MATERNAL NEWBORN EXAM QUESTIONS WITH CORRECT AND VERIFIED ANSWERS 2023-2024, Exams of Nursing

Download MATERNAL NEWBORN EXAM QUESTIONS WITH CORRECT AND VERIFIED ANSWERS 2023-2024 and more Exams Nursing in PDF only on Docsity! MATERNAL NEWBORN EXAM QUESTIONS WITH CORRECT AND VERIFIED ANSWERS 2023-2024 1. A home care nurse is instructing a client with hyperemesis gravidarum about measures to ease the nausea and vomiting. The nurse tells the client to: A. Eat foods high in calories and fat B. Lie down for at least 20 minutes after meals C. Eat carbohydrates such as cereals, rice, and pasta Correct D. Consume primarily soups and liquids at mealtimes Rationale: Low-fat foods and easily digested carbohydrates such as fruit, breads, cereals, rice, and pasta provide important nutrients and help prevent a low blood glucose level, which can cause nausea. Soups and other liquids should be taken between meals to avoid distending the stomach and triggering nausea. Sitting upright after meals reduces gastric reflux. Additionally, food portions should be small and foods with strong odors should be eliminated from the diet, because food smells often incite nausea. A nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate infusion to prevent eclampsia. Which finding indicates to the nurse that the medication is effective? E. Clonus is present. Incorrect F. Magnesium level is 10 mg/dL. G. Deep tendon reflexes are absent. H. The client experiences diuresis within 24 to 48 hours. Correct Rationale: Magnesium sulfate is effective in preventing seizures (eclampsia) if diuresis occurs within 24 to 48 hours of the start of the infusion. As part of the therapeutic response, renal perfusion is increased and the client is free of visual disturbances, headache, epigastric pain, clonus (the rapid rhythmic jerking motion of the foot that occurs when the client’s lower leg is supported and the foot is sharply dorsiflexed), and seizure activity. Hyperreflexia indicates cerebral irritability. Clonus is normally not present. The therapeutic magnesium level is 4 to 8 mg/dL. Reflexes range from 1+ to 2+ but should not be absent. A client with preeclampsia who is receiving magnesium sulfate in an intravenous infusion exhibits signs of magnesium toxicity. The nurse immediately prepares for the administration of: I. Vitamin K J. Protamine sulfate Incorrect K. Calcium gluconate Correct L. Naloxone hydrochloride Rationale: Calcium gluconate is the antidote to magnesium sulfate because it antagonizes the effects of magnesium at the neuromuscular junction. It should be readily available whenever magnesium is administered. Vitamin K is the antidote in cases of hemorrhage induced by the administration of oral anticoagulants such as warfarin sodium (Coumadin). Protamine sulfate is the AI. Encourage the intake of oral fluids Correct AJ. Tell the client that antibiotics will be prescribed Rationale: A temperature of 38° C (100.4° F) is common during the 24 hours after childbirth. It may be the result of dehydration or normal postpartum leukocytosis. If the increased temperature persists for longer than 24 hours or exceeds 38° C, infection is a possibility, and the fever is reported to the registered nurse. Because the client delivered her baby just 12 hours ago, the most appropriate nursing action is to encourage the intake of oral fluids. A nurse is assessing the uterine fundus of a client who has just delivered a baby and notes that the fundus is boggy. The nurse massages the fundus, and then presses to expel clots from the uterus. To prevent uterine inversion during this procedure, the nurse: AK. Has the client void before the uterine assessment AL. Tells the woman to bear down during fundal message AM. Simultaneously provides pressure over the lower uterine segment Correct AN. Asks the client to take slow, deep breaths during fundal assessment Incorrect Rationale: After massaging a boggy fundus until it is firm, the nurse presses the fundus to expel clots from the uterus. The nurse must also keep one hand pressed firmly just above the symphysis (over the lower uterine segment) the entire time. Removing the clots allows the uterus to contract properly. Providing pressure over the lower uterine segment prevents uterine inversion. Having the client void before uterine assessment will not prevent uterine inversion. Telling the woman to bear down while the nurse performs fundal message and asking the client to take slow, deep breaths during fundal assessment also will not prevent uterine inversion. A nurse is monitoring a client after vaginal delivery notes a constant trickle of bright-red blood from the client’s vagina. In which order would the nurse perform the following actions? Assign the number 1 to the first action and the number 5 to the last. Incorrect A. Assessing the client’s fundus B. Checking the client’s vital signs C. Changing the client’s peripads D. Contacting the physician E. Documenting the findings The correct order is: F. Assessing the client’s fundus G. Checking the client’s vital signs H. Contacting the physician I. Changing the client’s peripads J. Documenting the findings Rationale: A constant trickle of bright-red blood may indicate abnormal bleeding and requires immediate attention. The nurse first checks the client’s fundus. Once it has been determined that the bleeding is not the result of a boggy uterus, the nurse should check the vital signs to determine whether the blood loss has compromised the client’s condition. Next the nurse would contact the physician and report the bleeding, fundal height and condition, and vital signs. After contacting the physician the nurse would attend to the client’s comfort needs, including, in this case, frequent changes of peripads. The nurse would document the findings once assessment and implementation had been completed and the client’s condition was considered stable. A nonstress test is performed, and the physician documents “accelerations lasting less than 15 seconds throughout fetal movement.” The nurse interprets these findings as: A. Normal B. Reactive Incorrect C. Nonreactive Correct D. Inconclusive Rationale: A reactive nonstress test is a normal, or negative, result and indicates a healthy fetus. The result requires two or more fetal heart rate accelerations of at least 15 beats/min lasting at least 15 seconds from the beginning of the acceleration to the end, in association with fetal movement, during a 20-minute period. A nonreactive test is an abnormal test, showing no accelerations or accelerations of less than 15 beats/min or lasting less than 15 seconds during a 40-minute observation. An inconclusive result is one that cannot be interpreted because of the poor quality of the fetal heart rate recording. A stillborn infant was delivered a few hours ago. After the birth, the family remains together, holding and touching the baby. Which statement by the nurse is appropriate? E. “I know how you feel.” F. “This must be hard for you.” Correct G. “Now you have an angel in heaven.” H. “You’re young. You can have other children.” Rationale: Therapeutic communication helps the mother, father, and other family members express their feelings and emotions. “This must be hard for you” is a caring and empathetic response, focused on feelings and encouraging communication. The other options are nontherapeutic