Nur 160 Test 1 Exam (New 2024/ 2025 Update) | Questions and Verified Answers| 100% Correct, Exams of Advanced Education

Download Nur 160 Test 1 Exam (New 2024/ 2025 Update) | Questions and Verified Answers| 100% Correct and more Exams Advanced Education in PDF only on Docsity! Nur 160 Test 1 Exam (New 2024/ 2025 Update) | Questions and Verified Answers| 100% Correct| Grade A+ The nurse is assessing a client at 30 weeks' gestation who reports increased constipation. Which suggestion should the nurse prioritize for this client? 1. Increase intake of meat 2. Reduce iron supplements 2. Take mineral oil 4. Increase fluid intake - Correct Answer-4. Increase fluid intake Explanation: Increasing fluid content by drinking at least 8 glasses of noncaffeinated beverages helps relieve constipation in both pregnant and nonpregnant women. Reducing an iron supplement could lead to anemia; mineral oil can reduce absorption of fat-soluble vitamins. The client should add foods rich in fiber, which would include grains, vegetables, and fruits (instead of meat). The nurse is caring for a client who had consistent exposure to lead while pregnant. When the neonate is born, which focused assessment is essential? 1. Muscle tone 2. Hearing 3. Reflexes 4. Swallowing ability - Correct Answer-3. Reflexes Explanation: A factor determining the effects of a teratogen is the teratogen's affinity for specific body tissues. Lead and mercury attack and disable nervous tissue. Assessment of reflexes and cognitive alertness is a priority. A hearing assessment is completed on most neonates in the nursery before discharge. Screening does not indicate lead poisoning. Muscle tone and the ability to swallow are not related to lead poisoning. A pregnant client in the second trimester is diagnosed with hyperemesis gravidarum with a 10% weight loss. The nurse is gathering data to form the foundation of a nutritional nursing care plan. Which way is best to obtain a nutritional assessment? 3. Tell the client these are normal findings during pregnancy 4. Document these findings in the clients chart - Correct Answer-3. Tell the client these are normal findings during pregnancy Explanation: The hormone relaxin causes the smooth muscles, joints, and ligaments of the body to relax. Because of the production of relaxin during pregnancy, women often experience aches in the pelvic area. The nurse would explain to the client this is a normal finding of pregnancy and will resolve. The nurse should document this in the chart, but it is not priority over educating the client. The nurse discovers a soft systolic murmur when auscultating the heart of a client at 32 weeks' gestation. Which action would be most appropriate? 1. Ask another nurse to assess the heart 2. Inquire if the patient has chest pain 3. Document this and continue to monitor the murmur at future visits 4. Refer her for cardiac catheterization - Correct Answer-3. Document this and continue to monitor the murmur at future visits Explanation: Due to the increased blood volume that occurs with pregnancy, soft systolic murmurs may be heard and are considered normal To prevent exposure to hepatitis A virus, the nurse teaches the pregnant client to avoid which food? 1. Grilled tuna 2. Raw fish 3. Undercooked chicken 4. Raw eggs - Correct Answer-2. Raw fish Explanation: The hepatitis A virus is found in raw fish. Raw eggs and undercooked chicken can transmit salmonella, and swordfish can contain high levels of mercury. The nurse provides instructions to a client with hyperemesis gravidarum. Which outcome indicates that teaching has been effective? 1. The client is able to ingest clear liquids between episodes of vomiting. 2. The client has vomiting episodes only in the morning. 3. The client is able to tolerate soft foods after episodes of vomiting. 4. The client is able to ingest a regular diet after progressing through clear liquids and soft foods. - Correct Answer-4. The client is able to ingest a regular diet after progressing through clear liquids and soft foods. Explanation: The pregnant client with hyperemesis gravidarum may be hospitalized and treated with intravenous fluids. If there is no vomiting after the first 24 hours of oral restriction, small amounts of clear fluid can be started, and the woman discharged home. If able to take clear fluid without vomiting, small quantities of dry toast, crackers, or cereal can be added every 2 or 3 hours, then the woman may be gradually advanced to a soft diet and then to a regular diet. If vomiting To help the client alleviate varicosities of the legs, the nurse should instruct the client to refrain from crossing her legs when sitting for long periods. The nurse should instruct the client to avoid standing, not sitting, in one position for long periods of time. The nurse should instruct the client to wear support stockings to promote better circulation, though the client should stay away from constrictive stockings and socks. Applying heating pads on the extremities is not reported to alleviate varicosities of the legs. A pregnant woman at her first prenatal visit asks the nurse if it is safe to have sex during her pregnancy. Which client statement alerts the nurse to the need for further teaching? 1."I will avoid having intercourse following the rupture of the membranes." 2. "I should substitute intercourse with nonsexual touch to avoid harming the fetus." 3. "I will experience a heightened need for touch throughout my pregnancy." 4. "If I experience bleeding, I will abstain from vaginal intercourse." - Correct Answer-2. "I should substitute intercourse with nonsexual touch to avoid harming the fetus." Explanation: Sexual needs may be met through sexual intercourse with a partner as long as the pregnancy is healthy and there are no other risk factors, such as bleeding or rupture of membranes. Pregnancy is a time of a heightened need for touch, which may be met partially by sexual expression, but which can also be met through nonsexual touch, such as massage, caressing, or holding. During pregnancy most nutritional needs can be consumed in adequate amounts through the diet. Which nutrient is the exception to this statement? 