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 Contemporary Maternal Newborn Nursing 7th Edition by Patricia W. Ladewig – Test Bank 

 

Chapter 05_LO 01_Q01

The clinic nurse is returning phone calls. Which call should the nurse return first?

  1. 22-year-old reporting that she has menstrual cramps and vomiting every month
  2. 17-year-old asking if there is a problem with using one tampon for a whole day
  3. 46-year-old mother of a teen wondering if her daughter should be on birth control
  4. 34-year-old requesting information on douching after intercourse

Correct Answer: 2

Rationale:

  1. Because vomiting can lead to dehydration, this client is not completely normal or stable, but is not the top priority.
  2. Using a single tampon for an entire day can lead to toxic shock syndrome, a potentially life-threatening condition. This client needs education on the danger of using one tampon more than 3–6 hours.
  3. A sexually active teen could be at risk for unintended pregnancy, as well as sexually transmitted infections. However, it is unclear whether the daughter is sexually active. This call is a low priority.
  4. Douching is not recommended, because the practice causes a change in the pH of the vagina and impacts the normal flora, predisposing clients to candidiasis and bacterial vaginosis. This client requires education, but is not a top priority.

Cognitive level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Implementation

Learning Outcome: 5.1 Identify appropriate nursing care based on the results of the client’s sexual history.

 

Chapter 05_LO 01_Q02

 

When taking a sexual history from a client, the nurse should:

  1. Ask questions that the client can answer with a “yes” or “no.”
  2. Ask mostly open-ended questions.
  3. Have the client fill out a comprehensive questionnaire, and review it after the client leaves.
  4. Try not to make much direct eye contact.

 

Correct Answer:  2

 

Rationale:

  1. “Yes-or-no” answers indicate closed-ended questions that will not encourage the client to share the necessary information.
  2. Open-ended questions are often useful in eliciting information because they encourage more than a one-word answer.
  3. Filling out a questionnaire and reviewing it after the client leaves is not appropriate. It should be reviewed in the presence of the client, encouraging conversation regarding the results.
  4. It is helpful to use direct eye contact as much as possible, unless culturally unacceptable. Eye contact encourages a connection between the involved parties, and shows care and concern.

Cognitive Level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 5.1 Identify appropriate nursing care based on the results of the client’s sexual history.

 

 

Chapter 05_LO2 _Q03

Which patient would the nurse document as exhibiting signs and symptoms of primary dysmenorrhea?

  1. 17-year-old, has never had a menstrual cycle
  2. 16-year-old, had regular menses for four years, but has had no menses in four months
  3. 19-year-old, regular menses for five years that have suddenly become painful
  4. 14-year-old, irregular menses for one year, experiences cramping every cycle

Correct Answer:  4

Rationale:

  1. This is primary amenorrhea, or the lack of menses.
  2. Secondary amenorrhea is the term used when a client has had regular cycles that cease.
  3. Secondary dysmenorrheal is the sudden onset of pain and discomfort with menses.
  4. Primary dysmenorrhea is when menstruation has been painful from the first menstrual cycle, and consistently continues to be painful each month.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Diagnosis

Learning Outcome: 5.2 Describe accurate information to be provided to girls and women so that they can implement effective self-care measures for dealing with menstruation.

 

Chapter 05_LO2 _Q04

 

A client asks her nurse, “Is it okay for me to take a tub bath during the heavy part of my menstrual cycle?” The correct response by the nurse is:

  1. “Tub baths are contraindicated during menstruation.”
  2. “You should shower and douche daily instead.”
  3. “Either a bath or a shower is fine at that time.”
  4. “You should limit bathing and use a feminine deodorant spray during menstruation.”

Correct Answer: 3

Rationale:

  1. Bathing, whether it is a tub bath or shower, is as important during menses as at any other time, to reduce any odor associated with menstruation.
  2. Douching should be avoided during menstruation to prevent the risk of forcing blood into the pelvic cavity, which can contribute to endometriosis.
  3. Bathing, whether it is a tub bath or shower, is as important during menses as at any other time, to reduce any odor associated with menstruation.
  4. Feminine deodorant sprays are unnecessary. Bathing is sufficient hygiene.

Cognitive Level: Application

Category of Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 5.2 Describe accurate information to be provided to girls and women so that they can implement effective self-care measures for dealing with menstruation.

 

Chapter 05_LO03 _Q05

What should the gynecology clinic nurse recommend for the client experiencing premenstrual syndrome?

  1. “Eat more chocolate and drink more caffeine beginning a week prior to when your menstrual cycle bleeding should begin.”
  2. “Engage in aerobic activity often throughout the month, and continue exercising when your symptoms begin.”
  3. “Decrease your dietary intake of dairy and soy slightly during the month, and especially during your days of bleeding.”
  4. “Increase your consumption of red meat when you feel symptoms, and eat three large meals per day.”

Correct Answer:  2

Rationale:

  1. Chocolate and caffeine contain methylxanthines; therefore, intake of chocolate, coffee, and colas should be limited throughout the month.
  2. Regular aerobic activity helps to decrease PMS symptoms.
  3. 1,200 mg of calcium per day can help decrease PMS symptoms. The calcium can either come from supplements or be obtained through dietary intake of dairy and soy products.
  4. Decreased red meat consumption can be beneficial to reduce PMS symptoms, as will eating several small meals per day rather than three large meals.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Implementation

Learning Outcome: 5.3 Discriminate between the signs, symptoms, and nursing management of women with dysmenorrheal and premenstrual syndrome.

