whether the heart rate is more than 140 bpm or placing the diaphragm of the Doppler on the mother's abdomen will not ensure accuracy in obtaining the FHR. Leopold's maneuver may help the examiner locate the position of the fetus but will not ensure a distinction between the heart rates

82) B
- a normal fetal heart rate is 120 to 160 bpm. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue the oxytocin. The goal of labor augmentation is to achieve three good-quality contractions (appropriate intensity and duration) in a 10-minute period. The uterus should return to resting tone between contractions, and there should be no evidence of fetal distress. Increased urinary output is unrelated to the use of oxytocin.

83) C
- station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, measured in centimeters, and noted as a negative number above the line and a positive number below the line. At negative 1 (-1) station, the fetal presenting part is 1 cm above the ischial spines.

84) D
- variable decelerations occur if the umbilical cord becomes compressed, thus reducing blood flow between the placenta and the fetus. Early decelerations result from pressure on the fetal head during a contraction. Late decelerations are an ominous pattern in labor because they suggest uteroplacental insufficiency during a contraction. Short-term variability refers to the beat-to-beat range in fetal heart rate.

85) D
- magnesium sulfate is a central nervous system (CNS) depressant and the client could experience adverse effects that includes depressed respiratory rate (below 12 cpm), severe hypotension, and absent tendon reflexes (DTRs). This client should be seen before the clients in option A, B, and C because these clients conditions represent stable ones. 

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Obstetric Nursing CEUS Practice Test (76-80)

Obstetric Nursing CEUS Practice Test

76. A nurse is reviewing true and false labor signs with multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement?

a) I won't be in labor until the baby engages
b) my contractions will be felt in the abdominal area
c) my contractions will not be as painful if I walk around
d) my contractions will increase in duration and intensity

77. A client in labor has been pushing effectively for 1 hour. A nurse determines that the client,s primary physiological need at this time is to:

a) ambulate
b) rest between contractions
c) change positions frequently
d) consume oral food and fluids  


78. A nurse is caring for a client in labor. The nurse determines that the client is beginning the second stage of labor when which of the following assessments is noted?

a) the contractions are regular
b) the membranes have ruptured
c) the cervix is dilated completely
d) the client begins to expel clear vaginal fluids

79. A nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate a need to contact the physician?

a) hemoglobin of 11.0 g/dL
b) fetal heart rate of 180 bpm
c) maternal pulse rate of 85 bpm
d) white blood cell count of 12,000/mm3

80. A nurse has provided discharge instructions to a client who delivered a healthy newborn infant by cesarean delivery. Which statement, if made by the client, indicates a need fro further instructions?

a) I will begin abdominal exercises immediately
b) I will notify the physician if I develop a fever
c) I will turn on my side and push up with my arms to get out of bed
d) I will lift nothing heavier than the newborn infant for at least two weeks





Obstetric Nursing CEUS Practice Test:
ANSWERS AND RATIONALE

76) D
- true labor for multiparous client is present when the contractions increase in duration and intensity. A multiparous client experiences true labor before the fetus engages. Contractions felt in the abdominal area and contractions that ease with walking are signs of false labor.

77) B
- the birth process expends a great deal of energy. Encouraging rest between contractions conserves maternal energy, facilitating voluntary pushing efforts with contractions. Uteroplacental perfusion also is enhanced, which promotes fetal tolerance to stress of labor. Changing positions frequently is not the primary physiological need. Ambulation is encouraged during early labor. Ice chips should be provided. Food and fluids likely are to be withheld at this time.

78) C
- the second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. Options A, B, and D are not specific assessment findings of the second stage of labor.

79) B
- a normal fetal heart rate is 120 to 160 bpm. A count of 180 bpm could indicate fetal distress and would warrant physician notification. White blood cell counts in a normal pregnancy begin to rise in the second trimester and peak in the third trimester, with a normal range of 11,000 to 15,000/mm3, up to 18,000/mm3. During the initial postpartum period, the count may be as high as 25,000 to 30,000/mm3 as a result of increased leukocytosis during delivery. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL as a result of the hemodilution caused by an increase in plasma volume during pregnancy. The maternal pulse rate increases 10 to 15 bpm over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration.

