HESI Comprehensive NCLEX-RN Practice (Maternity)

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An expectant father tells the nurse he fears that his wife is “losing her mind.” He states that she is constantly rubbing her abdomen and talking to the baby and that she actually reprimands the baby when it moves too much. Which recommendation should the nurse make to this expectant father? A.Suggest that his wife seek professional counseling to deal with her symptoms. B.Explain that his wife is exhibiting ambivalence about the pregnancy. C. Ask him to report similar abnormal behaviors at the next prenatal visit. D.Reassure him that normal maternal-fetal bonding is occurring.
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D) Reassure him that normal maternal-fetal bonding is occurring. Rationale: These behaviors are positive signs of maternal-fetal bonding and do not reflect ambivalence. No intervention is needed. Quickening, the first perception of fetal movement, occurs at 17 to 20 weeks of gestation and begins a new phase of prenatal bonding during the second trimester. Options A and C are not necessary because the behaviors displayed are normal.
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The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure is completed, it is most important for the nurse to obtain which information? A.Maternal blood pressure B.Maternal temperature C.Fetal heart rate (FHR) D.White blood cell count (WBC)
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C. Fetal heart rate (FHR) Rationale: The FHR should be assessed before and after the procedure to detect changes that may indicate the presence of cord compression or prolapse. An amniotomy (artificial rupture of membranes [AROM]) is used to stimulate labor when the condition of the cervix is favorable. The fluid should be assessed for color, odor, and consistency. Option A should be assessed every 15 to 20 minutes during labor but is not specific for AROM. Option B is monitored hourly after the membranes are ruptured to detect the development of amnionitis. Option D should be determined for all clients in labor.
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A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In developing a plan of care, the nurse should give the highest priority to which finding? A.Cyanosis of the hands and feet B.Skin color that is slightly jaundiced C.Tiny white papules on the nose or chin D.Red patches on the cheeks and trunk
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B. Skin color that is slightly jaundiced Rationale: Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin, which should be further evaluated in a newborn <24 hours old. Acrocyanosis (blue color of the hands and feet) is a common finding in newborns; it occurs because the capillary system is immature. Milia are small white papules present on the nose and chin that are caused by sebaceous gland blockage and disappear in a few weeks. Small red patches on the cheeks and trunk are called erythema toxicum neonatorum, a common finding in newborns.
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A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client? A.Breastfeed the infant, ensuring that both breasts are completely emptied. B.Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast. C.Breastfeed on the unaffected breast only until the mastitis subsides. D.Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant.
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A.Breastfeed the infant, ensuring that both breasts are completely emptied. Rationale:Mastitis, caused by plugged milk ducts, is related to breast engorgement, and breastfeeding during mastitis facilitates the complete emptying of engorged breasts, eliminating the pressure on the inflamed breast tissue. Option B is less painful but does not facilitate complete emptying of the breast tissue. Option C will not relieve the engorgement on the affected side. Option D will not decrease antibiotic effects on the infant.
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A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction will aid in the prevention of pooling of blood in the lower extremities? A.Wear support stockings. B.Reduce salt in the diet. C.Move about every hour. D.Avoid constrictive clothing.
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C.Move about every hour. Rationale: Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the pelvic veins. Moving about every hour will relieve pressure on the pelvic veins and increase venous return. Option A would increase venous return from varicose veins in the lower extremities but would be of little help with swelling. Option B might be helpful with generalized edema but is not specific for edematous lower extremities. Option D does not address venous return, and there is no indication in the question that constrictive clothing is a problem.
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Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized swelling on the right side of his head. In a newborn, what is the most likely cause of this accumulation of blood between the periosteum and skull that does not cross the suture line? A.Cephalhematoma, which is caused by forceps trauma B.Subarachnoid hematoma, which requires immediate drainage C.Molding, which is caused by pressure during labor D.Subdural hematoma, which can result in lifelong damage
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A.Cephalhematoma, which is caused by forceps trauma Rationale: Cephalhematoma, a slight abnormal variation of the newborn, usually arises within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and skull. Option C is a cranial distortion lasting 5 to 7 days, caused by pressure on the cranium during vaginal delivery, and is a common variation of the newborn. Options B and D both involve intracranial bleeding and could not be detected by physical assessment alone.