 

Chapter 05_LO03 _Q06

 

A client comes to the clinic complaining of severe menstrual cramps. She has never been pregnant, has been diagnosed with ovarian cysts, and has had an intrauterine device (IUD) for two years. The most likely cause for the client’s complaint is:

  1. Primary dysmenorrhea.
  2. Secondary dysmenorrhea.
  3. Menorrhagia.
  4. Hypermenorrhea.

Correct Answer: 2

Rationale:

  1. Primary dysmenorrhea is defined as cramps without underlying disease.
  2. Secondary dysmenorrhea is associated with pathology of the reproductive tract, and usually appears after menstruation has been established. Conditions that most frequently cause secondary dysmenorrhea include ovarian cysts and the presence of an intrauterine device.
  3. Menorrhagia is excessive, profuse flow.
  4. Hypermenorrhea is an abnormally long menstrual flow.

Cognitive Level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Diagnosis

Learning Outcome: 5.3 Discriminate between the signs, symptoms, and nursing management of women with dysmenorrheal and premenstrual syndrome.

 

 

Chapter 05_LO 04_Q07

Which issues should the nurse consider when counseling a client on contraceptive methods? Select all that apply.

  1. Cultural perspectives on menstruation and pregnancy
  2. Efficacy of the method
  3. Future childbearing plans
  4. Whether the client is a vegetarian
  5. Age at menarche

Correct Answers:  1, 2, 3

Rationale:

  1. Cultural and religious beliefs, practices, and sanctions must be considered when discussing contraception with clients in order to avoid insulting a client for whom a particular type of contraceptive method is prohibited by her background.
  2. Efficacy of contraceptive methods vary, and must be considered when discussing contraception with clients. When pregnancy is medically contraindicated, high-efficacy methods (such as an IUD, hormonal methods, or sterilization) should be discussed with the client. When the client would like to avoid pregnancy at this time, but pregnancy is not medically contraindicated, lower-efficacy methods (such as diaphragm, cervical cap, or Today sponge) could be discussed.
  3. If a client desires children in the future, sterilization methods would be inappropriate to discuss.
  4. Vegetarianism has no impact on contraceptive method use.
  5. Age at menarche has no impact on contraceptive method use.

Cognitive level:  Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 5.4 Compare the advantages, disadvantages, and effectiveness of the various methods of contraception available today.

 

Chapter 05_LO 04_Q08

 

A client wants to use the vaginal sponge as a method of contraception. Which of the following statements indicate that she will need further instruction? Select all that apply.

  1. “I need to use a lubricant prior to insertion.”
  2. “I need to add spermicidal cream prior to intercourse.”
  3. “I need to moisten it with water prior to use.”
  4. “I need to leave it in no longer than 6 hours.”

 

Answer: 1, 2, 4

 

Rationale:

  1. A lubricant is not needed, as the sponge is moistened with water prior to insertion.
  2. Spermicidal cream is not needed, because it is already in the sponge.
  3. To activate the spermicide in the vaginal sponge, it must be moistened thoroughly with water.
  4. The sponge can remain in place for 24 hours.

Cognitive Level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Evaluation

Learning Outcome: 5.4 Compare the advantages, disadvantages, and effectiveness of the various methods of contraception available today.

 

Chapter 05_LO 04_Q09

 

Which client is not a good candidate for Depo-Provera (DMPA)?

  1. One who wishes to get pregnant within three months
  2. One who wishes to breastfeed
  3. One with a vaginal prolapse
  4. One who weighs 200 pounds

Correct Answer: 1

Rationale:

  1. Return of fertility after the use of Depo-Provera takes an average of nine months.
  2. Studies have proven there is no harm to a breastfed baby when a woman uses Depo-Provera.
  3. There is no correlation between a vaginal prolapse and use of Depo-Provera.
  4. There is no correlation between one’s weight and use of Depo-Provera.

Cognitive Level: Analysis

Category of Client Need: Physiological Integrity

Nursing Process: Assessment

Learning Outcome: 5.4 Compare the advantages, disadvantages, and effectiveness of the various methods of contraception available today.

 

Chapter 05_LO 05_Q10

The home care nurse is working with a 40-year-old developmentally delayed adult who has had no gynecologic well-woman care since her teens. What screenings are recommended for this client?

  1. STI screening and Pap smear
  2. Clinical breast exam, Pap smear, and serum calcium levels
  3. Clinical breast exam, Pap smear, and mammogram
  4. Pap smear and vaccination update

Correct Answer:  3

Rationale:

  1. A Pap smear is recommended, but STI screening might or might not be indicated, based on whether the client is sexually active and using contraception or not. Sexually transmitted infections are more common in teens and those in their early 20s.
  2. A clinical breast exam and Pap smear are recommended gynecologic examinations for women, but a serum calcium level is not part of a routine gynecologic routine physical exam. When any part of an answer is incorrect, the entire answer is incorrect.
  3. A clinical breast exam, Pap smear, and mammogram are recommended gynecologic screenings for 40-year-old women.
  4. A Pap smear is a recommended gynecologic screening for an adult woman, but a vaccination update is not considered part of gynecologic care.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 5.5 Support clients in following and partaking in basic gynecologic screening procedures indicated for well women.

