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Review for NCLEX-RN Examination 200

--> QUESTION NUMBER _ 101 _ about (MC)


QUESTION: "After the first breast-feeding, the client asks the nurse, "How often should I try to breast-feed?" Which of the following frequencies should the nurse recommend?"

CHOICES

( X ) a.) At least every hour for the first 48 hours.

( O ) b.) Every 2 to 3 hours for the first 48 hours.

( X ) c.) Every 4 to 5 hours for the first 5 days after delivery.

( X ) d.) Whenever she desires, until weaning occurs.


RATIONALE: Soon after delivery, the client should breast-feed every 2 to 3 hours until her milk supply is established. Feeding every hour is not necessary and will lead to maternal exhaustion. When beginning to breast feed, the milk supply needs to be established. This is accomplished by feeding the neonate every 2 to 3 hours. Feeding every 4 to 5 hours is not often enough to help establish the milk supply. Feeding whenever the mother desires is inappropriate because the client may only feel like feeding less often, thus not providing enough stimulation for milk production while not supplying the neonate with the needed nutrition. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 102 _ about (MC)


QUESTION: "A multipara who delivered a viable male neonate 12 hours ago plans to breast-feed her baby, although she bottle-fed her first two children. The client tells the nurse that she has cramps every time she breast-feeds. Which of the following should the nurse do?"

CHOICES

( O ) a.) Offer the client a prescribed analgesic.

( X ) b.) Advise the client to breast-feed more often.

( X ) c.) Suggest more frequent ambulation during the day.

( X ) d.) Offer the client a prescribed stool softener.


RATIONALE: An analgesic is most commonly offered to provide relief from discomfort. Multiparas tend to experience cramps while breast-feeding more frequently than do primiparas because breast-feeding releases oxytocin, causing uterine muscles to contract. The uterine muscles tend to be more tonically contracted after delivery in primiparas. Breast-feeding more often is not indicated because this would increase the client's complaints of cramping. Ambulation is not helpful because the cramps are due to the release of oxytocin, not gas accumulation. The client is experiencing cramping due to hormonal stimulation of the uterus, not from gas or constipation. Therefore, a stool softener would not help to alleviate the cramping. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 103 _ about (MC)


QUESTION: "When teaching a woman who is breast-feeding her baby how to express milk manually, the nurse instructs the client to use her thumb and forefinger and do which of the following?"

CHOICES

( X ) a.) Alternately release and compress each nipple.

( O ) b.) Compress and release the breast at the areolar edge.

( X ) c.) Slide forward from the areolar edge toward the nipple end.

( X ) d.) Roll the nipple while exerting a gentle pull on areola.


RATIONALE: The best technique for expressing milk from the breast is alternately compressing and releasing the breast at the edge of the areola. With the thumb on top and two fingers on the bottom of the breast at the edge of the areola, the client pushes in toward her chest and then squeezes her thumb and fingers together while pulling forward on the areola, without sliding her fingers or thumb on her skin. Compressing and releasing the nipple will not stimulate the milk ejection reflex but could possibly result in trauma or pain. Releasing and compressing at the edge of the areola will force milk out of the nipple. When manually expressing breast milk, the woman needs to avoid sliding the fingers and thumb on her skin because this could damage the tender breast tissue. Rolling the nipple while gently pulling on the areola could injure the breast tissue. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 104 _ about (MC)


QUESTION: "The nurse plans to instruct the postpartum client in methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan?"

CHOICES

( X ) a.) Feeding the neonate a maximum of 5 minutes per side on the first day.

( X ) b.) Wearing a supportive brassiere with nipple shields.

( O ) c.) Breast-feeding the neonate at frequent intervals.

( X ) d.) Decreasing fluid intake for the first 24 to 48 hours.



RATIONALE: Prevention of breast engorgement is key. The best technique is to empty the breasts regularly and frequently with feedings. Engorgement is less likely when the mother and neonate are together, as in single room maternity care or continuous rooming in, because nursing can be done conveniently to meet the neonate's and mother's needs. Feeding the neonate for only 5 minutes per side on the first day is not adequate because it takes 7 to 10 minutes for the milk ejection reflex to be initiated. Wearing a supportive brassiere does not prevent engorgement. The breasts need to be emptied frequently. Decreasing fluid intake is not advised because dehydration may result. Breast-feeding mothers should consume approximately 2 liters of fluid per day. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 105 _ about (MC)


QUESTION: "A woman who is breast-feeding tells the nurse that she plans to return to work in 6 months and will probably wean her baby then. The client asks the nurse, "How will I stop producing milk when I want to wean the baby?" The nurse should instruct the client about which of the following?"

CHOICES

( O ) a.) Gradual decrease in milk supply as the baby nurses less.

( X ) b.) The need to request a prescription for a lactation suppressant.

( X ) c.) Wearing a tight breast binder to effectively suppresses lactation.

( X ) d.) Natural diminishment in supply about 6 months after delivery.


RATIONALE: Over time, as the infant nurses less, the mother's milk supply diminishes normally. Gradual weaning by eliminating one feeding at a time over several weeks is the best recommendation. Lactation suppressants are no longer recommended because of the possible adverse effects, such as hypotension. Mechanical methods of suppressing lactation, such as a breast binder, are most effective when used as soon after delivery as possible. The milk supply persists beyond 6 months after delivery if the breasts are emptied regularly. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 106 _ about (MC)


QUESTION: "A 19-year-old primipara who delivered a viable male neonate 2 hours ago has decided to breast-feed. Her 22-year-old husband supports her decision. The client tells the nurse, "My mother breast-fed all of her children, but I'm going to need lots of help with breast-feeding. I'm worried that I won't be able to do this." Which of the following should the nurse include when assessing the client?"

CHOICES

( O ) a.) Determine the client's level of motivation to breast-feed.

( X ) b.) Ask the client if she has read any literature about breast-feeding.

( X ) c.) Perform a complete physical examination to determine her need for help.

( X ) d.) Assess her body-to-fat ratio and nutritional status before beginning breast-feeding.


RATIONALE: Successful breast-feeding depends on the client's willingness and motivation to breast-feed. Women who have a strong desire to breast-feed tend to continue breast-feeding longer and are often more tolerant of the discomforts of breast-feeding and more accepting of the need for frequent feedings. Although obtaining information about what the client has read about breast-feeding may provide clues about the client's knowledge level, the type of literature is not a significant factor in successful breast-feeding. A complete physical examination is not necessary. The client is asking for support and assistance with breast-feeding. Performing a physical examination does not provide this needed support. Although adequate nutrition during lactation is important, even clients who have had poor nutrition can be taught how to improve their diets. Assessing the client's body-to-fat ratio is not important for breast-feeding because it is not associated with the mother's ability to breast-feed or the amount of breast milk produced. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 107 _ about (MC)


QUESTION: "The client who is breast-feeding asks the nurse if she should supplement breast-feeding with formula feeding. The nurse bases the response on which of the following?"

CHOICES

( O ) a.) Formula feeding should be avoided to prevent interfering with the breast milk supply.

( X ) b.) Primarily, water supplements should be used to prevent jaundice

( X ) c.) Formula supplements can provide nutrients not found in breast milk.

( X ) d.) More vigorous sucking is needed for a bottle-feeding, so supplements should be avoided.


