Pediatric Nursing Exam Questions and Answers, Exams of Nursing

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PN223 ob and peds final exams questions

with answers

1. A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be performed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take?
2. administer an analgesic
3. release the skin traction
4. apply ice to the extremity 4. notify the HCP
5. A child is placed in skeletal traction for treatment of a fractured femur. The nurse creates a plan of care and should include which intervention?
6. ensure that all ropes are outside the pulleys
7. ensure that the weights are resting lightly on the floor
8. restrict diversional and play activities until the child is out of traction 4. check the HCP's prescriptions for the amount of weight to be applied
9. The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instruction?
10. "I will encourage my child to perform prescribed exercises."
11. "I will have my child wear soft fabric clothing under the brace."
12. "I should apply lotion under the brace to prevent skin breakdown."
13. "I should avoid the use of powder because it will cake under the brace."
14. "I should apply lotion under the brace to prevent skin breakdown."
15. Parents bring their 2-week-old infant to a clinic for treatment after a diagnosis of clubfoot made at birth. Which statement by the parents indicates a need for further teaching regarding this disorder?

"Treatment needs to be started as soon as possible."

"I realize my infant will require follow-up care until fully grown."

"I need to bring my infant back to the clinic in 1 month for a new cast."

"I need to come to the clinic every week with my infant for the casting."

Clubfoot is a complex deformity of the ankle and foot that includes forefoot adduction, midfoot supination, hindfoot varus, and ankle equinus; the defect may be unilateral or bilateral. Treatment for clubfoot is started as soon as possible after birth. Serial manipulation and casting are performed at least weekly. If sufficient correction is not achieved in 3 to 6 months, surgery usually is indicated. Because clubfoot can recur, all children with clubfoot require long-term interval follow-up until they reach skeletal maturity to ensure an optimal outcome. 5The nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included on the list? SATA A. Use the fingertips to lift the cast while it is drying B. Keep small toys and sharp objects away from the cast C. Use a paddle ruler or another padded object to scratch the skin under the cast if it itches D. Place a heating pad on the lower end of the cast and over the fingers if the finders feel cool E. Elevate the extremity on pillows for the first 24-48 hours after casting to prevent swelling F. Contact the HCP if the child complains of numbness or tingling in the extremity 6, A nurse is caring for a 10-month-old infant who is in a cast for developmental dysplasia of the hip (DDH). Which of the following strategies would the nurse implement to promote the infant's growth and development? A. Tie colorful latex balloons to the side of the crib. B. Provide a small electronic toy. C. Change the infant's diaper as soon as soiling occurs. D. Allow infant to stand in the crib.

D. Allow infant to stand in the crib.

Rationale:

The infant should not be restricted from normal activities. The

infant

can be held and allowed to walk in a cast or orthotic device.

Allowing the child to participate in normal developmental

activities will promote growth and development.

7, A nurse is providing teaching to a parent of a child who

has a fracture of an epiphyseal plate. Which of the following

statements should the nurse make?

Normal bone growth can be affected

8, A home health nurse is developing a plan of care for a

child who has hemiplegic cerebral palsy. which of the

following goals is the priority for the nurse to include in the

plan of care?

A. provide respite services for the parents

B. improve the clients communication skills

C. foster self-care

activities D. modify the

environment

Correct answer: D. modify the environment

9, A nurse is caring for a school-age client who possibly has

Reye syndrome. Which of the following is a risk factor for

developing Reye syndrome?

A. Recent history of infectious cystitis caused by Candida

B. Recent history of bacterial otitis media

C. Recent episode of gastroenteritis

D. Recent episode of Haemophilus influenzae meningitis

10, A nurse is caring for a client who has suspected

meningitis and a decreased level of consciousness. Which of

the following actions by the nurse is appropriate?

A. Place the client on NPO status.

B. Prepare the client for a liver biopsy.

C. Position the client dorsal recumbent.

D. Put the client in a protective environment

10, A nurse is caring for a child who has increased

intracranial pressure. Which of the following are appropriate

actions by the nurse? (Select all that apply.)

A. Suction the endotracheal tube every 2 hr.

B. Maintain a quiet environment.

C. Use two pillows to elevate the head.

D. Administer a stool softener.

E. Maintain body alignment.

11, A nurse is taking care of a 10-year-old child that weighs

30 kg. The doctor has ordered azithromycin PO 300 mg x 1

dose.

