Maternal And Child Health Nursing (Intrapartum And Postpartum)
Welcome to Maternal and Child Health Nursing (HESI EXAMINATION) Prepared by: Jeffrey Viernes
The care of childbearing and childrearing families is a major focus of nursing practice, because to have healthy adults you must have healthy children. To have healthy children, it is important to promote the health of the childbearing woman and her family from the time before children are born until they reach adulthood. Both preconceptual and prenatal care are essential contributions to the health of a woman and fetus and to a family’s emo- tional preparation for childbearing and childrearing. As chil- dren grow, families need continued health Read moresupervision and support. As children reach maturity and plan for their fam- ilies, a new cycle begins and new support becomes nec- essary. The nurse’s role in all these phases focuses on promoting healthy growth and development of the child and family in health and in illness. Although the field of nursing typically divides its con- cerns for families during childbearing and childrearing into two separate entities, maternity care and child health care, the full scope of nursing practice in this area is not two separate entities, but one: maternal and child health nursing.
Philosophy of Maternal and Child Health Nursing • Maternal and child health nursing is family- centered; assessment data must include a family and individual assessment. • Maternal and child health nursing is community- centered; the health of families depends on and influences the health of communities. • Maternal and child health nursing is research- oriented, because
- 1.
A client in the 28th week of gestation comes to the emergency department because she thinks that she's in labor. To confirm the diagnosis of PRETERM LABOR, the nurse would expect the physical examinations to reveal: Client's needs category: Physiological integrity Client's need subcategory: Physiological adaptation Cognitive level: Knowledge
- A.
Irregular uterine contractions with no cervical dilation
- B.
Painful contractions with cervical dilation
- C.
Regular uterine dilation with cervical dilation
- D.
Regular uterine contractions without cervical dilation
Correct Answer
C. Regular uterine dilation with cervical dilationExplanation
Regular uterine contractions (every 10 minutes or more) along with cervical dilation before 36 weeks' gestation or rupture of fluids indicates preterm labor.Rate this question:
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- 2.
A client in the active phase of labor has a reactive fetal monitor strip and has been encouraged to walk. When she returns to bed for a monitor check, she complains for an urge to push. The nurse notes that the amniotic membranes have ruptured and she can visualize the umbilical cord. What should the nurse do next? Client's needs category: Physiological Integrity Client's needs subcategory: Reduction of risk potential Cognitive level: Analysis
- A.
Put the client in a knee-to-chest position
- B.
Call the physician or midwife because it is emergent
- C.
Push down on the uterine fundus
- D.
Arrange for fetal blood sampling to assess for fetal acidosis
Correct Answer
A. Put the client in a knee-to-chest positionExplanation
The knee to chest position gets the weight off the baby and umbilical cord, which would prevent blood flow. Calling the physician or midwife, and arranging for blood sampling are IMPORTANT, but they have a lower priority than getting the baby off the cord.Rate this question:
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- 3.
A client is attempting to deliver vaginally despite the fact that her previous delivery was by cesarean delivery. Her contractions are 2 to 3 minutes apart, lasting from 75 to 100 seconds. Suddenly, the client complains of intense abdominal pain, and the fetal monitor stops picking up contractions. The nurse recognizes that which of the following events may have occured? Client's needs category: Physiological Integrity Cognitive level: Application
- A.
Abruptio placentae
- B.
Prolapsed cord
- C.
Partial placenta previa
- D.
Complete uterine rupture
Correct Answer
D. Complete uterine ruptureExplanation
With complete uterine contraction, the client would feel a sharp pain in the lower abdomen and contractions would cease. FHR would also cease within a few minutes.Rate this question:
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- 4.
A client with gravida 3 para 2 at 40 weeks' gestation is admitted with spontaneous contractions. The physician performs an amniotomy to augment her labor. The PRIORITY nursing action is to: Client's needs category: Physiological Integrity Cognitive level: Knowledge
- A.
Explain the rationale for the amniotomy to the patient
- B.
Monitor fetal heart tones after the amniotomy
- C.
Ambulate the client to strengthen the contraction pattern
- D.
Position the client in a lithotomy position to administer perineal care
Correct Answer
B. Monitor fetal heart tones after the amniotomyExplanation
The nurse should first monitor fetal heart tone. After an amniotomy is performed, the umbilical cord may be washed down below the presenting part and cause umbilical cord compression, which would indicate by vitiable deceleration on the fetal heart tracing.Rate this question:
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- 5.
What is the most IMPORTANT determinant of fetal maturity for extrauterine survival? Cognitive level: Application and Knowledge
- A.
