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Detailed Answer Key Homework 7 - Maternity

1. A nurse is reinforcing teaching to a client who is being fitted for a contraceptive diaphragm. The nurse should instruct the client to replace the device, A. Every 1 year. Rationale: It is important for the device to fit appropriately in the vaginal vault in order to provide adequate contraceptive protection. The client should replace the diaphragm every 2 yr. B. After a spontaneous abortion. Rationale: It is important for the device to fit appropriately in the vaginal vault in order to provide adequate contraceptive protection. It is not necessary for the client to replace the diaphragm following a spontaneous abortion. C. After a urinary tract infection. Rationale: It is important for the device to fit appropriately in the vaginal vault in order to provide adequate contraceptive protection. It is not necessary for the client to replace the diaphragm following the diagnosis of a urinary tract infection. D. After a 20% weight loss. Rationale: It is important for the device to fit appropriately in the vaginal vault in order to provide adequate contraceptive protection. The client should replace the diaphragm after a 20% weight loss or gain.

CAA_DetailedAnswerKey created 10/03/2012

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Detailed Answer Key Homework 7 - Maternity

2. A nurse is planning to reinforce teaching to a group of pregnant clients regarding management of constipation during pregnancy. Which of the following statements should the nurse include in the content? A. “Use mineral oil to relieve constipation.” Rationale: Clients should not use mineral oil to relieve constipation during pregnancy. B. “Drink 1 L of water daily to decrease constipation.” Rationale: Clients should drink 2 to 3 L of fluid from food and beverage sources per day to relieve constipation. C. “Use an enema when constipation occurs.” Rationale: Clients should not use enemas to relieve constipation during pregnancy. D. “Eat an apple to help with constipation.” Rationale: Constipation is a common discomfort occurring during pregnancy that results from relaxation of gastrointestinal (GI) muscle tone and motility related to increased progesterone levels, increased pressure of the GI tract by the fetus, and use of iron supplements. The nurse should teach the client to increase dietary roughage such as fruits, vegetables, and legumes which are excellent sources of fiber.

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Detailed Answer Key Homework 7 - Maternity

3. A nurse is conducting a gestational age assessment on a newborn. Which of the following should the nurse check during a neuromuscular assessment? (Select all that apply) A. Arm recoil B. Popliteal angle C. Scarf sign D. Heel to ear E. Moro reflex Rationale: Arm recoil is correct. The nurse should use the Ballard scale when performing a neuromuscular assessment on a newborn. The nurse should check arm recoil when performing this assessment.Popliteal angle is correct. The nurse should use the Ballard scale when performing a gestational age assessment on a newborn. The nurse should check the popliteal angle when performing this assessment.Scarf sign is correct. The nurse should use the Ballard scale when performing a gestational age assessment on a newborn. The nurse should check the scarf sign when performing this assessment.Heel to ear is correct. The nurse should use the Ballard scale when performing a gestational age assessment on a newborn. The nurse should check the heel to ear when performing this assessment.Moro reflex is incorrect. The nurse should use the Ballard scale when performing a gestational age assessment on a newborn. Checking the Moro reflex is not part of this gestational age assessment.

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Detailed Answer Key Homework 7 - Maternity

4. A nurse is collecting data on a newborn that is 48 hr old. Which of the following findings should the nurse report to the provider? A. Telangiectatic nevi Rationale: Telangiectatic nevi are also known as “stork bites” and are pink in appearance and blanch easily. They commonly appear on the upper lip, upper eyelids, nose, nape of the neck, and lower occiput bone. This finding has no clinical significance. B. Erythema toxicum Rationale: Erythema toxicum is a transient rash appearing during the first 3 weeks of age. The lesions appear at various stages: erythematous macules, papules, and small vesicles. This finding has no clinical significance. C. Generalized petechiae Rationale: Generalized petechiae may indicate a clotting factor deficiency or infection; therefore, the nurse should report these findings to the provider for further evaluation. D. Mongolian spot Rationale: Mongolian spots are bluish black areas which commonly appear over the back or buttocks. They are frequently seen in Latin America, African, or Asian newborns. This finding has no clinical significance.