 

Chapter 05_LO 05_Q11

 

A nurse is providing a client with instructions regarding breast self-examination (BSE). Which of the following statements by the client would indicate the likelihood that she understands how to detect changes such as lumps in her breast? Select all that apply.

  1. “I should perform BSE one week prior to the start of my period.”
  2. “When I reach menopause, I will perform BSE every two months.”
  3. “Knowing the texture and feel of my breasts is important.”
  4. “I should inspect my breasts in a circular manner.”
  5. “I should inspect my breasts while in a supine position, with my arms at my sides.”

Correct Answers: 3, 4

Rationale:

  1. BSE should be performed one week after the start of each menstrual period, because hormonal levels are lowest, and allow closer exam of softer breast tissue.
  2. BSE should be performed monthly, on the same day each month, during menopause.
  3. A woman who knows the texture and feel of her own breasts is far more likely to detect changes that develop.
  4. Checking breasts in a circular manner, feeling all parts of the breast, provides adequate palpation and possible detection of lumps.
  5. The breasts should be inspected while standing with arms at sides.

Cognitive Level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Evaluation

Learning Outcome: 5.5 Support clients in following and partaking in basic gynecologic screening procedures indicated for well women.

 

Chapter 05_LO 06_Q12

What is the best indicator that the client is experiencing menopause?

  1. No menses for eight consecutive months
  2. Hot flashes and night sweats
  3. High serum FSH with low serum estrogen
  4. Diagnosed with osteoporosis four months ago

Correct Answer:  3

Rationale:

  1. Menopause is defined as twelve months of amenorrhea.
  2. Although hot flashes and night sweats are common in menopause, lab values or twelve months of amenorrhea are better indicators.
  3. Examining serum levels of the hormones FSH and estrogen is a very accurate indication of menopause.
  4. Menopause is not the only cause of osteoporosis, therefore the diagnosis of osteoporosis four months ago is not an indicator of menopause.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 5.6 Explain the physical and psychologic aspects and clinical treatment options of menopause when caring for menopausal women.

 

Chapter 05_LO 06_Q13

 

A menopausal woman tells her nurse that she experiences discomfort from vaginal dryness during sexual intercourse, and asks, “What should I use as a lubricant?” The nurse should recommend:

  1. Petroleum jelly.
  2. A water-soluble lubricant.
  3. Body cream or body lotion.
  4. Less-frequent intercourse.

Correct Answer: 2

Rationale:

  1. Petroleum jelly is not water-soluble, and not recommended as a lubricant.
  2. A water-soluble lubricant should be used so it does not cause irritation.
  3. Body creams and body lotions are not water-soluble.
  4. Less-frequent intercourse does not increase vaginal lubrication.

Cognitive Level: Application

Category of Client Need: Physiological Integrity

Nursing Process: Implementation

Learning Outcome: 5.6 Explain the physical and psychologic aspects and clinical treatment options of menopause when caring for menopausal women.

 

Chapter 05_LO 07_Q14

The nurse is presenting a session on intimate partner violence. Which statement indicates a need for further education?

  1. “My daughter is not to blame for the violence in her marriage.”
  2. “Everyone experiences anger and hitting in a relationship.”
  3. “Abusers can be either husbands or boyfriends or girlfriends.”
  4. “The ‘honeymoon period’ follows an episode of violence.”

Correct Answer:  2

Rationale:

  1. The victims of violence are not the cause of the violence. Abusers are responsible for their violent behavior. Avoiding blaming and shaming of victims of domestic violence is important to establish a therapeutic relationship.
  2. Violence is not a normal part of intimate relationships. This statement indicates that the client has likely been a victim of domestic violence.
  3. Abusers can be spouses or boyfriends or girlfriends. Intimate partner violence can be experienced in any intimate relationship, regardless of whether the couple is straight, gay, or lesbian, and both within marriage and outside of marriage.
  4. An acute episode of battering is followed by the tranquil phase, or honeymoon period, when the abuser is often repentant and promising never to abuse the victim again. In some cases, the honeymoon period is the only time there is a lack of building tension.

Cognitive level: Analysis

Category of Client Need: Psychosocial Integrity

Nursing Process: Evaluation

Learning Outcome: 5.7 Examine the nurse’s role in screening and caring for women who have experienced domestic violence or rape.

 

Chapter 05_LO 07_Q15

 

When a woman who has been raped is admitted to the Emergency Department, which nursing intervention has priority?

  1. Explain exactly what will need to be done to preserve legal evidence.
  2. Assure the woman that everything will be all right.
  3. Create a safe, secure atmosphere for the woman.
  4. Contact family members.

Correct Answer: 3

Rationale:

  1. Explaining exactly what will need to be done to preserve legal evidence is not the top priority.
  2. Assuring the woman that everything will be all right is not the top priority, and is giving false promise.
  3. The first priority in caring for a survivor of a sexual assault is to create a safe, secure atmosphere that will allow the woman to process what has happened.
  4. Contacting family members is not the top priority, and can wait until a safe environment is established.