An L/S ratio of 2:1
- B.
The presence of IgG antibodies on the fetal bloodstream
- C.
An L/S ratio of 1:2
- D.
The presence of well functioning CNS, cardiovascular and respiratory system
Correct Answer
A. An L/S ratio of 2:1Explanation
The most important determinants of fetal maturity for extrauterine survival is L/S ratio of 2:1.Rate this question:
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- 6.
The characteristics of the HELLP syndrome are: Select all that apply. Cognitive level: Analysis and Knowledge
- A.
Hemolysis (blood destruction)
- B.
Elevated liver enzyme
- C.
Hypertension and generalized edema
- D.
Low platelet count
- E.
Proteinuria
- F.
It is usually occurring before the 37th weeks' gestation
Correct Answer(s)
A. Hemolysis (blood destruction)
B. Elevated liver enzyme
D. Low platelet count
F. It is usually occurring before the 37th weeks' gestationExplanation
HELLP syndrome is characterized by:
1. Hemolysis
2. Elevated liver enzyme
3. Low platelet count
4. usually occurring before the 37th weeks' gestationRate this question:
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- 7.
What are the manifestations of Hypertension in pregnancy (Preeclampsia)? Select all that apply.
- A.
Systolic blood pressure greater than 140 or diastolic blood pressure greater than 90
- B.
Proteinuria
- C.
Weight gain
- D.
Decreased urine output
- E.
Presence of HELLP syndrome
- F.
Headaches, blurred vision, hyperreflexia, nausea, vomiting
Correct Answer(s)
A. Systolic blood pressure greater than 140 or diastolic blood pressure greater than 90
B. Proteinuria
C. Weight gain
D. Decreased urine output
E. Presence of HELLP syndrome
F. Headaches, blurred vision, hyperreflexia, nausea, vomitingExplanation
The manifestations of Hypertension in pregnancy (Preeclampsia) include systolic blood pressure greater than 140 or diastolic blood pressure greater than 90, proteinuria, weight gain, decreased urine output, presence of HELLP syndrome, headaches, blurred vision, hyperreflexia, nausea, and vomiting. These symptoms are commonly seen in women with preeclampsia and indicate the presence of high blood pressure and organ damage.Rate this question:
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- 8.
A 36 years old pregnant patient (is on her 36th weeks of gestation) has been diagnosed with hypertension with a blood pressure of 140/90 for the past two weeks has been admitted to the labor and delivery department. Suddenly within the first 24 hours of her stay, the patient described a bright red bleeding on her drape. The nurse ask about her pain level, the patient rated her pain as 1 out of 10. What are the necessary nursing intervention you need to provide for this patient? Select all that apply.
- A.
Monitor maternal Vital Signs, including uterine activity
- B.
Monitor signs of infection
- C.
Monitor fetal heart rate
- D.
Obtain a blood glucose from the patient
- E.
Provide vitamin K because the patient is bleeding severely
- F.
Administer 2 Tylenol as needed order
Correct Answer(s)
A. Monitor maternal Vital Signs, including uterine activity
B. Monitor signs of infection
C. Monitor fetal heart rateExplanation
To evaluate maternal well-being, we need to monitor maternal vital signs, including uterine activity. Patients with placenta previa are at increased risk for infection. We need to monitor fetal heart rate to detect complications. You don't need to take her blood glucose, administer vitamin K and tylenol to the patient which will further compromised the condition of the patient.Rate this question:
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- 9.
Older adults are vulnerable to diseases because of decreased physiologic reserve, less flexible homeostatic processes, and less effective body defenses. What are the most common physiologic changes that is related to aging? Select all that apply.
- A.
Chronic illness becomes more prevalent as one ages
- B.
Resistance to stressors diminishes as one ages
- C.
Decreased absorption of vitamins B1 and B2
- D.
Decreased peristalsis and impaired absorption contribute to constipation problems
- E.
Increased thirst sensation
- F.
Increased hunger sensation
Correct Answer(s)
A. Chronic illness becomes more prevalent as one ages
B. Resistance to stressors diminishes as one ages
C. Decreased absorption of vitamins B1 and B2
D. Decreased peristalsis and impaired absorption contribute to constipation problemsExplanation
As individuals age, their physiologic reserve decreases, making them more vulnerable to diseases. Chronic illness becomes more prevalent as one ages because the body's ability to maintain homeostasis declines. The resistance to stressors also diminishes with age, making older adults more susceptible to various stress-related conditions. Additionally, there is a decreased absorption of vitamins B1 and B2 in older adults, which can lead to deficiencies and health issues. Furthermore, decreased peristalsis and impaired absorption contribute to constipation problems in older adults. However, increased thirst and hunger sensations are not mentioned as common physiologic changes related to aging.Rate this question:
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- 10.