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Prior to discharge, what instructions should the nurse give to parents regarding the newborn’s umbilical cord care at home? A.Wash the cord frequently with mild soap and water. B.Cover the cord with a sterile dressing. C.Allow the cord to air-dry as much as possible. D.Apply baby lotion after the baby’s daily bath
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C.Allow the cord to air-dry as much as possible. Rationale:Recent studies have indicated that air drying or plain water application may be equal to or more effective than alcohol in the cord healing process. Options A, B, and D are incorrect because they promote moisture and increase the potential for infection.
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A mother expresses fear about changing the infant’s diaper after circumcision. What information should the nurse include in the teaching plan? A.Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. B.Wash off the yellow exudate on the glans once every day to prevent infection. C.Place petroleum ointment around the glans with each diaper change and cleansing. D.Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding occurs.
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C.Place petroleum ointment around the glans with each diaper change and cleansing. Rationale: With each diaper change, the glans penis should be washed with warm water to remove any urine or feces, and petroleum ointment should be applied to prevent the diaper from sticking to the healing surface. Prepackaged wipes often contain other products that may irritate the site. The yellow exudate, which covers the glans penis as the area heals and epithelializes, is not an infective process and should not be removed. If bleeding occurs at home, the client should be instructed to apply gentle pressure to the site of the bleeding with sterile gauze squares and call the health care provider.
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A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in preterm labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her labor contractions. What are the primary side effects of terbutaline sulfate? A.Drowsiness and paroxysmal bradycardia B.Depressed reflexes and increased respirations C.Tachycardia and a feeling of nervousness D.A flushed warm feeling and dry mouth
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C.Tachycardia and a feeling of nervousness Rationale: Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the drug may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of nervousness. Option A is not a side effect. Options B and D are side effects of magnesium sulfate.
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A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective in preventing nipple soreness? A.Wear a cotton bra with nonbinding support. B.Increase nursing time gradually over several days. C.Ensure that the baby is positioned correctly for latching on. D.Manually express a small amount of milk before nursing.
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C.Ensure that the baby is positioned correctly for latching on. Rationale: The most common cause of nipple soreness is incorrect positioning of the infant on the breast for latching on. The baby’s body is in alignment with the ears, shoulders, and hips in a straight line, with the nose, cheeks, and chin touching the breast. Option A helps prevent chafing, and nonbinding support aids in prevention of discomfort from the stretching of the Cooper ligament. Option B is important but is not necessary for all women. Option D helps soften an engorged breast and encourages correct infant latching on but is not the best answer.
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A new mother asks the nurse, “How do I know that my daughter is getting enough breast milk?” Which explanation is appropriate? A.”Weigh the baby daily, and if she is gaining weight, she is getting enough to eat.” B.”Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day.” C.”Offer the baby extra bottled milk after her feeding and see if she still seems hungry.” D.”If you’re concerned, you might consider bottle feeding so that you can monitor intake.”
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B.”Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day.” Rationale: The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day), if the infant is adequately hydrated. Although a weight gain of 30 g/day is indicative of adequate nutrition, most home scales do not measure this accurately, and the suggestion will likely make the mother anxious. Option C causes nipple confusion and diminishes the mother’s milk production. Option D does not address the client’s question.
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The client comes to the hospital assuming she is in labor. Which assessment findings by the nurse would indicate that the client is in true labor? (Select all that apply.) A.Pain in the lower back that radiates to abdomen B.Contractions decreased in frequency with ambulation C.Progressive cervical dilation and effacement D.Discomfort localized in the abdomen E.Regular and rhythmic painful contractions
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A.Pain in the lower back that radiates to abdomen C.Progressive cervical dilation and effacement E.Regular and rhythmic painful contractions Rationale: These are all signs of true labor. Options B and D are signs of false labor.
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Which statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn? A.”Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period.” B.”Breastfeeding my baby immediately after drinking alcohol is safer than waiting for the alcohol to clear my breast milk.” C.”I can start smoking cigarettes while breastfeeding because it will not affect my breast milk.” D.”When I take a warm shower after I breastfeed, it relieves the pain from being engorged between breastfeedings.
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A.”Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period.” Rationale: Continuous breastfeeding on a 3- to 4-hour schedule during the day will cause a release of prolactin, which will suppress ovulation and menses, but is not completely effective as a birth control method. Option B is incorrect because alcohol can immediately enter the breast milk. Nicotine is transferred to the infant in breast milk. Taking a warm shower will stimulate the production of milk, which will be more painful after breastfeedings.