Azithromycin comes in an oral suspension 100mg/5 mL in a

15 mL bottle. According to the drug handbook for children 2-

15 years of age, 10 mg/kg/day but not to exceed 500

mg/day. How many milliliters should be given?

3 mL

12, A nurse is caring for a child who is on a clear liquid diet. At

lunch, the child consumed ½ cup of juice, 3 oz gelatin, 1 oz of

an ice pop, and 20 mL ginger ale. How many mL should the

nurse record as the child's fluid intake?

260 mL

13, What is the most important thing for a nurse to teach

parents of a child with Duchenne Muscular Dystrophy to do

for their school- aged-child?

A/ Maintain high caloric diet

B/ Institute seizure precautions

C/ Restrict the use of larger

muscles D/ Perform range of

motion exercises

D/ ROM

exercises

Rationale:

ROMs are essential to help achieve primary objectives of

maintaining optimal muscle function for as long as possible

and preventing the development of contractures. High caloric

diet would make them fat, which would push them to a

wheel-chair faster than you can say "fat guy in a little coat".

Seizures have nothing to do with duchenne, and restricting

large muscles could result is disuse atrophy and

contractures.

14, The nurse is counseling the parents of a 12-year-old child

with Duchenne muscular dystrophy about problems that

may develop during adolescence. What body system does

the nurse expect will be affected?

Cardiopulmonary Muscle degeneration is advanced in the adolescent with Duchenne muscular dystrophy. The disease process involves the diaphragm, auxiliary muscles of respiration, and the heart, resulting in life- threatening respiratory infections and heart failure. Central nervous system function is not affected by Duchenne muscular dystrophy; nor is the integumentary system. Nutritional problems related to the gastrointestinal system are less significant than cardiopulmonary problems.

15, A 16-year-old boy comes into the office of the school

nurse complaining of left hip pain that began when playing

basketball in gym class. The boy is in the 85th percentile for

height and weight. He complains of increased pain with

weight bearing. The nurse observes out-toeing of the left leg

with ambulation. Which nursing action is a priority?

Refer the boy to the emergency department.

16, A 12 year-old comes into the clinical with left thigh pain

and a lump over the distal femur. The nurse is aware that

these symptoms can be linked to which of the following

medical problems.

Osteosarcoma

17, The child has been complaining of joint pain in the knees

and jaw for the last 6 weeks, both joints are swollen and

warm to touch, but not red. The physician is ordering blood

to rule out Junior Idiopathic Arthritis. Which of the following

lab tests would the nurse expect the physician to order?

(Select all that apply)

Antinuclear

antibodies CBC with

differential

18, A nurse is planning care for a 6-year-old child who has

bacterial meningitis. Which of the following nursing

interventions should the nurse include in the plan of care?

Implement seizure precautions.

19, The 17 year-old Asian patient comes to the clinic with a

butterfly rash on the face, photosensitivity, and recently had

strep throat.

What diagnosis would you expect the doctor to make?

Systemic Lupus Erythematosus (SLE)

20, A patient recently came into the Emergency Department with a diagnosis of

Guillain-Barre Syndrome (GBS). What is the priority system to initially monitor for this patient?

Respiratory

21, Which assessment findings should the nurse note in a

school- age child with Duchenne Muscular Dystrophy (DMD)?

(Select all that apply.)

Lordosis

Gower sign

Waddling

gait

22,The mother brings her child with cerebral palsy in to the

clinic and is afraid the child is having seizures as the child

has the slow worm like movements in her arms and she

drools when this occurs. The nurse explains to the mother

that this is not a seizure but what type of activity?

Athetoid

23, An 11 year-old child has a recurrence of Ewing sarcoma

and is verbalizing wanting to stop all treatments. The nurse is

aware that the best ethical practice would be which of the

following plan?

Plan a meeting with the parents, child, and the medical

team to provide an opportunity to discuss the child's

concerns.

24, The nurse is assessing a child after a cardiac

catheterization. Which complication should the nurse be

assessing for?

A. Cardiac arrhythmia

B. Hypostatic pneumonia

C. Heart failure

D. Rapidly increasing blood pressure

24, Nursing interventions for the child after a cardiac

catheterization should include which actions? (Select all that

apply.)

A. Allow ambulation as tolerated.

B. Monitor vital signs every 2 hours.

C. Assess the affected extremity for temperature and color.

D. Check pulses above the catheterization site for

equality and symmetry.