RATIONALE: Bottle supplements tend to cause a decrease in the breast milk supply and demand for breast-feeding and should be avoided. Once in a while if the client is tired, a bottle supplement may be given to the neonate by another caregiver. Bottle supplements are not appropriate to prevent jaundice, although if neonatal bilirubin level is excessive, some pediatricians recommend temporary discontinuation of breast-feeding, while others recommend increasing the frequency of breast-feeding. Breast-feeding is considered the best nutritional source for infants. Although formula supplements should be avoided, neonates suck less vigorously on a bottle than on the breast. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 108 _ about (MC)


QUESTION: "After teaching the client about bottle-feeding, which of the following client statements indicates the need for additional teaching?"

CHOICES

( X ) a.) "Bottle-fed babies up to 6 months of age may gain as much as 1 ounce per day."

( X ) b.) "Iron-fortified formulas are usually recommended for newborns."

( X ) c.) "Bottle-fed babies will usually regain their birth weight by 10 days of age."

( O ) d.) "Whole milk is an acceptable alternative to formula once the baby is 4 months old."


RATIONALE: Neither unmodified cow's milk nor whole milk is an acceptable alternative for newborn nutrition. The American Academy of Pediatrics recommends that infants be given breast milk or formula until 1 year of age. However, the American Academy of Pediatrics Committee on Nutrition has decreed that cow's milk could be substituted in the second 6 months of life, but only if the amount of milk calories does not exceed 65% of total calories and iron is replaced through solid foods. The protein content in cow's milk is too high, is poorly digested, and may cause gastrointestinal tract bleeding. Bottle-fed infants may gain as much as 1 ounce per day up to age 6 months. Iron-fortified formulas are recommended. Bottle-fed neonates may regain their birth weight by 10 days of age. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 109 _ about (MC)


QUESTION: "On the first postpartum day after a cesarean delivery, the client is ordered a full liquid diet as tolerated. Before providing a full liquid breakfast, the nurse should assess which of the following?"

CHOICES

( X ) a.) Breath sounds.

( X ) b.) Desire to eat.

( O ) c.) Bowel sounds.

( X ) d.) Degree of pain.


RATIONALE: Before providing the client with a full liquid lunch, the nurse should first assess for the presence of bowel sounds to evaluate the functioning of the client's gastrointestinal tract. After cesarean delivery, the client is at risk for paralytic ileus or intestinal obstruction due to the effects of the surgery or anesthesia used. Assessing breath sounds, although an important assessment, would be indicated if the client was experiencing a respiratory problem. It has no relevance related to the client's eating. The client's desire to eat may or may not be present. The client's gastrointestinal function manifested by active bowel sounds indicates that the client can be allowed to eat. The degree of pain is an important assessment but not in relation to the client's diet. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 110 _ about (MC)


QUESTION: "On the second postpartum day after a cesarean delivery, the client complains of gas pains. The nurse should instruct the client to do which of the following?"

CHOICES

( X ) a.) Ask the physician for simethicone (Mylicon).

( X ) b.) Chew on some ice chips.

( X ) c.) Drink some hot coffee.

( O ) d.) Ambulate more often.


RATIONALE: During the first few days postpartum, the accumulation of gas in the intestines may cause discomfort. This is relieved by measures such as increasing activity, doing leg exercises, avoiding carbonated or very hot or cold beverages, avoiding using ice or straws, and maintaining a high-protein liquid diet for the first 24 to 48 hours. A rectal tube also may be used. A gastric or intestinal tube is sometimes used when other measures fail. Simethicone tablets may provide some relief, but the nurse, not the client, should ask the physician for this medication. Chewing on ice chips or using a straw may actually increase gas accumulation. Drinking hot coffee should be avoided because very hot or cold beverages increase gas accumulation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 111 _ about (MC)


QUESTION: "In developing a plan of care for the client who has just delivered a 7-pound baby, the nurse reviews her prenatal, labor, and delivery records. Which of the following data in the client's record would alert the nurse to the possibility of a problem?"

CHOICES

( O ) a.) Perineal laceration.

( X ) b.) White blood cell count of 12,000/mm 3.

( X ) c.) Blood loss of 400 mL at delivery.

( X ) d.) Temperature of 99%F (37.2%C) at 1 hour postpartum.


RATIONALE: Evidence of a laceration places the client at risk for a possible infection. Localized infection may occur in the perineum at laceration. During pregnancy and the puerperium, the white blood cell count may be slightly elevated. A blood loss of 400 mL is within normal range. Hemorrhage is denoted as a blood loss of 500 mL or greater. Temperature of 99%F (37.2%C) 1 hour after delivery is commonly due to dehydration. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 112 _ about (MC)


QUESTION: "While the postpartum client is receiving heparin for thrombophlebitis, which of the following drugs would the nurse expect to administer if the client develops complications related to heparin therapy?"

CHOICES

( X ) a.) Calcium gluconate.

( O ) b.) Protamine sulfate.

( X ) c.) Methylergonovine (Methergine).

( X ) d.) Nitrofurantoin (Macrodantin).


RATIONALE: Protamine sulfate is a heparin antagonist given intravenously to counteract bleeding complications caused by heparin overdose. Calcium gluconate is not used as a heparin antagonist. However, it may be used to treat magnesium sulfate toxicity for the client with pregnancy-induced hypertension. Methylergonovine (Methergine) is used to treat late postpartum hemorrhage. Nitrofurantoin (Macrodantin)is an anti-infective drug used to treat urinary tract infections. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 113 _ about (MC)


QUESTION: "For almost an hour after birth, a neonate was awake, alert, and startled and cried easily. Respirations rose to 70 breaths/minute, and heart rate on two occasions was 160 bpm. After sleeping quietly for about 2 hours, the neonate then awoke with a start, cried, extended and flexed all four extremities, and then choked, gagged, and regurgitated some thick mucus. Which of the following should the nurse do next?"

CHOICES

( X ) a.) Call the physician because the neonate appears to be choking.

( O ) b.) Change the neonate's position and aspirate mucus as necessary.

( X ) c.) Place the neonate under a radiant warmer because these signs suggest chilling.

( X ) d.) Wrap the neonate in a blanket and offer sips of glucose water.


RATIONALE: After the first period of reactivity, beginning at birth and lasting about 30 minutes, the neonate falls asleep for 2 to 4 hours. The neonate then begins the second period of reactivity, which lasts 4 to 6 hours. This neonate's signs and symptoms, the appearance of regurgitating and choking on mucus, are normal for the neonate's age and common during the second period of reactivity. Thus, the nurse should change the neonate's position and aspirate mucus as necessary. The neonate is exhibiting normal signs of the second period of reactivity. The physician does not need to be notified. These symptoms are not indicative of chilling. Placing the neonate in a radiant warmer is not warranted unless the temperature falls. Although wrapping the neonate may help to maintain a neutral thermal environment, offering glucose water is not appropriate if the neonate is choking. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 114 _ about (MC)


QUESTION: "During the first feeding, the nurse observes that the neonate becomes cyanotic after gagging on mucus. Which of the following should the nurse do first?"

CHOICES

( X ) a.) Start mouth-to-mouth resuscitation.

( X ) b.) Contact the neonatal resuscitation team.

( X ) c.) Raise the neonate's head and pat the back gently.

( O ) d.) Clear the neonate's airway with suction or gravity.


RATIONALE: If a neonate gags on mucus and becomes cyanotic during the first feeding, the airway is most likely closed. The nurse should clear the airway by gravity (by lowering the infant's head) or suction. Starting mouth-to-mouth resuscitation is not indicated unless the neonate remains cyanotic and lowering his head or suctioning doesn't clear his airway. Contacting the neonatal resuscitation team is not warranted unless the infant remains cyanotic even after measures to clear the airway. Raising the neonate's head and patting the back are not appropriate actions for removing mucus. Doing so allows the mucus to remain lodged causing further breathing difficulties. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 115 _ about (MC)


QUESTION: "The nurse is able to retract an uncircumcised neonate's foreskin only slightly beyond the urethral opening without using force. Before cleansing the penis, the nurse should do which of the following?"