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Detailed Answer Key Homework 7 - Maternity

5. A nurse is collecting data form an infant with Trisomy 21 (Down’s Syndrome). Which of the following are common characteristics? (Select all that apply.) A. Transverse palmar creases B. Large ears C. Muscular hypertonicity D. Protruding tongue E. Low birth weight Rationale: Transverse palmar creases is correct. A common characteristic of infants born with Trisomy 21 is transverse palmar creases. Large ears is incorrect. A common characteristic of infants born with Trisomy 21 is small ears. Muscular hypertonicity is incorrect. A common characteristic of infants born with Trisomy 21 is muscular hypotonicity. Protruding tongue is correct. A common characteristic of infants born with Trisomy 21 is protruding tongue. Low birth weight is incorrect. Infants born with Trisomy 21 do not demonstrate the common characteristic of low birth weight.

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Detailed Answer Key Homework 7 - Maternity

6. A nurse is discussing appropriate exercises during pregnancy with a client who is 24 weeks of gestation. Which of the following statements indicates a need for additional teaching? A. “I can continue my daily swimming routine.” Rationale: Clients can continue their usual exercise unless the provider advises against it during pregnancy. Swimming is an appropriate exercise. B. “I can go cycling daily.” Rationale: Clients can continue their usual exercise unless the provider advises against it during pregnancy. Cycling is an appropriate exercise C. “I will participate in a game of racquetball once a week.” Rationale: Racquetball is considered a risky activity requiring precise balance and coordination. Therefore, it is not an appropriate exercise choice during pregnancy. D. “I will attend a yoga class three times a week.” Rationale: Clients can continue their usual exercise unless the provider advises against it during pregnancy. Yoga is an appropriate exercise. 7. A nurse is caring for a client who is pregnant and whose routine diagnostic testing reveals a negative rubella titer. The nurse understands that this result means the client A. is immune to rubella. Rationale: This is not a correct assumption. B. needs an immunization following delivery. Rationale: The negative rubella titer means that the client is susceptible to the rubella virus and needs to be vaccinated after delivery. Immunization during pregnancy is contraindicated because of possible injury to the developing fetus. Following the rubella immunization, the client should be cautioned not to conceive for 3 months. C. needs to be immunized as soon as possible. Rationale: Immunization during pregnancy is contraindicated. D. had rubella as a child. Rationale: A client who has had rubella will have a positive rubella titer.

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Detailed Answer Key Homework 7 - Maternity

8. A nurse is caring for a client who is at 38 weeks of gestation and has a score of 10 on her biophysical profile. Based on this score, which of the following nursing actions is appropriate? A. Assure the client that the score is within the expected range. Rationale: The biophysical profile yields a score based on fetal breathing, movement, tone, amniotic fluid volume, and fetal heart rate reactivity. A score of 2 is assigned to each expected finding. A score of 10 indicates expected findings in all five areas. B. Administer oxygen and notify the provider. Rationale: There is no need to administer oxygen or notify the provider. C. Assist the client into a side-lying position. Rationale: There is no need to change the client's position. D. Offer the client orange juice and repeat the assessment in 1 hr. Rationale: Orange juice and repeating the assessment are not indicated.

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Detailed Answer Key Homework 7 - Maternity

9. A nurse is caring for a client who is 32 weeks of gestation who has hyperthyroidism. For which of the following clinical findings should the nurse monitor and report to the provider? (Select all that apply) A. Fever B. Tachycardia C. Vomiting D. Hypertension E. Restlessness Rationale: Fever is correct. Fever is a clinical manifestation of thyroid storm, a complication of hyperthyroidism, which can occur in response to stresses such as birth, surgery, or infection. The nurse should report this finding. Tachycardia is correct. Tachycardia is a clinical manifestation of thyroid storm, a complication of hyperthyroidism, which can occur in response to stresses such as birth, surgery, or infection. The nurse should report this finding. Vomiting is correct. Vomiting is a clinical manifestation of thyroid storm, a complication of hyperthyroidism, which can occur in response to stresses such as birth, surgery, or infection. The nurse should report this finding. Hypertension is incorrect. The nurse should monitor for hypotension as a complication of hyperthyroidism. Restlessness is correct. Restlessness is a clinical manifestation of thyroid storm, a complication of hyperthyroidism, which can occur in response to stresses such as birth, surgery, or infection. The nurse should report this finding.