and may devalue the family members' feelings. A nurse is providing nutritional counseling to pregnant client with a history of cardiac disease. What does the nurse advise the client to eat? I. Water and pretzels J. Low-fat cheese omelet Incorrect K. Nachos and fried chicken L. Apple and whole-grain toast Correct Rationale: The pregnant woman needs a well-balanced diet high in iron and protein and adequate in calories for weight gain. Iron supplements that are taken during pregnancy tend to cause constipation. Constipation causes the client to strain during defecation, inadvertently performing the Valsalva maneuver, which causes blood to rush to the heart and overload the cardiac system. The pregnant woman, then, should increase her intake of fluids and fiber. An unlimited intake of sodium (pretzels, cheese, nachos) could cause overload of the circulating blood volume and contribute to the cardiac condition. A nurse is reviewing the records of the clients admitted to the maternity unit during the past 24 hours. Which of the following clients does the nurse recognize as being at risk for the development of disseminated intravascular coagulation (DIC)? Select all that apply. M. A client with septicemia N. A client with mild preeclampsia O. A client with diabetes mellitus who delivered a 10-lb baby Incorrect P. A client who had a cesarean section because of abruptio placentae Correct Q. A client who delivered 12 hours ago and has lost 475 mL of blood Rationale: DIC is a pathologic form of clotting that is diffuse and consumes large amounts of clotting factors, including platelets, fibrinogen, prothrombin, and factors V and VII. In the obstetric population, DIC occurs as a result of abruptio placentae, amniotic fluid embolism, dead fetus syndrome (in which the fetus has died but is retained in utero for at least 6 weeks), severe preeclampsia, septicemia, cardiopulmonary arrest, or hemorrhage. A loss of 475 mL is not considered hemorrhage .A mild case of preeclampsia is not a risk factor for DIC. It is not unusual for a client with diabetes mellitus to deliver a large baby, and this condition is unrelated to DIC. A delivery room nurse is preparing a client for a cesarean delivery. The client is placed on the delivery room table, and the nurse positions the client: R. Prone S. In a semi-Fowler position T. In the Trendelenburg position U. Supine with a wedge under the right hip Correct Rationale: The pregnant client is positioned so that the uterus is displaced laterally to prevent compression of the inferior vena cava, which causes decreased placental perfusion. This is accomplished by placing a wedge under the hip. Positioning for abdominal surgery necessitates a supine position. The Trendelenburg position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler or prone position is not practical for this type of abdominal surgery. A nurse is preparing to perform the Leopold maneuvers on a pregnant client. The nurse should first: V. Locate the fetal heart tone Correct Incorrect Rationale: Signs associated with intrauterine infection includes fetal tachycardia (rising baseline or faster than 160 beats/min, a maternal fever (38° C or 100.4° F), foul or strong-smelling amniotic fluid, or cloudy or yellow amniotic fluid. The normal fetal heart rate is 110 to 160 beats/min. Clear amniotic fluid is normal. Maternal fatigue normally occurs during labor. A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing intervention in the care of this client? E. Providing pain relief Correct F. Preparing the client for amniotomy G. Monitoring the oxytocin (Pitocin) infusion closely Incorrect H. Encouraging the client to ambulate every 30 minutes Rationale: Management of hypertonic uterine dysfunction depends on the cause. Relief of pain is the primary intervention in promoting a normal labor pattern. Therapeutic management of hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate labor progression. The client with hypertonic uterine dysfunction would be encouraged to rest, not to ambulate every 30 minutes. A nurse is preparing to care for a client experiencing dystocia. To which of the following interventions does the nurse give priority? I. Monitoring fetal status Correct J. Providing comfort measures K. Changing the client’s position L. Informing the client’s partner of the progress of the labor Rationale: The priority intervention is monitoring fetal status. Once this is done, the nurse provides maternal comfort measures, including positioning the client, because this may decrease anxiety and hasten the progression of labor. Keeping the client’s partner informed of the progress of the labor is also an important aspect of client care during labor but is not an immediate priority. A postpartum client asks a nurse when she may safely resume sexual activity. The nurse tells the client that she may resume sexual activity: M. At any time Incorrect N. In 2 to 4 weeks Correct O. After the 6-week physician checkup P. When her normal menstrual period has resumed Rationale: Usually a woman may engage safely in sexual intercourse during the second to fourth week after childbirth as long as she experiences no discomfort during intercourse. The other options are incorrect. Engaging in intercourse too early in the postpartum course could result in further injury Rationale: More than one medication may be used to prevent the growth of resistant organisms in the pregnant woman with tuberculosis. Treatment must be continued for a prolonged period. The preferred treatment for the pregnant woman is isoniazid plus rifampin for a total of 9 months. Ethambutol is added initially if drug resistance is suspected. Pyridoxine (vitamin B6) is often administered with isoniazid to prevent fetal neurotoxicity. The infant will be tested at birth and may be started on preventive isoniazid therapy. Skin testing of the infant should be repeated at 3 months, and isoniazid may be stopped if the result remains negative. If the result is positive, the infant should receive isoniazid for at least 6 months. If the mother’s sputum is free of organisms, the infant does not need to be isolated from the mother while in the hospital. to perineal tissues damaged during childbirth. It usually takes about 3 weeks for an episiotomy to heal; therefore, it is unnecessary to wait 6 weeks. Menstruation may not resume in a postpartum woman for 12 weeks to 6 months after childbirth. A pregnant woman reports to the clinic complaining of loss of appetite, weight loss, and fatigue, and tuberculosis is suspected. A sputum culture reveals Mycobacterium tuberculosis. The nurse, providing instructions to the mother regarding therapeutic management of the disease, tells the mother that: Q. The infant must be isolated from the mother after birth R. Maternal medication will not be started until the baby is born S. The infant will require medication therapy immediately after birth T. The mother may need to take isoniazid (INH), pyrazinamide, and rifampin(Rifadin) for a total of 9 months Correct A nurse midwife performs an assessment of a pregnant client and documents the station of the fetal head as it is reflected in the figure below. The nurse reviews the assessment findings and determines that the fetal presenting part is: U. At +1 station V. At –1 station W. At zero station Correct X. Stationed at