Chapter 26 My Nursing Test Banks

DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 26

Question 1

Type: MCMA

A pregnant client reports concern about the development of reddish marks on her abdomen and breasts. The client asks about having a cream prescribed to help them disappear. What information should be included in the teaching provided to the client regarding this inquiry?

Standard Text: Select all that apply.

1. The stretch marks will fade but not disappear.

2. Cream will help the skin stay supple.

3. Cocoa butter lotions and creams will clear the marks completely.

4. The marks will lighten to a silvery tone after pregnancy.

5. Wearing supportive undergarments will help to support the skin and reduce the appearance of the marks.

Correct Answer: 1,2,4

Rationale 1: The stretch marks will fade but not disappear. Striae gravidarum are known as stretch marks. They commonly occur during pregnancy. They result from the stretching of the skin to accommodate fetal growth. These marks will not disappear but will fade and lighten after the pregnancy ends.

Rationale 2: Cream will help the skin stay supple. There is no need for a prescription cream. Over-the-counter preparations can be used to keep the skin soft and supple.

Rationale 3: Cocoa butter lotions and creams will clear the marks completely. These marks will not disappear but will fade and lighten after the pregnancy ends. There is no need for a prescription cream. Over-the-counter preparations can be used to keep the skin soft and supple.

Rationale 4: The marks will lighten to a silvery tone after pregnancy. These marks will not disappear but will fade and lighten after the pregnancy ends.

Rationale 5: Wearing supportive undergarments will help to support the skin and reduce the appearance of the marks. Wearing supportive undergarments will help promote comfort to the growing abdomen but will not prevent the development of stretch marks.

Global Rationale: Striae gravidarum are known as stretch marks. They commonly occur during pregnancy. They result from the stretching of the skin to accommodate fetal growth. These marks will not disappear but will fade and lighten after the pregnancy ends. There is no need for a prescription cream. Over-the-counter preparations can be used to keep the skin soft and supple. Wearing supportive undergarments will help promote comfort to the growing abdomen but will not prevent the development of stretch marks.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26.1: Recall the anatomy and physiology specific to assessment of the pregnant and postpartum female.

Question 2

Type: MCSA

A client who is 38 weeks pregnant reports she has been experiencing urinary frequency. Which response by the nurse is indicated?

1. Your reports are consistent with a urinary tract infection.

2. I will need to check your blood sugar as excessive urination is associated with gestational diabetes.

3. Reducing your fluid intake will be helpful to manage this problem.

4. This is normal occurrence in the later stages of pregnancy.

Correct Answer: 4

Rationale 1: During the last few weeks prior to delivery, the client will experience lightening. The pressure caused by this event results in frequent urination. It is a normal occurrence. In the absence of other information, this is the most correct response. There are no indications the client has a urinary tract infection.

Rationale 2: During the last few weeks prior to delivery, the client will experience lightening. The pressure caused by this event results in frequent urination. It is a normal occurrence. In the absence of other information, this is the most correct response. There are no indications the client has an elevation in blood glucose levels.

Rationale 3: The health of the pregnancy requires adequate fluid intake. Reduction of fluid intake is problematic as it will reduce fluids available to the fetus. In addition, the condition is not being caused by an increased oral fluid intake.

Rationale 4: During the last few weeks prior to delivery, the client will experience lightening. The pressure caused by this event results in frequent urination. It is a normal occurrence.

Global Rationale: During the last few weeks prior to delivery, the client will experience lightening. The pressure caused by this event results in frequent urination. It is a normal occurrence. In the absence of other information, this is the most correct response. There are no indications the client has an elevation in blood glucose levels or a urinary tract infection. The health of the pregnancy requires adequate fluid intake. Reduction of fluid intake is problematic as it will reduce fluids available to the fetus. In addition, the condition is not being caused by an increased oral fluid intake.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26.1: Recall the anatomy and physiology specific to assessment of the pregnant and postpartum female.

Question 3

Type: MCSA

The nurse is reading the history and physical on a pregnant client and reads that the cervix was noted as soft in texture and nontender during the pelvic examination. The nurse would correctly identify this as which of the following?

1. Piscaceks sign

2. Goodells sign

3. Chadwicks sign

4. Hegars sign

Correct Answer: 2

Rationale 1: Piscaceks sign is when the shape of the uterus becomes irregular due to the implantation of the ovum.

Rationale 2: During pregnancy, the vascularity of the cervix increases and contributes to the softening of the cervix. This is a normal finding called Goodells sign.

Rationale 3: Chadwicks sign is the appearance of a bluish-purple coloration of the cervix due to vascular congestion.

Rationale 4: Hegars sign occurs throughout pregnancy and is the softening of the region that connects the body of the uterus and the cervix.

Global Rationale: During pregnancy, the vascularity of the cervix increases and contributes to the softening of the cervix. This is a normal finding called Goodells sign. Chadwicks sign, also occurring during pregnancy, is the appearance of a bluish-purple coloration of the cervix due to vascular congestion. Piscaceks sign is when the shape of the uterus becomes irregular due to the implantation of the ovum. Hegars sign occurs throughout pregnancy and is the softening of the region that connects the body of the uterus and the cervix.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 26.1: Recall the anatomy and physiology specific to assessment of the pregnant and postpartum female.

Question 4

Type: MCSA

The nurse is assessing the fundal height of a pregnant client and notes the fundus is halfway between the symphysis pubis and the umbilicus. The nurse would correctly estimate the weeks in pregnancy as which of the following?

1. 1012

2. 16

3. 2022

4. 38

Correct Answer: 2

Rationale 1: At 10 to 12 weeks the fundus is slightly above the symphysis pubis.

Rationale 2: At 16 weeks, the fundus is halfway between the symphysis pubis and the umbilicus.

Rationale 3: Between 20 and 22 weeks the fundus reaches the umbilicus.

Rationale 4: At 38 weeks the fundus is above the umbilicus.

Global Rationale: At 16 weeks, the fundus is halfway between the symphysis pubis and the umbilicus. At 10 to 12 weeks the fundus is slightly above the symphysis pubis, and between 20 and 22 weeks the fundus reaches the umbilicus and increases above this until 38 weeks.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26.1: Recall the anatomy and physiology specific to assessment of the pregnant and postpartum female.