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A new mother who has just had her first baby says to the nurse, “I saw the baby in the recovery room. She sure has a funny-looking head.” Which response by the nurse is best? A.”This is not an unusually shaped head, especially for a first baby.” B.”It may look odd, but newborn babies are often born with heads like that.” C.”That is normal. The head will return to a round shape within 7 to 10 days.” D.”Your pelvis was too small, so the head had to adjust to the birth canal.”
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C.”That is normal. The head will return to a round shape within 7 to 10 days.” Rationale: Option C reassures the mother that this is normal in the newborn and provides correct information regarding the return to a normal shape. Although option A is correct, it implies that the client should not worry. Any implied or spoken “don’t worry” is usually the wrong answer. Option B is condescending and dismissing; the mother is seeking reassurance and information. Option D is a negative statement and implies that molding is the mother’s fault.
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Twenty minutes after a continuous epidural anesthetic is administered, a laboring client’s blood pressure drops from 120/80 to 90/60 mm Hg. Which action should the nurse take immediately? A.Notify the health care provider or anesthesiologist. B.Continue to assess the blood pressure every 5 minutes. C.Place the client in a lateral position. D.Turn off the continuous epidural.
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C.Place the client in a lateral position. Rationale: The nurse should immediately turn the client to a lateral position or place a pillow or wedge under one hip to deflect the uterus. Other immediate interventions include increasing the rate of the main line IV infusion and administering oxygen by facemask. If the blood pressure remains low after these interventions or decreases further, the anesthesiologist or health care provider should be notified immediately. To continue to monitor blood pressure without taking further action could constitute malpractice. Option D may also be warranted, but such action is based on hospital protocol.
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The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan? A.Avoid alcohol because it is excreted in breast milk. B.Eat a high-roughage diet to help prevent constipation. C.Increase caloric intake by approximately 500 cal/day. D.Increase fluid intake to at least 3 quarts each day.
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A.Avoid alcohol because it is excreted in breast milk. Rationale: Alcohol should be avoided while breastfeeding because it is excreted in breast milk and may cause a variety of problems, including slower growth and cognitive impairment for the infant. Options B, C, and D should also be included in diet teaching for a breastfeeding mother; however, because these do not involve safety of the infant, they do not have the same degree of importance as option A.
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A client at 28 weeks of gestation calls the antepartal clinic and states that she has just experienced a small amount of vaginal bleeding, which she describes as bright red. The bleeding has subsided. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? A.Come to the clinic today for an ultrasound. B.Go immediately to the emergency department. C.Lie on your left side for about 1 hour and see if the bleeding stops. D.Take a urine specimen to the laboratory to see if you have a urinary tract infection (UTI).
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A.Come to the clinic today for an ultrasound. Rationale:Third-trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first incident life threatening or cause for hypovolemic shock. Diagnosis is confirmed by transabdominal ultrasound. Bleeding that has a sudden onset and is accompanied by intense uterine pain indicates abruptio placenta, which is life threatening to the mother and fetus. If those symptoms were described, option B would be appropriate. Option C does not address the cause of the symptoms. The client is not describing symptoms of a UTI.
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A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and returns to baseline after the contraction. Which action should the nurse implement? A.Place a wedge under the client’s left side. B.Determine cervical dilation and effacement. C.Administer 10 L of oxygen via facemask. D.Increase the rate of the oxytocin (Pitocin) infusion.
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B.Determine cervical dilation and effacement. Rationale: The goal of labor augmentation is to produce firm contractions that occur every 2 to 3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress. FHR accelerations are a normal response to contractions, so the oxytocin (Pitocin) infusion should be increased per protocol to stimulate the frequency and intensity of contractions. Options A and C are indicated for fetal stress. A sterile vaginal examination places the client at risk for infection and should be performed when the client exhibits signs of progressing labor, which is not indicated at this time.
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A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating and states that because she has had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority? A.Altered nutrition, less than body requirements for lactation B.Alteration in comfort related to nausea and abdominal distention C.Impaired bowel motility related to pain medication and immobility D.Fatigue related to cesarean delivery and physical care demands of infant
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C.Impaired bowel motility related to pain medication and immobility Rationale: Impaired bowel motility caused by surgical anesthesia, pain medication, and immobility is the priority nursing diagnosis and addresses the potential problem of a paralytic ileus. Options A and B are both caused by impaired bowel motility. Option D is not as important as impaired motility.