Cognitive Level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 5.7 Examine the nurse’s role in screening and caring for women who have experienced domestic violence or rape.

Chapter 11_LO01_Q01

The nurse is preparing a class for expectant fathers. Which information should the nurse include?

  1. Siblings adjust readily to the new baby.
  2. Sexual activity is safe for normal pregnancy.
  3. The expectant mother decides the feeding method.
  4. Fathers are expected to be involved in labor and birth.

Correct Answer: 2

Rationale:

  1. Siblings often have difficulty adapting to the arrival of a new baby. Regression is often seen in siblings’ behaviors.
  2. During a normal pregnancy, sexual activity is safe for both mother and baby.
  3. Often, the father wants input into the feeding method.
  4. In some cultures, labor and birth are only for women, and it is inappropriate for fathers to be involved with the labor and birth.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 11.1 Describe the most appropriate nursing care to help maintain the well-being of the expectant father and siblings during a family’s pregnancy.

 

Chapter 11_LO01_Q02

The nurse is caring for a pregnant client. The client’s husband has come to the prenatal visit. Which question is best for the nurse to use to assess the adaptation to pregnancy by the father-to-be?

  1. “What kind of work do you do?”
  2. “What furniture have you gotten for the baby?”
  3. “How moody has your wife been lately?”
  4. “How are you feeling about becoming a father?”

Answer: 4

Rationale:

  1. What kind of work the husband does is not an indicator of his adaptation.
  2. What furniture has been obtained is not an indicator of his adaptation.
  3. The husband’s perception of his wife’s moodiness is not an indicator of his adaptation.
  4. The adaptation of a husband to pregnancy includes his feelings about impending fatherhood.

Cognitive Level: Application

Category of Client of Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome 11.1 Describe the most appropriate nursing care to help maintain the well-being of the expectant father and siblings during a family’s pregnancy.

 

Chapter 11_LO02 _Q03

The nurse is caring for a client in the prenatal clinic. The client recently arrived in the U.S. as a refugee from a country in Africa. This is the first client from this cultural background with whom the nurse has worked. What is the best method for the nurse to provide care for this client?

  1. Ask the client about her expectations during the labor and birth.
  2. Determine if the client has been tested for tuberculosis.
  3. Help the client into the paper dressing gown prior to her exam.
  4. Look for written handouts on prenatal care in the client’s language.

Correct Answer: 1

Rationale:

  1. Women new to the S. will have little or no experience with the U.S. health care system. Culture heavily influences a client’s behaviors and attitudes during pregnancy, labor, and birth, so determining what the client wants during her labor and birth will facilitate both a better experience for the family and a calmer situation for the health care team.
  2. Although tuberculosis is pandemic in refugee camps, and testing for tuberculosis in new arrivals to the S. is important, this question is about prenatal care. Testing for tuberculosis is not related to prenatal care.
  3. The client is probably unfamiliar with paper dressing gowns, and will need some instruction (often through demonstration). But this is not the highest priority. It is more important to find out what the client expects to happen during her labor and birth.
  4. Providing written handouts in the client’s primary language is important. But a higher priority for prenatal care would be to assess what the client’s expectations for labor and birth are.

Cognitive level:  Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 11.2 Examine the significance of cultural considerations in managing nursing care during pregnancy.

 

Chapter 11_LO02 _Q04

A Navajo client who is 36 weeks pregnant meets with the tribe’s medicine man as well as her physician. The nurse understands this to mean that the client:

  1. Is seeking spiritual direction.
  2. Does not trust her physician.
  3. Will not adapt to mothering well.
  4. Is experiencing complications of pregnancy.

Answer: 1

Rationale:

  1. As a result of the introspection that develops, pregnant women often will seek spiritual guidance from their preferred spiritual leader. The nurse has a professional responsibility to promote clients’ spiritual well-being. Understanding the belief systems of the client population will facilitate intercultural communication, and will help the nurse provide appropriate information using appropriate teaching methods.
  2. This does not indicate mistrust of the provider.
  3. This does not indicate mistrust of parenting ability.
  4. This does not indicate any type of pathology or complications.

Cognitive Level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome 11.2 Examine the significance of cultural considerations in managing nursing care during pregnancy.

 

Chapter 11_LO02 _Q05

 

A Chinese woman who is 16 weeks pregnant reports to the nurse that ginseng and bamboo leaves help to reduce her anxiety. How should the nurse respond to this client?

  1. Advise the client to avoid the use of all herbs.
  2. Assess the amount and frequency with which the client is using the remedy.
  3. Tell the client that her remedies have no scientific foundation.
  4. Assess where the client obtains her remedy, and investigate the source.

Answer: 2

Rationale:

  1. Because some herbs have negative effects on pregnancy, using a reliable reference to determine the actions of the herbs can educate both the nurse and the client.
  2. Use of herbs is a common alternative health care practice for many women. Pregnant women are often taught “secret family recipes” for avoiding or minimizing the discomforts of pregnancy. It is appropriate to assess the amount and frequency of the client’s use of the herbs.
  3. Some remedies do have scientific foundation, so it is not appropriate to instruct the client that none do.
  4. It is outside the nurse’s scope to assess the source of the herbs.