the bottom of the coccyx Rationale: Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. It is measured in centimeters and is noted as a negative number above the line, a positive number below the line, and zero at the line. A nurse performing an assessment of a pregnant client is preparing to take the client’s blood pressure. The nurse positions the client: Y. Supine, on the left side Z. Supine, on the right side AA. Lying down with the arm in a horizontal position at heart level AB. In a sitting position with the arm in a horizontal position at heart level Correct Rationale: Because position affects blood pressure in the pregnant woman, the method for obtaining blood pressure should be standardized as much as possible. Blood pressure should be obtained with the client sitting position and the arm supported in a horizontal position at heart level. Supine on the right or left side and lying down with the arm in a horizontal position at heart level are both incorrect and could cause physiological stress that would affect the blood pressure. A nurse is performing an assessment of a client who is at 20 weeks of gestation. The nurse asks the client to void, then measures the fundal height in centimeters. Which approximate measurement does the nurse expect to see? AC. 20 cm Correct AD. 28 cm AE. 32 cm AF. 40 cm Rationale: During the second and third trimesters (weeks 18 to 30), the height of the fundus in centimeters is approximately the same as the number of weeks of gestation, if the woman’s bladder is empty at the time of measurement. If the fundal height exceeds the number of weeks of gestation, additional assessment is necessary to investigate the cause for the unexpectedly large uterine size. An unexpected increase in uterine size may indicate that the estimated date of delivery is incorrect and the pregnancy is more advanced than previously thought. If the estimated date of delivery is correct, more than one fetus may be present. A nurse teaching a pregnant client about the expectations and complications of pregnancy is describing Braxton Hicks contractions. The nurse tells the client these contractions: AG. Indicate that labor has started AH. Must be reported to the physician AI. Are a common occurrence of pregnancy Correct AJ. Necessitate bed rest for the remainder of the pregnancy Rationale: Braxton Hicks contractions are irregular, painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. Because Braxton Hicks contractions are a normal finding experienced by many pregnant women during pregnancy, the other options represent inaccurate assumptions and an unnecessary intervention. A nurse is assisting a physician in performing a physical examination of a client who has just been told that she is pregnant. The physician tells the nurse that the Goodell sign is present. The nurse understands that this sign is indicative of: AK. The presence of fetal movement BL. A brownish-black cord with some moistness at the base Rationale: Symptoms of a cord infection include purulent drainage or redness or edema at the base of the cord. If symptoms of infection occur, the mother should be instructed to notify the healthcare provider, because antibiotics are necessary. The cord begins to dry shortly after birth. It turns a brownish black within 2 to 3 days and falls off within 10 to 14 days. A licensed practical nurse is performing assessments every 30 minutes on a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings would prompt the LPN to contact the registered nurse? BM. Urine output of 20 mL BN. Deep tendon reflexes of 2+ BO. Respirations of 10 breaths/min Correct BP. Fetal heart tone of 116 beats/min Rationale: Magnesium sulfate depresses the respiratory rate. If the rate is 12 breaths/min or slower, continuation of the medication must be reassessed. Acceptable urine output is 30 mL/hr or more. Urine output of 20 mL in 30 minutes is adequate. Deep tendon reflexes of 2+ are normal. The fetal heart tone is within normal limits for a resting fetus. A licensed practical nurse (LPN) is monitoring a client in the third trimester of pregnancy who has a diagnosis of severe preeclampsia. Which finding would prompt the LPN to contact the registered nurse? BQ. Complaint of feeling hot BR. Enlargement of the breasts BS. Diaphoresis and tachycardia Correct BT. Periods of fetal movement followed by quiet periods Rationale: Disseminated intravascular coagulation (DIC) is a complication of preeclampsia. Physical examination reveals unusual bleeding, spontaneous bleeding from the woman’s gums or nose, or the presence of petechiae around a blood pressure cuff placed on the woman’s arm. Excessive bleeding may occur from a site of slight trauma such as a venipuncture site, an intramuscular or subcutaneous injection site, a nick sustained during shaving of the perineum or abdomen, or injury inflicted during insertion of a urinary catheter. Tachycardia and diaphoresis indicate impending shock as a result of blood loss. Breast enlargement, fetal movement with rest periods, and complaints of feeling hot are all normal occurrences in the last trimester of pregnancy. A pregnant client is seen in the clinic for the first time. This is the client’s first pregnancy, and the client tells the nurse that she has diabetes mellitus. The nurse provides instruction to the client regarding health care during pregnancy. Which statements by the client indicate the need for further instruction? Select all that apply. BU. “I need to follow the prescribed diabetic diet.” BV. “I need to limit my exercise while I’m pregnant.” Correct BW. “I need to report signs of infection to my physician.” BX. “My insulin requirements may change while I’m pregnant.” BY. “I’ll come back for a prenatal visit every month during my first trimester.” Correct Rationale: Exercise is necessary for the pregnant diabetic client to help maintain control of her diabetes. Concepts related to the timing of exercise, control of food intake, and insulin around the time of exercise should be reviewed with the client. The prenatal visit schedule for clients with a history of diabetes mellitus is more frequent than the normal prenatal course. In the first and second trimesters, prenatal visits should be scheduled every 1 to 2 weeks. The remaining statements are correct, representing important information for the pregnant client with diabetes mellitus. During a prenatal visit, the nurse notes that an adolescent pregnant client with diabetes mellitus has lost 10 lb during the first 15 weeks of gestation. The nurse discusses the weight loss with the client, and the client states, “I don’t eat regular meals.” The appropriate response is: BZ. “Weight loss could hurt your baby.” CA. “Let’s make a list of what you’re eating.” Correct CB. “I’ll have the doctor review your diet history.” CC. “It’s all right to gain weight during pregnancy.” Rationale: It is important for the nurse to obtain additional information from the client. The nurse is using the therapeutic communication tool of validation and clarification to obtain more information about the client’s diet. The other options will block communication. The statement regarding harm to the baby devalues the client and shows disapproval. Informing the physician is avoiding the issue, and telling the client that it is all right to gain weight provides false