An 86 years old patient has been admitted into the Long Term Care facility. She has an admitting diagnosis of Hypertensio, diabetes mellitus, and she has a history of falls at home. Last night, the patient was trying to climb the rails and suddenly she fell with her face first on the floor. No blood was found on the scene. the physician ordere a MRI to check f there is internal bleeding on the patient. When the nurse assessed the patient's level of consciousness, she cannot identify her name and time. The patient is currently taking Atenolol 200 mg PO to control her blood pressure. The physician diagnosed a Transient Ischemic Attack for the patient. As a nurse, you know that TIA has the following hallmark signs and symptoms. Select all that apply.
- A.
Weakness
- B.
Persistent nausea and vomiting
- C.
Blackouts
- D.
Presence or leakage of CSF
- E.
Difficulty speaking
- F.
Tremors
Correct Answer(s)
A. Weakness
C. Blackouts
E. Difficulty speakingExplanation
Transient Ischemic Attack (TIA) is a temporary interruption of blood flow to the brain, causing temporary neurological symptoms. The hallmark signs and symptoms of TIA include weakness, blackouts (loss of consciousness), and difficulty speaking. Persistent nausea and vomiting, presence or leakage of cerebrospinal fluid (CSF), and tremors are not typically associated with TIA.Rate this question:
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- 11.
What are the ways to help prevent or decrease the occurence of falls in the older adult? Select all that apply.
- A.
Remove throw rugs
- B.
Paint the edges of stairs red color
- C.
Administer his antihypertensive medications during the night
- D.
Ambulate the patient with a gait belt
- E.
Ensure adequate lighting
- F.
Wear proper footwear that supports the foot
Correct Answer(s)
A. Remove throw rugs
D. Ambulate the patient with a gait belt
E. Ensure adequate lighting
F. Wear proper footwear that supports the footExplanation
Falls in older adults can be prevented or decreased by removing throw rugs, as they can be a tripping hazard. Ambulating the patient with a gait belt can provide support and stability while walking. Ensuring adequate lighting can help older adults see obstacles and hazards more clearly. Wearing proper footwear that supports the foot can improve balance and reduce the risk of falls. Painting the edges of stairs red color and administering antihypertensive medications during the night are not effective strategies for preventing or decreasing falls in older adults.Rate this question:
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- 12.
What is the condition called whereby the placenta is implanted in the lower uterine segment. It can be classified as partially, totally, or marginal.?
Correct Answer(s)
placenta previa
Placenta previaExplanation
Placenta previa is a condition where the placenta is implanted in the lower uterine segment. It can be classified as partially, totally, or marginal. This condition can cause bleeding during pregnancy, especially during the third trimester, and can be a risk factor for complications during childbirth. It requires close monitoring and may require medical intervention or a cesarean delivery to ensure the safety of both the mother and the baby.Rate this question:
- 13.
It is th partial or complete premature detachment of the placenta from its site of implantation in the uterus. It is usually occuring in the late third trimester or in labor.
Correct Answer(s)
abruptio placentae
Abruptio placentaeExplanation
Abruptio placentae refers to the partial or complete premature detachment of the placenta from its site of implantation in the uterus. This condition typically occurs in the late third trimester of pregnancy or during labor. The term "abruptio placentae" is used to describe this medical condition.Rate this question:
- 14.
What the do you call the procedure whereby the OB/GYN physician removes amniotic fluid sample from the uterus during 14th to 16 th weeks of gestation?
Correct Answer(s)
amniocentesis
AmniocentesisExplanation
Amniocentesis is the procedure where an OB/GYN physician removes a sample of amniotic fluid from the uterus during the 14th to 16th weeks of gestation. This procedure is commonly performed to diagnose any genetic abnormalities or chromosomal disorders in the fetus. It involves inserting a needle into the amniotic sac and withdrawing a small amount of fluid for testing. Amniocentesis is a crucial diagnostic tool in prenatal care and allows for early detection of potential health issues in the unborn baby.Rate this question:
- 15.
What is the procedure called whereby the physician removes a small piece of villi between 8 to 12 weeks' gestation under ultrasound guidance?
Correct Answer(s)
Chorionic villi sampling
chorionic villi samplingExplanation
Chorionic villi sampling is the procedure in which a physician removes a small piece of villi, which are finger-like projections in the placenta, between 8 to 12 weeks' gestation under ultrasound guidance. This procedure is used to diagnose genetic disorders and chromosomal abnormalities in the fetus.Rate this question:
- 16.