Cognitive Level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Implementation

Learning Outcome 11.2 Examine the significance of cultural considerations in managing nursing care during pregnancy.

 

 

Chapter 11_LO03_Q06

The nurse is teaching an early pregnancy class for clients in the first trimester of pregnancy. Which statement requires immediate intervention by the nurse?

  1. “When my nausea is bad, I will drink some ginger tea.”
  2. “The fatigue I am experiencing will improve in the second trimester.”
  3. “It is normal for my vaginal discharge to get green-colored.”
  4. “I will urinate less often during the middle of my pregnancy.”

Correct Answer: 3

Rationale:

  1. Ginger helps nausea, and is safe for use during pregnancy.
  2. First-trimester fatigue is common; fatigue usually improves during the second trimester.
  3. Leukorrhea is an increase in white vaginal discharge, and is an expected finding during pregnancy. Green discharge is not a normal finding, and indicates a bacterial infection. The infection can be a sexually transmitted infection, or bacterial vaginosis. Further assessment is required for a client with green vaginal discharge.
  4. As the uterus rises in the pelvis during the second trimester, urinary frequency improves. Urinary frequency increases again during the end of the third trimester as the fetal head descends into the pelvis.

Cognitive level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 11.3 Explain the causes of the common discomforts of pregnancy in each of the three trimesters.

 

Chapter 11_LO03_Q07

The primiparous client has told the nurse that she is afraid that she will develop hemorrhoids during pregnancy, because her mother did. Which of the following statements would be best for the nurse to make?

  1. “It is not unusual for women to develop hemorrhoids during pregnancy.”
  2. “Most women don’t have any problem until after they’ve delivered.”
  3. “If your mother had hemorrhoids, you will get them too. Get used to the idea.”
  4. “If you get hemorrhoids, you probably will need surgery to get rid of them.”

Answer: 1

Rationale:

  1. Hemorrhoids are anal varicose veins. The increased weight of the gravid uterus, combined with constipation, can result in the varicosities prolapsing.
  2. Many pregnant women will develop hemorrhoids either during pregnancy or after delivery from the pushing efforts of the second stage of labor. Topical relief agents such as Preparation H or Tucks pads can provide relief of the itching and burning sensations.
  3. Although there is a familial tendency to develop varicosities, including hemorrhoids, a family history does not automatically mean that a client will develop the condition.
  4. Most hemorrhoids will resolve spontaneously, and will not require surgical intervention.

Cognitive Level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Implementation

Learning Outcome 11.3 Explain the causes of the common discomforts of pregnancy in each of the three trimesters.

 

 

Chapter 11_LO04_Q08

Which phone call should the prenatal clinic nurse return first?

  1. Primip at 7 weeks’ gestation reporting nasal stuffiness.
  2. Multip at 38 weeks experiencing rectal itching and hemorrhoids
  3. Primip at 15 weeks with nausea and vomiting and a 15-pound weight loss
  4. Multip at 32 weeks treating constipation with prune juice

Correct Answer: 3

Rationale:

  1. Nasal stuffiness is common in the first trimester as a result of increased estrogen.
  2. Hemorrhoids are common during pregnancy, and often cause itching.
  3. This client is the highest priority. A 15-pound weight loss is not an expected finding. A client who has frequent vomiting is at risk for dehydration and electrolyte imbalances.
  4. Constipation during the third trimester is a common finding. Prune juice is a safe and gentle way to increase peristalsis and decrease constipation.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 11.4 Describe appropriate measures interventions to alleviate the common discomforts of pregnancy.

 

Chapter 11_LO04_Q09

A 38-year-old client in her second trimester states a desire to begin an exercise program to decrease her fatigue. Which of the following would be the most appropriate nursing response?

  1. “Fatigue should resolve in the second trimester, but walking daily might help.”
  2. “Avoid a strenuous exercise regimen at your age. Drink coffee t.i.d.”
  3. “Avoid an exercise regimen due to your pregnancy. Try to nap daily.”
  4. “Fatigue will increase as pregnancy progresses, but jogging daily might help.”

Answer: 1

Rationale:

  1. Mild-to-moderate exercise during pregnancy is healthy for moms and babies. The increased stamina that correlates with physical fitness can help decrease fatigue in pregnancy, but the second trimester will bring greater fatigue, as fetal metabolism creates demands on the maternal system.
  2. The age of 38 is not too old to begin an exercise routine, but during pregnancy, a client should not begin a new type of extremely strenuous or high-impact activity.
  3. Those clients who have regularly engaged in strenuous or high-impact activities prior to pregnancy can continue that practice unless they develop pregnancy complications that contraindicate exercise.
  4. Mild-to-moderate exercise during pregnancy is healthy for moms and babies.

Cognitive Level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Implementation

Learning Outcome 11.4 Describe appropriate interventions to alleviate the common discomforts of pregnancy.

 

 

Chapter 11_LO04_Q10

 

The client in her first trimester of pregnancy is experiencing nausea. To promote self-care, the nurse should help the pregnant client understand that the nausea might be relieved by:

  1. Eating spicy foods.
  2. Not eating until two hours after rising.
  3. Eating small, frequent meals.
  4. Avoiding carbonated beverages.