Question 5

Type: HOTSPOT

The nurse is assessing the abdomen of a client who is 20 weeks gestation. Indicate the anticipated height of the fundus.

Screen Shot 2015-09-24 at 12.50.19 PM

Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The fundal height can be anticipated passed upon gestational age. At 20 weeks gestation, the fundal height will be at the level of the umbilicus.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26.1: Recall the anatomy and physiology specific to assessment of the pregnant and postpartum female.

Question 6

Type: MCSA

The nurse is interviewing a female client who reports no menstrual periods for 2 months and breast soreness. The nurse would document this data as which classification of signs of pregnancy?

1. Objective

2. Probable

3. Presumptive

4. Positive

Correct Answer: 3

Rationale 1: Objective findings are those things that are measurable as opposed to subjective findings that are condition reports by an individual that cannot directly be validated.

Rationale 2: Probable signs are those that may be documented by an examiner and include positive pregnancy test, abdominal enlargement, Piskaceks sign, Hegars sign, Goodells sign, Chadwicks sign, and Braxton Hicks contractions.

Rationale 3: Presumptive signs of pregnancy are symptoms the client reports that may have multiple causes other than pregnancy. These include amenorrhea, breast tenderness, nausea and vomiting, frequent urination, perceived quickening, skin changes, and fatigue.

Rationale 4: Positive signs of pregnancy have no possible explanation other than pregnancy and include hearing the fetal heart tone and visualization of the fetus with ultrasound or radiology.

Global Rationale: Presumptive signs of pregnancy are symptoms the client reports that may have multiple causes other than pregnancy. These include amenorrhea, breast tenderness, nausea and vomiting, frequent urination, perceived quickening, skin changes, and fatigue. Probable signs are those that may be documented by an examiner and include positive pregnancy test, abdominal enlargement, Piskaceks sign, Hegars sign, Goodells sign, Chadwicks sign, and Braxton Hicks contractions. Positive signs of pregnancy have no possible explanation other than pregnancy and include hearing the fetal heart tone and visualization of the fetus with ultrasound or radiology. Objective findings are those things that are measurable as opposed to subjective findings that are condition reports by an individual that cannot directly be validated. Many of the presumptive and all of the probable and positive signs of pregnancy are objectives findings.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 26.1: Recall the anatomy and physiology specific to assessment of the pregnant and postpartum female.

Question 7

Type: MCSA

The healthcare provider is performing an assessment on a pregnant client. The examiner notes a softening in the area being assessed. Review the photograph below and identify the probable sign of pregnancy being assessed.

Screen Shot 2015-09-24 at 12.50.57 PM

1. Goodells sign

2. Hegars sign

3. Chadwicks sign

4. Ladins sign

Correct Answer: 1

Rationale 1: Goodells sign refers to the softening of the cervix.

Rationale 2: Hegars sign refers to the softening of the lower uterine segment.

Rationale 3: Chadwicks sign refers to the change in coloration of the mucous membranes of the female genitalia during pregnancy

Rationale 4: Ladins sign refers to the softening of the mid uterus during pregnancy.

Global Rationale: Goodells sign refers to the softening of the cervix. Hegars sign refers to the softening of the lower uterine segment. Chadwicks sign refers to the change in coloration of the mucous membranes of the female genitalia during pregnancy. Ladins sign refers to the softening of the mid uterus during pregnancy.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26.2: Identify anatomical and physiologic variations in body systems that guide assessment in pregnancy and postpartum.

Question 8

Type: MCSA

The nurse is performing a pelvic examination on a client who is 20 weeks pregnant and notes a white, odorless discharge from the vagina. The nurse would correctly choose which of the following actions?

1. Ask the client about vaginal discomfort.

2. Inquire about recent sexual intercourse.

3. Obtain a culture of the discharge.

4. Document the findings as normal.

Correct Answer: 4

Rationale 1: During pregnancy it is normal for vaginal secretions to be increased, white, and odorless, also called leukorrhea. The presence of leukorrhea is normal and does not require a culture or additional subjective information. It is appropriate to document the findings of the nursing assessment.

Rationale 2: During pregnancy it is normal for vaginal secretions to be increased, white, and odorless, also called leukorrhea. The presence of leukorrhea is normal and does not require a culture or additional subjective information. It is appropriate to document the findings of the nursing assessment.

Rationale 3: During pregnancy it is normal for vaginal secretions to be increased, white, and odorless, also called leukorrhea. The presence of leukorrhea is normal and does not require a culture or additional subjective information. It is appropriate to document the findings of the nursing assessment.

Rationale 4: During pregnancy it is normal for vaginal secretions to be increased, white, and odorless, also called leukorrhea. The presence of leukorrhea is normal and does not require a culture or additional subjective information. It is appropriate to document the findings of the nursing assessment.

Global Rationale: During pregnancy it is normal for vaginal secretions to be increased, white, and odorless, also called leukorrhea. The presence of leucorrhea is normal and does not require a culture or additional subjective information. It is appropriate to document the findings of the nursing assessment.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 26.2: Identify anatomical and physiologic variations in body systems that guide assessment in pregnancy and postpartum.

Question 9

Type: MCSA

The nurse is assessing a postpartum client and notes the peri-pad has whitish-yellow discharge. The nurse would correctly document this vaginal discharge as which of the following?

1. Postpartal bleeding

2. Lochia rubra

3. Lochia serosa

4. Lochia alba

Correct Answer: 4

Rationale 1: To refer to the discharge simply as postpartal bleeding does not provide an adequate description.

Rationale 2: The uterine lining, or endometrium, returns to the nonpregnant state through the process of a postpartum vaginal discharge called lochia. The initial lochia rubra contains blood from the placental site, amniotic membrane, cells from the decidua basalis, vernix and lanugo from the infants skin, and meconium. It is dark red and has a fleshy odor, and lasts anywhere from 2 days to 18 days.

Rationale 3: The uterine lining, or endometrium, returns to the nonpregnant state through the process of a postpartum vaginal discharge called lochia. Once the lochia rubra has subsided the discharge becomes pinkish and is called lochia serosa. It is composed of blood, placental site exudates, erythrocytes, leukocytes, cervical mucus, microorganisms, and decidua, and lasts approximately a week.