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Detailed Answer Key Homework 7 - Maternity

10. A nurse is caring for a client who has had a dilation and curettage (D&C) following a spontaneous abortion. The client tells the nurse that she is hungry. Which of the following initial actions by the nurse is appropriate? A. Auscultate the client's abdomen. Rationale: Before giving the client anything by mouth, the nurse must validate bowel function by auscultating the client's abdomen with a stethoscope. B. Offer clear liquids. Rationale: This is not the initial action by the nurse. C. Ask the client if she is experiencing pain. Rationale: This is not the initial action by the nurse. D. Check the client's chart for a diet prescription. Rationale: This is not the initial action by the nurse. 11. A nurse is caring for a client in the prenatal clinic who is at 7 weeks of gestation. The client reports urinary frequency and asks the nurse if this will continue throughout her pregnancy. Which of the following is an appropriate response? A. "Yes, it will, but if you decrease your fluid intake, especially at bedtime, it won't be so bothersome." Rationale: Fluid intake should not be restricted during pregnancy. B. "No, in most cases it only lasts until about the 12th week, but it will continue if you have poor bladder tone." Rationale: The presence or absence of bladder tone has no effect on urinary frequency during pregnancy. C. "There is no way to predict how long it will last for each individual client, so you'll just have to wait and see." Rationale: This statement is not helpful to the client, as it does not address the client's immediate concerns. D. "No, it should only last until about your 12th week, but it will return near the end of the pregnancy." Rationale: Urinary frequency usually disappears at about 12 weeks of gestation but returns near term as the enlarging uterus presses on the bladder. It may also worsen following fetal descent.

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Detailed Answer Key Homework 7 - Maternity

12. A nurse is caring for a client in the immediate postpartum period. The nurse realizes that the client is at risk for postpartal hemorrhage due to uterine atony because she had a A. midline episiotomy. Rationale: A midline episiotomy does not cause uterine atony. B. precipitous delivery. Rationale: The risk of uterine atony increases whenever the uterus has been overstressed or overstretched, as with a precipitous delivery (one that occurs in less than 2.5 hr). C. vaginal delivery. Rationale: The risk of hemorrhage does not increase after an uncomplicated vaginal delivery. D. periurethral tear. Rationale: This injury does not increase the risk of uterine atony. 13. A nurse is caring for a client at the prenatal clinic who is at 38 weeks of gestation with heavy, red vaginal bleeding without contractions that started spontaneously. She is in no distress and states that she can "feel the baby moving." The nurse should explain to the client that the stat ultrasound the provider prescribed will determine A. fetal lung maturity. Rationale: Fetal lung maturity is not determined via ultrasound; it is determined via amniocentesis, a sampling of the amniotic fluid. B. location of the placenta. Rationale: Painless, spontaneous vaginal bleeding may be an indication of placenta previa. With the ultrasound, the provider can identify the location of the placenta and urgency of the delivery. C. fetal viability. Rationale: Determining the viability of the fetus is not the purpose of the ultrasound. D. biparietal diameter. Rationale: Determining the biparietal diameter is not the purpose of the ultrasound.

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Detailed Answer Key Homework 7 - Maternity