1. Sodium 2. Iron 3. Vitamin D 4. Calcium - Correct Answer-2. Iron Explanation: Although most nutrients are needed in greater amounts during pregnancy, most women who are at low nutritional risk can meet their nutrient needs throughout pregnancy from food alone. A notable exception is iron. Folic acid is another possible exception. As previously noted, fortified foods or supplements containing 600 micrograms of folic acid are recommended during pregnancy. A woman at low nutritional risk can meet the needs for calcium, sodium, and vitamin D in her diet. Which of these cardiac variations, if found in the client who is pregnant, should the nurse recognize as a normal finding in pregnancy? 1. Premature Ventricular contractions 2. S4 (atrial gallop) 3. Split S1S2 4. Soft systolic murmur - Correct Answer-4. Soft systolic murmur Explanation: A soft systolic murmur is common in pregnancy secondary to the increased blood volume. The other findings are not normal and require further assessment by the nurse. 2. More frequent tooth brushing is recommended to prevent caries related to ptyalism 4. Applying lanolin ointment to the breasts is recommended to prevent cracked nipples - Correct Answer-1. Swimming in a pool is recommended exercise during pregnancy Explanation: Swimming in a pool is good exercise for a pregnant woman. However, swimming in a lake can be harmful because of the danger of infection, especially in the latter months. Douching can increase the risk of vaginal infections. Increased salivation or ptyalism, seen in some women during pregnancy, does not cause tooth decay and necessitate more frequent brushing. Lanolin ointments may damage the areola and nipple and have not been shown to be effective in preventing sore and cracked nipples. A client presents at the emergency department. During the assessment, the nurse notes the following: Client is a 22-week primipara, age 25, pulse 82, BP 110/76, temp 38.3°C (100.9°F). The client is diagnosed with pyelonephritis. What would be the treatment of choice? 1. Hospitalization and intravenous antibiotics 2. Oral antibiotics and bed rest at home 3. Hospitalization and intravenous hydration 4. Home care and oral hydration and antibiotics - Correct Answer-1. Hospitalization and intravenous antibiotics Explanation: Pyelonephritis can develop when a urinary tract infection (UTI) is not treated promptly. Because the immune system does not fight infections as well during pregnancy, a bladder infection can quickly become a kidney infection, characterized by severe flank pain and a fever above 100.4°F (38°C). While pyelonephritis is often treated on an outpatient basis for nonpregnant clients, during pregnancy, pyelonephritis requires intravenous antibiotics immediately to prevent generalized sepsis, which is potentially fatal. A nurse is providing care to a woman who has just found out that she is pregnant. The nurse is describing the events that have occurred and the structures that are forming. When describing the trophoblast to the client, the nurse would explain that this structure forms: 1. Zygote 2. Placental 3. Morula 4. Fetal membrane - Correct Answer-2. Placenta Explanation: The trophoblast forms the placenta and chorion. The blastocyst forms the embryo and amnion. The zygote is formed from the union of the sperm and ovum. The morula is a mass of 16 cells that develop as cleavage cell division continues after fertilization. The nurse is instructing on maternal hormones which may impact the onset of labor. Which hormones are included in the discussion? Select all that apply. 1. Insulin 2. Testosterone 3. Thyroxine 4. Progesterone 5. Prostaglandins 6. Oxytocin - Correct Answer-4. Progesterone 5. Prostaglandins There are two umbilical arteries and one umbilical vein. The arteries carry waste from the fetus to the placenta; the vein carries oxygenated blood to the fetus from the placenta. Which hormone(s) is secreted by the placenta during the pregnancy? Select all that apply. 1. Prolactin 2. Estrogen 3. Testosterone 4. Progesterone 5. Human Chorionic Gonadotropin - Correct Answer-2. Estrogen 4. Progesterone 5. Human Chorionic Gonadotropin Explanation: The placenta secretes hormones that help to sustain the pregnancy. These include progesterone, estrogen, human placental lactogen, and human chorionic gonadotropin. Testosterone is secreted by the male testes. Prolactin is secreted by the anterior pituitary gland. Which would be a normal finding by the nurse during a physical exam of a woman in her third trimester? 1. Kyphosis 2. Dyspnea 3. Increased hematocrit 4. Ptyalism - Correct Answer-2. Dyspnea Explanation: In the third trimester, a women experiences dyspnea from the uterus pushing up into the diaphragm. A pregnant woman will experience lordosis, not kyphosis. Ptyalism is excessive saliva production and is often seen in the first trimester of pregnancy. The hematocrit of a pregnant woman will decrease in the third trimester, not increase. A nursing instructor identifies a need for further instruction in regards to the three stages of fetal development when a nursing student makes which statement? 1. "The embryonic stage begins approximately 2 weeks after fertilization." 2. "The fetal stage begins at 9 weeks after fertilization" 3. "The fetal stage ends at birth" 4. "The pre-embryonic stage begins approximately 2 weeks after fertilization" - Correct Answer-4. "The pre-embryonic stage begins approximately 2 weeks after fertilization" Explanation: The three stages of human development are the pre- embryonic stage, which begins at fertilization and lasts through the end of the second week after fertilization; the embryonic stage, which begins approximately 2 weeks after fertilization and ends at the conclusion of the 8th week after fertilization; and the fetal stage, which begins approximately 9 weeks after fertilization and ends at birth. A nurse is providing care to several pregnant women at different weeks of gestation. The nurse would expect to screen for group B streptococcus (GBS) infection in the client who is at: 1. 28 weeks' gestation movement is limited in the birth canal. Decelerations do not indicate well-being. Acoustic vibrations do not descend the fetus into the birth canal. A new dad is alarmed at the shape of his newborn's head. When responding to the dad, the nurse reminds him this is due to: 1. A congenital defect 2. Prolonged labor 3. Cranial bones overlapping at the suture line 4. Extreme pressure in the vaginal vault - Correct Answer-3. Cranial bones overlapping at the suture line Explanation: This is due to molding, which is the result of overlapping of the cranial bones at the suture lines. It is a temporary situation that will correct itself. It is due to the fetus passing through the pelvis. Molding is not the result of extreme pressure, a congenital defect, or prolonged labor. A client is in the first stage of labor and asks the nurse what type of pain she should expect at this stage. What is the nurse's most appropriate response? 