Answer: 3

 

Rationale:

  1. The nausea of pregnancy can be exacerbated by ketosis, fatigue, and certain foods, such as those containing caffeine or spices.
  2. Eating dry carbohydrates prior to rising each day can help to prevent or decrease the severity of the nausea.
  3. Avoiding severe hunger by eating small, frequent meals throughout the day can help to prevent or decrease the severity of the nausea.
  4. Carbonated beverages might be helpful in decreasing nausea.

Cognitive Level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome 11.4 Describe appropriate measures interventions to alleviate the common discomforts of pregnancy.

 

 

Chapter 11_LO04_Q11

A client in her third trimester of pregnancy reports frequent leg cramps. What strategy would be most appropriate for the nurse to suggest?

  1. Point the toes of the affected leg.
  2. Increase intake of protein-rich foods.
  3. Limit activity for several days.
  4. Flex the foot to stretch the calf.

Answer: 4

 

Rationale:

  1. Pointing the toes will exacerbate leg cramps.
  2. Protein intake does not affect leg cramps.
  3. Limiting activity is not appropriate.
  4. Leg cramps are a common problem in pregnancy, resulting from an imbalance in the calcium–phosphorus ratio; pressure on nerves or decreased circulation in the legs from the enlarged uterus; or fatigue. Dorsiflexing the foot will stretch the calf muscles, and will help relieve the cramps.

Cognitive Level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

 

Learning Outcome 11.4 Describe appropriate measures interventions to alleviate the common discomforts of pregnancy.

 

Chapter 11_LO05_Q12

The prenatal client in her third trimester tells the clinic nurse that she works eight hours a day as a cashier and stands when at work. What response by the nurse is best?

  1. “No problem. Your baby will be fine.”
  2. “Do you get regular breaks for eating?”
  3. “Your risk of preterm labor is higher.”
  4. “Standing might increase ankle swelling.”

Correct Answer: 3

Rationale:

  1. Standing more than five hours a day increases the risk of preterm labor. To be therapeutic in communication, avoid false reassurance.
  2. Although breaks for eating, drinking, and toileting are important for pregnant employees, it is more important to tell the client about the increased risk of preterm labor.
  3. Pregnant women who stand for more than five a day have an increased risk of preterm labor. Because preterm labor can put the infant’s life at risk, this statement would be the highest priority.
  4. Although this is true, it is less important than teaching the client about the risks of preterm labor when standing more than five hours a day.

Cognitive level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 11.5 Describe self-care measures that a pregnant woman can take to maintain and promote her well-being during pregnancy.

 

Chapter 11_LO05_Q13

The pregnant client has asked the nurse what kinds of medications cause birth defects. Which statement would best answer this question?

  1. “Birth defects are very rare. Don’t worry; your doctor will watch for problems.”
  2. “To be safe, don’t take any medication without talking to your doctor.”
  3. “Too much vitamin C is one of the most common issues, but is avoidable.”
  4. “Almost all medications will cause birth defects in the first trimester.”

Answer: 2

 

Rationale:

  1. The nurse should avoid a “don’t worry” answer to ensure therapeutic communication, but it is appropriate to instruct the client to talk to the doctor about medications.
  2. Teratogens are substances that can cause birth defects. Alcohol is one example, as are warfarin (Coumadin) and isotretinoin (Accutane). The greatest risk is during the first trimester, but not all medications are teratogenic. Those medications with clear evidence of teratogenicity are classified in pregnancy category X, and should be avoided when conception is being attempted and during the first trimester.
  3. Vitamin C can cause rebound scurvy, but is not teratogenic.
  4. Not all medications are teratogenic.

Cognitive Level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Implementation

Learning Outcome 11.5 Describe self-care measures that a pregnant woman can take to maintain and promote her well-being during pregnancy.

 

Chapter 11_LO05_Q14

A pregnant client who swims 3–5 times per week asks the nurse if she should stop this activity. What is the appropriate nursing response?

  1. “You should decrease the number of times you swim per week.”
  2. “You should continue your exercise program, because it would be beneficial.”
  3. “You should discontinue your exercise program immediately.”
  4. “You should increase the number of times you swim per week.”

Answer: 2

Rationale:

  1. Thirty minutes of moderate-intensity exercise daily is recommended for pregnant women, but even mild exercise is helpful. Women who exercise regularly have better muscle tone, self-image, bowel function, energy levels, sleep, and postpartum recovery than do those who are sedentary.
  2. Thirty minutes of moderate-intensity exercise daily is recommended for pregnant women, but even mild exercise is helpful. Women who exercise regularly have better muscle tone, self-image, bowel function, energy levels, sleep, and postpartum recovery than do those who are sedentary.
  3. Thirty minutes of moderate-intensity exercise daily is recommended for pregnant women, but even mild exercise is helpful. Women who exercise regularly have better muscle tone, self-image, bowel function, energy levels, sleep, and postpartum recovery than do those who are sedentary.
  4. Thirty minutes of moderate-intensity exercise daily is recommended for pregnant women, but even mild exercise is helpful. Women who exercise regularly have better muscle tone, self-image, bowel function, energy levels, sleep, and postpartum recovery than do those who are sedentary.