reassurance. A nurse provides information about the treatment for hypoglycemia to a client with gestational diabetes who will be taking insulin. The nurse tells the client that if signs and symptoms of hypoglycemia occur, she must immediately: CD. Lie down CE. Contact the physician CF. Drink 8 oz of diet soda CG. Check her blood glucose level Correct Rationale: If signs and symptoms of hypoglycemia occur, the client should immediately check the blood glucose level. The results will determine the required treatment. If the blood glucose is less than 60 mg/dL, the client should immediately eat or drink something that contains 10 to 15 g of simple carbohydrate. Examples include a half cup (4 oz) of unsweetened fruit juice, a half cup (4 oz) of regular (not diet) soda, 5 or 6 LifeSavers candies, 1 tablespoon of honey or corn (Karo) syrup; 1 cup (8 oz) of milk; or 2 or 3 glucose tablets. The blood glucose is tested again 15 minutes after intake of the carbohydrate. If the glucose level is still below 60 mg/dL, the client should eat or drink another 10 to 15 g of simple carbohydrate. The blood glucose is tested once again 15 minutes after intake of the carbohydrate, and the physician is notified immediately if it is still below 60 mg/dL, because further intervention is necessary. Lying down will not increase the blood glucose level and will delay necessary intervention. A nurse is reviewing the criteria for early discharge of a newborn infant. Which of the following, if noted in the infant, would indicate that the criteria for early discharge have been met? Select all that apply. CH. The infant has urinated. CI. The infant has passed 1 stool. CJ. Vital signs are documented as normal. Correct CK. The infant has completed one successful feeding. CL. The infant has shown no evidence of jaundice in the first 6 hours of life. Rationale: Criteria for early discharge in the newborn infant include no evidence of significant jaundice in the 24 hours after birth. The infant should have urinated and passed at least one stool, completed at least two successful feedings, and have normal vital signs for at least 12 hours. A client admitted to the maternity unit 12 hours ago has been experiencing strong contractions every 3 minutes but has remained at station 0. The fetal heart rate on admission was 140 beats/min and regular. The fetal heart rate is slowing, and a persistent nonreassuring fetal heart rate pattern is present. The appropriate nursing action in this situation is: CM. Preparing to induce labor CN. Turning the client on her left side CO. Preparing the client for a cesarean delivery Correct CP. Continuing to monitor the fetal heart rate pattern Rationale: Dystocia, failure of labor to progress, and a persistent nonreassuring fetal heart rate pattern are indications of the need for cesarean delivery. Induction of labor is not indicated in this case because the client has been in labor for 12 hours without progress and signs of fetal distress are present. Placing the client on her left side will increase oxygen to the uterus by relieving pressure on the aorta and the inferior vena cava. However, this intervention would be implemented with any client in labor, not specifically with a client experiencing dystocia. Monitoring the fetal heart rate pattern is also appropriate for any client in labor and is not the appropriate nursing action in this situation. Immediately after the delivery of a newborn infant, the nurse prepares to deliver the placenta. The nurse initially: CQ. Pulls on the placenta as it enters the vaginal canal Correct Correct DN. Hemorrhage Correct DO. A vaginal hematoma Rationale: The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, making this site more prone to bleeding. The client with a low-lying placenta is not at greater risk for seizures, postpartum infection, or vaginal hematoma. A nurse working in a prenatal clinic is reviewing the records of several clients scheduled for prenatal visits today. Which client does the nurse identify as being at risk for abruptio placentae? Select all that apply. DP. A primipara DQ. A 36- year-old DR. A hypertensive client Correct DS. A pack-a-day smoker Correct DT. A client who exercises regularly Rationale: The cause of abruptio placentae is unknown, but several risk factors have been identified. Maternal use of cocaine, which causes vasoconstriction of the endometrial arteries, is a leading cause. Other risk factors include hypertension, cigarette smoking, abdominal trauma, and a history of previous premature separation of the placenta. A nurse caring for a client in labor performs an assessment. The client is having consistent contractions less than 2 minutes apart. The fetal heart rate (FHR) is 170 beats/min, and fetal monitoring indicates a pattern of decreased variability. In light of these findings, the appropriate nursing action is: DU. Contacting the physician Correct DV. Documenting the findings DW. Continuing to monitor the client DX. Reassuring the client and her partner that labor is progressing normally Rationale: Signs of potential complications of labor include contractions consistently lasting 90 seconds or longer, contractions consistently occurring 2 minutes or less apart, fetal bradycardia, tachycardia, persistently decreased variability, or an irregular FHR. The normal FHR is 110 to 160 beats/min. Therefore, because the finding is abnormal, the physician must be contacted. Continuing to monitor the client delays necessary intervention. Reassuring the client that labor is progressing normally is incorrect. The nurse would document the data, actions taken, and the client’s response, but, of the options provided, contacting the physician is the most appropriate. A nurse provides instructions regarding postpartum exercises to a client who has delivered a newborn vaginally. The nurse tells the client that: DY. The exercises should be delayed for 1 month to allow healing Rationale: Postpartum exercises may be started soon after birth, although the woman should be encouraged to begin with simple exercises and gradually progress to more strenuous ones. Abdominal exercises are postponed until approximately 4 weeks after a cesarean birth. Kegel exercises (alternated contraction and relaxation of the muscles of the perineal area) are extremely important in strengthening the muscle tone of the perineal area after vaginal birth. Kegel exercises help restore the muscle tone that is often lost as pelvic tissues are stretched and torn during pregnancy and birth. Women who maintain muscle strength may benefit years later, experiencing continued urinary continence. A nurse is assessing the respiratory rate of a newborn. Which finding would the nurse document as normal? DZ. Performing such exercises in the postpartum period may result in stress urinary incontinence EA. Alternating contraction and relaxation of the muscles of the perineal area should be practiced Correct EB. Abdominal exercises will be started while the client is in the hospital as a means of evaluating tolerance EC. 20 breaths/min ED. 25 breaths/min EE. 50 breaths/min Correct EF. 70 breaths/min Rationale: The normal respiratory rate for a newborn infant is 30 to 60 breaths/min. All of the other options are outside the normal range. A licensed practical nurse is monitoring a newborn who has been admitted to the