1. Distention of the vagina and perineum 2. Pressure on the lower back, buttocks, and thighs 3. Pain from the dilation or stretching of the cervix 4. Hypoxia of the contracting uterine muscles - Correct Answer-3. Pain from the dilation or stretching of the cervix Explanation: In the first stage of labor, the primary source of pain is the dilation (dilatation) of the cervix. Hypoxia of the contracting uterine muscles, distension of the vagina and perineum, and pressure on the lower back, buttocks, and thighs may occur in the first stage but are more significantly associated with the second stage of labor. A client is scheduled for a cesarean section under spinal anesthesia. After instruction is given by the anesthesiologist, the nurse determines the client has understood the instructions when the client states: 1. "I will need to lie on my right side to reduce vena cava compression." 2. "I can continue sitting up after the spinal is given." 3. "I may end up with a severe headache from the spinal anesthesia." 4. "The anesthesia will numb both of my legs to a level above my breasts." - Correct Answer-3. "I may end up with a severe headache from the spinal anesthesia." Explanation: Cerebrospinal fluid (CSF) leakage from the needle insertion site and irritation caused by a small amount of air that enters at the injection site and shifts the pressure of the CSF causes strain on the cerebral meninges, initiating pain from a postdural puncture (spinal) headache. The nurse is reviewing the medical record of a woman in labor and notes that the fetal position is documented as LSA. The nurse interprets this information as indicating which part as the presenting part? 1. Face 2. Shoulder Trendelenburg positions. Ice packs are not indicated to reduce this pain. A nursing instructor is conducting a class on the various types of pelvic shapes to a group of nursing students. The instructor determines the class is successful when the students correctly choose which factor is specific for an anthropoid pelvis? 1. Has weaker bones than normal 2. Is "male" shaped 3. Is narrow transversely 4. Is ideal for birth - Correct Answer-3. Is narrow transversely A gynecoid pelvis is the best shape for birth. An anthropoid pelvis is usually narrow. A "male" pelvis is termed an "android pelvis." The condition of the bones is not a determining factor for the shape of the pelvis. ROA was documented in the babys chart. Which position was the baby born in? 1. Rear facing with the occiput facing the posterior quadrant of the pelvis 2. With the brow facing the right anterior quadrant of the pelvis 3. With the right side presenting, and the occiput facing the anterior quadrant 4. With the occiput facing the right anterior quadrant of the pelvis - Correct Answer-4. With the occiput facing the right anterior quadrant of the pelvis A fetus in the vertex presentation has the occiput as the reference point. If the occiput is facing the anterior quadrant of the pelvis, the nurse is correct to record the position as ROA. Proper notation does not include a rear or right facing position. The vertex presentation is associated with the fetal occiput, not brow. The nurse is preparing materials to instruct a pregnant client about the use of a local anesthetic to block specific nerve pathways. About which type of pain reduction technique will the nurse instruct the client? 1. General anesthesia 2. Regional anesthesia 3. Pressure anesthesia 4. Pudendal nerve blok - Correct Answer-2. Regional anesthesia Regional anesthesia is the injection of a local anesthetic to block specific nerve pathways. This achieves pain relief by blocking sodium and potassium transport in the nerve membrane so the nerve is unable to conduct sensations. General anesthesia is rarely used and is not referred to as being general anesthesia. Pressure anesthesia results from the fetal head pressing against the stretched perineum. A pudendal nerve block is the injection of a local anesthetic through the vagina to anesthetize the pudendal nerve. The client presents in the early stage of labor with mild contractions 7 to 9 minutes apart and blood pressure 130/80 mm Hg. The client changes from happy, excited, and confident to introverted and restless. Assessment reveals heart rate 100, blood pressure 137/85 mm Hg, and hyperventilation. EFM reveals no variability for almost 20 minutes, then evident variability with no late decelerations. Which action should the nurse prioritize? 4. Critical; it represents metabolic acidosis. - Correct Answer- 2. Reassuring; it is associated with normal acid-base balance. The fetal pH slowly decreases during labor as a result of the normal stress of labor. Although 7.26 is low for an adult, it is not problematic during labor for an emerging fetus. Which positions would be most appropriate for the nurse to suggest as a comfort measure to a woman who is in the first stage of labor? Select all that apply. 1. straddling with forward-leaning over a chair 2. walking with partner support 3. rocking back and forth with foot on chair 4. closed knee-chest position 5. supine with legs raised at a 90-degree angle - Correct Answer-1. straddling with forward leaning over a chair 2. walking with partner support 3. rocking back and forth with foot on chair Positioning during the first stage of labor includes walking with support from the partner; side-lying with pillows between the knees; leaning forward by straddling a chair, table, or bed; kneeling over a birthing ball; lunging by rocking weight back and forth with a foot up on a chair or birthing ball; or an open knee-chest position. Patterned breathing techniques used in labor provide which benefits? Select all that apply. 