If there is a decrease of alpha-fetoprotein in the amniotic fluid, it would signify what disease is the fetus risk for?
Correct Answer(s)
trisomy 21
Trisomy 21
down syndrome
Down syndromeExplanation
A decrease in alpha-fetoprotein in the amniotic fluid is associated with an increased risk of trisomy 21, also known as Down syndrome. Trisomy 21 is a genetic disorder caused by the presence of an extra copy of chromosome 21. It is characterized by intellectual disability, developmental delays, distinct physical features, and an increased risk of certain health conditions. The decrease in alpha-fetoprotein levels can be detected through prenatal screening tests and can help identify the risk of Down syndrome in the fetus.Rate this question:
- 17.
If there is an INCREASE in alpha-fetoprotein
Correct Answer(s)
neural tube defect
Neural tube defectExplanation
An increase in alpha-fetoprotein is associated with neural tube defects. Alpha-fetoprotein is a protein produced by the developing fetus and is normally found in high levels in the amniotic fluid and maternal blood. An increase in alpha-fetoprotein levels can indicate a problem with the development of the neural tube, which is the precursor to the brain and spinal cord. Neural tube defects are birth defects that occur when the neural tube fails to close properly during early embryonic development. This can lead to conditions such as spina bifida and anencephaly.Rate this question:
- 18.
The LPN is helping the RN to complete the necessary assessment data on the Biophysical Profile (BPP) to detect if the fetus is healthy and well. What are the necessary components of this profile?
- A.
Fetal breathing movement
- B.
Fetal tone
- C.
Gross body movement
- D.
L/S ratio
- E.
Reactivity of fetal heart rate
- F.
Amniotic fluid volume
- G.
Presence of alpha-fetoprotein
Correct Answer(s)
A. Fetal breathing movement
B. Fetal tone
C. Gross body movement
E. Reactivity of fetal heart rate
F. Amniotic fluid volumeExplanation
There are five components of the biophysical profile
a. fetal breathing movement
b. fetal tone
c. gross body movement
d. reactivity of FHR
e. amniotic fluid volumeRate this question:
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- 19.
Infection that occurs during pregnancy is very compromising for the fetus. A 12 weeks pregant Asian female is asking the LPN what TORCH disease is. As a knowledgable LPN, you know that TORCH disease includes:
- A.
Rubella
- B.
Cytomegalovirus
- C.
Tuberculosis
- D.
Influenza
- E.
Chlamydia
- F.
Human papilloma virus
- G.
Herpes Simplex
Correct Answer(s)
A. Rubella
B. Cytomegalovirus
G. Herpes SimplexExplanation
TORCH (Toxoplasmosis and other infections: rubella, cytomegalovirus, herpes simplex)Rate this question:
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- 20.
What are the normal physical responses of a pregnant woman who is on a Latent Phase of the First Stage of Labor?
- A.
Able to continue usual activities
- B.
Contractions mild, initially 10 to 20 minutes apart
- C.
Contractions moderate to severe, 2 to 3 minutes apart
- D.
Nausea, hiccups
Correct Answer(s)
A. Able to continue usual activities
B. Contractions mild, initially 10 to 20 minutes apartExplanation
During the Latent Phase of the First Stage of Labor, a pregnant woman may experience contractions that are mild and occur at intervals of 10 to 20 minutes apart. Additionally, she should be able to continue her usual activities without significant discomfort or disruption. This is because the cervix is starting to efface and dilate, but the contractions are not yet intense or frequent. Nausea and hiccups are not typically associated with this phase of labor.Rate this question:
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- 21.
An LPN is watching a nurse practitioner performs an abdominal palpation that is used to determine fetal presentatio, lie, postion, and engagement. As an LPN, you know that this is procedure is called:
Correct Answer(s)
leopold maneuvers
Leopold Maneuvers
Leopold maneuversExplanation
The correct answer is "Leopold maneuvers." This procedure is used to determine fetal presentation, lie, position, and engagement. It involves a series of palpations on the abdomen to assess the position and orientation of the fetus. The term "Leopold maneuvers" is named after the German obstetrician Christian Gerhard Leopold, who developed this technique in the late 19th century.Rate this question:
- 22.
A nursing student is discussing the normal findings in labor to a 39 weeks pregnant patient. What are the normal findings common to laboring client and the fetus? Select all that apply.
- A.
FHR of 130
- B.
maternal blood pressure of 139/89
- C.
Maternal pulse of 100
- D.