CHOICES

( O ) a.) Retract the foreskin as far as it will move back easily.

( X ) b.) Use gentle force to retract the foreskin gradually farther each day.

( X ) c.) Leave the foreskin in place and use cotton balls to clean the penis.

( X ) d.) Report the condition to the physician for possible corrective measures.


RATIONALE: For uncircumcised neonates, efforts should not be made to move the foreskin back any farther than it will retract with ease because adhesions between the prepuce and the glans are common. By age 3 to 5 years, the foreskin usually is easily retracted. Force, even gentle force, should never be used to retract the foreskin due to the possible risk of injury. Leaving the foreskin in place and using cotton balls is not an appropriate way to clean the penis, because debris may collect under the foreskin. Notifying the physician is not necessary at this time because this is a normal finding in an uncircumcised neonate. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 116 _ about (MC)


QUESTION: "Which of the following would be the best technique to use when assessing the neonate for jaundice?"

CHOICES

( O ) a.) Blanch the skin on the forehead during a feeding.

( X ) b.) Blanch the skin on the buttocks during a diaper change.

( X ) c.) Observe the skin in natural daylight.

( X ) d.) Observe the skin when the neonate is asleep.


RATIONALE: Assessing for jaundice in the neonate is an important nursing responsibility. The best technique is to blanch the skin over a bony prominence, such as the forehead, chest, or tip of the nose, by applying pressure to the area and observing the area before the normal skin color returns. Until blood returns to the area, the yellow color of the jaundice is relatively obvious. The nurse may also examine the sclera to assess for jaundice. Blanching an area over a bony prominence is important for assessing jaundice. The buttocks is not such an area. Although sufficient lighting is necessary for an accurate assessment, simply observing the skin does not provide an accurate assessment of the jaundice. Blanching the skin provides a more accurate assessment. Although sufficient lighting is necessary for an accurate assessment, simply observing the skin with the infant asleep does not provide an accurate assessment of the jaundice. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 117 _ about (MC)


QUESTION: "After teaching a new mother about the neonate's fontanels and when they close, which of the following ages when cited by the client for closure of the posterior fontanel would indicate effective teaching?"

CHOICES

( O ) a.) 2 to 3 months.

( X ) b.) 6 to 8 months.

( X ) c.) 10 to 12 months.

( X ) d.) 14 to 16 months.


RATIONALE: Normally, the posterior fontanel closes by age 2 to 3 months. Normally, the posterior fontanel closes by age 2 to 3 months, not 6 to 8 months. Normally, the posterior fontanel closes by age 2 to 3 months, not 10 to 12 months. Normally, the posterior fontanel closes by age 2 to 3 months, not 14 to 16 months NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 118 _ about (MC)


QUESTION: "Which of the following actions would be most appropriate after assessing a neonate's cry as infrequent, weak, and very high-pitched?"

CHOICES

( X ) a.) Tell the mother that excessive analgesia in labor can cause this type of cry.

( O ) b.) Notify the physician because this may indicate a neurologic problem.

( X ) c.) Stimulate the neonate to cry to obtain information to document.

( X ) d.) Continue to monitor the infant periodically for changes in the cry.


RATIONALE: Typically a neonate's cry is loud and lusty. A weak, shrill, or high-pitched cry is not normal, possibly indicating a neurologic problem, such as increased intracranial pressure, drug (eg, heroin) withdrawal or hypoglycemia. Thus, the nurse should notify the physician so further evaluation can be done. Telling the mother that the cry is due to excessive analgesia in labor is not warranted. The cry is most likely due to a neurologic problem or drug withdrawal. Stimulating the neonate to cry is not helpful because the cry is most likely due to a neurologic problem or drug withdrawal. Continuing to monitor the infant is a routine nursing responsibility that may be helpful if the neonate needs to be treated for a neurologic problem or drug withdrawal. However, the physician needs to be notified first. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 119 _ about (MC)


QUESTION: "Which of the following actions is most appropriate when noting small, shiny white specks on the neonate's gums and hard palate during assessment?"

CHOICES

( X ) a.) Place the neonate in an isolation area.

( X ) b.) Try to remove the specks with a wet washcloth.

( X ) c.) Attempt to obtain a sterile specimen on a swab.

( O ) d.) Continue monitoring because these spots are normal.


RATIONALE: Small, shiny white specks on the neonate's gums and hard palate are known as Epstein's pearls. They have no special significance and often disappear within a few weeks. However, white patches on the inside of the mouth possibly signaling thrush due to Candida albicans infection warrant further investigation. Isolation is not necessary because this finding is normal and the neonate is not contagious. Because these specks often disappear within a few weeks, the nurse does not need to remove these with a wet washcloth. Sending a sterile specimen to the laboratory is not necessary because this finding is normal. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 120 _ about (MC)


QUESTION: "During the initial assessment, the nurse notes that the neonate's hands and feet appear blue while the neonate's torso appears pale pink. Which of the following would the nurse do next?"

CHOICES

( O ) a.) Wrap the neonate in several warm blankets.

( X ) b.) Ask the mother to massage the neonate's hands and feet.

( X ) c.) Keep the neonate in an isolation incubator for at least 2 hours.

( X ) d.) Report the neonate's cyanosis to the physician promptly.


RATIONALE: The neonate is demonstrating acrocyanosis, a normal finding evidenced by bluish hands and feet due to the neonate being cold or poor perfusion of the blood to the periphery of the body. The most appropriate action is to wrap the neonate in a warm blanket or place the neonate under a radiant warmer. Massaging the extremities is inappropriate because it will not help to improve the circulation. Keeping the neonate in an isolation incubator is not warranted because acrocyanosis is not an infection but rather a manifestation of the neonate's sluggish peripheral circulation. Because acrocyanosis is a normal finding, notifying the physician is not necessary. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 121 _ about (MC)


QUESTION: "The nurse is to assess a male neonate who was delivered vaginally about 12 hours ago. At which of the following times would the nurse anticipate performing the assessment?"

CHOICES

( O ) a.) Midway between feedings.

( X ) b.) While the neonate is awake and crying.

( X ) c.) After the neonate has been NPO for 4 hours.

( X ) d.) At least every hour.


RATIONALE: If possible, the nurse should examine a neonate about midway between feedings because the hungry neonate is often fussy and irritable, making physical examination difficult. Performed after eating, the manipulation involved with the physical examination may cause the neonate to regurgitate or vomit. Assessing the neonate when awake and crying would most likely make the physical examination difficult. The neonate should not be kept NPO for 4 hours because of the potential for hypoglycemia. Unless the neonate is experiencing complications, the nurse does not need to assess the infant every hour. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 122 _ about (MC)


QUESTION: "During the assessment, the nurse observes a gray pigmented nevus on the neonate's buttocks. The nurse documents this as which of the following? "

CHOICES

( O ) a.) Mongolian spot.

( X ) b.) Harlequin's sign.

( X ) c.) Port wine stain.

( X ) d.) Cafe au lait spots.