80) A
- abdominal exercises should not start immediately following abdominal surgery, and the client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision. Option B, C, and D are appropriate instructions for the client following a cesarean delivery. 

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Obstetric Nursing CEUS Practice Test (71-75)

Obstetric Nursing CEUS Practice Test

71.A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement, if made by the client, indicates a need for further teaching?

a) I should stay on the diabetic diet
b) I should perform glucose monitoring at home
c) I should avoid exercise because of the negative effects on insulin production
d) I should be aware of any infections and report signs of infection immediately to my health care provider

72. A client has just had surgery to deliver a nonviable fetus resulting from abruptio placentae. As a result of abruptio placentae, the client develops disseminated intravascular coagulation (DIC) and is told about the complication. The client begins to cry and screams, "God, just let me die now!" Which nursing diagnosis should direct care for this client at time?

a) grieving related to the loss of the baby
b) situational low self-esteem related to being ill
c) deficient knowledge related to the disease process
d) hopelessness related to the loss of the baby and personal health

73. A pregnant client in the last trimester has been admitted to the hospital with a diagnosis of severe preeclampsia. A nurse monitors for complications associated with the diagnosis and assesses the client for:

a) enlargement of the breast
b) complaints of feeling hot when the room is cool
c) periods of fetal movement followed by quiet periods
d) evidence of bleeding, such as in the gums, petechia, and purpura

74. A nurse in a maternity unit is reviewing the records of the clients on the unit. Which client would the nurse identify as being at the greatest risk for developing disseminated intravascular coagulation (DIC)?

a) a primigravida with mild preeclampsia
b) a primigravida who delivered a 10-lb baby 3 hours ago
c) a gravida II who has just been diagnosed with dead fetus syndrome
d) a gravida IV who delivered 8 hours ago and has lost 500 ml of blood

75. A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement, if made by the client, indicates a need for further instructions.

a) I will watch for the evidence of the passage of tissue
b) I will maintain strict bed rest throughout the remainder of the pregnancy
c) I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad
d) I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of bleeding





Obstetric Nursing CEUS Practice Test:
ANSWERS AND RATIONALE

71) C
- exercise is safe for the client with gestational diabetes mellitus and is helpful in lowering the blood glucose level. Dietary modifications are the mainstay of treatment, and the client is placed on a standard diabetic diet. Many client are taught to perform blood glucose monitoring. If the client is not performing the blood glucose monitoring at home, then it will be performed at the clinic or health care provider's office. Signs of infection need to be reported to the health care provider.

72) D
- by seeing no way out of the situation except for death, the client meets the criteria for hopelessness. A person who lacks hope thinks that life is too much to handle. Option A is a possible nursing diagnosis at a later time; however, at this time, the diagnosis of hopelessness should take precedence. Option C is a possible nursing diagnosis later, but not enough data support it at this point. The data given do not support the nursing diagnosis of situational self-esteem.

73) D
- severe preeclampsia can trigger disseminated intravascular coagulation (DIC) because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the health care provider if noted on assessment. Option A, B, and C are normal occurrences in the last trimester of pregnancy.

74) C
- dead fetus syndrome is considered a risk factor for DIC. Sever preeclampsia is considered a risk factor for DIC; a mild case is not. Delivering a large baby is not considered a risk factor for DIC. Hemorrhage is a risk factor with DIC; however, a loss of 500 ml is not considered hemorrhage.

75) B
- strict bed rest throughout the remainder of the pregnancy is not required. The client is advised to curtail sexual activities until bleeding has ceased, and for 2 weeks following the last evidence of bleeding or as recommended by the physician or other health care provider. The client is instructed to count the number of perineal pads used daily and to note the quantity and color of blood on the pad. The client also should watch for the evidence of the passage of tissue.