Rationale 4: The uterine lining, or endometrium, returns to the nonpregnant state through the process of a postpartum vaginal discharge called lochia. In the final stages the discharge becomes whitish-yellow, lochia alba, and is composed of leukocytes, mucus, bacteria, epithelial cells, and decidua.

Global Rationale: The uterine lining, or endometrium, returns to the nonpregnant state through the process of a postpartum vaginal discharge called lochia. The initial lochia rubra contains blood from the placental site, amniotic membrane, cells from the decidua basalis, vernix and lanugo from the infants skin, and meconium. It is dark red and has a fleshy odor, and lasts anywhere from 2 days to 18 days. Next the discharge becomes pinkish and is called lochia serosa. It is composed of blood, placental site exudates, erythrocytes, leukocytes, cervical mucus, microorganisms, and decidua, and lasts approximately a week. Finally, the discharge becomes whitish-yellow, lochia alba, and is composed of leukocytes, mucus, bacteria, epithelial cells, and decidua. Most females will have vaginal discharge from 10 days to 5 or 6 weeks. To refer to the discharge simply as postpartal bleeding does not provide an adequate description.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 26.2: Identify anatomical and physiologic variations in body systems that guide assessment in pregnancy and postpartum.

Question 10

Type: MCSA

The nurse is assessing a client in the third trimester of pregnancy and notes a yellowish discharge from both breasts. The nurse would correctly choose which of the following actions?

1. Ask the client if she is preparing for breastfeeding.

2. Notify the healthcare provider.

3. Document the findings as normal.

4. Obtain a culture of the discharge immediately.

Correct Answer: 3

Rationale 1: Colostrum, a yellowish, specialized form of early breast milk, is produced starting in the second trimester and is replaced by mature milk during the early days of lactation after birth. This substance is produced regardless of whether the woman is planning to breastfeed, making this inquiry unnecessary.

Rationale 2: Colostrum, a yellowish, specialized form of early breast milk, is produced starting in the second trimester and is replaced by mature milk during the early days of lactation after birth. This substance is produced regardless of whether the woman is planning to breastfeed, making this inquiry unnecessary. This is a normal finding and does not require a culture, additional subjective information, or notification of the healthcare provider.

Rationale 3: Colostrum, a yellowish, specialized form of early breast milk, is produced starting in the second trimester and is replaced by mature milk during the early days of lactation after birth. This substance is produced regardless of whether the woman is planning to breastfeed, making this inquiry unnecessary. This is a normal finding and does not require a culture, additional subjective information, or notification of the healthcare provider.

Rationale 4: Colostrum, a yellowish, specialized form of early breast milk, is produced starting in the second trimester and is replaced by mature milk during the early days of lactation after birth. This substance is produced regardless of whether the woman is planning to breastfeed, making this inquiry unnecessary. This is a normal finding and does not require a culture, additional subjective information, or notification of the healthcare provider.

Global Rationale: Colostrum, a yellowish, specialized form of early breast milk, is produced starting in the second trimester and is replaced by mature milk during the early days of lactation after birth. This substance is produced regardless of whether the woman is planning to breastfeed, making this inquiry unnecessary. This is a normal finding and does not require a culture, additional subjective information, or notification of the healthcare provider.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 26.2: Identify anatomical and physiologic variations in body systems that guide assessment in pregnancy and postpartum.

Question 11

Type: MCSA

The nurse is assisting the healthcare provider during a vaginal examination. The healthcare provider notes the cervix has a bluish-purple change in coloration. The nurse would recognize this condition is known as:

1. Goodells sign

2. Leukorrhea

3. Chadwicks sign

4. Mucous plug

Correct Answer: 3

Rationale 1: Hormonal changes in pregnancy cause a series of changes to the female genitalia. The vascularity of the cervix increases contributing to the softening of the cervix, and is called Goodells sign.

Rationale 2: Hormonal changes in pregnancy cause a series of changes to the female genitalia. Leukorrhea is a profuse, nonodorous, nonpainful, vaginal discharge, which is a normal finding.

Rationale 3: Hormonal changes in pregnancy cause a series of changes to the female genitalia. Chadwicks sign appears during pregnancy and is the appearance of a bluish-purple coloration of the cervix due to vascular congestion.

Rationale 4: The endocervical canal is closed by a plug of mucus. This mucus remains in place until the final days of the pregnancy. At that time it is expelled, producing a discharge referred to as bloody show.

Global Rationale: Hormonal changes in pregnancy cause a series of changes to the female genitalia. Chadwicks sign appears during pregnancy and is the appearance of a bluish-purple coloration of the cervix due to vascular congestion. This vascularity of the cervix also contributes to the softening of the cervix, and is called Goodells sign. The endocervical canal is closed by a plug of mucus. This mucus remains in place until the final days of the pregnancy. At that time it is expelled, producing a discharge referred to as bloody show. Leukorrhea is a profuse, nonodorous, nonpainful, vaginal discharge.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26.2: Identify anatomical and physiologic variations in body systems that guide assessment in pregnancy and postpartum.

Question 12

Type: MCSA

The nurse is discussing dietary recommendations with a client who has been experiencing a larger than recommended weight gain during her pregnancy. The client reports reducing the amount of empty calories and of red meat consumed while significantly increasing intake of fish, poultry, and fresh fruits and vegetables. What response is indicated by the nurse?

1. It looks like you have things under control. Do you have any other questions?

2. Have you considered seeing a dietitian for nutritional counseling?

3. Tell me more about the meat and fish you are eating each day.

4. I think we should discuss the risky dietary choices you are making with the healthcare provider.

Correct Answer: 3

Rationale 1: Questions should be sought from the client; however, there are areas for potential problems such as the reduction in protein sources and intake of still-undetermined varieties of fish.

Rationale 2: Nutritional counseling is within the scope of practice for the nurse and a dietary consult is still premature.

Rationale 3: Some of the clients actions are positive changes. The reduction of empty calories is a good change. Red meat is a good source of protein and should not be entirely eliminated. Mercury levels can be problematic in some types of fish. The nurse will need to evaluate the types of fish being eaten. Swordfish, shark, king mackerel, and tilefish should be avoided. Intake of white tuna and game fish should also be restricted.