RATIONALE: Mongolian spots are gray, blue, or black marks that are found most frequently on the sacral area but also may be on the buttocks, arms, shoulders, or other areas. No treatment is necessary because these usually fade or disappear during the first few years of life. Harlequin's sign, manifested as one side of the body turning a deep red color, occurs when blood vessels on one side of the body constrict while those on the other side of the body dilate. The observance of Harlequin's sign should be documented and reported. Port wine stains, flat purple-red sharply demarcated areas, or hemangiomas, dark-red color lesions, or vascular tumors are nevi flammeus and do not disappear with time. Cafe au lait are flat, patchy, light brown areas. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 123 _ about (MC)


QUESTION: "When assessing a neonate's temperature with a disposable digital thermometer, in which of the following locations would the nurse place the thermometer?"

CHOICES

( X ) a.) Under the neonate's tongue.

( O ) b.) Under the neonate's arm.

( X ) c.) Into the neonate's rectum.

( X ) d.) Into the neonate's ear.


RATIONALE: The correct method of assessing a neonate's temperature is to place the thermometer under the neonate's arm for an axillary reading. The oral route is not appropriate for obtaining the temperature in a neonate because the neonate is unable to close the mouth around the thermometer, thus leading to an inaccurate reading. Additionally, inserting a thermometer into a neonate's mouth may cause trauma to delicate tissues. Rectal temperatures are to be avoided in neonates because of the risk of injury to the delicate rectal mucosa. Only a specialized tympanic membrane device should be used to obtain a temperature reading via the ear. Inserting a disposable digital thermometer into the neonate's ear may cause trauma to the delicate tissues. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 124 _ about (MC)


QUESTION: "Which of the following instructions would the nurse give to a client after noting a white, cheese-like substance on the neonate's body creases?"

CHOICES

( X ) a.) Remove it with hand lotion.

( X ) b.) Clean the area with alcohol.

( O ) c.) Allow it to remain on the skin.

( X ) d.) Brush it off with a dry washcloth.


RATIONALE: The white, cheese-like substance on the neonate's body creases is called vernix caseosa. Unless the vernix is stained with meconium, it should be left on the skin because it serves as a protective coating. This substance, vernix caseosa, provides a protective coating that usually disappears within about 24 hours after birth. It does not need to be removed with oil or hand lotion. Alcohol should be avoided because it is drying to the skin. Brushing the vernix off with a washcloth will be difficult because of its sticky nature. Attempting to do so may injure the neonate's fragile skin. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 125 _ about (MC)


QUESTION: "Which of the following actions would be most appropriate for a neonate whose hemoglobin is 16 g/100 mL immediately after birth?"

CHOICES

( O ) a.) Document this as a normal finding.

( X ) b.) Assess for symptoms of polycythemia.

( X ) c.) Recheck the hemoglobin in 1 hour.

( X ) d.) Assess for skin pallor and anemia.


RATIONALE: Normal neonatal hemoglobin level ranges from 15 to 20 g/mL blood. After birth, the hemoglobin level gradually decreases. The nurse should document this as a normal finding. The neonate does not demonstrate symptoms of polycythemia, such as red, ruddy skin color or a hematocrit greater than 65% or a hemoglobin greater than 20 g/mL. Because the hemoglobin value is within normal parameters, there is no need for the nurse to recheck the hemoglobin in an hour. The hemoglobin level is within normal parameters. If it was decreased, then assessing for skin pallor and anemia would be warranted. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 126 _ about (MC)


QUESTION: "After teaching the mother about the neonate's positive Babinski's reflex, the nurse determines that the mother understands the instructions when she says that a positive Babinski's reflex indicates which of the following?"

CHOICES

( X ) a.) Possible spinal cord defect.

( O ) b.) Immaturity of central nervous system.

( X ) c.) Possible partial paralysis.

( X ) d.) Injury to nerves innervating the legs.


RATIONALE: A positive Babinski's reflex in a neonate is a normal finding demonstrating the immaturity of the central nervous system in corticospinal pathways. A positive Babinski's reflex does not indicate a defect in the spinal cord. However, a positive Babinski's reflex in an adult indicates disease. A positive Babinski's reflex does not indicate an injury to nerves that innervate the legs. However, a positive Babinski's reflex in an adult indicates disease. A positive Babinski's reflex in a neonate is a normal finding demonstrating the immaturity of the central nervous system in corticospinal pathways. No evidence is presented to suggest partial paralysis. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
******************************

--> QUESTION NUMBER _ 127 _ about (MC)


QUESTION: "When preparing to obtain a blood sample to screen the neonate for phenylketonuria (PKU), from which of the following areas would the nurse anticipate obtaining the sample?"

CHOICES

( O ) a.) Heel.

( X ) b.) Radial artery.

( X ) c.) Scalp vein.

( X ) d.) Brachial artery.


RATIONALE: The blood sample for routine screening for phenylketonuria, done after the neonate has been eating for 48 hours, is obtained from a heel stick. The lateral heel is the best site because it prevents damage to the posterior tibial nerve and artery, plantar artery, and the important longitudinally oriented fat pad of the heel. The radial artery is an inappropriate site to obtain the blood sample because of the risk for severe trauma. The scalp vein is used for intravenous infusions, not to obtain a blood sample for PKU. The brachial artery is not an appropriate site for obtaining a PKU blood sample because the artery is too small and severe trauma may result. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
******************************

--> QUESTION NUMBER _ 128 _ about (MC)


QUESTION: "While assessing a post-term neonate, the nurse explains to the mother that post-term neonates typically exhibit which of the following?"

CHOICES

( X ) a.) Soft, oily skin.

( O ) b.) A long, thin body.

( X ) c.) Very few sole creases.

( X ) d.) Abundant lanugo.


RATIONALE: Typical physical characteristics of post-term neonates, those born after the 42nd week of gestation, include a long, thin body; abundant scalp hair; absence of vernix caseosa; dry, thin, cracked, or peeling skin; long, thin nails; abundant sole creases; and an absence of lanugo. At birth, these neonates tend to look as though they were 1 to 3 weeks old. The post-term neonate's skin is typically dry, thin, cracked, or peeling, not soft and oily due to decreased amniotic fluid and lack of vernix. The post-term neonate usually has abundant sole creases because the neonate is beyond 40 weeks' gestation. The post-term neonate commonly has an absence of lanugo because the neonate is beyond 39 weeks' gestation. As the pregnancy progresses and the neonate grows and develops, lanugo tends to decrease or disappear beyond 39 weeks' gestation. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
******************************

--> QUESTION NUMBER _ 129 _ about (MC)


QUESTION: "Which of the following would the nurse do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision?"

CHOICES

( X ) a.) Notify the neonate's pediatrician immediately.

( X ) b.) Check the diaper and circumcision again in 30 minutes.

( X ) c.) Secure the diaper tightly to apply pressure on the site.

( O ) d.) Apply gentle pressure to the site with a sterile gauze pad.


RATIONALE: If bleeding occurs after circumcision, the nurse should first apply gentle pressure on the area with sterile gauze. Bleeding is not common but requires attention when it occurs. The physician needs to be notified when bleeding cannot be stopped by conservative measures because this may signal a clotting disorder. Typically the neonate's circumcision site including the diaper is examined every 15 minutes for 1 hour to assess bleeding. Rechecking in 30 minutes may be too late if the neonate is actively bleeding. Securing the diaper tightly to apply pressure does not allow the nurse to observe whether bleeding has stopped. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
******************************

--> QUESTION NUMBER _ 130 _ about (MC)


QUESTION: "When formulating outcomes for the post-term neonate at discharge, which of the following would be most appropriate?"

CHOICES

( X ) a.) Establishment of a deep respiratory pattern.

( X ) b.) Gain of 4 ounces by the time of discharge.

( O ) c.) Maintenance of normal body temperature.

( X ) d.) Maintenance of a normal bilirubin level.