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The nurse is counseling a client who wants to become pregnant. She tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. When will the client’s next fertile period occur? A.January 14 to 15 B.January 22 to 23 C.January 29 to 30 D.February 6 to 7
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C.January 29 to 30 Rationale: This client can expect her next period to begin 36 days from the first day of her last menstrual period. Her next period would begin on February 12. Ovulation occurs 14 days before the first day of the menstrual period. The client can expect ovulation to occur January 29 to 30. Options A, B, and D are incorrect.
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In developing a teaching plan for expectant parents, the nurse decides to include information about when the parents can expect the infant’s fontanels to close. Which statement is accurate regarding the timing of closure of an infant’s fontanels that should be included in this teaching plan? A.The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the end of the first week. B.The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the end of the second week. C.The anterior fontanel closes at 8 to 11 months and the posterior fontanel by the end of the first month. D.The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month
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D.The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month Rationale: In the normal infant, the anterior fontanel closes at 12 to 18 months of age and the posterior fontanel closes by the end of the second month. These growth and development milestones are frequently included in questions on the licensure examination. Options A, B, and C are incorrect.
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A client who is 3 days postpartum and breastfeeding asks the nurse how to reduce breast engorgement. Which instruction should the nurse provide? A.Avoid using the breast pump. B.Breastfeed the infant every 2 hours. C.Reduce fluid intake for 24 hours. D.Skip feedings to let the sore breasts rest.
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B.Breastfeed the infant every 2 hours. Rationale: The mother should be instructed to attempt feeding her infant every 2 hours while massaging the breasts as the infant is feeding. If the infant does not feed adequately and empty the breast, using a breast pump helps extract the milk and relieve some of the discomfort. Dehydration irritates swollen breast tissue. Skipping feedings may cause further engorgement and discomfort.
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An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? A.Use thread to tie off the umbilical cord. B.Provide privacy for the woman. C.Reassure the husband and keep him calm. D.Put the newborn to the breast immediately.
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D.Put the newborn to the breast immediately. Rationale: Putting the newborn to the breast will help contract the uterus and prevent a postpartum hemorrhage. This intervention has the highest priority. Option A is not necessary; the infant can be transported attached to the placenta. Option B is an important psychosocial need but does not have the priority of option D. Although the husband is an important part of family-centered care, he is not the most important concern at this time.
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The nurse calls a client who is 4 days postpartum to follow up about her transition with her newborn son at home. The woman tells the nurse, “I don’t know what is wrong. I love my son, but I feel so let down. I seem to cry for no reason!” Which adjustment phase should the nurse determine the client is experiencing? A.Taking-in phase B.Postpartum blues C.Attachment difficulty D.Letting-go phase
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B.Postpartum blues Rationale: During the postpartum period, when serum hormone levels fall, women are emotionally labile, often crying easily for no apparent reason. This phase is commonly called postpartum blues, which peaks around the fifth postpartum day. The taking-in phase is the period following birth when the mother focuses on her own psychological needs; typically, this period lasts for 24 hours. Crying is not a maladaptive attachment response. It indicates a normal physical and emotional response. The letting-go phase is when the mother sees the child as a separate individual.
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Which findings are of most concern to the nurse when caring for a woman in the first trimester of pregnancy? (Select all that apply.) A.Cramping with bright red spotting B.Extreme tenderness of the breast C.Lack of tenderness of the breast D.Increased amounts of discharge E.Increased right-side flank pain
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A.Cramping with bright red spotting C.Lack of tenderness of the breast E.Increased right-side flank pain Rationale: Options A and C are signs of a possible miscarriage. Cramping with bright red bleeding is a sign that the client’s menstrual cycle is about to begin. A decrease of tenderness in the breast is a sign that hormone levels have declined and that a miscarriage is imminent. Option E could be a sign of an ectopic pregnancy, which could be fatal if not discovered in time before rupture. Options B and D are normal signs during the first trimester of a pregnancy.
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On admission to the prenatal clinic, a client tells the nurse that her last menstrual period began on February 15 and that previously her periods were regular (28-day cycle). Her pregnancy test is positive. What is this client’s expected date of birth (EDB)? A.November 22 B.November 8 C.December 22 D.October 22
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A.November 22 Rationale: Option A correctly applies the NĂ€gele rule for estimating the due date by counting back 3 months from the first day of the last menstrual period (January, December, November) and adding 7 days (15 + 7 = 22). Options B, C, and D are not calculated correctly.
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A newborn infant, diagnosed with developmental dysplasia of the hip (DDH), is being prepared for discharge. Which nursing intervention should be included in this infant’s discharge teaching plan? A.Observe the parents applying a Pavlik harness. B.Provide a referral for an orthopedic surgeon. C.Schedule a physical therapy follow-up home visit. D.Teach the parents to check for hip joint mobility.