 

Cognitive Level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Implementation

Learning Outcome 11.5 Describe self-care measures that a pregnant woman can take to maintain and promote her well-being during pregnancy.

 

 

Chapter 11_LO05_Q15

The pregnant client is in her 21st week of pregnancy, and is planning a vacation with her family. She asks the nurse which method of travel would be recommended for her to use. How should the nurse respond? “The safest method of travel is to:

  1. “Take an automobile.
  2. “Fly on an airplane.
  3. “Travel by train.
  4. “Not travel this late in pregnancy.

Answer: 3

Rationale:

  1. Automobile travel does not allow for frequent enough movement.
  2. Airplane travel does not allow for frequent enough movement.
  3. In the latter half of pregnancy, frequent movement is recommended for pregnant women, both to increase comfort and to decrease venous pooling, which can lead to thrombophlebitis. The train allows the most movement for the traveling pregnant woman.
  4. It is not necessary to cease travel altogether.

Cognitive Level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome 11.5 Describe self-care measures that a pregnant woman can take to maintain and promote her well-being during pregnancy.

 

Chapter 11_LO05_Q16

The nurse is explaining the importance of fetal activity assessment to the client. What should the nurse do to best reinforce the significance of fetal kick counting to the client?

  1. Perform daily phone calls to the client at work or home.
  2. Review the client’s written record of fetal movement at each visit.
  3. Ask the client to remember to count the fetal movements.
  4. Explain the rationale for counting fetal movement to the client.

Answer: 2

 

Rationale:

  1. Daily phone calls would take emphasis away from the importance of the client’s counting of fetal movement.
  2. Clients should be instructed to begin counting fetal movement between 24 and 28 weeks. A fetus that has been active and has a sudden decrease in movements could be conserving energy due to hypoxia. Movements are counted in a specified time period, such as for one hour after each meal, or beginning with arising in the morning.
  3. Writing down the count is more accurate than the client’s simply remembering. When the nurse examines the written record the client has kept, it reinforces the importance of the record, and improves the likelihood of continued record keeping.
  4. Knowing the reasons for the counting will increase understanding of the process, but will not reinforce its significance of the task.

Cognitive Level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome 11.5 Describe self-care measures that a pregnant woman can take to maintain and promote her well-being during pregnancy.

 

 

Chapter 11_LO06_Q17

Which statement by the pregnant client indicates that teaching has been effective?

  1. “I should not have sex, because this is my first pregnancy.”
  2. “Some sexual positions should be avoided during pregnancy.”
  3. “We should quit having sex when I get to 8 months.”
  4. “I can tell my partner that having sex won’t hurt the baby.”

Correct Answer: 4

Rationale:

  1. Sexual activity is neither harmful nor contraindicated in an uncomplicated pregnancy.
  2. Although some sexual positions are more comfortable for the pregnant woman as the uterus enlarges, there are no sexual positions that are contraindicated during pregnancy.
  3. This is not necessary. Sexual activity is neither harmful nor contraindicated in an uncomplicated pregnancy.
  4. Sexual activity is neither harmful nor contraindicated in an uncomplicated pregnancy.

Cognitive level:  Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Evaluation

Learning Outcome: 11.6 Examine the concerns that the expectant couple may have about sexual activity.

 

Chapter 11_LO07_Q18

The nurse is preparing a brochure for couples considering pregnancy after the age of 35. Which statements should be included? During pregnancy after age 35: (Select all that apply’)

  1. There is a decreased risk of Down syndrome.
  2. Pre-existing medical conditions can complicate pregnancy.
  3. Very preterm births are more common.
  4. Amniocentesis can be performed to detect genetic anomalies.
  5. Gestational diabetes is no longer a risk.

Correct Answers: 2, 3, 4

Rationale:

  1. Down syndrome risk increases when maternal age exceeds 34 years.
  2. The older a woman is, the more likely she is to have developed chronic health care issues such as type II diabetes or hypertension. The presence of chronic conditions can further complicate pregnancy in women over 35.
  3. Very preterm births and low birth weight are more common in pregnancy of women over 35.
  4. Amniocentesis is offered to women over 35 due to the increased of trisomy 18 and 21. However, amniocentesis has risks, and is not performed on all women over 35. In addition, some women would not terminate a pregnancy regardless of the findings of the amniocentesis, and therefore refuse this test.
  5. The older a client is during pregnancy, the higher her risk of developing gestational diabetes.

Cognitive level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Evaluation

Learning Outcome: 11.7 Describe the medical risks and special concerns of the older expectant woman and her partner in managing nursing care to this population.

Chapter 25_LO01_Q01

The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infant is 33 weeks by early ultrasound and last menstrual period. The nurse expects the infant to exhibit:

  1. Full sole creases, nails extending beyond the fingertips, scarf sign shows the elbow beyond the midline.
  2. Testes located deep in the scrotum, rugae cover the scrotum, vernix covering the entire body.
  3.  Ear cartilage remains folded over, lanugo present over much of the body, some flexion of arms and legs at rest,
  4. 1cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension.