RATIONALE: Hypothermia and temperature instability are primary problems in the post-term neonate, so maintaining a normal temperature pattern is the most appropriate goal. Post-term neonates have little subcutaneous fat, predisposing them to cold stress. Establishment of a deep respiratory pattern is inappropriate because all neonates tend to breathe in a shallow manner. A weight gain of 4 ounces may not be feasible because most neonates lose 5% to 15% of their birth weight during the first few days of life. All infants should be assessed for hyperbilirubinemia. Although polycythemia is common in post-term infants and may take a while to resolve, hyperbilirubinemia is not more common in the post-term neonate than it is in neonates born at term. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
******************************

--> QUESTION NUMBER _ 131 _ about (MC)


QUESTION: "When developing the plan of care for a neonate, which of the following would the nurse include to prevent heat loss from conduction?"

CHOICES

( X ) a.) Drying the neonate with warm sterile towels.

( X ) b.) Keeping the neonate away from air conditioner.

( X ) c.) Placing the neonate in a radiant warmer.

( O ) d.) Warming the stethoscope before using it.


RATIONALE: Because a neonate has poor thermal stability, reducing heat loss is very important. Conduction involves the loss of heat to a cooler surface by direct skin contact. Cold stethoscopes, cold hands, and cold scales can all cause heat loss by conduction. Therefore, warming the stethoscope before using it would be appropriate. Drying the neonate with sterile towels prevents heat loss from evaporation, the loss of heat when water is converted to a vapor. Keeping the neonate away from an air conditioner prevents heat loss from radiation. Radiation losses occur when heat is transferred from a heated body surface to a cooler solid object not in direct contact with the body. Administering warm oxygen and placing the neonate in a radiant warmer or incubator prevents heat loss from convection, loss of heat from the warm body surface to cooler air currents. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
******************************

--> QUESTION NUMBER _ 132 _ about (MC)


QUESTION: "When performing gavage feeding for a neonate, the nurse should first lubricate the catheter with which of the following?"

CHOICES

( X ) a.) Lactated Ringer's solution.

( O ) b.) Sterile water.

( X ) c.) Plain tap water.

( X ) d.) Water-soluble jelly.


RATIONALE: The catheter used for gavage feeding a neonate should be lubricated with sterile water before introduction so that if the catheter is inadvertently introduced into the lungs, serious damage would not occur. Lactated Ringer's solution is not recommended for lubricating a gavage feeding catheter because if the catheter inadvertently enters the lung, pneumonia or lung damage may result. Plain tap water is not recommended for lubricating a gavage feeding catheter. Plain tap water may be contaminated. If introduced inadvertently into the lungs, it could result in damage or pneumonia. Water-soluble jelly is not recommended for lubricating a gavage-feeding catheter because if the catheter is inadvertently inserted into the lungs, the jelly could damage the lung tissue or cause pneumonia. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
******************************

--> QUESTION NUMBER _ 133 _ about (MC)


QUESTION: "After inserting a gavage feeding catheter for the neonate's next feeding, which of the following should the nurse do next? "

CHOICES

( X ) a.) Clamp the catheter for 1 minute.

( X ) b.) Obtain an order for a chest radiograph.

( O ) c.) Aspirate stomach contents through the catheter.

( X ) d.) Instill about 10 mL of sterile water into the catheter.


RATIONALE: After inserting a gavage feeding catheter, the nurse should next check that the catheter is in the stomach before instilling nourishment. One way is to aspirate stomach contents. Another method is to inject a few millimeters of air into the catheter while auscultating over the stomach with a stethoscope to listen for the sound of air entering the stomach. Clamping the catheter momentarily is unnecessary and does not indicate the proper placement of the catheter. Routine chest radiograph to check for placement of the feeding tube usually is not done because of the increased cost and exposure of the neonate to radiation. Instilling 10 mL of sterile water is to be avoided because the feeding tube could be in the lungs, causing aspiration or pneumonia. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
******************************

--> QUESTION NUMBER _ 134 _ about (MC)


QUESTION: "Before the neonate's discharge, the mother tells the nurse that she is worried that her 5-year-old daughter will be jealous of the new baby when they get home. After explaining ways to deal with sibling rivalry, the nurse determines that the mother understands the instructions when she says she will do which of the following?"

CHOICES

( X ) a.) Divide her time equally between the baby and the daughter.

( X ) b.) Tell the daughter that the baby is just like one of her dolls.

( X ) c.) Let the 5-year-old feed the baby at least once every day.

( O ) d.) Allow the 5-year-old undivided attention several times a day.


RATIONALE: The most appropriate guideline is to suggest that the mother give some undivided time each day to her 5-year-old, who may be jealous of the new baby, thus allowing the older child to feel special and loved. Ignoring the behaviors of the older child related to jealously fails to meet the child's needs. Dividing time equally between the two children may not be feasible, especially because infants often require full-time care. Telling the 5-year-old that the infant is just like a doll is inappropriate, possibly resulting in injury to the infant from rough play. Although allowing the older child to hold and feed the baby occasionally helps the older child feel like a participant in the family, it is unlikely to help overcome jealousy. Also, the older child may injure the infant if the behavior typical of jealously is ignored. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
******************************

--> QUESTION NUMBER _ 135 _ about (MC)


QUESTION: "A neonate, admitted to the neonatal intensive care nursery for probable meconium aspiration syndrome (MAS), weighs 10 pounds, 4 ounces, and is at 42 weeks' gestation. The neonate has a heart rate of 110 bpm and a respiratory rate of 40 breaths/minute with periods of apnea. The nurse should further assess the neonate for which of the following? "

CHOICES

( X ) a.) Alkalosis.

( O ) b.) Hypoglycemia.

( X ) c.) Hyporesonance.

( X ) d.) Excessive coughing.


RATIONALE: MAS affects small-for-gestational age, term, and post-term neonates that have experienced long labor. Meconium in the lungs allows inhalation but not exhalation. These neonates often require resuscitative efforts at birth to establish adequate respirations. Hypoglycemia is common due to low glucose reserves at birth. Acidosis, not alkalosis, is associated with MAS. Hyporesonance is not associated with MAS. However, coarse bronchial sounds may be auscultated from air trapped in the alveoli. Excessive coughing is not associated with MAS. Rather the neonate exhibits signs of respiratory distress. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
******************************

--> QUESTION NUMBER _ 136 _ about (MC)


QUESTION: "When developing a teaching plan for the parents of a neonate who is to receive phototherapy, which of the following instructions will be included?"

CHOICES

( O ) a.) Covering of the eyes.

( X ) b.) Temperature assessment every 30 minutes.

( X ) c.) Orogastric tube feedings for nutrition.

( X ) d.) Inability of parents to provide any care.


RATIONALE: Typically, the neonate's eyes must be covered while the neonate is receiving phototherapy. However, the covers can be removed when the neonate is taken out for feedings. Vital signs, including temperature, should be monitored every 2 hours during phototherapy. The neonate receiving phototherapy may be breast- or formula-fed. Orogastric tube feedings are not necessary. The parents are allowed and encouraged to provide care while the neonate is receiving phototherapy. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
******************************

--> QUESTION NUMBER _ 137 _ about (MC)


QUESTION: "Which of the following client statements indicates the need for further teaching about percutaneous umbilical blood sampling (PUBS) to assess fetal hemoglobin and hematocrit?"

CHOICES

( O ) a.) "I will lie on my back in a cylinder-type machine."

( X ) b.) "My baby's heart rate might drop temporarily after this test."

( X ) c.) "A blood transfusion can be given to my baby if he needs it."

( X ) d.) "A needle will be inserted into my belly for this test."