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Obstetric Nursing CEUS Practice Test (66-70)

Obstetric Nursing CEUS Practice Test

66. A clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment finding indicates to the nurse that the client is at high risk for contracting immunodeficiency virus (HIV)?

a) a client who has a history of intravenous drug use
b) a client who has a significant other who is heterosexual
c) a client who has a history of sexually transmitted diseases
d) a client who has had one sexual partner for the past 10 years

67. A nurse in maternity unit is providing emotional support to a client and her husband who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement, if made by the client, indicates a component of the normal grieving process?

a) we want to attend a support group
b) we never want to try to have a baby again
c) we are going to try to adopt a child immediately
d) we are okay, and we are going to have another baby immediately

68. A nurse evaluates a hepatitis B-positive mother' ability for safe bottle-feeding of her infant during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the infant.

a) the mother requests that the window be closed before feeding
b) the mother holds the infant properly during feeding and burping
c) the mother tests the temperature of the formula before initiating feeding
d) the mother washes and dries her hands before and following self-care of the perineum and asks for a pair of gloves before feeding

69. A home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia and who is being monitored for gestational hypertension. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the physician?

a) urinary output has increased
b) dependent edema has resolved
c) blood pressure reading is at the prenatal baseline
d) the client complaints of headache and blurred vision

70. A client with a 38-week twin gestation is admitted to a birthing center in early labor. One of the fetuses is a breech presentation. Of the following interventions, which is the lowest priority in planning the nursing care of this client?

a) measure fundal height
b) attach electronic fetal monitoring
c) prepare the client for possible cesarean section
d) visually examine the perineum and vaginal opening





Obstetric Nursing CEUS Practice Test:
ANSWERS AND RATIONALE

66) A
- human immunodeficiency virus (HIV) is transmitted by intimate sexual contact and the exchange of body fluids, exposure to infected blood, and passing from infected woman to her fetus. Clients who fall into the high-risk category for HIV infection include those with persistent and recurrent sexually transmitted diseases, a history of multiple partners, or have used intravenous drugs. A heterosexual partner, in 10 years, does not have a high risk for contracting HIV.

67) A
- a support group can help the parents work through their pain by nonjudgmental sharing of feelings. Option A identifies a statement that would indicate positive, normal grieving. Although the other options may indicate reactions of the client and significant other, they are not specifically a part of the normal grieving process.

68) D
- hepatitis B virus is highly contagious and transmitted by direct contact with blood and body fluids of infected persons. The rationale for identifying childbearing clients with this disease is to provide adequate protection of the fetus and the newborn infant, to minimize transmission to other human beings, and to reduce maternal complications. Option D provides the best evaluation of maternal understanding of disease transmission. Option A will not affect disease transmission. Option B and C are appropriate feeding techniques for bottle-feeding but do not minimize disease transmission for hepatitis B.

69) D
- if the client complains of headache and blurred vision, the physician should be notified because these are signs of worsening preeclampsia. Option A, B, and C are normal signs.

70) A
- option A is a low priority because fundal height should be measured at each antepartum clinic visit, not in the intrapartum period. Option B, C and D are high priorities. Intrapartum management and assessment require careful attention to maternal and fetal status. The fetuses should be monitored by dual electronic fetal monitoring, and any signs of distress need to be reported to the physician or health care provider. A cesarean section may be necessary if a fetus is breech. The nurse should examine the perineum and vaginal opening visually for signs of the cord, which sometimes will prolapse through the cervix.

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Obstetric Nursing CEUS Practice Test (61-65)

Obstetric Nursing CEUS Practice Test

61. A pregnant client visits a clinic for a scheduled prenatal appointment. The client tells the nurse that she frequently has a backache, and the nurse provides instructions regarding measures that will assist in relieving the backache. Which statement by the client indicates a need for further instructions?

a) I should wear flat-heeled shoes
b) I should sleep on firm mattress
c) I should try to maintain good posture
d) I should do more exercises to strengthen my back muscles

62. A clinic nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy. Which statement by the client indicates a need for further instructions?

a) I should wear panty hose
b) I should wear support hose
c) I should be wearing flat nonslip shoes that have good support
d) I should wear knee-high hose as long as I don't leave them on longer than 8 hours

63. A clinic nurse is providing instructions to a pregnant client regarding measures that will assist in alleviating heartburn. Which statement by the client indicates an understanding of the instructions?

a) I should avoid between-meal snacks
b) I should lie down for an hour after eating
c) I should use spices for cooking rather than using salt
d) I should avoid eating foods that produce gas, such as beans, vegetables, and fatty foods like deep fried chicken

64. A nurse in a health care clinic is instructing a pregnant client about how to perform "kick counts." Which statement by the client indicates a need for further instructions?