E. Remove pressure dressing after 4 hours.

F. Maintain a patent peripheral intravenous catheter until

discharge.

25, Ryan is an 11 month old with Down’s syndrome and Atrial

Septal Defect. His parents report that Ryan has been

lethargic and has had diarrhea the last 24 hours. His

weight is 7 kg (15.4lb).

His Vital signs are:

• Temperature 36.5C (97.7F) rectal
• Pulse 80 beats/minute
• Respirations 35 breaths/minute
• Pulse ox 95% on

room air His lab results

are:

• Potassium 2.9 mmol/L
• Digoxin 2.5 mg/mL 1.

The nurse questions digoxin toxicity. What results support

this? (Select all that apply).

Dig level

26, Nisha is a 14 year old girl with sickle cell anemia. She

comes into the clinic with complaints for severe generalized

pain following a softball game. She is admitted to the pediatric

unit.

Her vital signs are:

• Temperature 37.7 C (99.7 F) orally
• Pulse 110 beats/minute
• Respirations 30 breaths/minute
• Blood Pressure 96/
• O2 sat. 89%
• Pain 8/10, sharp, stabbing
• Weight 110

lbs Her lab

results:

• Hemoglobin= 9g/L
• Hematocrit= 24%
• WBC= 12 , 000 cells/mm 2
• Platelet count= 140 , 000 cells/mm 2

The physician has written the following orders for Nisha.

Which if any of these orders should the nurse questions?

Incorrect answer:

Vital signs q 4 hours. Notify the health care provider if

temp > 38 C (100.4 f).

CBC with manual differential in the morning.

, Not Selected

IV fluids of 3% dextrose in water with 0.43% normal saline

to infuse at 175 ml/hr

, Not Selected

PCA Meperidine 20 mg continuous with 3mg every 8

minutes PCA dose

, Not Selected

Oxygen 2L per nasal cannula titrating to maintain oxygen

sat. > 94%

, Not Selected

All are fine

, Not Selected

27, An 8-year-old girl is receiving a blood transfusion when

the nurse notes that she has developed precordial pain,

dyspnea, distended neck veins, slight cyanosis, and a dry

cough. These manifestations are most suggestive of:

a. Air

embolism.

c. Hemolyti

c

reaction.

b. Allergic

reaction.

d. Circulator

y

overload.

ANS: D

The signs of circulatory overload include distended neck

veins, hypertension, crackles, dry cough, cyanosis, and

precordial pain. Signs of air embolism are sudden difficulty

breathing, sharp pain in the chest, and apprehension. Allergic

reactions are manifested by urticaria, pruritus, flushing,

asthmatic wheezing, and laryngeal edema. Hemolytic

reactions are characterized by chills, shaking, fever, pain at

infusion site, nausea, vomiting, tightness in chest, flank pain,

red or black urine, and progressive signs of shock and renal

failure.

28, Which specific nursing interventions are implemented in

the care of a child with leukemia who is at risk for infection?

Select all that apply.

1. Maintain the child in a semiprivate room.

2. Reduce exposure to environmental organisms.

3. Use strict aseptic technique for all procedures.

4. Ensure that anyone entering the child's room wears a

mask.

5. Apply firm pressure to a needle stick area for at least 10

minutes.

• 2. Reduce exposure to environmental organisms.

• 3. Use strict aseptic technique for all procedures.
• 4. Ensure that anyone entering the child's room wears a

mask.

29, The nurse is conducting a staff in-service on sickle cell

anemia. Which describes the pathologic changes of sickle cell

anemia?

a. Sickle-shaped cells carry excess oxygen.

b. Sickle-shaped cells decrease blood viscosity.

c. Increased red blood cell destruction occurs.

d. Decreased adhesion of sickle-shaped cells occurs.

30, A Hispanic toddler has pneumonia. The nurse notices that the

parent consistently feeds the child only the broth that comes on

the clear liquid tray. Food items, such as Jell-O, Popsicles, and

juices, are left. Which statement best explains this?

The parent is trying to restore normal balance through

appropriate "hot" remedies

In several cultures, including Filipino, Chinese, Arabic, and

Hispanic, hot and cold describe certain properties completely

unrelated to temperature. Respiratory conditions such as

pneumonia are "cold" conditions and are treated with "hot"

foods. The child may like broth but is unlikely to always prefer it

to Jell-O, Popsicles, and juice. The evil eye applies to a state of

imbalance of health, not curative actions. Chinese individuals,

not Hispanic individuals, believe in chi as an innate energy.