RATIONALE: With PUBS, the client is scanned with a linear-array ultrasound placed in a sterile glove and a 25-gauge spinal needle is inserted into the client's abdomen and into the fetal vein. Fetal blood is aspirated into a syringe containing an anticoagulant. The client will not be placed in a cylindrical unit; this type of unit is used for magnetic resonance imaging. Transient fetal bradycardia is possible following this procedure. PUBS may be used for a fetal blood transfusion. With PUBS, the client is scanned with a linear-array ultrasound placed in a sterile glove and a 25-gauge spinal needle is inserted into the client's abdomen and into the fetal vein. Fetal blood is aspirated into a syringe containing an anticoagulant. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
******************************

--> QUESTION NUMBER _ 138 _ about (MC)


QUESTION: "A primigravid client at about 36 weeks' gestation in active labor has had no prenatal care and admits to cocaine use during the pregnancy. Which of the following persons must the nurse notify?"

CHOICES

( X ) a.) Nursing unit manager so appropriate agencies can be notified.

( X ) b.) Head of the hospital's security department.

( X ) c.) Chaplain in case the fetus dies in utero.

( O ) d.) Physician who will attend the delivery of the infant.


RATIONALE: The fetus of a cocaine-addicted mother is at risk for hypoxia, meconium aspiration, and intrauterine growth retardation (IUGR). Therefore, the nurse must notify the physician of the client's cocaine use because this knowledge will influence the care of the client and neonate. The information is used only in relation to the client's care. With the client's consent, the information about cocaine use may be shared with other social service or health agencies that become involved with the client's long-term care. The head of the hospital's security department does not need to be notified unless there is a suspicion of drug dealing taking place. The chaplain need not be notified at this time. If the fetus dies in utero and the client requests a chaplain, then the nurse can contact one. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care
******************************

--> QUESTION NUMBER _ 142 _ about (MC)


QUESTION: "After teaching a primigravid client at 24 weeks' gestation, who has received permission from the physician to make a 6-hour automobile trip to visit her parents, about precautions to take during the trip, which of the following client statements indicates the need for further teaching?"

CHOICES

( X ) a.) "I'll drink plenty of fluids to avoid dehydration."

( O ) b.) "I'll sleep for 1 hour at the halfway point of the trip."

( X ) c.) "I'll take frequent rest breaks every 2 hours."

( X ) d.) "I'll be sure to wear the car seat belt while traveling."


RATIONALE: Taking a 1-hour nap at the halfway point of the trip is not necessary. However, taking frequent rest breaks (for example, every 2 hours) is advisable. Drinking plenty of fluids is recommended to promote adequate hydration and prevent dehydration. The client should be encouraged to take frequent rest breaks and stretch her muscles by walking approximately every 2 hours to increase circulation to the lower extremities and prevent venous stasis. Wearing the seat belt is a recommended safety measure for all people including pregnant women. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
******************************

--> QUESTION NUMBER _ 143 _ about (MC)


QUESTION: "The nurse has provided health teaching to a postpartum client who is bottle-feeding her neonate about physiologic changes that the client can expect during the postpartum period. Which of the following client statements indicates that this teaching has been effective?"

CHOICES

( X ) a.) "I can expect to have heart palpitations for several weeks."

( X ) b.) "It's normal for me to have reddish lochia until my 6-week checkup."

( X ) c.) "Any varicosities I had during pregnancy will disappear within 2 weeks."

( O ) d.) "My menstrual flow should resume in approximately 6 to 10 weeks."


RATIONALE: For clients who are bottle-feeding, menstrual flow usually returns in 6 to 10 weeks. Heart palpitations for several weeks are not normal and require further investigation. Reddish lochia at 6 weeks postpartum is not normal and warrants further evaluation. Although varicosities may fade, they rarely disappear completely after delivery. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
******************************

--> QUESTION NUMBER _ 144 _ about (MC)


QUESTION: "A 32-year-old female client visits the family planning clinic and requests an intrauterine device for contraception. When assessing the client, a history of which of the following would be most important to determine?"

CHOICES

( X ) a.) Thrombophlebitis.

( O ) b.) Pelvic inflammatory disease.

( X ) c.) Previous liver disease.

( X ) d.) Coronary artery disease.


RATIONALE: The nurse should assess the client for a history of pelvic inflammatory disease because intrauterine devices have been associated with an increased risk of pelvic inflammatory disease and perforation of the uterus. A history of thrombophlebitis would be important to assess if the client were to receive oral contraceptives. Thrombophlebitis is a contraindication for oral contraceptives. A history of previous liver disease would be important to assess if the client were to receive oral contraceptives. Previous liver disease is a contraindication for oral contraceptives. A history of cardiovascular disease would be important to assess if the client were to receive oral contraceptives. Coronary artery disease is a contraindication for oral contraceptives. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
******************************

--> QUESTION NUMBER _ 147 _ about (MC)


QUESTION: "A pregnant client at about 29 weeks' gestation asks the nurse "What can I do about this dark brown line running down my stomach?" When teaching the client about this brown line, which of the following descriptions would be most appropriate?"

CHOICES

( O ) a.) Linea nigra that will fade after the baby is born.

( X ) b.) A melanoma which requires further evaluation.

( X ) c.) The mask of pregnancy that will remain dark after delivery.

( X ) d.) Stretch marks that will turn a silvery color after delivery.


RATIONALE: This dark brown line is a darkened pigmentation termed linea nigra. The pigmentation will fade after delivery. A melanoma, commonly associated with skin cancer, is a raised brown or black lesion on the skin. The mask of pregnancy, called chloasma, appears as darkened areas of pigmentation on the cheeks and across the nose. It usually lightens and disappears after pregnancy. Stretch marks are reddish or purplish in color and result from the skin stretching due to the growing fetus. After delivery, the marks typically become silvery-white in appearance. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
******************************

--> QUESTION NUMBER _ 149 _ about (MC)


QUESTION: "After delivering a viable term male neonate vaginally under epidural anesthesia, a primiparous client asks the nurse, "Why are my baby's breasts so swollen?" The nurse responds to the client stating that slight breast engorgement in term neonates is due to which of the following?"

CHOICES

( O ) a.) Maternal hormonal influences.

( X ) b.) Epidural anesthesia.

( X ) c.) Maternal hyperthyroidism.

( X ) d.) Genetic influences from both parents.


RATIONALE: Slight breast engorgement in term neonates is related to the maternal hormone elevations that occur during pregnancy. Epidural anesthesia has no effect on breast tissue engorgement in the neonate. Hyperthyroidism in the mother is frequently associated with preterm labor and low birth weight infants. It is unlikely that a preterm infant would have breast engorgement. Genetic influences have no effect on breast tissue engorgement in the neonate. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
******************************

--> QUESTION NUMBER _ 151 _ about (MC)


QUESTION: "A primigravida in active labor has been diagnosed with chorioamnionitis. After explaining this condition to the client, the nurse determines that the client understands the instructions when the client says which of the following?"

CHOICES

( X ) a.) "My baby's heart rate is slow because of my infection."

( X ) b.) "My infection is the cause of my hypertonic labor pattern."

( X ) c.) "Women who are overweight are more likely to get this infection."

( O ) d.) "If left untreated, my baby might be born with pneumonia."