1. pain relief without special tools 2. conscious relaxation 3. distraction 4. spirituality - Correct Answer-1. pain relief without special tools 2. conscious relaxation 3. distraction Patterned breathing can be very effective when the woman has practiced before labor and has an attentive coach. It can provide distraction, conscious relaxation, and pain relief without any special tools. The basic breathing patterns can be taught by the nurse and are easy to learn and simple to perform. During which phase of labor would the nurse anticipate providing the most emotional support for the mother? 1. Final phase of labor 2. Latent phase of labor 3. Active phase of labor 4. Transition phase of labor - Correct Answer-4. Transition phase of labor The transition phase of labor is the most difficult. This phase of the first stage of labor starts when the cervix is dilated at 8 cm and ends with full cervical dilation (dilatation). The contractions at this point are strong and lasting 60 to 90 seconds. It is important for the nurse to help the woman through this stage and encourage her to rest between contractions. The nurse is preparing to assess the duration of contractions for a client in labor. Which process should the nurse use to time the contractions? 1. A gravida 5 para 2 mother in active labor 2. A gravida 3 para 0 mother at 36 weeks' gestation 3. A gravida 1 para 0 mother with mild preeclampsia 4. A gravida 2 para 1 mother for TOLAC - Correct Answer-1. A gravida 5 para 2 mother in active labor The gravida 5 para 2 mother is in active labor, is in no apparent distress, and is expected to deliver without complications. The other 3 clients all have documented medical problems and may require more experience and critical thinking than the new nurse with only 6 months experience. A client in labor is anxious about having an intravenous infusion. Following insertion of the intravenous line, which nursing action is best? 1. Maintain the client in the supine position. 2. Use distraction therapy. 3. Wrap the intravenous line with a cling wrap. 4. Instruct the client to lie still so not to dislodge the catheter. - Correct Answer-2. Use distraction therapy. Many women in labor may receive intravenous fluid to maintain hydration. Distraction therapy helps the client to focus her attention on the birthing process. The woman can be out of bed with this in place. She should lie on her side as should all women in labor. Pediatric clients are upset by the site of the intravenous infusion site so the site is wrapped with a cling wrap or gauze. Immediately following an epidural block, a pregnant client's blood pressure suddenly falls to 86/44 mm Hg. What action should the nurse take first? 1. Ask the client to take deep breaths. 2. Administer an angiotensin-converting enzyme (ACE) inhibitor. 3. Raise the client's legs. 4. Place the client supine. - Correct Answer-3. Raise the client's legs To help prevent supine hypotension syndrome, the nurse will place the pregnant client on the left side after an epidural block. If hypotension should occur, the client's legs should be raised in addition to providing oxygen, intravenous fluids, and medication such as an antihypotensive agent like ephedrine. The supine position encourages hypotension syndrome. Deep breathing would not nhelp with hypotension syndrome. An ACE inhibitor is an anti-hypertensive agent that would cause the client's blood pressure to decrease. Which nursing intervention offered in labor would probably be the most effective in applying the gate control theory for relief of labor pain? 1. Massage the woman's back. 2. Encourage the woman to rest between contractions. 3. Change the woman's position. 4. Give the prescribed medication. - Correct Answer-1. Massage the woman's back. Gate-control is based on the idea of distraction or redirection of the conduction of impulses up the neural pathways. Massage redirects the paths of sensation away from the pain to the other area. Encouragement is a form of psychological support. Position change will only distract the client. Nur 160 Test 1 Exam (New 2024/ 2025 Update) | Questions and Verified Answers| 100% Correct| Grade A+ The nurse is assessing a client at 30 weeks' gestation who reports increased constipation. Which suggestion should the nurse prioritize for this client? 1. Increase intake of meat 2. Reduce iron supplements 2. Take mineral oil 4. Increase fluid intake - Correct Answer-4. Increase fluid intake Explanation: Increasing fluid content by drinking at least 8 glasses of noncaffeinated beverages helps relieve constipation in both pregnant and nonpregnant women. Reducing an iron supplement could lead to anemia; mineral oil can reduce absorption of fat-soluble vitamins. The client should add foods rich in fiber, which would include grains, vegetables, and fruits (instead of meat). The nurse is caring for a client who had consistent exposure to lead while pregnant. When the neonate is born, which focused assessment is essential? 1. Muscle tone 2. Hearing 3. Reflexes 4. Swallowing ability - Correct Answer-3. Reflexes Explanation: A factor determining the effects of a teratogen is the teratogen's affinity for specific body tissues. Lead and mercury attack and disable nervous tissue. Assessment of reflexes and cognitive alertness is a priority. A hearing assessment is completed on most neonates in the nursery before discharge. Screening does not indicate lead poisoning. Muscle tone and the ability to swallow are not related to lead poisoning. A pregnant client in the second trimester is diagnosed with hyperemesis gravidarum with a 10% weight loss. The nurse is gathering data to form the foundation of a nutritional nursing care plan. Which way is best to obtain a nutritional assessment? 3. Tell the client these are normal findings during pregnancy 4. Document these findings in the clients chart - Correct Answer-3. Tell the client these are normal findings during pregnancy Explanation: The hormone relaxin causes the smooth muscles, joints, and ligaments of the body to relax. Because of the production of relaxin during pregnancy, women often experience aches in the pelvic area. The nurse would explain to the client this is a normal finding of pregnancy and will resolve. The nurse should document this in the chart, but it is not priority over educating the client. The nurse discovers a soft systolic murmur when auscultating the heart of a client at 32 weeks' gestation. Which action would be most appropriate? 