31The nurse is preparing to assess a 10-month-old infant. He is

sitting on his father's lap and appears to be afraid of the nurse

and of what might happen next. Which initial actions by the

nurse should be most appropriate?

Ans: Initiate a game of peek-a-boo

32, What should nursing care of an infant with oral candidiasis

(thrush) include?

Ans: Continue medication for the prescribed number of days

33,. Phenylketonuria (PKU) is a genetic disease that results in the bodys

inability to correctly metabolize: a. glucose. b. phenylalanine. c. phenylketones. d. thyroxin e. ANS: B

34. What is the preferred site of intramuscular injections for infants under three? Vastus Lateralis
35. The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction? A. The child exhibits nasal flaring and bradycardia. B. The child is leaning forward, with the chin thrust out. C. The child has a low-grade fever and complains of a sore throat. D. The child is leaning backward, supporting himself or herself with the hands and arms. Ans B. Epiglottitis is a bacterial form of croup. A primary concern is that it can progress to acute respiratory distress.
36. Pancreatic enzymes are administered to the child with cystic fibrosis. What nursing consideration should be included in the plan of care? A. Give pancreatic enzymes between meals if at all possible. B. Do not administer pancreatic enzymes if child is receiving antibiotics. C. Decrease dose of pancreatic enzymes if child is having frequent, bulky stools. D. Pancreatic enzymes can be swallowed whole or sprinkled on a small amount of food taken at beginning of meal. Ans D. Pancreatic enzymes can be swallowed whole or sprinkled on a small amount of food taken at the beginning of a meal. Enzymes may be administered in a small amount of cereal or fruit at the beginning of a meal or swallowed whole. 37.The nurse is caring for a 5-year-old child who is scheduled for a tonsillectomy in 2 hours. Which of the following actions should the nurse include in the child's postoperative care plan? (Select all that apply.) a. Notify the surgeon if the child swallows frequently. b. Apply a heat collar to the child for pain relief.

c. Place the child on the abdomen until fully wake. d. Allow the child to have diluted juice after the procedure. e. Encourage the child to cough frequently. Ans. A, C, D. a. Notify the surgeon if the child swallows frequently. c. Place the child on the abdomen until fully wake. d. Allow the child to have diluted juice after the procedure. Rationale: Frequent swallowing is a sign of bleeding in children after a tonsillectomy. The child should be placed on the abdomen or the side to facilitate drainage. 38.An appropriate nursing intervention when caring for an unconscious child would be which of the following? a. Change the child's position infrequently to minimize the chance of increased ICP. b. Avoid using narcotics or sedatives to provide comfort and pain relief. c. Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema. d. Give tepid sponge baths to reduce fever, since antipyretics are contraindicated. ANS: C Often comatose patients cannot cope with the quantity of fluids that they normally tolerate. Overhydration must be avoided to prevent fatal cerebral edema.

39. A child steps on a nail and sustains a puncture wound of the foot. Which of the following is the most appropriate method for cleansing this wound? a. Wash wound thoroughly with chlorhexidine. b. Wash wound thoroughly with povidone-iodine. c. Soak foot in warm water and soap. d. Soak foot in solution of 50% hydrogen peroxide and 50% water. ANS: C Puncture wounds should be cleansed by soaking the foot in warm water and soap. 40.The school nurse is conducting pediculosis capitis (head lice) assessments. which finding indicates a child has a positive head check? Ans .white sacs attached to the hair shafts in the occipital area

42. Home care is being considered for a young child who is ventilator- dependent. Which factor is most important in deciding whether home care is appropriate?

a. Level of parents' education b. Presence of two parents in the home c. Preparation and training of family d. Family's ability to assume all health care costs ANS: C One of the essential elements is the family's training and preparation. The family must be able to demonstrate all aspects of care for the child. In many areas, it cannot be guaranteed that nursing care wi

43. A nurse is teaching an adolescent who has asthma about how to use a peak expiratory flow meter (PEFM). Which of the following responses by the adolescent indicates an understanding of the teaching? Ans .I will record the highest reading of three attempts 44.An important nursing intervention when caring for a child who is experiencing a seizure would be which of the following? a. Describe and record the seizure activity observed. b. Restrain the child when seizure occurs to prevent bodily harm. c. Place a tongue blade between the teeth if they become clenched. d. Suction the child during a seizure to prevent aspiration. ANS: A When a child is having a seizure, the priority nursing care is observation of the child and seizure. The nurse then describes and records the seizure activity.