Maternal temperature of 100.4
- E.
Dehydration due to work of labor
- F.
Leukorrhea
Correct Answer(s)
A. FHR of 130
B. maternal blood pressure of 139/89
C. Maternal pulse of 100
D. Maternal temperature of 100.4
E. Dehydration due to work of laborExplanation
The normal findings common to a laboring client and the fetus include a FHR of 130, maternal blood pressure of 139/89, maternal pulse of 100, maternal temperature of 100.4, and dehydration due to the work of labor. These findings indicate that the fetus is experiencing a normal heart rate, the mother's blood pressure and pulse are within normal range, and she is experiencing the normal physiological response of dehydration during labor. The elevated temperature may indicate a slight fever, which can be a normal finding during labor. Leukorrhea, or increased vaginal discharge, is also a common finding in pregnancy but is not specific to labor.Rate this question:
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- 23.
Which of the following characteristics of contractions would the nurse expect to find in a client experiencing true labor?
- A.
Occurring at irregular intervals
- B.
Starting mainly in the abdomen
- C.
Gradually increasing intervals
- D.
Increasing intensity with walking
Correct Answer
D. Increasing intensity with walkingExplanation
With true labor, contractions increase in intensity with walking. In addition, true labor contractions occur at regular intervals, usually starting in the back and sweeping around to the abdomen. The interval of
true labor contractions gradually shortens.Rate this question:
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- 24.
During which of the following stages of labor would the nurse assess “crowning”?
- A.
First stage
- B.
Second stage
- C.
Third stage
- D.
Fourth stage
Correct Answer
B. Second stageExplanation
Crowing, which occurs when the newborn’s head
or presenting part appears at the vaginal opening, occurs during the second stage of labor. During the first stage of labor, cervical dilation and effacement occur. During the third stage of labor, the newborn and placenta are delivered. The fourth stage of labor lasts from 1 to 4 hours after birth, during which time the mother and newborn recover from the physical process of birth and the mother’s organs undergo the initial readjustment to the nonpregnant state.Rate this question:
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- 25.
Barbiturates are usually not given for pain relief during active labor for which of the following reasons?
- A.
The neonatal effects include hypotonia, hypothermia, generalized drowsiness, and reluctance to feed for the first few days.
- B.
These drugs readily cross the placental barrier, causing depressive effects in the newborn 2 to 3 hours after intramuscular injection.
- C.
They rapidly transfer across the placenta, and lack of an antagonist make them generally inappropriate during labor.
- D.
Adverse reactions may include maternal hypotension, allergic or toxic reaction or partial or total respiratory failure
Correct Answer
C. They rapidly transfer across the placenta, and lack of an antagonist make them generally inappropriate during labor.Explanation
Barbiturates are rapidly transferred across the placental barrier, and lack of an antagonist makes them generally inappropriate during active labor. Neonatal side effects of barbiturates include central nervous system depression, prolonged drowsiness, delayed establishment of feeding (e.g. due to poor sucking reflex or poor sucking pressure). Tranquilizers are associated with neonatal effects such as hypotonia, hypothermia, generalized drowsiness, and reluctance to feed for the first few days. Narcotic analgesic readily cross the placental barrier, causing depressive effects in the newborn 2 to 3 hours afterintramuscular injection. Regional anesthesia is associated with adverse reactions such as maternal hypotension, allergic or toxic reaction, or partial or total respiratory failure.Rate this question:
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- 26.
Which of the following nursing interventions would the nurse perform during the third stage of labor?
- A.
Obtain a urine specimen and other laboratory tests.
- B.
Assess uterine contractions every 30 minutes.
- C.
Coach for effective client pushing
- D.
Promote parent-newborn interaction.
Correct Answer
D. Promote parent-newborn interaction.Explanation
During the third stage of labor, which begins with the delivery of the newborn, the nurse would promote parent-newborn interaction by placing the newborn on the mother’s abdomen and encouraging the parents to touch the newborn. Collecting a urine specimen and other laboratory tests is done on admission during the first stage of labor. Assessing uterine contractions every 30 minutes is performed during the latent phase of the first stage of labor. Coaching the client to push effectively is appropriate during the second stage of labor.Rate this question:
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- 27.
Which of the following is described as premature separation of a normally implanted placenta during the second half of pregnancy, usually with severe hemorrhage?
- A.
Placenta previa
- B.
Ectopic pregnancy
- C.
Incompetent cervix
- D.