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A.Observe the parents applying a Pavlik harness. Rationale: It is important that the hips of infants with hip dysplasia are maintained in an abducted position, which can be accomplished by using the Pavlik harness; this keeps the hips and knees flexed, the hips abducted, and the femoral head in the acetabulum. Early treatment often negates the need for surgery, and option B is not indicated until approximately 6 months of age. Option C is not indicated for hip dysplasia. It is best for the pediatrician to monitor hip joint mobility, and teaching the parents to perform this technique is likely to increase their anxiety.
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Which findings are most critical for the nurse to report to the primary health care provider when caring for the client during the last trimester of her pregnancy? (Select all that apply.) A.Increased heartburn that is not relieved with doses of antacids B.Increase of the fetal heart rate from 126 to 156 beats/min from the last visit C.Shoes and rings that are too tight because of peripheral edema in extremities D.Decrease in ability for the client to sleep for more than 2 hours at a time E.Chronic headache that has been lingering for a week behind the client’s eyes
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A.Increased heartburn that is not relieved with doses of antacids E.Chronic headache that has been lingering for a week behind the client’s eyes Rationale: Options A and E are possible signs of preeclampsia or eclampsia but can also be normal signs of pregnancy. These signs should be reported to the health care provider for further evaluation for the safety of the client and the fetus. Options B, C, and D are all normal signs during the last trimester of pregnancy.
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Client teaching is an important part of the perinatal nurse’s role. Which factor has the greatest influence on successful teaching of the pregnant client? A.The client’s investment in what is being taught B.The couple’s highest levels of education C.The order in which the information is presented D.The extent to which the pregnancy was planned
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A.The client’s investment in what is being taught Rationale: When teaching any client, readiness to learn is related to how much the client has invested in what is being taught or how important the materials are to the client’s particular life. For example, the client with severe morning sickness in the first trimester may not be ready to learn about labor and delivery but is probably very ready to learn about ways to relieve morning sickness. Options B and C are factors that may influence learning but are not as influential as option A. Even if a pregnancy is planned and very desirable, the client must be ready to learn the content presented.
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When preparing a class on newborn care for expectant parents, which is correct for the nurse to teach concerning the newborn infant born at term gestation? A.Milia are red marks made by forceps and will disappear within 7 to 10 days. B.Meconium is the first stool and is usually yellow gold in color. C.Vernix is a white cheesy substance, predominantly located in the skin folds. D.Pseudostrabismus found in newborns is treated by minor surgery.
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C.Vernix is a white cheesy substance, predominantly located in the skin folds. Rationale: Vernix, found in the folds of the skin, is a characteristic of term infants. Milia are not red marks made by forceps but are white pinpoint spots usually found over the nose and chin that represent blockage of the sebaceous glands. Meconium is the first stool, but it is tarry black, not yellow. Pseudostrabismus (crossed eyes) is normal at birth through the third or fourth month and does not require surgery.
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Six hours after an oxytocin (Pitocin) induction was begun and 2 hours after spontaneous rupture of the membranes, the nurse notes several sudden decreases in the fetal heart rate with quick return to baseline, with and without contractions. Based on this fetal heart rate pattern, which intervention is best for the nurse to implement? A.Turn the client to her side. B.Begin oxygen by nasal cannula at 2 L/min. C.Place the client in a slight Trendelenburg position. D.Assess for cervical dilation.
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C. Place the client in a slight Trendelenburg position. Rationale:The goal is to relieve pressure on the umbilical cord, and placing the client in a slight Trendelenburg position is most likely to relieve that pressure. The FHR pattern is indicative of a variable fetal heart rate deceleration, which is typically caused by cord compression and can occur with or without contractions. Option A may be helpful but is not as likely to relieve the pressure as the Trendelenburg position. Option B is not helpful with cord compression. Option D is not the priority intervention at this time. After repositioning the client, a vaginal examination is indicated to rule out cord prolapse and assess for cervical change.
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A mother who is HIV-positive delivers a full-term newborn and asks the nurse if her baby will become HIV-infected. Which explanation should the nurse provide? A.Most infants of HIV-positive women will continue to test positive for HIV antibodies. B.Infants who have HIV-positive mothers carry the virus and will eventually develop the disease. C.Medication taken during pregnancy to reduce the mother’s viral load ensures that the infant is HIV-negative. D.HIV infection is determined at 18 months of age, when maternal HIV antibodies are no longer present.