1. Ask another nurse to assess the heart 2. Inquire if the patient has chest pain 3. Document this and continue to monitor the murmur at future visits 4. Refer her for cardiac catheterization - Correct Answer-3. Document this and continue to monitor the murmur at future visits Explanation: Due to the increased blood volume that occurs with pregnancy, soft systolic murmurs may be heard and are considered normal To prevent exposure to hepatitis A virus, the nurse teaches the pregnant client to avoid which food? 1. Grilled tuna 2. Raw fish 3. Undercooked chicken 4. Raw eggs - Correct Answer-2. Raw fish Explanation: The hepatitis A virus is found in raw fish. Raw eggs and undercooked chicken can transmit salmonella, and swordfish can contain high levels of mercury. The nurse provides instructions to a client with hyperemesis gravidarum. Which outcome indicates that teaching has been effective? 1. The client is able to ingest clear liquids between episodes of vomiting. 2. The client has vomiting episodes only in the morning. 3. The client is able to tolerate soft foods after episodes of vomiting. 4. The client is able to ingest a regular diet after progressing through clear liquids and soft foods. - Correct Answer-4. The client is able to ingest a regular diet after progressing through clear liquids and soft foods. Explanation: The pregnant client with hyperemesis gravidarum may be hospitalized and treated with intravenous fluids. If there is no vomiting after the first 24 hours of oral restriction, small amounts of clear fluid can be started, and the woman discharged home. If able to take clear fluid without vomiting, small quantities of dry toast, crackers, or cereal can be added every 2 or 3 hours, then the woman may be gradually advanced to a soft diet and then to a regular diet. If vomiting To help the client alleviate varicosities of the legs, the nurse should instruct the client to refrain from crossing her legs when sitting for long periods. The nurse should instruct the client to avoid standing, not sitting, in one position for long periods of time. The nurse should instruct the client to wear support stockings to promote better circulation, though the client should stay away from constrictive stockings and socks. Applying heating pads on the extremities is not reported to alleviate varicosities of the legs. A pregnant woman at her first prenatal visit asks the nurse if it is safe to have sex during her pregnancy. Which client statement alerts the nurse to the need for further teaching? 1."I will avoid having intercourse following the rupture of the membranes." 2. "I should substitute intercourse with nonsexual touch to avoid harming the fetus." 3. "I will experience a heightened need for touch throughout my pregnancy." 4. "If I experience bleeding, I will abstain from vaginal intercourse." - Correct Answer-2. "I should substitute intercourse with nonsexual touch to avoid harming the fetus." Explanation: Sexual needs may be met through sexual intercourse with a partner as long as the pregnancy is healthy and there are no other risk factors, such as bleeding or rupture of membranes. Pregnancy is a time of a heightened need for touch, which may be met partially by sexual expression, but which can also be met through nonsexual touch, such as massage, caressing, or holding. During pregnancy most nutritional needs can be consumed in adequate amounts through the diet. Which nutrient is the exception to this statement? 1. Sodium 2. Iron 3. Vitamin D 4. Calcium - Correct Answer-2. Iron Explanation: Although most nutrients are needed in greater amounts during pregnancy, most women who are at low nutritional risk can meet their nutrient needs throughout pregnancy from food alone. A notable exception is iron. Folic acid is another possible exception. As previously noted, fortified foods or supplements containing 600 micrograms of folic acid are recommended during pregnancy. A woman at low nutritional risk can meet the needs for calcium, sodium, and vitamin D in her diet. Which of these cardiac variations, if found in the client who is pregnant, should the nurse recognize as a normal finding in pregnancy? 1. Premature Ventricular contractions 2. S4 (atrial gallop) 3. Split S1S2 4. Soft systolic murmur - Correct Answer-4. Soft systolic murmur Explanation: A soft systolic murmur is common in pregnancy secondary to the increased blood volume. The other findings are not normal and require further assessment by the nurse. 2. More frequent tooth brushing is recommended to prevent caries related to ptyalism 4. Applying lanolin ointment to the breasts is recommended to prevent cracked nipples - Correct Answer-1. Swimming in a pool is recommended exercise during pregnancy Explanation: Swimming in a pool is good exercise for a pregnant woman. However, swimming in a lake can be harmful because of the danger of infection, especially in the latter months. Douching can increase the risk of vaginal infections. Increased salivation or ptyalism, seen in some women during pregnancy, does not cause tooth decay and necessitate more frequent brushing. Lanolin ointments may damage the areola and nipple and have not been shown to be effective in preventing sore and cracked nipples. A client presents at the emergency department. During the assessment, the nurse notes the following: Client is a 22-week primipara, age 25, pulse 82, BP 110/76, temp 38.3°C (100.9°F). The client is diagnosed with pyelonephritis. What would be the treatment of choice? 1. Hospitalization and intravenous antibiotics 2. Oral antibiotics and bed rest at home 3. Hospitalization and intravenous hydration 4. Home care and oral hydration and antibiotics - Correct Answer-1. Hospitalization and intravenous antibiotics Explanation: Pyelonephritis can develop when a urinary tract infection (UTI) is not treated promptly. Because the immune system does not fight infections as well during pregnancy, a bladder infection can quickly become a kidney infection, characterized by severe flank pain and a fever above 100.4°F (38°C). While pyelonephritis is often treated on an outpatient basis for nonpregnant clients, during pregnancy, pyelonephritis requires intravenous antibiotics immediately to prevent generalized sepsis, which is potentially fatal. A nurse is providing care to a woman who has just found out that she is pregnant. The nurse is describing the events that have occurred and the structures that are forming. When describing the trophoblast to the client, the nurse would explain that this structure forms: 1. Zygote 2. Placental 3. Morula 4. Fetal membrane - Correct Answer-2. Placenta Explanation: The trophoblast forms the placenta and chorion. The blastocyst forms the embryo and amnion. The zygote is formed from the union of the sperm and ovum. The morula is a mass of 16 cells that develop as cleavage cell division continues after fertilization. The nurse is instructing on maternal hormones which may impact the onset of labor. Which hormones are included in the discussion? Select all that apply. 