Rationale 4: The client is making some positive changes and notification of the healthcare provider is premature.

Global Rationale: Some of the clients actions are positive changes. The reduction of empty calories is a good change. Red meat is a good source of protein and should not be entirely eliminated. Mercury levels can be problematic in some types of fish. The nurse will need to evaluate the types of fish being eaten. Swordfish, shark, king mackerel, and tilefish should be avoided. Intake of white tuna and game fish should also be restricted. It is premature to consult with the dietitian. Dietary education is within the scope of nursing practice and the clients behaviors do not warrant further action at this time. It is premature to notify the healthcare provider of the nutritional status without additional information.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26.3: Identify questions used when completing the focused interview.

Question 13

Type: MCSA

A client at 33 weeks gestation calls the healthcare providers office and reports she was attempting to nap when she became dizzy and felt faint. What assessment data should be collected by the nurse first?

1. The position the client was in during the nap period

2. Dietary intake prior to the episode

3. History of hyperemesis

4. No additional data as this appears to be an isolated incident

Correct Answer: 1

Rationale 1: The client has most likely experienced an episode of supine hypotension. This is caused by compression on the aorta and the inferior vena cava by the pregnant uterus. This is a common occurrence when the client is in the supine position.

Rationale 2: The client has most likely experienced an episode of supine hypotension. This is caused by compression on the aorta and the inferior vena cava by the pregnant uterus. This is a common occurrence when the client is in the supine position. Dietary factors and the presence of hyperemesis are not implicated in this clients scenario.

Rationale 3: The client has most likely experienced an episode of supine hypotension. This is caused by compression on the aorta and the inferior vena cava by the pregnant uterus. This is a common occurrence when the client is in the supine position. Dietary factors and the presence of hyperemesis are not implicated in this clients scenario.

Rationale 4: The client has most likely experienced an episode of supine hypotension. This is caused by compression on the aorta and the inferior vena cava by the pregnant uterus. This is a common occurrence when the client is in the supine position. The nurse must investigate the complaints to ensure client safety.

Global Rationale: The client has most likely experienced an episode of supine hypotension. This is caused by compression on the aorta and the inferior vena cava by the pregnant uterus. This is a common occurrence when the client is in the supine position. Dietary factors and the presence of hyperemesis are not implicated in this clients scenario. The nurse must investigate the complaints to ensure client safety.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26.3: Identify questions used when completing the focused interview.

Question 14

Type: MCSA

The healthcare provider is using Leopolds maneuvers to assess fetal positioning. Which of the following maneuvers is being used in the figure below?

Screen Shot 2015-09-24 at 12.51.33 PM

1. First Leopolds maneuver

2. Second Leopolds maneuver

3. Third Leopolds maneuver

4. Fourth Leopolds maneuver

Correct Answer: 3

Rationale 1: Leopolds maneuvers utilize a specialized palpation of the abdomen in sequence to answer a series of questions to determine the position of the fetus in the abdomen and pelvis after 28 weeks gestation. The first maneuver places the ulnar surface of both hands on the fundus, with the fingertips pointing toward the midline to palpate the shape and firmness of the contents of the upper uterus.

Rationale 2: Leopolds maneuvers utilize a specialized palpation of the abdomen in sequence to answer a series of questions to determine the position of the fetus in the abdomen and pelvis after 28 weeks gestation. The second maneuver moves the hands along the sides of the abdomen to palpate the contour of the uterus.

Rationale 3: Leopolds maneuvers utilize a specialized palpation of the abdomen in sequence to answer a series of questions to determine the position of the fetus in the abdomen and pelvis after 28 weeks gestation. The third maneuver determines which part of the fetus is presenting at the pelvis. It is done by sliding the hands down to the area above the symphysis pubis to determine the presenting part of the fetus, the part of the fetus entering the pelvic inlet. The shape and firmness of the presenting part is palpated by using the thumb and third finger of one hand to grasp the presenting part.

Rationale 4: Leopolds maneuvers utilize a specialized palpation of the abdomen in sequence to answer a series of questions to determine the position of the fetus in the abdomen and pelvis after 28 weeks gestation. The fourth Leopolds maneuver is used to determine the depth of the presenting part in the pelvis. It is done by placing the ulnar surface of your two hands on each side of the clients abdomen and following the uterine/fetal contour to the pelvic brim.

Global Rationale: Leopolds maneuvers utilize a specialized palpation of the abdomen in sequence to answer a series of questions to determine the position of the fetus in the abdomen and pelvis after 28 weeks gestation. The first maneuver places the ulnar surface of both hands on the fundus, with the fingertips pointing toward the midline to palpate the shape and firmness of the contents of the upper uterus. The second maneuver moves the hands along the sides of the abdomen to palpate the contour of the uterus. The third maneuver determines which part of the fetus is presenting at the pelvis. It is done by sliding the hands down to the area above the symphysis pubis to determine the presenting part of the fetus, the part of the fetus entering the pelvic inlet. The shape and firmness of the presenting part is palpated by using the thumb and third finger of one hand to grasp the presenting part. The fourth Leopolds maneuver is used to determine the depth of the presenting part in the pelvis. It is done by placing the ulnar surface of your two hands on each side of the clients abdomen and following the uterine/fetal contour to the pelvic brim.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26.4: Describe techniques used in the assessment of the pregnant and postpartum female.

Question 15

Type: HOTSPOT

The nurse is preparing to assess the fetal heart tones for a client whose fetus is in the LOA position. Review the photograph below and draw an X to indicate the best location to assess for the heart tones.

Screen Shot 2015-09-24 at 12.52.10 PM

Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The position of the fetus can be used to ascertain the best location for listening for fetal heart tones. When the fetus is in the LOA (left occiput posterior) position, the head of the fetus is the presenting part. The occipital region of the fetal head and back will be facing the left anterior side of the mother. This will allow the assessment of heart tones in a region closest to the back of the fetus.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26.4: Describe techniques used in the assessment of the pregnant and postpartum female.