nursery. The LPN notes that the anterior fontanel measures 4 cm across and bulges when the infant is at rest. In light of this observation, what is the most appropriate nursing action? EG. Notifying the registered nurse Correct EH. Documenting the finding EI. Assessing the infant’s blood pressure EJ. Reassessing the fontanel in 30 minutes Rationale: The anterior fontanel, which is diamond shaped, is located on the top of the head. It should be flat and soft. It measures 1 to 4 cm, varying as a result of molding and individual differences. It normally closes by 12 to 18 months of age. Although the anterior fontanel may bulge slightly when the infant cries, bulging at rest may indicate increased intracranial pressure. If this is suspected, the registered nurse is notified. The other options would delay necessary treatment. Rationale: Uterine inversion occurs when the uterus turns completely or partially inside out, usually during the third stage of labor. The physician tries to replace the uterus, by way of the vagina, in a normal position. If this is not possible, laparotomy with replacement is performed. A hysterectomy may be required. Two intravenous lines are established to allow rapid fluid and blood replacement. A tocolytic medication or general anesthesia usually is needed to relax the uterus enough to replace it. To help ensure that the inverted fundus is not trapped in the cervix, oxytocin is not given until the uterus has been repositioned. Fundal massage should be avoided if possible, but, if it is prescribed, it should be conducted very carefully. A Foley catheter may be inserted to keep the bladder empty so that the uterus can contract well, but this is not the immediate action. Rationale: Discomfort and pain associated with true labor contractions typically begin in the lower abdomen and back, then radiate over the entire abdomen. Mild, irregular contractions and a lack of changes in the cervix are findings associated with false labor. A firm uterus is present when contractions occur. Rationale: Supportive interventions are instituted immediately to maintain cardiac and respiratory function, and oxygen is a necessary supportive therapy. The woman is intubated, and positive end expiratory pressure (PEEP) may be prescribed. The family should be notified; however, the nurse would first administer the oxygen, then prepare for intubation. A cardiac monitor may be needed, but this is not the initial action. After a vaginal delivery, a woman suddenly begins to complain of severe pelvic pain and extreme fullness in the vagina, and the nurse suspects uterine inversion. The nurse immediately prepares to: FI. Insert a Foley catheter FJ. Perform fundal massage FK. Administer oxytocin (Pitocin) FL. Assist in repositioning the uterus through the vagina into a normal position Correct A nurse is performing an assessment of a pregnant woman to determine whether labor has begun. For which sign of true labor does the nurse assess the client? FM. A lack of cervical changes FN. A soft uterus with indentable contractions FO. Contractions that are irregular in rhythm and duration FP. Contractions that begin in the lower abdomen and back and radiate over the entire abdomen Correct A nurse is preparing to assess the fetal heartbeat in a pregnant woman who is at gestational week 12. Which piece of equipment does the nurse use to assess the fetal heartbeat? FQ. Fetoscope FR. Adult stethoscope FS. Electronic Doppler Correct FT. Fetal heart monitor Rationale: The fetal heartbeat can be heard with the use of a fetoscope at 18 to 20 weeks’ gestation. When an electronic Doppler ultrasound device is used, the fetal heartbeat can be detected as early as 10 weeks’ gestation. An adult stethoscope will not adequately produce the fetal heartbeat. A fetal heart monitor is used during labor or in other situations when the fetal heart rate requires continuous monitoring. A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 19, 2013. Using Nagele’s Rule, the nurse calculates the estimated date of delivery as: FU. May 26, 2014 FV. June 12, 2014 FW. June 26, 2014 Correct FX. May 12, 2014 Rationale: Accurate use of Nagele’s Rule requires that the woman have a regular 28-day menstrual cycle. It is calculated by subtracting 3 months from the first day of the LMP, adding 7 days, and then adding 1 year to that date. First day of the LMP: September 19, 2013; subtract 3 months: June 19, 2013; add seven days: June 26, 2013; add 1 year: June 26, 2014. A pregnant client is positive for HIV. The client asks the nurse whether her newborn will contract the virus. The appropriate response is: FY. “Yes, the newborn will also have the virus.” FZ. “HIV can only be transmitted through sexual contact.” GA. “The newborn does have a risk of contracting the infection.” Correct GB. “The newborn will have signs of HIV at birth if the virus has been transmitted.” Rationale: An infant born to an HIV-positive mother is at risk for contracting the infection. The modes of transmission are sexual, parenteral, and perinatal. Characteristically the newborn is asymptomatic at birth, but signs and symptoms in an infected child usually become obvious during the first year of life. Therefore the remaining options are incorrect. A delivery room nurse performing an initial assessment on a newborn notes that the ears are lowset. In light of this finding, which nursing action is appropriate initially? GC. Notifying the physician Correct GD. Documenting the finding GE. Taping the ears so they lie flat against the head GF. Covering the ears with gauze pads and taping the pads to the head Rationale: Low or oddly placed ears are associated with a variety of congenital defects, including Down syndrome, and should be reported immediately. Taping the ears and covering them with gauze are unacceptable nursing interventions. Although the finding would be documented, the appropriate initial action is notification of the physician. A nurse is reviewing the medical record of a pregnant client with sickle cell anemia. To which of the following information related by the client would the nurse give the highest priority? GG. Poor appetite GH. Drinking less than 4 glasses of fluid daily Correct GI. Concern about her inability to care for her baby GJ. Occasional slight dizziness when standing up Rationale: Dehydration will precipitate sickling of the red blood cells in the person with sickle cell disease. Sickling can lead to life-threatening consequences, such as an interruption of blood flow to the respiratory system and placenta, for the pregnant woman and fetus. Therefore a low fluid intake is the priority. Although the client’s complaints of poor appetite and occasional dizziness on standing require attention, they are not the priority in this situation. The client’s concerns about being able to care for her baby may be a priority after delivery, depending on the specific client situation at the time. A nurse is caring for a client receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. Which of the following findings would prompt the nurse to stop the infusion? GK. Contractions every 3 minutes GL. Nonreassuring fetal heart rate pattern Correct GM. Soft uterine tone palpated between contractions GN. The presence of three contractions every 10 minutes Rationale: The goal of labor augmentation is to