1. Insulin 2. Testosterone 3. Thyroxine 4. Progesterone 5. Prostaglandins 6. Oxytocin - Correct Answer-4. Progesterone 5. Prostaglandins There are two umbilical arteries and one umbilical vein. The arteries carry waste from the fetus to the placenta; the vein carries oxygenated blood to the fetus from the placenta. Which hormone(s) is secreted by the placenta during the pregnancy? Select all that apply. 1. Prolactin 2. Estrogen 3. Testosterone 4. Progesterone 5. Human Chorionic Gonadotropin - Correct Answer-2. Estrogen 4. Progesterone 5. Human Chorionic Gonadotropin Explanation: The placenta secretes hormones that help to sustain the pregnancy. These include progesterone, estrogen, human placental lactogen, and human chorionic gonadotropin. Testosterone is secreted by the male testes. Prolactin is secreted by the anterior pituitary gland. Which would be a normal finding by the nurse during a physical exam of a woman in her third trimester? 1. Kyphosis 2. Dyspnea 3. Increased hematocrit 4. Ptyalism - Correct Answer-2. Dyspnea Explanation: In the third trimester, a women experiences dyspnea from the uterus pushing up into the diaphragm. A pregnant woman will experience lordosis, not kyphosis. Ptyalism is excessive saliva production and is often seen in the first trimester of pregnancy. The hematocrit of a pregnant woman will decrease in the third trimester, not increase. A nursing instructor identifies a need for further instruction in regards to the three stages of fetal development when a nursing student makes which statement? 1. "The embryonic stage begins approximately 2 weeks after fertilization." 2. "The fetal stage begins at 9 weeks after fertilization" 3. "The fetal stage ends at birth" 4. "The pre-embryonic stage begins approximately 2 weeks after fertilization" - Correct Answer-4. "The pre-embryonic stage begins approximately 2 weeks after fertilization" Explanation: The three stages of human development are the pre- embryonic stage, which begins at fertilization and lasts through the end of the second week after fertilization; the embryonic stage, which begins approximately 2 weeks after fertilization and ends at the conclusion of the 8th week after fertilization; and the fetal stage, which begins approximately 9 weeks after fertilization and ends at birth. A nurse is providing care to several pregnant women at different weeks of gestation. The nurse would expect to screen for group B streptococcus (GBS) infection in the client who is at: 1. 28 weeks' gestation movement is limited in the birth canal. Decelerations do not indicate well-being. Acoustic vibrations do not descend the fetus into the birth canal. A new dad is alarmed at the shape of his newborn's head. When responding to the dad, the nurse reminds him this is due to: 1. A congenital defect 2. Prolonged labor 3. Cranial bones overlapping at the suture line 4. Extreme pressure in the vaginal vault - Correct Answer-3. Cranial bones overlapping at the suture line Explanation: This is due to molding, which is the result of overlapping of the cranial bones at the suture lines. It is a temporary situation that will correct itself. It is due to the fetus passing through the pelvis. Molding is not the result of extreme pressure, a congenital defect, or prolonged labor. A client is in the first stage of labor and asks the nurse what type of pain she should expect at this stage. What is the nurse's most appropriate response? 1. Distention of the vagina and perineum 2. Pressure on the lower back, buttocks, and thighs 3. Pain from the dilation or stretching of the cervix 4. Hypoxia of the contracting uterine muscles - Correct Answer-3. Pain from the dilation or stretching of the cervix Explanation: In the first stage of labor, the primary source of pain is the dilation (dilatation) of the cervix. Hypoxia of the contracting uterine muscles, distension of the vagina and perineum, and pressure on the lower back, buttocks, and thighs may occur in the first stage but are more significantly associated with the second stage of labor. A client is scheduled for a cesarean section under spinal anesthesia. After instruction is given by the anesthesiologist, the nurse determines the client has understood the instructions when the client states: 1. "I will need to lie on my right side to reduce vena cava compression." 2. "I can continue sitting up after the spinal is given." 3. "I may end up with a severe headache from the spinal anesthesia." 4. "The anesthesia will numb both of my legs to a level above my breasts." - Correct Answer-3. "I may end up with a severe headache from the spinal anesthesia." Explanation: Cerebrospinal fluid (CSF) leakage from the needle insertion site and irritation caused by a small amount of air that enters at the injection site and shifts the pressure of the CSF causes strain on the cerebral meninges, initiating pain from a postdural puncture (spinal) headache. The nurse is reviewing the medical record of a woman in labor and notes that the fetal position is documented as LSA. The nurse interprets this information as indicating which part as the presenting part? 1. Face 2. Shoulder Trendelenburg positions. Ice packs are not indicated to reduce this pain. A nursing instructor is conducting a class on the various types of pelvic shapes to a group of nursing students. The instructor determines the class is successful when the students correctly choose which factor is specific for an anthropoid pelvis? 