Question 16

Type: MCSA

The nurse is monitoring a pregnant client in labor and is wants to determine the length of time from the beginning of the contraction until the end of the contraction. The nurse is assessing which of the following in this client?

1. Contraction intensity

2. Contraction palpation

3. Contraction frequency

4. Contraction duration

Correct Answer: 4

Rationale 1: The intensity of the contraction refers to its strength.

Rationale 2: Assessing the intensity or strength of contractions is done by palpation and is described by comparing the rigidity of the uterus to the firmness of certain other body features such as the nose, the chin, and the forehead for mild, moderate, and hard.

Rationale 3: The frequency of the contractions is determined by measuring the interval from the beginning of one contraction to the beginning of the next contraction.

Rationale 4: The duration of contractions is measured from the beginning of the contraction until the end of the contraction.

Global Rationale: The duration of contractions is measured from the beginning of the contraction until the end of the contraction. The frequency of the contractions is determined by measuring the interval from the beginning of one contraction to the beginning of the next contraction. The intensity of the contraction refers to its strength. Assessing the intensity or strength of contractions is done by palpation and is described by comparing the rigidity of the uterus to the firmness of certain other body features such as the nose, the chin, and the forehead for mild, moderate, and hard.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26.4: Describe techniques used in the assessment of the pregnant and postpartum female.

Question 17

Type: MCSA

The nurse is caring for a pregnant client who desires to know the estimated date of birth (EDB) for the baby. The client reports the last menstrual period (LMP) was April 10. Using Naegeles Rule, the nurse would correctly calculate the EDB as which of the following?

1. February 1

2. May 17

3. May 24

4. January 17

Correct Answer: 4

Rationale 1: Using Naegeles Rule to determine EDB, add 7 days to the date of the first day of the last menstrual period; subtract 3 months from the number of the month.

Rationale 2: Using Naegeles Rule to determine EDB, add 7 days to the date of the first day of the last menstrual period; subtract 3 months from the number of the month.

Rationale 3: Using Naegeles Rule to determine EDB, add 7 days to the date of the first day of the last menstrual period; subtract 3 months from the number of the month.

Rationale 4: Using Naegeles Rule to determine EDB, add 7 days to the date of the first day of the last menstrual period; subtract 3 months from the number of the month.

Global Rationale: Using Naegeles Rule to determine EDB, add 7 days to the date of the first day of the last menstrual period; subtract 3 months from the number of the month.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 26.4: Describe techniques used in the assessment of the pregnant and postpartum female.

Question 18

Type: MCSA

The nurse is interviewing a primigravida client who is 17 weeks pregnant. During the data collection the client reports she has not felt the baby move yet. The most appropriate response by the nurse would be:

1. We will listen for the heartbeat today.

2. You need an ultrasound.

3. Fetal movement does not occur until the 18th week.

4. Do you have reason to believe your baby is not ok?

Correct Answer: 3

Rationale 1: While all prenatal care appointments at this gestational age and beyond will include an assessment of the fetal heartbeat, this option does not meet the clients need for education.

Rationale 2: Ultrasounds may be performed to assess for fetal viability but there is no indication at this time the pregnancy is at risk.

Rationale 3: Quickening, the fluttery initial sensations of fetal movement perceived by the mother, usually occurs at approximately 18 weeks, possibly earlier in women who have given birth before. This mother is in need of factual information from the nurse.

Rationale 4: Asking if the client is feeling uneasy about the health of the pregnancy does not meet the clients need for information.

Global Rationale: Quickening, the fluttery initial sensations of fetal movement perceived by the mother, usually occurs at approximately 18 weeks, possibly earlier in women who have given birth before. This mother is in need of factual information from the nurse. While all prenatal care appointments at this gestation and beyond will include an assessment of the fetal heartbeat, this option does not meet the clients need for education. Ultrasounds may be performed to assess for fetal viability but there is no indication at this time the pregnancy is at risk. Asking if the client is feeling uneasy about the health of the pregnancy does not meet the clients need for information.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26.5: Differentiate normal from abnormal findings in the interview and physical assessment.

Question 19

Type: MCSA

The nurse is examining a client who is 37 weeks pregnant. Which of the following findings would require immediate intervention by the nurse?

1. Patellar reflex 4+/0-4+ bilaterally

2. Heart rate 104

3. Trace protein in the urine

4. Weight gain of 2 pounds in 2 months

Correct Answer: 1

Rationale 1: Hyperreflexia may be indicative of preeclampsia, and there is a need for the nurse to further evaluate this finding. Evaluation of reflexes should be done using the following scale: 0 = no response; 1+ = diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive.

Rationale 2: Heart rates in pregnant women are normally elevated as a result of the increased circulating volume and increases in metabolic rate.

Rationale 3: Normal urine components do not include protein; however, the increased workload for the kidneys and the increased GFR may result in episodes of protein in the urine. The presence of protein in the urine warrants investigation but it is not an immediate need or of the same level of importance of the reflex findings.

Rationale 4: Weight gain of 2 pounds in an 8-week period is not excessive and does not require immediate action.

Global Rationale: Hyperreflexia may be indicative of preeclampsia, and there is a need for the nurse to further evaluate this finding. Evaluation of reflexes should be done using the following scale: 0 = no response; 1+ = diminished; 2+ = normal; 3+ = brisk, above normal; 4+ = hyperactive. Heart rates in pregnant women are normally elevated as a result of the increased circulating volume and increases in metabolic rate. Normal urine components do not include protein; however, the increased workload for the kidneys and the increased GFR may result in episodes of protein in the urine. The presence of protein in the urine warrants investigation but it is not an immediate need or of the same level of importance of the reflex findings. Weight gain of 2 pounds in an 8-week period is not excessive and does not require immediate action.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 26.5: Differentiate normal from abnormal findings in the interview and physical assessment.

Question 20

Type: MCSA

The nurse is interviewing a client who is 36 weeks pregnant. Which of the following statements, if made by the client, would require immediate intervention by the nurse?

1. I have to get up during the night to void.

2. I have not felt the baby move today.

3. I am leaking a yellowish fluid from my breasts.

4. I have been taking Tylenol (acetaminophen) for my backaches.

Correct Answer: 2

Rationale 1: Urinary frequency is common during the last months of pregnancy as the uterus places pressure on the bladder.