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D.HIV infection is determined at 18 months of age, when maternal HIV antibodies are no longer present. Rationale: All newborns of HIV-positive mothers receive passive HIV antibodies from the mother, so the evaluation of an infant for the HIV virus is determined at 18 months of age, when all the maternal antibodies are no longer in the infant’s blood. Passive HIV antibodies disappear in the infant within 18 months of age. Option B is inaccurate. Although administration of HIV medication during pregnancy can significantly reduce the risk of vertical transmission, treatment does not ensure that the virus will not become manifest in the infant.
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A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement? A.Encourage frequent use of a pacifier so that the infant becomes accustomed to sucking. B.Hold the infant’s head firmly against the breast until he latches onto the nipple. C.Encourage the mother to stop feeding for a few minutes and comfort the infant. D.Provide formula for the infant until he becomes calm, and then offer the breast again.
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C.Encourage the mother to stop feeding for a few minutes and comfort the infant. Rationale: The infant is becoming frustrated and so is the mother; both need a time out. The mother should be encouraged to comfort the infant and to relax herself. After such a time out, breastfeeding is often more successful. Options A and D would cause nipple confusion. Option B would only cause the infant to be more resistant, resulting in the mother and infant becoming more frustrated.
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A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her lochia is getting lighter in color. Which action should the nurse take? A.Instruct the client to go to the emergency room. B.Recommend vaginal douching. C.Explain this is a normal finding. D.Determine if ovulation has occurred.
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C.Explain this is a normal finding. Rationale:The client is describing lochia serosa, a normal change in the lochial flow. Options A, B, and D are not recommended for this normal finding.
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A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The home health nurse has taught her how to take her own blood pressure and gave her parameters to judge a significant increase in blood pressure. When the client calls the clinic complaining of indigestion, which instruction should the nurse provide? A.Lie on your left side and call 911 for emergency assistance. B.Take an antacid and call back if the pain has not subsided. C.Take your blood pressure now, and if it is seriously elevated, go to the hospital. D.See your health care provider to obtain a prescription for a histamine blocking agent.
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C.Take your blood pressure now, and if it is seriously elevated, go to the hospital. Rationale: Checking the blood pressure for an elevation is the best instruction to give at this time. A blood pressure exceeding 140/90 mm Hg is indicative of preeclampsia. Epigastric pain can be a sign of an impending seizure (eclampsia), a life-threatening complication of gestational hypertension. Additional data are needed to confirm an emergency situation as described in option A. Options B and D ignore the threat to client safety posed by a significant increase in blood pressure.
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The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct? A.Two weeks before menstruation B.Immediately after menstruation C.Immediately before menstruation D.Three weeks before menstruation
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A.Two weeks before menstruation Rationale:Ovulation occurs 14 days before the first day of the menstrual period. Although ovulation can occur in the middle of the cycle or 2 weeks after menstruation, this is only true for a woman who has a perfect 28-day cycle. For many women, the length of the menstrual cycle varies. Options B, C, and D are incorrect.
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A client in active labor is becoming increasingly fearful because her contractions are occurring more often than she had expected. Her partner is also becoming anxious. Which of the following should be the focus of the nurse’s response? A.Telling the client and her partner that the labor process is often unpredictable B.Informing the client that this means she will give birth sooner than expected C.Asking the client and her partner if they would like the nurse to stay in the room D.Affirming that the fetal heart rate is remaining within normal limits
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C.Asking the client and her partner if they would like the nurse to stay in the room Rationale: Offering to remain with the client and her partner offers support without providing false reassurance. The length of labor is not always predictable, but options A and B do not offer the client the support that is needed at this time. Option D may be reassuring regarding the fetal heart rate but does not provide the client the emotional support she needs at this time during the labor process.
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When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? A.At 16 weeks of gestation B.At 20 weeks of gestation C.At 24 weeks of gestation D.At 30 weeks of gestation
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D.At 30 weeks of gestation Rationale: Learning is facilitated by an interested pupil. The couple is most interested in childbirth toward the end of the pregnancy, when they are beginning to anticipate the onset of labor and the birth of their child. Option D is closest to the time when parents would be ready for such classes. Options A, B, and C are not the best times during a pregnancy for the couple to attend childbirth education classes. At these times they will have other teaching needs. Early pregnancy classes often include topics such as nutrition, physiologic changes, coping with normal discomforts of pregnancy, fetal development, maternal and fetal risk factors, and evolving roles of the mother and her significant others.