RATIONALE: Chorioamnionitis is a serious intrapartum infection that may result in fetal tachycardia and a hypotonic labor pattern. If left untreated, infected amniotic fluid in the fetal lungs may result in pneumonia during the neonatal period. Typically chorioamnionitis results in fetal tachycardia, not bradycardia. Chorioamnionitis usually results in a maternal fever and tachycardia. It is not associated with either hypotonic or hypertonic labor patterns. No relationship is known between being overweight and development of chorioamnionitis. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
******************************

--> QUESTION NUMBER _ 155 _ about (MC)


QUESTION: "After delivering a viable neonate 12 hours ago, the client's fundus is firm at midline, her breasts are soft. She has scant lochia and a negative Homans' sign. The client reports pain in her lower back. Which of the following should the nurse do next?"

CHOICES

( X ) a.) Contact the physician for an order to obtain a urinalysis.

( X ) b.) Ask the client how long she was in labor.

( O ) c.) Administer an ordered mild analgesic.

( X ) d.) Instruct the client to perform abdominal exercises.


RATIONALE: After delivery, it is not unusual for postpartum clients to complain of backache, which results from stretching of the muscles during the labor and delivery process. The nurse can provide the client with a mild analgesic to help alleviate the backache. The client is not demonstrating any evidence of a urinary tract infection at this time, so calling the physician to obtain an order for a urinalysis is not necessary. Although asking the client how long she was in labor may encourage her to discuss her labor and delivery experience and provide the nurse with additional information, it will not alleviate the client's backache. On the day of delivery, it is too soon for the client to begin abdominal exercises. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
******************************

--> QUESTION NUMBER _ 165 _ about (MC)


QUESTION: "While assisting a multiparous client to the bathroom for the first time 1 hour after a vaginal delivery of a viable neonate, the nurse notes that the client's urine has two small blood clots in the measuring container. Which of the following should the nurse do next?"

CHOICES

( X ) a.) Massage the client's fundus vigorously.

( X ) b.) Ask the client if she passed clots with her previous deliveries.

( X ) c.) Review the client's records for the length of the 3rd stage of labor.

( O ) d.) Document this observation as a normal finding.


RATIONALE: The passage of two small blood clots from a multiparous woman 1 hour after a vaginal delivery is not an unusual occurrence. The nurse should continue to monitor the client and document this as a normal finding. The nurse should never massage a postpartum client's fundus vigorously because of the risk for uterine inversion and discomfort to the mother. Asking whether the client passed clots with her previous deliveries is irrelevant. The length of the third stage of labor has no relation to whether or not the client passes clots. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
******************************

--> QUESTION NUMBER _ 166 _ about (MC)


QUESTION: "During a home visit with a primipara who delivered 7 days ago, the client tells the nurse that her lochia serosa has been profuse and foul-smelling and she has had chills. During palpation of the uterus, the client indicates that she is very sore. Which of the following would the nurse suspect?"

CHOICES

( X ) a.) Normal uterine involution.

( X ) b.) Retained placental fragments.

( O ) c.) Puerperal infection.

( X ) d.) Uterine atony.


RATIONALE: The client is exhibiting signs and symptoms of puerperal infection, which include profuse foul-smelling lochia, chills, fever, and a uterus that is larger than expected for the postdelivery day. Infection may spread through the lymphatic system; antibiotic therapy is necessary. During normal uterine involution, the lochia becomes less profuse and should not be foul-smelling. If the client had retained placental fragments, lochia rubra, not foul-smelling lochia serosa, would continue. Uterine atony refers to relaxation of the uterus and subsequent failure to contract properly. It may be a result of retained placental fragments. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
******************************

--> QUESTION NUMBER _ 170 _ about (MC)


QUESTION: "While caring for a multigravid client in early labor in a birthing center, which of the following foods would be best if the client requests a snack?"

CHOICES

( O ) a.) Yogurt.

( X ) b.) Cereal with milk.

( X ) c.) Vegetable soup.

( X ) d.) Peanut butter cookies.


RATIONALE: In some birth settings, intravenous therapy is not used with low-risk clients. Thus, clients in early labor are encouraged to eat healthy snacks and drink fluids to avoid dehydration. Yogurt, which is an excellent source of calcium and riboflavin, is soft and easily digested. During pregnancy, gastric emptying time is delayed. In most hospital settings, clients are allowed only ice chips or clear liquids. Cereal with milk, although nutritious, can result in potential aspiration if nausea and vomiting occur because they take longer to digest than yogurt. Vegetable soup, although nutritious, can result in potential aspiration if nausea and vomiting occur because it takes longer to digest than yogurt. Peanut butter cookies are not as nutritious as yogurt for the client in labor. Although cookies are a source of carbohydrate, yogurt is a dairy product rich in calcium. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
******************************

--> QUESTION NUMBER _ 179 _ about (MC)


QUESTION: "When caring for a primigravid client who is being induced with intravenous oxytocin because she is at 41 weeks' gestation, the nurse observes that the fetal heart rate drops to 60 bpm at the end of the last two contractions and then rises to 120 bpm. Which of the following should the nurse do first?"

CHOICES

( O ) a.) Discontinue the oxytocin infusion.

( X ) b.) Position the client on her right side.

( X ) c.) Administer oxygen at 3 liters.

( X ) d.) Notify the client's physician.


RATIONALE: Induction of labor with oxytocin is associated with risks. Hyperstimulation of the uterus can lead to fetal distress. A drop in the fetal heart rate to 60 bpm at the end of a contraction may be indicative of late decelerations due to placental insufficiency. Stopping the oxytocin infusion will reduce uterine activity and improve uteroplacental perfusion. Turning the client to her left side, not the right side, increases placental perfusion. Oxygen should be administered at 8 liters, not 3 liters. Oxytocin, a vasoconstrictor, is given to stimulate contractions. The physician should be notified after the oxytocin is discontinued. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************

--> QUESTION NUMBER _ 182 _ about (MC)


QUESTION: "A 15-year-old primipara who delivered a viable neonate vaginally tells the nurse, "My mother started feeding me rice cereal when I was only 2 weeks old." Which of the following would be the most appropriate response to the client?"

CHOICES

( X ) a.) "A small amount of rice cereal given once in a while is okay."

( X ) b.) "Give cereal in a bottle mixed well with the formula."

( O ) c.) "Wait until the infant is at least 4 months of age before using cereal."

( X ) d.) "Give the infant iron-fortified rice cereal at 1 year of age."


RATIONALE: Breast milk or formula should provide adequate nourishment for a neonate until 4 to 6 months of age. Cereal before the age of 4 months is not easily digested by the neonate and may lead to food allergies and possibly aspiration. Cereal, regardless of the amount, given before the age of 4 months is not easily digested by the neonate and may lead to food allergies and possibly aspiration. Mixing the cereal with formula when the infant is ready for cereal is appropriate. However, the cereal should not be given in a bottle. Doing so could lead to obesity or aspiration. The infant's iron stores need to be fortified with formula with iron or cereal with iron at 4 to 6 months of age. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
******************************

--> QUESTION NUMBER _ 186 _ about (MC)


QUESTION: "When instructing a pregnant client diagnosed with a chlamydial infection at 28 weeks' gestation, which of the following would the nurse include about this infection during pregnancy?"

CHOICES

( X ) a.) Possible central nervous systems disorders in the fetus.

( O ) b.) Usual treatment with a 10-day course of erythromycin.

( X ) c.) Cesarean delivery most likely necessary.

( X ) d.) Possible fetal death before delivery.