Rationale 2: The absence or change in fetal movement can signal a problem with the pregnancy. When no fetal movement has been noted in the past 8 hours, there are fewer than 10 movements in 12 hours, there is a change in the usual pattern of movements, or a sudden increase in violent fetal movements followed by a complete cessation of movement, further investigation is warranted. Immediate evaluation of the fetus should take place.

Rationale 3: Pregnant women begin to produce and secrete colostrum from the breast during pregnancy.

Rationale 4: Tylenol (acetaminophen) is appropriate for the back pain that accompanies third trimester pregnancy.

Global Rationale: The absence or change in fetal movement can signal a problem with the pregnancy. When no fetal movement has been noted in the past 8 hours, there are fewer than 10 movements in 12 hours, there is a change in the usual pattern of movements, or a sudden increase in violent fetal movements followed by a complete cessation of movement, further investigation is warranted. Immediate evaluation of the fetus should take place. Urinary frequency is common during the last months of pregnancy as the uterus places pressure on the bladder. Pregnant women begin to produce and secrete colostrum from the breasts during pregnancy. Tylenol is appropriate for the back pain that accompanies third trimester pregnancy.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 26.5: Differentiate normal from abnormal findings in the interview and physical assessment.

Question 21

Type: MCMA

The nurse is preparing a teaching plan for a group of pregnant clients. Which of the following should the nurse include in this teaching session?

Standard Text: Select all that apply.

1. Do not use soap on my nipples.

2. Sleep 810 hours each night.

3. Eat four servings of dairy products daily.

4. Do not take iron supplements due to constipation.

5. Avoid resting in a back lying position.

Correct Answer: 1,2,3,5

Rationale 1: Do not use soap on my nipples. The use of soap on the nipples will result in drying and should be avoided.

Rationale 2: Sleep 810 hours each night. Pregnant women are in need of adequate rest and sleep. Sleeping 8 to 10 hours each night is recommended.

Rationale 3: Eat four servings of dairy products daily. The dietary needs of the pregnant woman will involve approximately 1000 mg of calcium daily. The needed calcium can be obtained by ingesting 4 servings from the dairy group each day.

Rationale 4: Do not take iron supplements due to constipation. Dietary intake during pregnancy cannot meet the iron required for the needs of both mother and baby. Iron supplements are needed to meet the needs of pregnant women. While constipation may be associated with iron supplementation, discontinuing the medication is contraindicated. The client experiencing constipation should be instructed to increase fluid and fiber intake to promote bowel regulation instead of not taking the needed iron supplements.

Rationale 5: Avoid resting in a back-lying position. Lying on the back is contraindicated as the pregnancy progresses. Back-lying positions will result in the compression of the vena cava and may cause reduced perfusion, lightheadedness, and dizziness.

Global Rationale: The use of soap on the nipples will result in drying and should be avoided. Pregnant women are in need of adequate rest and sleep. Sleeping 8 to 10 hours each night is recommended. The dietary needs of the pregnant woman will involve approximately 1000 mg of calcium daily. The needed calcium can be obtained by ingesting 4 servings from the dairy group each day. Dietary intake during pregnancy cannot meet the iron required for the needs of both mother and baby. Iron supplements are needed to meet the needs of the pregnant women. While constipation may be associated with iron supplementation, discontinuing the medication is contraindicated. The client experiencing constipation should be instructed to increase fluid and fiber intake to promote bowel regulation instead of not taking the needed iron supplements. Lying on the back is contraindicated as the pregnancy progresses. Back-lying positions will result in the compression of the vena cava and may cause reduced perfusion, lightheadedness, and dizziness.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 26.6: Describe the health promotion and education topics necessary in the care of the pregnant female.

Question 22

Type: MCSA

A client at 33 weeks gestation has a complete blood cell count drawn. When the client hears that her hemoglobin level was higher before her pregnancy, she asks if this will increase the risk to her unborn baby. What information should be provided to the client?

1. If the client increases the number of prenatal vitamins taken, the risk to the fetus will be eliminated.

2. The fetus is at an increased risk of prematurity.

3. Dietary management will eliminate the risk to the fetus.

4. The fetus will likely suffer from anemia as well.

Correct Answer: 2

Rationale 1: Changes in prenatal vitamin intake and dietary modification may improve the condition and reduce risk, but this will not totally eliminate the associated risk factors.

Rationale 2: The risk to the fetus as a result of the maternal anemia includes prematurity, low birth weight, and perinatal mortality.

Rationale 3: Changes in prenatal vitamin intake and dietary modification may improve the condition and reduce risk, but this will not totally eliminate the associated risk factors.

Rationale 4: There is no evidence the fetus will experience anemia as a result of the maternal anemia.

Global Rationale: The risk to the fetus as a result of the maternal anemia includes prematurity, low birth weight and perinatal mortality. Changes in prenatal vitamin intake and dietary modification may improve the condition and reduce risk, but this will not totally eliminate the associated risk factors. There is no evidence the fetus will experience anemia.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26.6: Describe the health promotion and education topics necessary in the care of the pregnant female.

Question 23

Type: MCMA

The nurse is planning a prenatal education class for a group of women who are in their second trimester of pregnancy. Regarding the gestation of the pregnancy, which of the following topics are considered most appropriate?

Standard Text: Select all that apply.

1. Preparation of breasts for breastfeeding

2. Fetal development

3. Warning signs to report

4. Psychologic concerns associated with becoming pregnant

5. Preterm labor signs

Correct Answer: 2,3,5

Rationale 1: Preparation of breasts for breastfeeding. Education is important during the pregnancy. Topics are best when arranged to promote current concerns of the pregnant woman and her family. The preparation of breasts for breastfeeding is a topic that is best presented during the third trimester.

Rationale 2: Fetal development. Education is important during the pregnancy. Topics are best when arranged to promote current concerns of the pregnant woman and her family. Each educational opportunity should include information concerning fetal development and warning signs to report.

Rationale 3: Warning signs to report. Education is important during the pregnancy. Topics are best when arranged to promote current concerns of the pregnant woman and her family. Each educational opportunity should include information concerning fetal development and warning signs to report.