a) I will record the number of movements or kicks
b) I need to lie flat on my back to perform the procedure
c) a count of fewer than 10 kicks in a 12-hour period indicates the need to contact the physician
d) I should place my hands on the largest part of my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks

65. During a prenatal visit, the nurse is explaining dietary management to a client with diabetes mellitus. The nurse determines that the teaching has been effective if the client makes which statement?

a) diet and insulin needs change during pregnancy
b) I will plan my diet based on the results of urine glucose testing
c) I will need to eat 600 more calories every day since I am pregnant
d) I can continue with the same diet as before pregnancy, as long as it is well-balanced





Obstetric Nursing CEUS Practice Test:
ANSWERS AND RATIONALE

61) D

- some measures that will assist in relieving a backache include maintaining good posture and body mechanics, resting and avoiding fatigue, wearing flat-heeled shoes, and sleeping on a firm mattress. The back discomfort that occurs in pregnant client is often caused by the exaggerated lumbar and cervicorthoracic curves resulting from a change in the center of gravity because of the enlarged uterus. Performing more exercises to strengthen the back muscles could be harmful to a pregnant client.

62.  D

- varicose veins often develop in the lower extremities during pregnancy. Any constrictive clothing, such as knee-high hose, impedes venous return from the lower legs and places the client at risk for developing varicosities. The client should be encouraged to wear support hose or panty hose. Flat nonslip shoes with proper support are important to assist the pregnant woman to maintain proper posture and balance and minimize falls.

63) D

- lying down is likely to lead reflux of stomach contents, especially immediately following a meal. The client should be instructed to avoid spices, along with salt, because spices will trigger heartburn. Salt will produce edema. The client should be encouraged to eat between-meal snacks and should instructed that to control heartburn, eating smaller, more frequent portions is preferred over eating three large meals. The client also should limit or avoid gas-producing and fatty foods.

64) B

- the client should sit or lie quietly on her side to perform kick counts. Lying flat on the back is not necessary to perform this procedure, can cause discomfort, and presents a risk of vena cava (hypotensive) syndrome. The client is instructed to place her hands on the largest part of the abdomen and concentrate on the fetal movements. The client records the number of movements felt during a specified time period. The client needs to notify the physician or nurse-midwife if there are fewer than 10 kicks in a 12-hour period or as instructed by the physician or nurse-midwife.

65) A

- the diet for a pregnant client with diabetes mellitus is individualized to allow for increased fetal and metabolic requirements, with consideration of such factors as pre-pregnancy weight and dietary habits, overall health, ethnic background, lifestyle, stage of pregnancy, knowledge of nutrition, and insulin therapy. An increase of 600 additional calories a day is not required. Diet and insulin needs change during the pregnancy in direct correlation to hormonal changes and energy needs. In the third trimester, insulin needs increase. Dietary management during diabetic pregnancy must be based on blood, not urine, glucose changes.


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NCLEX Flashcards on Obstetric Nursing (56-60)

NCLEX Flashcards on Obstetric Nursing

56. A nurse has performed a nonstress test on a pregnant client and is reviewing the fetal monitor strip. The nurse interprets the test as reactive and understands that this indicates:

a) normal findings
b) abnormal findings
c) the need for further evaluation
d) that the findings on the monitor were difficult to interpret

57. A nonstress test is performed on a client who is pregnant and the results of the test indicate nonreactive findings. The physician orders a contraction stress test to be done and the results are documented as negative. The nurse interprets this finding as indicating:

a) a normal test result
b) an abnormal test result
c) a high risk for fetal demise
d) the need for a cesarean delivery  

58. A nurse is reviewing a nutritional plan of care with a pregnant client and is identifying the food items highest in folic acid. The nurse determines that the client understands the foods that supply the highest amounts of folic acid if the client states that she will include which of the following in the daily diet?

a) milk
b) yogurt
c) bananas
d) leafy, green vegetables

59. A pregnant client tells a nurse that she has been craving "unusual foods." The nurse gathers additional assessment data from the client and discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Laboratory studies are performed on the client. The nurse reviews the laboratory results and determines that which of the following indicates a physiological consequence of this client's practice?