Abruptio placentae
Correct Answer
D. Abruptio placentaeExplanation
Abruptio placentae is described as premature separation of a normally implanted placenta during the second half of pregnancy, usually with severehemorrhage. Placenta previa refers to implantation of the placenta in the lower uterine segment, causing painless bleeding in the third trimester of pregnancy. Ectopic pregnancy refers to the implantation of the products of conception in a site other than the endometrium. Incompetent cervix is a conduction characterized by painful dilation of the cervical os without uterine contractions.Rate this question:
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- 28.
Which of the following would the nurse assess in a client experiencing abruptio placenta?
- A.
Bright red, painless vaginal bleeding
- B.
Concealed or external dark red bleeding
- C.
Palpable fetal outline
- D.
Soft and nontender abdomen
Correct Answer
B. Concealed or external dark red bleedingExplanation
A client with abruptio placentae may exhibit concealed or dark red bleeding, possibly reporting sudden intense localized uterine pain. The uterus is typically firm to boardlike, and the fetal presenting part may be engaged. Bright red, painless vaginal bleeding, a palpable fetal outline and a soft nontender abdomen are manifestations of placenta previa.Rate this question:
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- 29.
Which of the following best describes preterm labor?
- A.
Labor that begins after 20 weeks gestation and before 37 weeks gestation
- B.
Labor that begins after 15 weeks gestation and before 37 weeks gestation
- C.
Labor that begins after 24 weeks gestation and before 28 weeks gestation
- D.
Labor that begins after 28 weeks gestation and before 40 weeks gestation
Correct Answer
A. Labor that begins after 20 weeks gestation and before 37 weeks gestationExplanation
Preterm labor is best described as labor that begins after 20 weeks’ gestation and before 37 weeks’ gestation. The other time periods are inaccurate.Rate this question:
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- 30.
Which of the following is the nurse’s initial action when umbilical cord prolapse occurs?
- A.
Begin monitoring maternal vital signs and FHR
- B.
Place the client in a knee-chest position in bed
- C.
Notify the physician and prepare the client for delivery
- D.
Apply a sterile warm saline dressing to the exposed cord
Correct Answer
B. Place the client in a knee-chest position in bedExplanation
The immediate priority is to minimize pressure on the cord. Thus the nurse’s initial action involves placing the client on bed rest and then placing the client in a knee-chest position or lowering the head of the bed, and elevating the maternal hips on a pillow to minimize the pressure on the cord. Monitoring maternal vital signs and FHR, notifying the physician and preparing the client for delivery, and wrapping the cord with sterile saline soaked warm gauze are important. But these actions have no effect on minimizing the pressure on the cord.Rate this question:
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- 31.
Which of the following best describes thrombophlebitis?
- A.
Inflammation and clot formation that result when blood 4 b. PROM removes the fetus most effective defense against infection c. Nursing care is based on fetal viability and gestational components combine to form an aggregate body
- B.
Inflammation and blood clots that eventually become lodged within the pulmonary blood vessels
- C.
Inflammation and blood clots that eventually become lodged within the femoral vein
- D.
Inflammation of the vascular endothelium with clot formation on the vessel wall
Correct Answer
D. Inflammation of the vascular endothelium with clot formation on the vessel wallExplanation
Thrombophlebitis refers to an inflammation of the vascular endothelium with clot formation on the wall of the vessel. Blood components combining to form an aggregate body describe a thrombus or thrombosis. Clots lodging in the pulmonary vasculature refers to pulmonary embolism; in the
femoral vein, femoral thrombophlebitis.Rate this question:
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- 32.
Which of the following assessment findings would the nurse expect if the client develops DVT?
- A.
Midcalf pain, tenderness and redness along the vein
- B.
Chills, fever, malaise, occurring 2 weeks after delivery
- C.
Muscle pain the presence of Homans sign, and swelling in the affected limb
- D.
Chills, fever, stiffness, and pain occurring 10 to 14 days after delivery
Correct Answer
C. Muscle pain the presence of Homans sign, and swelling in the affected limbExplanation
Classic symptoms of DVT include muscle pain, the
presence of Homans sign, and swelling of the affected limb. Midcalf pain, tenderness, and redness, along the vein reflect superficial thrombophlebitis. Chills, fever and malaise occurring 2 weeks after delivery reflect pelvic thrombophlebitis. Chills, fever, stiffness and pain occurring 10 to 14 days afterRate this question:
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- 33.
Which of the following statement about L/S ratio in amniotic fluid is correct?
- A.
A slight variation in technique does not significantly affect the accuracy of result
- B.
a L/S ratio of 2:1 is incompatible with life
- C.
A L/S ratio of less than 1:0 is compatible with fetal survival
- D.