Rationale 4: Psychologic concerns associated with becoming pregnant. Education is important during the pregnancy. Topics are best when arranged to promote current concerns of the pregnant woman and her family. The client is most interested in discussing the psychologic concerns associated with pregnancy during the first trimester.

Rationale 5: Preterm labor signs. Education is important during the pregnancy. Topics are best when arranged to promote current concerns of the pregnant woman and her family. The second trimester is a period in which preterm labor becomes an increasing risk factor and should be discussed with the client.

Global Rationale: Education is important during the pregnancy. Topics are best when arranged to promote current concerns of the pregnant woman and her family. Each educational opportunity should include information concerning fetal development and warning signs to report. The second trimester is a period in which preterm labor becomes an increasing risk factor and should be discussed with the client. The preparation of breasts for breastfeeding is a topic that is best presented during the third trimester. The client is most interested in discussing the psychologic concerns associated with pregnancy during the first trimester.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 26.6: Describe the health promotion and education topics necessary in the care of the pregnant female.

Question 24

Type: MCSA

During a prenatal counseling session a client indicates concern about her potential HIV positive status. The client states she does not want to jinx the pregnancy by getting tested because if she is positive, so is the baby. Which statement by the nurse is indicated?

1. You are right to avoid the stress of finding out you are HIV positive during the pregnancy.

2. If you are HIV positive, your baby will also have HIV.

3. Even if you do test HIV positive, preventive treatments have a good chance of providing protection for your baby.

4. As long as you do not breastfeed and have a cesarean section, your baby will be protected.

Correct Answer: 3

Rationale 1: While testing during pregnancy may be stressful to the mother, the potential benefits are immeasurable. The highest priority for the nurse is to provide education concerning the benefits of prenatal testing.

Rationale 2: Prophylactic antiviral therapies can significantly reduce the incidence of transmission between mother and baby during the pregnancy. Without treatment, the risk of transmission to the baby is greatest.

Rationale 3: Prophylactic antiviral therapies can significantly reduce the incidence of transmission between mother and baby during the pregnancy. Without treatment, the risk of transmission to the baby is greatest.

Rationale 4: Although breastfeeding and a cesarean section delivery will reduce the rate of transmission, they are not 100% effective tools of prevention.

Global Rationale: Prophylactic antiviral therapies can significantly reduce the incidence of transmission between mother and baby during the pregnancy. Without treatment, the risk of transmission to the baby is greatest. Although breastfeeding and a cesarean section delivery will reduce the rate of transmission, they are not 100% effective tools of prevention.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26.7: Identify the objectives in Healthy People 2020 that apply to the pregnant female.

Question 25

Type: MCMA

A client at 15 weeks gestation has just been advised she has tested positive for syphilis. The client is tearful and inquires about the risk to her infant. Which of the elements will be included in the management of the condition?

Standard Text: Select all that apply.

1. The client will be treated with IV antibiotic therapy during the prenatal period.

2. The sexual partners of the client will require notification and testing.

3. The client will begin antibiotic therapy at this time.

4. The client will begin antibiotic therapy after birth of the baby.

5. The infant will require intrauterine management for the condition.

Correct Answer: 2,3

Rationale 1: The client will be treated with IV antibiotic therapy during the prenatal period. The client will be managed with oral antibiotic therapy at the time of diagnosis.

Rationale 2: The sexual partners of the client will require notification and testing. Syphilis is a communicable disease. It is the legal responsibility of the healthcare facility to perform the appropriate reporting. The sexual partners of the client must be notified, tested, and treated if indicated.

Rationale 3: The client will begin antibiotic therapy at this time. The client will begin treatment at the time of diagnosis. Allowing the client to wait until after the birth of the baby would prolong exposure to the pathogen.

Rationale 4: The client will begin antibiotic therapy after birth of the baby. The client will begin treatment at the time of diagnosis. Allowing the client to wait until after the birth of the baby would prolong exposure to the pathogen.

Rationale 5: The infant will require intrauterine management for the condition. Infants born with syphilis will be treated. Therapies are not indicated for the fetus.

Global Rationale: The client will begin treatment at the time of diagnosis. Allowing the client to wait until after the birth of the baby would prolong exposure to the pathogen. The condition will be managed with oral antibiotic therapy. Syphilis is a communicable disease. It is the legal responsibility of the healthcare facility to perform the appropriate reporting. The sexual partners of the client must be notified, tested, and treated if indicated. IV antibiotic therapy is not indicated. Infants who are infected with syphilis will be treated after birth.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 26.7: Identify the objectives in Healthy People 2020 that apply to the pregnant female.

Question 26

Type: MCSA

The nurse is examining a client in the third trimester of pregnancy. Which of the following findings would require immediate intervention by the nurse?

1. Pulse of 98 beats per minute

2. Weight gain of 1.5 pounds in a month

3. Blood pressure of 148/94

4. Respiratory rate of 26 per minute

Correct Answer: 3

Rationale 1: The pregnant clients heart and respiratory rates will increase slightly due to an increased circulatory volume and a decrease in intrathoracic space.

Rationale 2: Weight gain should be a pound per month in the second and third trimesters.

Rationale 3: A pregnant clients blood pressure should not be greater than 140/90 and if elevated could be a sign of gestational hypertension or preeclampsia.

Rationale 4: The pregnant clients heart and respiratory rates will increase slightly due to an increased circulatory volume and a decrease in intrathoracic space.

Global Rationale: A pregnant clients blood pressure should not be greater than 140/90 and if elevated could be a sign of gestational hypertension or preeclampsia. The pregnant clients heart and respiratory rates will increase slightly due to an increased circulatory volume and a decrease in intrathoracic space. Weight gain should be a pound per month in the second and third trimesters.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 26.8: Apply critical thinking in a selected simulation related to physical assessment of the postpartum client.

Question 27

Type: MCSA

The client who is at 5 weeks gestation is seen in the Emergency Department with complaints of severe abdominal and pelvic pain. A vaginal examination reveals tenderness and a palpable mass near the uterus. Based upon your knowledge, which of the following can the nurse anticipate will take place first?