achieve three good-quality contractions (of appropriate intensity and duration) in a 10-minute period. The uterus should return to resting tone between contractions, and there should be no evidence of fetal distress. If a nonreassuring fetal heart rate pattern is detected, the oxytocin infusion is stopped. A nonreassuring fetal heart rate pattern is associated with fetal hypoxia. A licensed practical nurse (LPN) is monitoring a woman in labor and notes the presence of accelerations on the fetal monitor tracing. Which action should the LPN take in response to this observation? GO. Contacting the registered nurse GP. Documenting the finding Correct GQ. Repositioning the mother Rationale: A maternal 1-hour blood glucose test may be prescribed as a screen for gestational diabetes. If it is increased (140 mg/dL or greater), a 3-hour glucose-tolerance test may be recommended to confirm the presence of gestational diabetes. Oral hypoglycemics and insulin would not be prescribed solely on the basis of an increased maternal 1-hour glucose level. Additionally, oral hypoglycemic agents are contraindicated during pregnancy. A result of less than 140 mg/dL indicates no need for further glucose testing and continued routine prenatal care. HM. Limit maternal activity HN. Turn the client on her side Correct HO. Monitor maternal vital signs HP. Provide emotional support to reduce anxiety Rationale: With a client in shock, the goal is to increase perfusion to the placenta. The immediate nursing action would be to turn the client on her side. This would increase blood flow to the placenta by relieving pressure from the gravid uterus on the great vessels. The remaining options are also interventions that would be implemented, but only after this immediate action had been taken. Additionally, oxygen at 8 to 10 L/min by way of face mask would be administered. A multigravida asks a nurse when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted as early as: HQ. 8 to 10 weeks of gestation HR. 11 to 13 weeks of gestation HS. 14 to 16 weeks of gestation Correct HT. 18 to 20 weeks of gestation Rationale: The first recognition of fetal movements by the multigravida may occur as early as the 14th to 16th week of gestation. The primigravida may not notice these sensations until week 18 or later. Therefore the other options are incorrect. A 1-hour oral glucose tolerance test is performed on a pregnant client, with a result of 155 mg/dL. The nurse tells the client that: HU. Daily NPH insulin will be needed HV. Her glucose level is within normal limits HW. A daily oral hypoglycemic agent will be prescribed HX. A 3-hour glucose tolerance test will likely be performed to confirm gestational diabetes Correct A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. The nurse tells the client that: HY. She must be retested in 1 week Rationale: Strict bed rest throughout the remainder of the pregnancy is not required. The woman is advised to curtail sexual activities until bleeding has ceased and for 2 weeks after the last evidence of bleeding, as recommended by the physician or nurse-midwife. The woman is instructed to count the perineal pads she uses each day and to note the quantity and color of blood on each pad. The woman should also watch for the evidence of the passage of tissue. Rationale: The labia of a newborn female may be darker in color than the surrounding skin; this is a normal finding, a result of exposure to the mother’s hormones before birth. Edema of the labia and a white mucous vaginal discharge are also normal. Therefore the nurse would document the findings. The other options are unnecessary. Rationale: A hepatitis B screen is performed to detect the presence of antigens in maternal blood. If antigens are present, the infant should receive hepatitis immune globulin and a vaccine soon after birth. Repeating the screen and prescribing liver function tests are incorrect measures and are unnecessary. HZ. Liver function tests will be prescribed IA. A repeat hepatitis screen will be performed during the pregnancy IB. The infant should receive both the vaccine and hepatitis immune globulin soon after birth Correct A client in the first trimester of pregnancy arrives at the clinic and reports that she has been experiencing vaginal bleeding. Threatened abortion is suspected, and the nurse provides instructions to the client regarding care. Which statement by the client indicates the need for further instruction? IC. “I need to stay in bed for the rest of my pregnancy.” Correct ID. “I need to avoid having sex until the bleeding has stopped.” IE. “I need to watch for stuff that looks like tissue coming from my vagina.” IF. “I need to count the number of perineal pads that I use each day and make a note of the amount and color of blood on each pad.” A licensed practical nurse (LPN) is changing the diaper of a 1-day-old full-term female newborn. The nurse notes that the labia are edematous and darker than the surrounding skin and that a white mucous vaginal discharge is present. On the basis of these findings, the nurse determines that the appropriate action is: IG. Contacting the registered nurse IH. Documenting the findings Correct II. Obtaining a specimen of the discharge for culture IJ. Reviewing the mother’s record to determine whether she has a history of gonorrhea Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Recalling normal newborn findings and remembering that the findings noted in the question are normal will direct you to the correct option. If you had difficulty with this question, review normal newborn findings. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Newborn Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., pp. 522, 838). St. Louis: Elsevier. Awarded 0.0 points out of 1.0 possible points. B. 82.ID: 327528095 A nurse is told that a newborn with myelomeningocele will be admitted to the newborn nursery. In which position does the nurse plan to place the infant? A. Prone Correct B. Supine C. On the back, in semi-Fowler D. On the back, in Trendelenburg Rationale: A myelomeningocele is a neural tube defect caused by failure of the posterior neural tube to close. The meninges are exposed through the surface of the skin in a herniated sac that may be either healed or leaking. One major preoperative intervention is protection of the sac from injury to prevent its rupture and resultant risk of central nervous system infection. The infant should be positioned in a side-lying or prone position to prevent pressure on the sac until surgical repair can be performed. Supine positioning would increase pressure on the sac, thereby increasing the risk for sac rupture. Test-Taking Strategy: Focus on the newborn’s diagnosis and use the process of elimination. Eliminate the positions that are comparable or alike in that they involve placing the newborn on the back. If you had difficulty with this question, review care of a newborn with myelomeningocele. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity D. It is necessary to avoid contact with all individuals to help prevent infection Rationale: Physical activity should be limited so that demand does not exceed the functional capacity of the heart. It is not necessary to avoid contact with all individuals as a means of preventing infection, but contact with individuals with active infections should be avoided. The client should avoid excessive weight gain, which increases demand on the heart. Too much weight gain causes an increase in body requirements and stress on the heart. The client should lie on the left side to promote blood return. Test-Taking Strategy: Use the process of elimination. Eliminate the options containing the closed- ended words “not” and “all.” To select from the remaining options, recall the concepts of blood return during pregnancy, which will assist you in answering correctly. If you had difficulty with this question, review care of the pregnant client with heart disease. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Maternity/Antepartum Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., p. 646). St. Louis: Elsevier. Awarded 0.0 points out of 1.0 possible points. F. 86.ID: 327528677 A nurse is monitoring a pregnant client with placental abruption. Which pattern on the fetal monitor indicates to the nurse that fetal tissue perfusion is adequate? A. B. C. Correct D. Rationale: Accelerations, shown in the correct answer, are brief temporary increases in the fetal heart rate of at least 15 beats/min from baseline and lasting at least 15 seconds. They are an indication of fetal well-being and an oxygenated fetal central nervous system. Variable decelerations do not have the uniform appearance of early or late decelerations. Early decelerations are decreases in the fetal heart rate to below baseline; late decelerations look similar to early decelerations but begin well after the contraction begins and return to baseline after the contraction ends. Test-Taking Strategy: Use the process of elimination and your knowledge of the indications of fetal well-being. To answer this question correctly it is necessary to be able to interpret fetal heart rate patterns and identify those that indicate fetal well-being. If you had difficulty with this question, review fetal heart rate patterns. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Antepartum Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., p. 620). St. Louis: Elsevier. Awarded 0.0 points out of 1.0 possible points. G. 87.ID: 327528049 A clinic nurse is developing a plan of care for a pregnant client with AIDS. Which problem does the nurse identify as the priority to be addressed in the plan of care? A. Poor hygiene B. Inverted nipples C. History of IV drug use Correct D. Intake of fewer than 6 glasses of fluid daily Rationale: AIDS is a breakdown in immune function caused by a retrovirus known as human immunodeficiency virus, or HIV. The infected person contracts opportunistic infections or malignancies that ultimately are fatal. For this reason, the prevention of infection is a priority of nursing care. Although poor hygiene may affect the client’s risk for infection, addressing and helping the client cease her use of IV drugs, which is an immediate contributor to the risk for infections, is priority. Inverted nipples and intake of less than 6 glasses of fluid daily are not specifically related to this syndrome. Test-Taking Strategy: Note the strategic word “priority.” Recalling that AIDS affects the body’s immune system and remembering the factors that increase the risk for infections will direct you to the correct option. If you had difficulty with this question, review the priority concerns related to the client with AIDS. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Maternity/Antepartum Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2010). Maternal-child nursing care (4th ed., pp. 328, 329). St Louis: Mosby. Awarded 0.0 points out of 1.0 possible points. H. 88.ID: 327529200 A woman with severe preeclampsia delivers a healthy newborn infant and continues to receive magnesium sulfate therapy in the postpartum period. Twenty-four hours after delivery, the client begins passing more than 100 mL of urine every hour. The nurse recognizes this volume of urine output as an indication of: A. Imminent seizures B. Hyperkalemia C. High-output renal failure D. Diminished edema and vasoconstriction in the brain and kidneys Correct Rationale: In this client, diuresis is a positive sign, indicating that edema and vasoconstriction in the brain and kidneys have decreased. Diuresis also reflects increased tissue perfusion in the kidneys. Clients with severe preeclampsia are not considered out of danger until birth and diuresis have taken place. Diuresis is not an indication of impending seizures. Although renal failure is a complication of severe preeclampsia, it is not the high-output type of failure. Potassium is lost through the urine; therefore hyperkalemia is not associated with diuresis. Test-Taking Strategy: Use the process of elimination. Recalling that oliguria is associated with severe preeclampsia will help you determine that diuresis in this scenario is associated with an improvement in preeclampsia. This will direct you to the correct option. If you had difficulty with this question, review the expected responses to treatment of severe preeclampsia. Level of Cognitive Ability: Analyzing Client’s Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Maternity/Postpartum References: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., p. 627). St. Louis: Elsevier. Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal-child nursing care (4thed., pp. 345, 346). St. Louis: Elsevier. D. Rupture of the amniotic sac Rationale: The primary symptom of placenta previa is painless vaginal bleeding in the second or third trimester of pregnancy. Findings of abruptio placentae include dark-red vaginal bleeding and abdominal pain. A ruptured amniotic sac is characterized by findings such as watery vaginal drainage. Passage of the mucus plug is manifested as pink or as blood-tinged mucus. Test-Taking Strategy: Use the process of elimination. Focus on the data in the question and recall that painless vaginal bleeding occurs in placenta previa. If you had difficulty with this question, review the assessment signs associated with the conditions identified in the options. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Maternity/Antepartum Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., pp. 614, 615). St. Louis: Elsevier. Awarded 0.0 points out of 1.0 possible points. L. 92.ID: 327529231 A nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative, refusing any interventions until her husband arrives at the hospital. The nurse analyzes the client’s behavior as most likely the result of: A. Emotional immaturity B. A stubborn personality C. Anxiety and the need for support Correct D. An undiagnosed psychiatric disorder Rationale: Any of the situations identified in the options could contribute to the client’s behavior, but the most likely reason is anxiety. Anxiety is the only emotion that supports the information identified in the question. The client may be anxious about the unknown effects of complications and want the presence of a support person while she deals with the crisis. There is no information in the question to support the other options. Test-Taking Strategy: Use the process of elimination, focusing on the data in the question. Noting the strategic words “refusing any interventions until her husband arrives” will direct you to the correct option. Additionally, there is no information in the question to