44. When caring for the child with Reye syndrome, the priority nursing intervention would be which of the following? a. Monitor intake and output. b. Prevent skin breakdown. c. Observe for petechiae. d. Do range-of-motion exercises. ANS: A Accurate and frequent monitoring of intake and output is essential for adjusting fluid volumes to prevent both dehydration and cerebral edema.

45. Four-year-old David is placed in Buck extension traction for Legg-Calvé-Perthes disease. He is crying with pain as the nurse assesses that the skin of his right foot is pale with an absence of pulse. What should the nurse do first? a. Notify the practitioner of the changes noted. b. Give the child medication to relieve the pain.

c. Reposition the child and notify physician. d. Chart the observations and check the extremity again in 15 minutes. ANS: A The absence of a pulse and change in color of the foot must be reported immediately for evaluation by the practitioner.

48. he nurse educator is preparing to conduct a teaching session for the nursing staff regarding the theories of growth and development and plans to discuss Kohlberg's theory of moral development. What information should the nurse include in the session? Select all that apply.

1. Individuals move through all six stages in a sequential fashion.
2. Moral development progresses in relationship to cognitive development.
3. A person's ability to make moral judgments develops over a period of time.
4. The theory provides a framework for understanding how individuals determine a moral code to guide their behavior.
5. In stage 1 (punishment-obedience orientation), children are expected to reason as mature members of society.
6. In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned.
   • (^) 2. Moral development progresses in relationship to cognitive development.
   • (^) 3. A person's ability to make moral judgments develops over a period of time.
   • (^) 4. The theory provides a framework for understanding how individuals determine a moral code to guide their behavior.
   • (^) 6. In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned.
7. A nurse is planning to use an interpreter during a health history interview of a non- English speaking patient and family. Which nursing care guidelines should the nurse include when using an interpreter (Select all that apply)? a. Elicit one answer at a time. b. Interrupt the interpreter if the response from the family is lengthy. c. Comments to the interpreter about the family should be made in English. d. Arrange for the family to speak with the same interpreter, if possible. e. Introduce the interpreter to the family. ANS: A, D, E When using an interpreter, the nurse should pose questions to elicit only one answer at a time, such as: "Do you have pain?" rather than "Do you have any pain, tiredness, or loss of appetite?" Refrain from interrupting family members and the interpreter while

they are conversing. Introduce the interpreter to family and allow some time before the interview for them to become acquainted. Refrain from interrupting family members and the interpreter while they are conversing. Avoid commenting to the interpreter about family members because they may understand some English.

50. characteristics of physical development of a 30-month-old child are (Select all that apply): A. anterior fontanel is open. B. birth weight has doubled. C. genital fondling is noted. D. sphincter control is achieved. E. primary dentition is complete. D, E D. sphincter control is achieved. E. primary dentition is complete. Sphincter control in preparation for bowel and bladder control is usually achieved by 30 months of age. Primary dentition is usually completed by 30 months of age. Anterior fontanel closes between 12- 18 months of age. Birth weight should double at 5-6 months of age and quadruple by 2½ years of age. Genital fondling is not a characteristic of physical development of this age group. This is part of the development of gender identity.
51. A woman has come to the clinic for preconception counseling because she wants to start trying to get pregnant in 3 months. She can expect the following advice: a. "Discontinue all contraception now." b. "Lose weight so that you can gain more during pregnancy." c. "You may take any medications you have been taking regularly." d. "Make sure that you include adequate folic acid in your diet." Ans d. "Make sure that you include adequate folic acid in your diet."
52. While taking a diet history, the nurse might be told that the expectant mother has cravings for ice chips, cornstarch, and baking soda. This represents a nutritional problem known as: a. Preeclampsia. b. Pyrosis. c. Pica. d. Purging.

Ans c. Pica.