a) hematocrit, 38%
b) glucose, 86 mg/dL
c) hemoglobin, 9.1 g/dL
d) white blood cell count, 12,400 mm3

60. A pregnant client who is at 30 weeks gestation comes to the clinic for a routine visit, and the nurse performs an assessment on the client. Which observation made by the nurse during the assessment indicates need for teaching?

a) the client is wearing sneakers
b) the client is wearing knee-high hose
c) the client is wearing flat shoes with rubber soles
d) the client is wearing pants with an elastic waistband





NCLEX Flashcards on Obstetric Nursing:
ANSWERS AND RATIONALE

  56) A
- a reactive nonstress is a normal result. To be considered reactive, the baseline fetal heart rate must be within normal range (120 to 160 bpm) with good long-term variability. In addition, two or more fetal heart rate accelerations of at least 15 bpm must occur, each with a duration of at least 15 seconds, in a 20-minute interval.

57) A
- contraction stress test results may be interpreted as negative (normal), positive (abnormal), or equivocal. A negative test result indicates that no late decelerations occurred in the fetal heart rate, although the fetus was stressed by three contractions of at least 40 seconds duration in a 10-minute period. Therefore, options B, C, and D are incorrect interpretations.

58) D
- leafy green vegetables are rich in folate (folic acid). Bananas provide potassium, milk and yogurt supply calcium.

59) C
- Pica cravings often lead to iron deficiency anemia, resulting in a lowered hemoglobin level. The laboratory values options A, B, and D are within normal limits for the pregnant client.

60) B
- varicose veins often develop in the lower extremities during pregnancy. Any constricting clothing such as knee-high hose impede venous return from the lower legs and thus place the client at high risk for developing varicosities. Client should be encourage to wear panty hose or support hose. Flat nonslip shoes with proper support are important to assist the pregnant woman to maintain proper posture and balance and minimize the risk for falls. Pants with an elastic waistband are comfortable and not constricting.

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NCLEX Flashcards on Obstetric Nursing (51-55)

NCLEX Flashcards on Obstetric Nursing

51. A nurse is performing an assessment of primipara who is being evaluated in clinic during her second trimester of pregnancy. Which of the following indicates an abnormal physical finding that necessities further testing?

a) quickening
b) braxton hicks contractions
c) consistent increase in fundal height
d) fetal heart rate of 180 bpm

52. A nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and expects the finding to be which of the following?

a) 22 cm
b) 30 cm
c) 36 cm
d) 40 cm

53. A nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The physician has documented the presence of Goodell's sign. The nurse determines that his sign indicates:

a) a softening of the cervix
b) the presence of fetal movement
c) the presence of human chorionic gonadotrophin in the urine
d) a soft blowing sound that corresponds to the maternal pulse during auscultation of the uterus.

54. A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy.

a) ballotment
b) chadwick's sign
c) uterine enlargement
d) braxton hicks contractions
e) outline of fetus via radiography or ultrasonography
f) fetal heart rate detected by a nonelectronic device

55. A nurse is providing instructions regarding treatment of hemorrhoids to a client who is in the second trimester of pregnancy. Which statement by the client indicates a need for further teaching?

a) I should avoid straining during bowel movements
b) I can gently replace the hemorrhoids into the rectum
c) I can apply ice packs to the hemorrhoids to reduce the swelling
d) I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink




NCLEX Flashcards on Obstetric Nursing:
ANSWERS AND RATIONALE

51) D
- the normal range of the fetal heart rate depends on gestational age. The heart rate is usually 160 to 170 bpm in the first trimester and slows with fetal growth. Near at term, the fetal heart rate ranges from 120 to 160 bpm. Option A, B and C are normal expected findings.

52) B
- during the second and third trimester (weeks 18 to 30), fundal height in centimeters approximately equal s the fetus age in weeks +- 2cm. At 16 weeks, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the umbilicus, and at 36 weeks the fundus is at the xiphoid process.

53) A
- in the early weeks of pregnancy, the cervix becomes softer as a result of increased vascularity and hyperplasia, which cause Goodell's sign. Cervical softening is noted by the examiner dung pelvic examination. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus and is caused by blood circulating through the placenta. Human chorionic gonadotrophin is noted in maternal urine in a positive urine pregnancy test. Goodell's sign does not indicate the presence of fetal movement.