support the remaining options. Review the psychosocial aspects of care for a client with a partial placental abruption if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Analysis Content Area: Maternity/Antepartum Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., p. 621). St. Louis: Elsevier. Awarded 0.0 points out of 1.0 possible points. M. 93.ID: 327528057 A neonate is irritable, cries incessantly, and has a temperature of 99.4° F. The neonate is also tachypneic, diaphoretic, feeding poorly, and hyperactive in response to environmental stimuli. The nurse determines that these signs and symptoms are consistent with: A. Sepsis B. Hypercalcemia C. Intraventricular hemorrhage D. Neonatal abstinence syndrome Correct Rationale: Neonatal abstinence syndrome is the term given to the group of signs and symptoms associated with drug withdrawal in the neonate. Drug withdrawal causes a hyperactive response in the infant because of the increased central nervous system (CNS) stimulation. This hyperactive response and the signs and symptoms of drug withdrawal seem to be most apparent around 1 week of age. Sepsis, hypercalcemia, and intraventricular hemorrhage cause symptoms of CNS depression. Test-Taking Strategy: Use the process of elimination, focusing on the data in the question. Note the strategic word “hyperactive,” which indicates CNS stimulation and should direct you to the correct option. If you had difficulty with this question, review the signs and symptoms of drug withdrawal in the neonate. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Newborn Rationale: One contraindication to the administration of Rho(D) immune globulin is previous hypersensitivity to immune globulin. Rho(D) immune globulin is indicated when an Rh-negative client is exposed to Rh-positive fetal blood cells in any way, including amniocentesis. The other options are all indications for administering RhoGam. Test-Taking Strategy: Use the process of elimination and focus on the subject, a contraindication. Read each option carefully and note the word “hypersensitivity” in the correct option. Review the contraindications to and precautions for the administration of this medication if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Pharmacology Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., p. 462). St. Louis: Elsevier. Reference: Lowdermilk, D., Perry, S., & Cashion, K. (2010). Maternity nursing (8th ed., pp. 785, 786). St. Louis: Mosby. Awarded 0.0 points out of 1.0 possible points. N. 94.ID: 327529233 Rho(D) immune globulin (RhoGam) is prescribed for a client after delivery. Before administering the medication, the nurse reviews the client’s history. Which of the following findings is a contraindication to administration of the medication? A. A previous hypersensitivity reaction to immune globulin Correct B. Delivery of an Rh-positive infant by an Rh-negative woman C. Amniocentesis in an Rh-negative woman carrying an Rh-positive fetus D. Known or suspected entry of Rh-positive fetal blood cells to the circulation of anRh- negative woman Awarded 0.0 points out of 1.0 possible points. O. 95.ID: 327528063 A nurse is caring for a client experiencing hypotonic labor contractions. The client is discouraged by the lack of progress with labor but refuses an amniotomy or oxytocin (Pitocin) stimulation. The nurse determines that the client’s behavior may be a result of: communication techniques. This will direct you to the correct option. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Applying Clients Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Maternity/Antepartum Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., pp. 27-29, 653). St. Louis: Elsevier. Awarded 0.0 points out of 1.0 possible points. R. 98.ID: 327528627 A clinic nurse is performing an assessment of an HIV-positive pregnant woman during the 32nd week of gestation. Which finding requires further follow-up? A. Weight gain of 22 lb B. Active fetal movement C. Slight lower extremity edema D. Increased shortness of breath and bilateral crackles in the lungs Correct Rationale: HIV infection in a pregnant woman may result in both maternal and fetal complications. Fetal compromise may occur as a result of premature rupture of the membranes, preterm birth, or low birth weight. Potential maternal effects include an increased risk for opportunistic infections. Individuals in the later stages of HIV infection are susceptible to other invasive conditions, such as tuberculosis and a wide variety of bacterial infections. The assessment finding in the correct option could be indicative of an opportunistic infection and requires follow-up. Test-Taking Strategy: Use the process of elimination. Eliminate the incorrect options because these are normal findings. Additionally, use your knowledge of the ABCs — airway, breathing, and circulation — to direct you to the correct option. Review care of the HIV-positive pregnant woman if you had difficulty with this question. Level of Cognitive Ability: Analyzing Clients Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Maternity/Antepartum Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., pp. 656, 657). St. Louis: Elsevier. Awarded 0.0 points out of 1.0 possible points. S. 99.ID: 327528615 A nurse palpates the anterior fontanel of a neonate and notes that it feels soft. This nurse interprets this assessment data as: A. A normal finding Correct B. Indicative of dehydration C. Indicative of increased intracranial pressure D. Indicative of decreased intracranial pressure Rationale: The anterior fontanel, which is diamond shaped, is located on the top of the head. It measures 1 to 4 cm but varies because of molding and individual differences. It normally closes by 12 to 18 months of age. It may be described as soft, which is normal, or full and bulging, which may be indicative of increased intracranial pressure. Conversely, a depressed fontanel could mean that the neonate is dehydrated. Test-Taking Strategy: Use the process of elimination, noting the strategic words “feels soft” in the question. Remember that the anterior fontanel is soft in the neonate. If you had difficulty answering this question, review normal assessment findings in the neonate. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Newborn Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., p. 512). St. Louis: Elsevier. Awarded 0.0 points out of 1.0 possible points. T. 100.ID: 327528673 A nurse notes that the laboratory report of a pregnant client with suspected HIV infection indicates leukopenia, thrombocytopenia, anemia, and an increased erythrocyte sedimentation rate. Which laboratory test that would further confirm the presence of HIV does the nurse anticipate that the physician will prescribe? A. Platelet count B. Angiotensin level C. Glomerular filtration rate D. T-lymphocyte determination Correct Rationale: HIV has a strong affinity for surface marker proteins on lymphocytes. This affinity of HIV for T-lymphocytes leads to significant cell destruction. Angiotensin is produced in the kidney and plays a role in blood pressure control. Glomerular filtration rate is an indicator of kidney function. The platelet count is important and may be used as an indicator of the effects of HIV, but the platelet count (thrombocytopenia) has already been addressed in the question.