53. 1. A woman's obstetric history indicates that she is pregnant for the fourth time and all of her children from previous pregnancies are living. One was born at 39 weeks of gestation, twins were born at 34 weeks of gestation, and another child was born at 35 weeks of gestation. What is her gravidity and parity using the GTPAL system? a. 3-1-1-1-3 b .4-1-2-0-4 c. 3-0-3-0-3c d. 4-2-1-0-3 ANS: B The correct calculation of this woman's gravidity and parity is 4-1-2-0-4. The numbers reflect the woman's gravidity and parity information. Using the GPTAL system, her information is calculated as: G: The first number reflects the total number of times the woman has been pregnant; she is pregnant for the fourth time. T: This number indicates the number of pregnancies carried to term, not the number of deliveries at term; only one of her pregnancies has resulted in a fetus at term. P: This is the number of pregnancies that resulted in a preterm birth; the woman has had two pregnancies in which she delivered preterm. A: This number signifies whether the woman has had any abortions or miscarriages before the period of viability; she has not. L: This number signifies the number of children born that currently are living; the woman has four children.
54. 2. A woman at 10 weeks of gestation who is seen in the prenatal clinic with presumptive signs and symptoms of pregnancy likely will have: a. Amenorrhea. c. Chadwick's sign. b. Positive pregnancy test. d. Hegar's sign. ANS: A Amenorrhea is a presumptive sign of pregnancy. Presumptive signs of pregnancy are felt by the woman. A positive pregnancy test, the presence of Chadwick's sign, and the presence of Hegar's sign all are probable signs of pregnancy.

55. Probable signs of pregnancy are :

Ballottement, Chadwick’s sign, Goodell’s sign, Hegar’s sign, uterine

enlargement, Braxton Hicks contractions, positive blood pregnancy

test

56.A woman arrives at the clinic for a pregnancy test. Her last menstrual

period (LMP) was February 14, 2011. Her expected date of birth (EDB) is: a. September 17, 2011 b. November 7, 2011 c. November 21, 2011 d. December 17, 2011 ANS: C Using Nägele's rule, the EDB is calculated by subtracting 3 months from the month of the LMP and adding 7 days + 1 year to the day of the LMP. Therefore, with an LMP of February 14, 2011, her due date is November 21, 2011. September 17, 2011, is too short a period to complete a normal pregnancy. Using Nägele's rule, an EDB of November 7, 2011 is 2 weeks early. December 17, 2011, is almost a month past the correct EDB.

57.. Which statement about pregnancy is accurate?

a. A normal pregnancy lasts about 10 lunar months. b. A trimester is one third of a year. c. The prenatal period extends from fertilization to conception. d. The estimated date of confinement (EDC) is how long the mother will have to be bedridden after birth. ANS: A A lunar month lasts 28 days, or 4 weeks. Pregnancy spans 9 calendar months but 10 lunar months. A trimester is one third of a normal pregnancy, or about 13 to 14 weeks. The prenatal period covers the full course of pregnancy (prenatal means before birth). The EDC is now called the EDB, or estimated date of birth. It has nothing to do with the duration of bed rest.

58. Signs and symptoms that a woman should report immediately to her health care provider include (Select all that apply): a. Vaginal bleeding. b. Rupture of membranes. c. Heartburn accompanied by severe headache. d. Decreased libido. e. Urinary frequency.

ANS: A, B, C

Vaginal bleeding, rupture of membranes, and severe headaches all are signs of potential complications in pregnancy. Clients should be advised to report these signs to the health care provider. Decreased libido and urinary frequency are common discomforts of pregnancy that do not require immediate health care interventions. 59.Which of the following positions would be least effective when gravity is desired to assist in fetal descent? Lithotomy

60. The nurse recognizes that a woman is in true labor when she states: a. "I passed some thick, pink mucus when I urinated this morning." b. "My bag of waters just broke." c. "The contractions in my uterus are getting stronger and closer together." d. "My baby dropped, and I have to urinate more frequently now." Ans c. "The contractions in my uterus are getting stronger and closer together."
61. The nurse has received a report regarding a client in labor. The woman's last vaginal examination was recorded as 3 cm, 30%, and -2. What is the nurse's interpretation of this assessment? a. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm above the ischial spines. b. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm above the ischial spines. c. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm below the ischial spines. d. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm below the ischial spines. ANS: B The sterile vaginal examination is recorded as centimeters of cervical dilation, percentage of cervical dilation, and the relationship of the presenting part to the ischial spines (either above or below). For this woman, the cervix is dilated 3 cm and effaced 30%, and the presenting part is 2 cm above the ischial spines. 62.A woman who is pregnant for the first time is dilated 3 cm and having contractions every 5 minutes. She is groaning and perspiring excessively; she states that she did not attend childbirth classes. What is the optimal intervention for the nurse to provide at this time? a.Notify the woman's health care provider.