1. Has weaker bones than normal 2. Is "male" shaped 3. Is narrow transversely 4. Is ideal for birth - Correct Answer-3. Is narrow transversely A gynecoid pelvis is the best shape for birth. An anthropoid pelvis is usually narrow. A "male" pelvis is termed an "android pelvis." The condition of the bones is not a determining factor for the shape of the pelvis. ROA was documented in the babys chart. Which position was the baby born in? 1. Rear facing with the occiput facing the posterior quadrant of the pelvis 2. With the brow facing the right anterior quadrant of the pelvis 3. With the right side presenting, and the occiput facing the anterior quadrant 4. With the occiput facing the right anterior quadrant of the pelvis - Correct Answer-4. With the occiput facing the right anterior quadrant of the pelvis A fetus in the vertex presentation has the occiput as the reference point. If the occiput is facing the anterior quadrant of the pelvis, the nurse is correct to record the position as ROA. Proper notation does not include a rear or right facing position. The vertex presentation is associated with the fetal occiput, not brow. The nurse is preparing materials to instruct a pregnant client about the use of a local anesthetic to block specific nerve pathways. About which type of pain reduction technique will the nurse instruct the client? 1. General anesthesia 2. Regional anesthesia 3. Pressure anesthesia 4. Pudendal nerve blok - Correct Answer-2. Regional anesthesia Regional anesthesia is the injection of a local anesthetic to block specific nerve pathways. This achieves pain relief by blocking sodium and potassium transport in the nerve membrane so the nerve is unable to conduct sensations. General anesthesia is rarely used and is not referred to as being general anesthesia. Pressure anesthesia results from the fetal head pressing against the stretched perineum. A pudendal nerve block is the injection of a local anesthetic through the vagina to anesthetize the pudendal nerve. The client presents in the early stage of labor with mild contractions 7 to 9 minutes apart and blood pressure 130/80 mm Hg. The client changes from happy, excited, and confident to introverted and restless. Assessment reveals heart rate 100, blood pressure 137/85 mm Hg, and hyperventilation. EFM reveals no variability for almost 20 minutes, then evident variability with no late decelerations. Which action should the nurse prioritize? 4. Critical; it represents metabolic acidosis. - Correct Answer- 2. Reassuring; it is associated with normal acid-base balance. The fetal pH slowly decreases during labor as a result of the normal stress of labor. Although 7.26 is low for an adult, it is not problematic during labor for an emerging fetus. Which positions would be most appropriate for the nurse to suggest as a comfort measure to a woman who is in the first stage of labor? Select all that apply. 1. straddling with forward-leaning over a chair 2. walking with partner support 3. rocking back and forth with foot on chair 4. closed knee-chest position 5. supine with legs raised at a 90-degree angle - Correct Answer-1. straddling with forward leaning over a chair 2. walking with partner support 3. rocking back and forth with foot on chair Positioning during the first stage of labor includes walking with support from the partner; side-lying with pillows between the knees; leaning forward by straddling a chair, table, or bed; kneeling over a birthing ball; lunging by rocking weight back and forth with a foot up on a chair or birthing ball; or an open knee-chest position. Patterned breathing techniques used in labor provide which benefits? Select all that apply. 1. pain relief without special tools 2. conscious relaxation 3. distraction 4. spirituality - Correct Answer-1. pain relief without special tools 2. conscious relaxation 3. distraction Patterned breathing can be very effective when the woman has practiced before labor and has an attentive coach. It can provide distraction, conscious relaxation, and pain relief without any special tools. The basic breathing patterns can be taught by the nurse and are easy to learn and simple to perform. During which phase of labor would the nurse anticipate providing the most emotional support for the mother? 1. Final phase of labor 2. Latent phase of labor 3. Active phase of labor 4. Transition phase of labor - Correct Answer-4. Transition phase of labor The transition phase of labor is the most difficult. This phase of the first stage of labor starts when the cervix is dilated at 8 cm and ends with full cervical dilation (dilatation). The contractions at this point are strong and lasting 60 to 90 seconds. It is important for the nurse to help the woman through this stage and encourage her to rest between contractions. The nurse is preparing to assess the duration of contractions for a client in labor. Which process should the nurse use to time the contractions? 1. A gravida 5 para 2 mother in active labor 2. A gravida 3 para 0 mother at 36 weeks' gestation 3. A gravida 1 para 0 mother with mild preeclampsia 4. A gravida 2 para 1 mother for TOLAC - Correct Answer-1. A gravida 5 para 2 mother in active labor The gravida 5 para 2 mother is in active labor, is in no apparent distress, and is expected to deliver without complications. The other 3 clients all have documented medical problems and may require more experience and critical thinking than the new nurse with only 6 months experience. A client in labor is anxious about having an intravenous infusion. Following insertion of the intravenous line, which nursing action is best? 1. Maintain the client in the supine position. 2. Use distraction therapy. 3. Wrap the intravenous line with a cling wrap. 4. Instruct the client to lie still so not to dislodge the catheter. - Correct Answer-2. Use distraction therapy. Many women in labor may receive intravenous fluid to maintain hydration. Distraction therapy helps the client to focus her attention on the birthing process. The woman can be out of bed with this in place. She should lie on her side as should all women in labor. Pediatric clients are upset by the site of the intravenous infusion site so the site is wrapped with a cling wrap or gauze. Immediately following an epidural block, a pregnant client's blood pressure suddenly falls to 86/44 mm Hg. What action should the nurse take first? 1. Ask the client to take deep breaths. 2. Administer an angiotensin-converting enzyme (ACE) inhibitor. 