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The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The nurse determines that the client is dilated 7 cm and is 100% effaced at 0 station, with intact membranes. The monitor indicates that the FHR decelerates at the onset of several contractions and returns to baseline before each contraction ends. Which action should the nurse take? A.Reapply the external transducer. B.Insert the intrauterine pressure catheter. C.Discontinue the oxytocin infusion. D.Continue to monitor labor progress
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D.Continue to monitor labor progress Rationale: The fetal heart rate indicates early decelerations, which are not an ominous sign, so the nurse should continue to monitor the labor progress and document the findings in the client’s record. There is no reason to reapply the external transducer if the FHR tracings are being captured. Options B and C are not indicated at this time.
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The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling fingers and dizziness. Which action should the nurse take? A.Administer oxygen by facemask. B.Notify the health care provider of the client’s symptoms. C.Have the client breathe into her cupped hands. D.Check the client’s blood pressure and fetal heart rate.
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C.Have the client breathe into her cupped hands. Rationale: Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper bag or cupped hands. Option A is inappropriate because the carbon dioxide level is low, not the oxygen level. Options B and D are not specific for this situation.
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Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time? A.She eagerly reaches for the infant, undresses the infant, and examines the infant completely. B.Her arms and hands receive the infant and she then traces the infant’s profile with her fingertips. C.Her arms and hands receive the infant and she then cuddles the infant to her own body. D.She eagerly reaches for the infant and then holds the infant close to her own body.
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B.Her arms and hands receive the infant and she then traces the infant’s profile with her fingertips. Rationale:Attachment and bonding theory indicates that most mothers will demonstrate behaviors described in option B during the first visit with the newborn, which may be at delivery or later. After the first visit, the mother may exhibit different touching behaviors such as eagerly reaching for the infant and cuddling the infant close to her
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A 25-year-old client has a positive pregnancy test. One year ago she had a spontaneous abortion at 3 months of gestation. Which is the correct description of this client that should be documented in the medical record? A.Gravida 1, para 0 B.Gravida 1, para 1 C.Gravida 2, para 0 D.Gravida 2, para 1
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C.Gravida 2, para 0 Rationale: This is the client’s second pregnancy or second gravid event, so option C is correct. The spontaneous abortion (miscarriage) occurred at 3 months of gestation (12 weeks), so she is a para 0. Parity cannot be increased unless delivery occurs at 20 weeks of gestation or beyond. Option A does not take into account the current pregnancy, nor does option B, which also counts the miscarriage as a “para,” an incorrect recording. Although option D is correct concerning gravidity, para 1 is incorrect.
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Just after delivery, a new mother tells the nurse, “I was unsuccessful breastfeeding my first child, but I would like to try with this baby.” Which intervention should the nurse implement first? A.Assess the husband’s feelings about his wife’s decision to breastfeed their baby. B.Ask the woman to describe why she was unsuccessful with breastfeeding her last child. C.Encourage the woman to develop a positive attitude about breastfeeding to help ensure success. D.Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.
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D.Provide assistance to the mother to begin breastfeeding as soon as possible after delivery. Rationale: Infants respond to breastfeeding best when feeding is initiated in the active phase soon after delivery. Options A and B might provide interesting data, but gathering this information is not as important as providing support and instructions to the new mother. Although option C is also true, this response by the nurse might seem judgmental to a new mother.
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A primigravida, when returning for the results of her multiple marker screening (triple screen), asks the nurse how problems with her baby can be detected by the test. What information will the nurse give to the client to describe best how the test is interpreted? A.If MSAFP (maternal serum alpha-fetoprotein) and estriol levels are high and the human chorionic gonadotropin (hCG) level is low, results are positive for a possible chromosomal defect. B.If MSAFP and estriol levels are low and the hCG level is high, results are positive for a possible chromosomal defect. C.If MSAFP and estriol levels are within normal limits, there is a guarantee that the baby is free of all structural anomalies. D.If MSAFP, estriol, and hCG are absent in the blood, the results are interpreted as normal findings.
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B.If MSAFP and estriol levels are low and the hCG level is high, results are positive for a possible chromosomal defect. Rationale:Low levels of MSAFP and estriol and elevated levels of hCG found in the maternal blood sample are indications of possible chromosomal defects. High levels of MSAFP and estriol in the blood sample after 15 weeks of gestation can indicate a neural tube defect, such as spina bifida and anencephaly, not chromosomal defects. One of the limitations of the multiple marker screening is that any defects covered by skin will not be evident in the blood sampling. After 15 weeks of gestation, there will be traces of MSAFP, estriol, and hCG in the blood sample.