RATIONALE: Chlamydial infection during pregnancy has been associated with preterm labor, resulting in a low-birth-weight infant and with preterm rupture of the membranes. Chlamydial infection is usually treated with a 10-day course of erythromycin, tetracycline, or doxycycline. Central nervous system disorders in the fetus are not associated with the infection. Neonatal complications include conjunctivitis, pneumonitis, chronic otitis media, and asthma. Although the neonate can be infected during passage through the birth canal, there is no evidence to suggest that the client will require a cesarean delivery. Fetal demise from this infection during pregnancy is rare. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
******************************

--> QUESTION NUMBER _ 187 _ about (MC)


QUESTION: "Twelve hours after delivery, a primigravid client who delivered a viable neonate under epidural anesthesia and low forceps tells the nurse that she noticed some blood in her urine. Which of the following should the nurse do next?"

CHOICES

( X ) a.) Palpate the client's fundus.

( X ) b.) Measure the next voiding.

( X ) c.) Insert an indwelling catheter.

( O ) d.) Contact the client's physician or nurse midwife.


RATIONALE: Hematuria during the first 24 hours after delivery is most likely due to bladder trauma. Although the condition usually resolves in 1 to 2 days postpartum, the nurse should contact the physician or nurse midwife to determine the extent of the problem and the need for further evaluation. Palpating the client's fundus is a normal assessment technique for the postpartum client. If the client is experiencing bladder trauma, palpating the fundus would provide no additional information. Measuring intake and output, including the next voiding, would be appropriate if the client has dysuria or urinary retention. The client is most likely experiencing bladder trauma, which typically resolves in a day or two. Catheterization should be performed only if ordered by the physician. Catheterization is a known contributing factor to the development of urinary tract infections. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 191 _ about (MC)


QUESTION: "A client who visits the clinic 2 months after having a Pap smear and beginning oral contraceptives tells the nurse that her menstrual flow has decreased since taking the oral contraceptives. The nurse should instruct the client that she most likely needs which of the following?"

CHOICES

( X ) a.) Another Pap smear.

( X ) b.) Thorough endocrine workup.

( O ) c.) Continuation of the oral contraceptives.

( X ) d.) Lower dosage of oral contraceptives.


RATIONALE: A common side effect of oral contraceptives is decreased menstrual flow. Other side effects include breast tenderness, irritability, nausea, headaches, cyclic weight gain, and increased vaginal yeast infections. More serious side effects include hypertension, myocardial infarction, and cervical dysplasia. The nurse should instruct the client that decreased menstrual flow is normal. The client does not need another Pap smear because these are usually performed annually. Nothing is suggested in the situation to suggest the need for another Pap smear. The client does not need an endocrine workup because the client's complaint is a normal and common side effect of the drug therapy. The client does not need a lower dosage of oral contraceptives because the client's complaint is a normal and common side effect of the drug therapy. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 192 _ about (MC)


QUESTION: "When assisting the nurse midwife with a vaginal delivery of a term neonate, which of the following would the nurse expect to do immediately after the birth?"

CHOICES

( X ) a.) Place a cord clamp on the umbilical cord.

( X ) b.) Instill an antibiotic ointment into the neonate's eyes.

( X ) c.) Perform a complete neonatal assessment.

( O ) d.) Dry the neonate thoroughly with sterile towels.


RATIONALE: Immediately after birth, the nurse is responsible for ensuring that the neonate is dried thoroughly, including the head, to prevent heat loss from evaporation. The infant may be placed temporarily in a slight Trendelenburg position to facilitate drainage. The nurse midwife will place the cord clamp on the cord before cutting it after delivery of the placenta. Once a clear airway and normal respirations have been established, other procedures may be performed, such as instilling antibiotic ointment into the eyes and performing a thorough assessment. Once a clear airway and normal respirations have been established, other procedures may be performed, such as instilling antibiotic ointment into the eyes and performing a thorough assessment. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 193 _ about (MC)


QUESTION: "A 39-year-old multigravid client who is visiting the clinic at 14 weeks' gestation tells the nurse that she has had severe nausea and vomiting since becoming pregnant. The client's fundal measurement is 20 cm. The nurse would assess the client for signs and symptoms of which of the following?"

CHOICES

( O ) a.) Pregnancy-induced hypertension.

( X ) b.) Multifetal pregnancy.

( X ) c.) Increased fetal activity.

( X ) d.) History of polycythemia.


RATIONALE: Severe nausea and vomiting that continue throughout the first trimester of pregnancy and into the second trimester in conjunction with the client's enlarged fundus for her gestational age may be indicative of a hydatidiform mole. A molar pregnancy, occurring more often in multigravid clients, is associated with early symptoms of pregnancy-induced hypertension and an enlarged fundus. An enlarged fundus may be associated with multifetal pregnancies but not with the client's symptoms of severe nausea and vomiting. A molar pregnancy, suggested by the severe nausea and vomiting in conjunction with the enlarged fundus, is not associated with increased fetal activity because there is no fetus. A molar pregnancy, suggested by the severe nausea and vomiting in conjunction with the enlarged fundus, is not associated with polycythemia. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 196 _ about (MC)


QUESTION: "A 16-year-old primigravida at 36 weeks' gestation who has had no prenatal care experienced a seizure at work and is being transported to the hospital by ambulance. Which of the following would the nurse do upon the client's arrival?"

CHOICES

( X ) a.) Position the client in a supine position.

( X ) b.) Auscultate breath sounds every 4 hours.

( X ) c.) Monitor the vital signs every 4 hours.

( O ) d.) Admit the client to a quiet, darkened room.


RATIONALE: Because of her age and report of a seizure, the client is probably experiencing eclampsia, a condition in which convulsions occur in the absence of any underlying cause. Although the actual cause is unknown, adolescents and women older than 35 years are at higher risk. The client's environment should be kept as free of stimuli as possible. Thus, the nurse should admit the client to a quiet, darkened room. Clients experiencing eclampsia should be kept on the left side to promote placental perfusion. In some cases, edema of the lungs develops after seizures and is a sign of cardiovascular failure. Because the client is at risk for pulmonary edema, breath sounds should be monitored every 2 hours. Vital signs should be monitored frequently, at least every hour. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 198 _ about (MC)


QUESTION: "While palpating the breasts of a client who is breast-feeding her 12-hour old neonate, which of the following would the nurse expect to find?"

CHOICES

( O ) a.) Soft, not tender breasts.

( X ) b.) Slightly firm, filling breasts.

( X ) c.) Firm breasts beginning milk production.

( X ) d.) Firm breasts that are tender to touch.


RATIONALE: Because the client is 12 hours postpartum, the breasts should still be soft and not tender. Breast milk production does not begin until the second or third postpartum day. Therefore, the breasts would not be firm with noticeable filling. Breast milk production does not begin until the second or third postpartum day at which time the breasts become larger, firm, and tender to touch. Breast milk production does not begin until the second or third postpartum day at which time the breasts become larger, firm, and tender to touch. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 199 _ about (MC)


QUESTION: "When caring for a 27-year-old primigravida at 20 weeks' gestation, the client asks if she should plan to attend childbirth preparation classes. Which of the following effects of these classes would the nurse include?"

CHOICES

( X ) a.) Decreased length of labor.

( O ) b.) Need for less pain medication in labor.

( X ) c.) Greater control over birth plans.

( X ) d.) Increased support from the significant other.


RATIONALE: The single documented effect of childbirth preparation classes is the use of less pain medication in labor. Additionally, the belief is that childbirth education classes are critically important in empowering women with the knowledge of the choices that they may have to make during the birth experience, possibly enhancing their self-esteem and decreasing dissatisfaction with the birth experience.
No documented evidence suggests that childbirth preparation classes affect the length of labor. No documented evidence suggests that childbirth preparation classes affect the mother's control over her birth plans. No documented evidence suggests that childbirth preparation classes affect the support provided by the significant other. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None

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