14. A nurse caring for a client who is in labor is reinforcing teaching about why epidural anesthesia is not initiated until a good labor pattern has been established. The nurse should tell the client, "Given too soon, epidural anesthesia A. can cause fetal depression." Rationale: This is not an accurate statement for the nurse to make. B. will delay rupture of fetal membranes." Rationale: An epidural will not affect when the fetal membranes rupture. C. may prolong labor." Rationale: Progress in labor slows when clients are given anesthesia before the active phase of labor. The medication depresses the central nervous system, thus it will take longer for the cervix to dilate and efface. D. may cause maternal hypertension." Rationale: Epidural anesthesia reduces maternal blood pressure because of central nervous system depression. 15. A client delivers a 6-lb, 12-oz male infant at 39 weeks of gestation. The nurse caring for the client 14 hr after delivery, makes the following observations: breasts soft; fundus firm, uterus slightly deviated to the right; lochia moderate rubra; T 37.7° C (100° F), P 88, R 18. Which of the following actions should the nurse perform? A. Encourage the client to nurse more frequently so her milk will come in. Rationale: This is not an appropriate action; the breasts are expected to be soft after delivery. B. Report the client's temperature elevation. Rationale: A temperature up to 38° C (100.4° F) following delivery is often the result of dehydration. Once the client is hydrated, the temperature typically returns to normal. C. Ask the client to empty her bladder. Rationale: Whenever the fundus is deviated from the midline a full bladder must be considered. A full bladder could result in complications such as uterine atony or infection. D. Administer oxytocin (Pitocin) as prescribed. Rationale: Oxytocin is not indicated for this client.

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Detailed Answer Key Homework 7 - Maternity

16. Two hours after a spontaneous vaginal delivery, a client has saturated two perineal pads with blood in a 30min period. Which of the following actions is the priority for the nurse to take at this time? A. Check the consistency of the client’s uterine fundus. Rationale: Although the expectation is moderate bleeding in the first 2 hr after delivery, saturating a perineal pad in 15 min or less indicates excessive blood loss. The first action the nurse should take using the nursing process is to collect data from the client. Thus the nurse should determine the consistency of the client’s fundus first. If it is boggy, fundal massage might control the bleeding. B. Have the client use the bedpan to urinate. Rationale: Assisting the client to urinate might help control the bleeding if the fundus is displaced, so that might become necessary. C. Prepare to administer oxytocic medication. Rationale: Preparing to administer oxytocic medication might become necessary if priority actions do not control the bleeding. D. Increase the client’s fluid intake. Rationale: Increasing fluids, either IV or PO, is essential for restoring fluid volume, but it is not the nurse’s highest priority at this time.

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Detailed Answer Key Homework 7 - Maternity

17. Immediately after a cesarean delivery, a nurse is caring for a newborn who weighs 5,160 g (11 lb, 6 oz) and whose mother has diabetes mellitus. The priority data collection for this newborn is for A. hypoglycemia. Rationale: Newborns of clients who have diabetes are at high risk for hypoglycemia as the constant supply (now removed) of glucose creates fetal hyperinsulinemia. It can take several days for the newborn to adjust to secreting appropriate amounts of insulin for the new lesser supply of glucose. Because severe hypoglycemia can lead to cyanosis and seizures and they pose the greatest risk to the newborn at this time, this is the nurse’s highest priority. B. hypomagnesemia. Rationale: Newborns of clients who have diabetes are at risk for hypomagnesemia, but this is not the highest priority immediately after delivery. C. hyperbilirubinemia. Rationale: Newborns of clients who have diabetes are at risk for hyperbilirubinemia, but this is not the highest priority immediately after delivery. D. hypocalcemia. Rationale: Newborns of clients who have diabetes are at risk for hypocalcemia, but this is not the highest priority immediately after delivery. 18. A provider prescribes methylergonovine (Methergine) IM for a client who had a vaginal delivery earlier that day. The nurse should explain to the client that this medication will help prevent A. postpartum infection. Rationale: Methylergonovine has no anti-infective properties. B. hypertension. Rationale: Methylergonovine is more likely to cause hypertension than to prevent it. C. postpartum hemorrhage. Rationale: Methylergonovine is an oxytocic. It causes uterine contractions to help control postpartum bleeding. D. thromboembolic events. Rationale: Methylergonovine has no anticoagulation properties.

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Detailed Answer Key Homework 7 - Maternity

19. A nurse places the newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in the newborn? A. Cold stress Rationale: Prevention of cold stress is important to decrease metabolic and physiologic demands on the newborn. B. Shivering Rationale: The shivering mechanism in newborns is rarely operable. Warming the newborn is needed to decrease metabolic and physiologic demands. C. Thermogenesis Rationale: Thermogenesis is the process of heat production in the newborn and occurs by the metabolism of brown fat. D. Brown fat production Rationale: Warming the infant does not affect the prod...