3. Raise the client's legs. 4. Place the client supine. - Correct Answer-3. Raise the client's legs To help prevent supine hypotension syndrome, the nurse will place the pregnant client on the left side after an epidural block. If hypotension should occur, the client's legs should be raised in addition to providing oxygen, intravenous fluids, and medication such as an antihypotensive agent like ephedrine. The supine position encourages hypotension syndrome. Deep breathing would not nhelp with hypotension syndrome. An ACE inhibitor is an anti-hypertensive agent that would cause the client's blood pressure to decrease. Which nursing intervention offered in labor would probably be the most effective in applying the gate control theory for relief of labor pain? 1. Massage the woman's back. 2. Encourage the woman to rest between contractions. 3. Change the woman's position. 4. Give the prescribed medication. - Correct Answer-1. Massage the woman's back. Gate-control is based on the idea of distraction or redirection of the conduction of impulses up the neural pathways. Massage redirects the paths of sensation away from the pain to the other area. Encouragement is a form of psychological support. Position change will only distract the client. 1. ischial spines 2. pelvic inlet 3. pelvic outlet 4. pelvic crest - Correct Answer-1. ischial spines During the cervical check for fetal station, 0 station is the engagement of the fetus at the level of the ischial spines of the pelvis. The ischial spines are a landmark that is used mark the passage of the fetus. The pelvic crest is a landmark location on the pelvis for documenting fetal station. The pelvic inlet must be shaped accordingly to allow for passage of the fetus. The pelvic outlet is associated with internal rotation of the fetal head. The nurse is caring for a laboring client. The nurse observes that there are early decelerations. The fetal heart rate remains within normal limits with adequate variability. What is the nurse's best action? 1. Promptly inform the primary care provider. 2. Advocate for the client to have a vaginal examination. 3. Continue to monitor the client and the fetal heart rate.. 4. Reposition the client. - Correct Answer-3. Continue to monitor the client and the fetal heart rate.. As long as baseline remains within normal limits and the variability is good, early decelerations are benign and no further action is necessary. A pregnant client with a history of spinal injury is being prepared for a cesarean birth. Which method of anesthesia is to be administered to the client? 1. regional anesthesia 2. local infiltration 3. General anesthesia 4. epidural block - Correct Answer-3. General anesthesia General anesthesia is administered in emergency cesarean births. Local anesthetic is injected into the superficial perineal nerves to numb the perineal area generally before an episiotomy. Although an epidural block is used in cesarean births, it is contraindicated in clients with spinal injury. Regional anesthesia is contraindicated in cesarean births. A nurse is assisting a client who is in the first stage of labor. Which principle should the nurse keep in mind to help make this client's labor and birth as natural as possible? 1. Routine intravenous fluid should be implemented. 2. Women should be able to move about freely throughout labor. 3. A woman should be allowed to assume a supine position. 4. The support person's access to the client should be limited to prevent the client from becoming overwhelmed. - Correct Answer-2. Women should be able to move about freely throughout labor. Six major concepts that make labor and birth as natural as possible are as follows: 1) labor should begin on its own, not be artificially induced; 2) women should be able to move about freely throughout labor, not be confined to bed; 3) women should receive continuous support from a caring other during labor; 4) no interventions such as intravenous fluid The nurse would refer the male client with a family history of a sickle cell disease, a genetic disorder, for prenatal genetic testing. Women older than 35 years of age and men older than 45 years of age should be referred. However, age is not priority over a known family history. Women with diabetes need not necessarily be referred for genetic testing. A female client is concerned about the rate of fertility because the client is older than age 35 years. The client states, "Have I given up the chance to be a parent?" Which response from the nurse is accurate? - Correct Answer-"A woman's fertility peaks in the 20s, declines gradually until age 35, and then rapidly declines until it ends." Which body system is most affected throughout the embryonic and fetal period by teratogens? 1. musculoskeletal system 2. central nervous system 3. genitourinary system 4. gastrointestinal system - Correct Answer-2. Central nervous system Whether the teratogen is ingested, injected, occurs through an infectious agent, or is environmental, the CNS and brain are the body systems most seriously affected during this period. A client is trying to have a baby and wants to know the best time to have intercourse to increase the chances of pregnancy. Which time for intercourse is ideal to help her chances of conceiving? 1. one or two days before ovulation 2. any time after ovulation 3. a week after ovulation 4. any time during the week before ovulation - Correct Answer-1. one or two days before ovulation To increase the chances of conceiving, the best time for intercourse is 1 or 2 days before ovulation. This ensures that the sperm meets the ovum at the right time. The average life of a sperm cell is 2 to 3 days, and the sperm cells will not be able to survive until ovulation if intercourse occurs a week before ovulation. The chances of conception are minimal for intercourse after ovulation. A recently married couple come to the prenatal clinic because they are concerned about genetic testing. The husband is of Jewish heritage. The nurse should recommend the couple undergo genetic testing to determine if the fetus has which disorder common among Ashkenazi Jews (Jews of Eastern European lineage)? 1. Tay-Sachs disease 2. Down syndrome 3. cystic fibrosis 4. Turner syndrome - Correct Answer-1. Tay-Sachs disease Tays-Sachs disease is a autosomal recessive disorder that occurs primarily in Ashkenazi Jews. A nurse is providing information regarding ovulation to a couple who want to have a baby. Which fact should the nurse tell the clients?