When L/S ratio is 2:1 below, majority of infants develop respiratory distress
Correct Answer
D. When L/S ratio is 2:1 below, majority of infants develop respiratory distressExplanation
When the L/S ratio is below 2:1, the majority of infants develop respiratory distress. This means that a lower L/S ratio indicates a higher risk of respiratory issues in newborns.Rate this question:
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- 34.
Which of the following is not true regarding the third stage of labor?
- A.
Care should be taken in the administration of bolus of oxytocin because it can cause hypertension
- B.
Signs of placental separation are lengthening of the cord, sudden gush of blood and sudden change in shape of the uterus
- C.
It ranges from the time of expulsion of the fetus to the delivery of the placenta
- D.
The placenta is delivered approximately 5-15 minutes after delivery of the baby
Correct Answer
A. Care should be taken in the administration of bolus of oxytocin because it can cause hypertensionExplanation
The administration of a bolus of oxytocin during the third stage of labor does not cause hypertension. Oxytocin is commonly used to prevent postpartum hemorrhage by stimulating uterine contractions and aiding in the delivery of the placenta. However, it is important to monitor the administration of oxytocin and adjust the dosage to avoid excessive uterine contractions, which can lead to hypertonicity and potentially cause hypertension.Rate this question:
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- 35.
Calculate the heart rate of the patient using the ECG strip above.
Correct Answer
140 bpm
140bpm
140Explanation
The given answer states that the heart rate of the patient is 140 bpm. This indicates that the patient's heart is beating at a rate of 140 beats per minute. The ECG strip provided may contain information or patterns that suggest this heart rate. However, without visual representation of the ECG strip, it is difficult to provide a more detailed explanation.Rate this question:
- 36.
Calculate the heart rate of the patient using the ECG strip provided above.
Correct Answer
40 bpm
40bpm
40Explanation
The answer provided is 40 bpm, 40bpm, 40. This indicates that the heart rate of the patient is 40 beats per minute.Rate this question:
- 37.
How would you correctly document this ECG strip on the client's chart using the correct medical terminology?
Correct Answer
sinus rhythm
Sinus rhythmExplanation
The correct answer is "sinus rhythm" or "Sinus rhythm". Sinus rhythm refers to the normal electrical activity of the heart, where the electrical impulses originate from the sinus node. This is the normal rhythm of a healthy heart and is characterized by a regular and consistent pattern on the ECG strip. By documenting "sinus rhythm" or "Sinus rhythm" on the client's chart, it accurately describes the normal electrical activity of the heart during the ECG recording.Rate this question:
- 38.
Basing on the normal Conduction System of the heart, numer 2 is called the:
Correct Answer
AV nodeExplanation
The correct answer is AV node. In the normal conduction system of the heart, the AV node is responsible for conducting electrical signals from the atria to the ventricles. It acts as a gatekeeper, delaying the transmission of the signal to allow for the atria to fully contract before the ventricles are activated. This delay ensures efficient pumping of blood and coordination between the atria and ventricles.Rate this question:
- 39.
What is the normal ratio of bicarbonate to carbonic acid to maintain the HOMEOSTASIS of the body?
Correct Answer
20:1Explanation
The normal ratio of bicarbonate to carbonic acid in the body is 20:1. This ratio is important for maintaining homeostasis, as it helps regulate the pH of the blood and other bodily fluids. Bicarbonate acts as a buffer, helping to neutralize acids in the body, while carbonic acid helps regulate the levels of carbon dioxide in the blood. This balance is crucial for proper functioning of various physiological processes in the body.Rate this question:
- 40.
A second year nursing student has just suf- fered a needlestick while working with a patient that is positive for AIDS. Which of the following is the most important action that nursing student should take?
- A.
Immediately see a social worker
- B.
Start prophylactic AZT treatment
- C.
Start prophylactic Pentamide treatment
- D.
Seek counseling
Correct Answer
B. Start prophylactic AZT treatmentExplanation
AZT treatment is the most critical innervention.Rate this question:
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- 41.
A patient asks a nurse, “My doctor recom- mended I increase my intake of folic acid. What type of foods contain the highest concentration of folic acids?”
- A.
Green vegetables and liver
- B.
Yellow vegetables and red meat
- C.
Carrots
- D.
Milk
Correct Answer
A. Green vegetables and liverExplanation
Green vegetables and liver are a great source of folic acid.Rate this question:
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- 42.
A 65 year old man has been admitted to the hospital for spinal stenosis surgery. When does the discharge training and planning begin for this patient?
- A.
Following surgery
- B.
Upon admit
- C.
Within 48 hours of discharge
- D.