1. The client will be sent home on bed rest.

2. The client will be admitted to the acute care facility for observation.

3. The client will be evaluated in the labor and delivery department with a nonstress test.

4. An ultrasound will be ordered.

Correct Answer: 4

Rationale 1: The client is presenting with manifestations consistent with an ectopic pregnancy. Sending the client home and placing her on bed rest without completing a thorough evaluation may result in harm to the client.

Rationale 2: The client is presenting with manifestations consistent with an ectopic pregnancy. The findings from the ultrasound will determine the next steps in the clients care.

Rationale 3: The client is presenting with manifestations consistent with an ectopic pregnancy. The clients gestational age is not yet advanced enough to utilize a nonstress test for evaluation.

Rationale 4: The client is presenting with manifestations consistent with an ectopic pregnancy. The ultrasound will be used to assist in confirming the condition.

Global Rationale: The client is presenting with manifestations consistent with an ectopic pregnancy. The ultrasound will be used to assist in confirming the condition. Sending the client home without a thorough evaluation could result in rupture of the ectopic and place the client at great risk. Observation may be indicated if the ectopic pregnancy is ruled out. The clients gestational age is not yet advanced enough to utilize a nonstress test for evaluation.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 26.8: Apply critical thinking in a selected simulation related to physical assessment of the postpartum client.

Question 28

Type: MCSA

A client has been diagnosed with Group B Streptococcus at 33 weeks gestation. The client becomes tearful when the diagnosis is discussed. She asks what will be done next. What information should be provided to the client?

1. The client will receive oral antibiotics to be taken over the next 7 weeks.

2. The infection will be managed with IV antibiotics when the client is in active labor.

3. Due to the limited risk of transmission, the client will begin treatment during the postpartum period.

4. The client will require IM antibiotic treatment to facilitate a rapid cure.

Correct Answer: 2

Rationale 1: Group B Streptococcus is treated when the client goes into active labor. The treatment involves IV antibiotics. Initiating treatment during labor allows for the transmission of the medications across the placental barrier.

Rationale 2: Group B Streptococcus is treated when the client goes into active labor. The treatment involves IV antibiotics. Initiating treatment during labor allows for the transmission of the medications across the placental barrier.

Rationale 3: Group B Streptococcus is treated when the client goes into active labor. The treatment involves IV antibiotics. Initiating treatment during labor allows for the transmission of the medications across the placental barrier.

Rationale 4: Group B Streptococcus is treated when the client goes into active labor. The treatment involves IV antibiotics. Initiating treatment during labor allows for the transmission of the medications across the placental barrier. Oral and intramuscular antibiotics are not indicated for this infection.

Global Rationale: Group B Streptococcus is treated when the client goes into active labor. The treatment involves IV antibiotics. Initiating treatment during labor allows for the transmission of the medications across the placental barrier. Oral and intramuscular antibiotics are not indicated for this infection.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26.8: Apply critical thinking in a selected simulation related to physical assessment of the postpartum client.

Question 29

Type: MCSA

While performing data collection for a client who has recently had her pregnancy confirmed, the client reports taking daily herbal supplements. What action by the nurse is of the highest priority?

1. Instruct the client to increase the supplements to promote nutritional well-being.

2. Advise the client to reduce the amount of supplements taken to allow for the prescribed prenatal vitamins being taken.

3. Encourage the client to speak with the healthcare provider about the herbal supplements.

4. Record the clients reports on the permanent medical record.

Correct Answer: 3

Rationale 1: Herbal supplements are not regulated. They should be avoided during the pregnancy. If taken, it should only be under the recommendation of the healthcare provider. Increasing the supplementations may endanger the fetus.

Rationale 2: Herbal supplements are not regulated. They should be avoided during the pregnancy. If taken, it should only be under the recommendation of the healthcare provider. Increasing the supplementations may endanger the fetus.

Rationale 3: Herbal supplements are not regulated. They should be avoided during the pregnancy. If taken, it should only be under the recommendation of the healthcare provider. Increasing the supplementations may endanger the fetus.

Rationale 4: Reports of the supplements being taken should be documented on the medical record but this is not the action of the greatest importance. The notification of the potential dangers of supplements is a higher importance.

Global Rationale: Herbal supplements are not regulated. They should be avoided during the pregnancy. If taken, it should only be under the recommendation of the healthcare provider. Increasing the supplementations may endanger the fetus. Although the clients reports are to be noted in the medical record, it is not the initial action by the nurse. The nurses documentation must also include the clients response and type of supplements being ingested.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26.8: Apply critical thinking in a selected simulation related to physical assessment of the postpartum client.

Question 30

Type: MCMA

The nurse is reviewing the tests planned for a pregnant client. Traditionally testing done for gestational diabetes will be performed between 24 and 28 weeks gestation. Which of the following findings in the clients history will prompt the test to be performed earlier in the pregnancy?

Standard Text: Select all that apply.

1. The client is a multigravida.

2. The client has a history of a previous stillbirth.

3. The client has a strong family history of diabetes.

4. The client experienced infertility prior to becoming pregnant.

5. The clients last baby was large for gestational age.

Correct Answer: 2,3,5

Rationale 1: The client is a multigravida. The number of past pregnancies does not impact the risk factors of gestational diabetes.

Rationale 2: The client has a history of a previous stillbirth. Diabetic women have a higher incidence of stillbirth.

Rationale 3: The client has a strong family history of diabetes. Diabetes may have familial tendencies.

Rationale 4: The client experienced infertility prior to becoming pregnant. Infertility is not directly linked to the presence of diabetes.

Rationale 5: The clients last baby was large for gestational age. Babies born to gestational diabetics are often large for gestational age as a result of uncontrolled serum glucose levels of the mother.

Global Rationale: The assessment for gestational diabetes is most often done between 24 and 28 weeks gestation. In cases in which the client is deemed to be at an increased risk the testing can be done sooner. Diabetic women have a higher incidence of stillbirth. Diabetes may have familial tendencies. Babies born to gestational diabetics are often large for gestational age as a result of uncontrolled serum glucose levels of the mother. The number of past pregnancies does not impact the risk factors of gestational diabetes. Infertility is not directly linked to the presence of diabetes.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26.8: Apply critical thinking in a selected simulation related to physical assessment of the postpartum client.

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