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During the transition phase of labor, a client complains of tingling and numbness in her fingers and tells the nurse that she feels like she is going to pass out. What action should the nurse take? A.Encourage her to pant between contractions and blow with contractions. B.Coach her to take a deep cleansing breath and then refocus. C.Instruct her to pant three times and then exhale through pursed lips. D.Have her cup both hands over her nose and mouth while breathing.
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D.Have her cup both hands over her nose and mouth while breathing. Rationale: Hyperventilation blows off carbon dioxide, depletes carbonic acid in the blood, and causes transient respiratory alkalosis, so the client should cup both her hands over her mouth and nose so that she can rebreathe carbon dioxide. Options A, B, and C do not help restore carbon dioxide levels as effectively as rebreathing air in the cupped hands or from a paper bag.
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One hour following a normal vaginal delivery, a newborn infant boy’s axillary temperature is 96° F, his lower lip is shaking, and when the nurse assesses for a Moro reflex, the boy’s hands shake. Which intervention should the nurse implement first? A.Stimulate the infant to cry. B.Wrap the infant in warm blankets. C.Feed the infant formula. D.Obtain a serum glucose level.
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D.Obtain a serum glucose level. Rationale: This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body temperature. The nurse should first determine the serum glucose level. Option A is an intervention for a lethargic infant. Option B should be done based on the temperature, but first the glucose level should be obtained. Option C helps raise the blood sugar, but first the nurse should determine the glucose level.
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During a prenatal visit, the nurse discusses the effects of smoking on the fetus with a client. Which statement is most characteristic of an infant whose mother smoked during pregnancy compared with the infant of a nonsmoking mother? A.Lower Apgar score recorded at delivery B.Lower initial weight documented at birth C.Higher oxygen use to stimulate breathing D.Higher prevalence of congenital anomalies
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B.Lower initial weight documented at birth Rationale:Smoking is associated with low-birth-weight infants. Therefore, mothers are encouraged not to smoke during pregnancy. Options A, C, and D have not been clearly associated with smoking during pregnancy, but there is a strong correlation between smoking and lower birth weights.
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The nurse is using the Silverman-Anderson index to assess an infant with respiratory distress and determines that the infant is demonstrating marked nasal flaring, an audible expiratory grunt, and just visible intercostal and xiphoid retractions. Using this scale, which score should the nurse assign? A.3 B.4 C.5 D.8
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C.5 Rationale: The Silverman-Anderson index is an assessment scale that scores a newborn’s respiratory status as grade 0, 1, or 2 for each component; it includes synchrony of the chest and abdomen, retractions, nasal flaring, and expiratory grunt. No respiratory distress is graded 0, and a total of 10 indicates maximum respiratory distress. This infant is demonstrating respiratory distress with maximal effort, so a grade 2 is assigned for marked nasal flaring, grade 2 for an audible expiratory grunting, plus grade 1 for just visible retractions, which is a total score of 5. Options A, B, and D are not accurate.
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The nurse observes that an antepartum client who is on bed rest for preterm labor is eating ice rather than the food on her breakfast tray. The client states that she has a craving for ice and then feels too full to eat anything else. Which is the best response by the nurse? A.Remove all ice from the client’s room. B.Ask the client what foods she might consider eating. C.Remind the client that what she eats affects her baby. D.Notify the health care provider.
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D.Notify the health care provider. Rationale: The health care provider should be notified when a client practices pica (craving for and consumption of nonfood substances). The practice of pica may displace more nutritious foods from the diet, and the client should be evaluated for anemia. Option A is overreacting and may be perceived as punishment by the client. Option B allows the dietary department to customize the client’s tray but fails to address physiologic problems associated with not consuming nutritious foods in pregnancy. Option C is judgmental and blocks further communication.
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The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, “What type of disease causes infections in babies that can be prevented by using this ointment?” Which response by the nurse is accurate? A.Herpes B.Trichomonas C.Gonorrhea D.Syphilis
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C.Gonorrhea Rationale: Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmia neonatorum, an infection caused by gonorrhea, and inclusion conjunctivitis, an infection caused by Chlamydia. The infant may be exposed to these bacteria when passing through the birth canal. Ophthalmic ointment is not effective against option A, B, or D.

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