Preoperative discussion
Correct Answer
B. Upon admitExplanation
Discharge education begins upon admit.Rate this question:
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- 43.
A nurse is making rounds taking vital signs. Which of the following vital signs is abnormal?
- A.
11 year old male – 90 b.p.m, 22 resp/min. , 100/70 mm Hg
- B.
13 year old female – 105 b.p.m., 22 resp/min., 105/60 mm Hg
- C.
5 year old male- 102 b.p.m, 24 resp/min., 90/65 mm Hg
- D.
6 year old female- 100 b.p.m., 26 resp/min., 90/70mm Hg
Correct Answer
B. 13 year old female – 105 b.p.m., 22 resp/min., 105/60 mm HgExplanation
HR and Respirations are slightly in- creased. BP is down.Rate this question:
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- 44.
A patient’s chart indicates a history of hyperkalemia. Which of the following would you not expect to see with this patient if this condition were acute?
- A.
Decrease HR
- B.
Paresthesia
- C.
Muscle weakness of the extremities
- D.
Migranes
Correct Answer
D. MigranesExplanation
Answer choices A-C were symptoms of acute hyperkalemia.Rate this question:
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- 45.
A nurse is administering a shot of Vitamin K to a 30 day-old infant. Which of the following tar- get areas is the most appropriate?
- A.
Gluteus maximus
- B.
Gluteus minimus
- C.
Vastus lateralis
- D.
Vastus medialis
Correct Answer
C. Vastus lateralisExplanation
Vastus lateralis is the most appropriate location.Rate this question:
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- 46.
A client is prescribed warfarin sodium (Coumadin) to be continued at home. Which focus is critical to be included in the nurse’s discharge instruction?
- A.
Maintain a consistent intake of green leafy foods
- B.
Report any nose or gum bleeds
- C.
Take Tylenol for minor pains
- D.
Use a soft toothbrush
Correct Answer
B. Report any nose or gum bleedsExplanation
Report any nose or gum bleeds
The client should notify the health care provider if blood is noted in stools or urine, or any other signs of bleeding occur.Rate this question:
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- 47.
At a senior citizens meeting a nurse talks with a client who has Type 1 diabetes mellitus. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity?
- A.
“I give my insulin to myself in my thighs.”
- B.
“Sometimes when I put my shoes on I don’t know where my toes are.”
- C.
“Here are my up and down glucose readings that I wrote on my calendar.”
- D.
“If I bathe more than once a week my skin feels too dry.”
Correct Answer
B. “Sometimes when I put my shoes on I don’t know where my toes are.”Explanation
“Sometimes when I put my shoes on I don’’t know where my toes are.”
Peripheral neuropathy can lead to lack of sensa- tion in the lower extremities. Clients who do not feel pressure and/or pain are at high risk for skin impairment.Rate this question:
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- 48.
A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?
- A.
Drink small amounts of liquids frequently
- B.
Eat the evening meal just before retiring
- C.
Take sodium bicarbonate after each meal
- D.
Sleep with head propped on several pillows
Correct Answer
D. Sleep with head propped on several pillowsExplanation
Sleep with head propped on several pillows Heartburn is a burning sensation caused by re- gurgitation of gastric contents. It is best relieved by sleeping position, eating small meals, and not eating before bedtime.Rate this question:
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- 49.
The nurse is caring for a client with extracellular fluid volume deficit. Which of the following assessments would the nurse anticipate finding?
- A.
Bounding pulse
- B.
Rapid respiration
- C.
Oliguria
- D.
Neck vein distention
Correct Answer
C. OliguriaExplanation
oliguria
Kidneys maintain fluid volume through adjust- ments in urine volume.Rate this question:
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- 50.
The client tells the nurse that her last menstrual period started on January 14 and ended on January 20. Using Nagele’s rule, the nurse determines her EDD to be which of the following?
- A.
September 27
- B.
October 21
- C.
November 7
- D.
December 27
Correct Answer
B. October 21Explanation
To calculate the EDD by Nagele’s rule, add 7 days to the first day of the last menstrual period and count back 3 months, changing the year appropriately. To obtain a date of September 27, 7 days have been added to the last day of the LMP (rather than the first day of the LMP), plus 4 months (instead of 3 months) were counted back. To obtain the date of November 7, 7 days have been subtracted (instead of added) from the first day of LMP plus November indicates counting back 2 months (instead of 3 months) from January. To obtain the date of December 27, 7 days were added to the last day of the LMP (rather than the first day of the LMP) and December indicates counting back only 1 month (instead of 3 months) from January.Rate this question:
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