54) A, B, C, D
- the probable signs of pregnancy include uterine enlargement, hegar's sign (softening and thinning of the lower uterine segment that occurs about week 6), goodell's sign (softening of the cervix that occurs at the beginning of the second month), chadwick's sign (bluish coloration of the mucous membranes of the cervix, vagina and vulva that occurs about week 6), ballotment (rebounding of the fetus against the examiner's fingers on palpation), braxton hicks contractions, and a positive pregnancy test for the presence of human chorionic gonadotrophin (HCG). Positive signs of pregnancy include fetal heart rate detected by electronic device (doppler tranducer) at 10 to 12 weeks and by a nonelectronic device (fetoscope) at 20 weeks of gestation, active fetal movements palpable by the examiner, and an outline of the fetus by radiography or ultrasonography.

55) D
- measures that provide relief from hemorrhoids include avoiding constipation and straining during bowel movements; applying ice packs to reduce the hemorrhoidal swelling; gently replacing the hemorrhoids into the rectum; using stool softeners; ointments or sprays as prescribed; and assuming certain positions to relieve pressure on the hemorrhoids. Heat packs will increase the blood flow to the area and worsen the discomfort from hemorrhoids. 

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Obstetric Nursing Test (46-50)

Obstetric Nursing Test Questions 46-50

46. A mother complains of pain due to breast engorgement and is bottle-feeding her newborn. Which action by the mother needs follow-up?

a) the mother applies warm compress on her breasts
b) the mother wears support bra
c) the mother applies cold compress on her breasts
d) the mother takes prescribed analgesics

47. A nurse is assisting a client who is in first stage of labor (active phase). A priority nursing action for the nurse is:

a) encourage the woman to blow out strong, short breaths
b) assist the client to a comfortable position in bed
c) monitor client's temperature every hour
d) evaluate fetal heart rate (FHR) every hour

48. A nurse on the obstetric unit is providing care to a woman in the active phase of the first stage of labor. Which statement if made by the mother should be a priority concern for the nurse?

a) I will like to take a nap between contractions
b) I have not voided in the last hour, although I feel I need to
c) I am feeling some rectal pressure that is relieved when I push
d) I am feeling contractions every 5 minutes

49. A nursing instructor asks a nursing student to describe the procedure for performing the Helmlich maneuver on an unconscious pregnant woman at 8 month's gestation. The student describes the procedure correctly if the student states that she or he will:

a) place the hands in the pelvis to perform the thrusts
b) perform abdominal thrusts until the object is dislodged
c) perform left lateral abdominal thrusts until the object is dislodged
d) place a rolled blanket under the right abdominal flank and hip area

50. A nursing student is assigned to a client in labor. A nursing instructor asks the student to describe fetal circulation, specially the ductus venosus. The nursing instructor determines that the student understands fetal circulation if the student states that the ductus venosus:

a) connects the pulmonary artery to the aorta
b) is an opening between the right and left atria
c) connects the umbilical vein to the inferior vena cava
d) connects the umbilical artery to the inferior vena cava




Obstetric Nursing Test:
ANSWERS AND RATIONALE

46) A
- the mother who bottle-feeds her infant should apply cold compress on her breasts to relieve engorgement; not warm compress. Warm compress stimulates milk production.

47) A
- during active labor, pant-blow breathing exercises may minimize discomfort during uterine contraction. Pushing is done only when there is full cervical dilatation (10cm) to prevent exhaustion of the mother and to prevent laceration.

48) A
- the client should relax and be alert, but not to take a nap between contractions. Taking a nap may also make the fetus sleep and labor will be prolonged.

49) D
- to perform the Helmlich maneuver on an unconscious woman in an advanced stage of pregnancy, place a wedge, such as a pillow or rolled blanket, under the right abdominal flank and hip to displace the uterus to the left side of the abdomen. Option A, B and C are incorrect and can harm the woman and the fetus.


50) C
- the ductus venosus connects the umbilical vein to the inferior vena cava. Option A, B, and D are incorrect. The foramen ovale is a temporary opening between the right and left atria. The ductus arteriosus joins the aorta and the pulmonary artery. 

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