Correct Answer: 3

Rationale:

  1. Full sole creases and nails beyond the fingertips will be seen in term infants; scarf sign beyond the midline is an indication of a preterm infant.
  2. Deep testes and rugae-covered scrotum are seen in term infants; vernix covering the body is an indication of a preterm infant.
  3. All of these characteristics are indications of a preterm infant.
  4. 1cm breast bud, peeling skin, the presence of adipose so that veins are not visible, and rapid recoil of the legs and arms are all indications of term–to–post-term infants.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 25.1 Describe the physical and neuromuscular maturity characteristics assessed to determine gestational age of the newborn.

 

Chapter 25_LO02 _Q02

The nurse is working with a student nurse during assessment of a 2-hour-old newborn. Which action indicates that the student nurse understands neonatal assessment? The student nurse:

  1. Listens to bowel sounds then assesses the head for skull consistency, and size and tension of fontanels.
  2. Checks for Ortolani’s sign, then palpates femoral pulse, then assesses respiratory rate.
  3. Determines skin color, then describes shape of the chest and looks at structures and flexion of the feet.
  4. Counts the number of cord vessels, then assess genitals, then sclera color and eyelids.

Correct Answer: 3

Rationale:

  1. The assessment should proceed in a head-to-toe order; the head should be assessed before the bowel sounds.
  2. The assessment should proceed in a head-to-toe order; the respiratory rate should be assessed first, when the infant is at rest and undisturbed.
  3. This assessment proceeds in a head-to-toe fashion.
  4. The assessment should proceed in a head-to-toe order; the sclera and eye assessment should be done prior to assessing genitals.

Cognitive level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 25.2 Explain the components and methods of a systematic physical assessment of the newborn.

 

Chapter 25_LO03 _Q03

The nurse is preparing new parents to be discharged with their newborn. The father asks the nurse why the baby’s head is so pointed and puffy-looking. The best response by the nurse is:

  1. “His head is molded from fitting through the birth canal. It will become more round.”
  2. “We refer to that as ‘cone head,’ which is a temporary condition that goes away.”
  3. “It might mean that your baby sustained brain damage during birth, and could have delays.”
  4. “I think he looks just like you. Your head is much the same shape as your baby’s.”

Correct Answer: 1

Rationale:

  1. This statement is accurate, and directly answers the father’s question.
  2. Although nursing staff might refer to molding as looking like a ‘cone head,’ and the shape is temporary, it is better to be more specific in describing why the head is shaped as it is. In addition, this answer does not answer the question “why” as stated by the father.
  3. A molded head shape does not indicate brain damage. Molding is normal and transient.
  4. Although this might be true, it is better to give a factual answer that does not imply that you think the father’s head is abnormally shaped. This answer could be perceived as insulting by the father.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Implementation

Learning Outcome: 25.3 Describe the normal physical characteristics and normal variations of the newborn considered in a newborn assessment.

 

Chapter 25_LO04_Q04

The nurse is assessing a newborn a few minutes after birth. The neonate has overlapping anterior fontanelles and suture lines. The best nursing action is to:

  1. Contact the physician immediately.
  2. Verify the presence of lanugo.
  3. Document the findings.
  4. Assess for rectal patency.

Correct Answer: 3

Rationale:

  1. There is no need to contact the physician. Overlapping fontanels and sutures are a common variation of normal.
  2. Lanugo is not related to overlapping fontanels and sutures, which are a common variation of normal.
  3. Because overlapping fontanels and sutures are a common variation of normal, documenting the findings is appropriate.
  4. Rectal patency is not related to overlapping fontanels and sutures, which are a common variation of normal.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 25.4 Compare abnormal findings in a newborn physical assessment to possible causes and nursing responses.

 

Chapter 25_LO05_Q05

The nurse is preparing to assess a newborn’s neurological status. Which finding would require an immediate intervention?

  1. At rest, the infant has partially flexed arms and her legs drawn up to the abdomen.
  2. When the corner of the mouth is touched, the infant turns her head that direction.
  3. Blinking occurs when the exam light is turned on over the infant’s face and body.
  4. The right arm is flaccid while the infant brings her left arm and fist upwards to the head.

Correct Answer: 4

Rationale:

  1. This is the normal resting posture of the infant.
  2. This is the rooting reflex, a normal finding in a newborn.
  3. Blinking in response to bright lights is an expected finding.
  4. Asymmetrical movement is not an expected finding, and could indicate neurological abnormality. This should be reported to the physician immediately.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 25.5 Explain the components and methods for assessing neurologic/neuromuscular status and reflexes.

 

Chapter 25_LO06_Q06

The nurse is completing a newborn care class. The nurse knows that teaching has been effective if a new parent states:

  1. “My baby may open his arms wide and pull her legs up to her tummy if she is passing gas.”
  2. “If my baby curls his toes downward when I stroke the sole of his foot, he is normal.”
  3. “When I put my finger in the palm of my daughter’s hand, she will curl her fingers and hold on.”
  4. “I can get my baby to turn her head towards the right side if I lift her right arm over her head.”

Correct Answer: 3

Rationale:

  1. This is the Moro or startle reflex, and will occur when the infant is startled by sudden movement or a loud noise.
  2. The Babinski reflex of a newborn should elicit a fanning of the toes and hyperextension.
  3. This is the palmar grasp reflex. The plantar surface of the foot has a similar reflex.
  4. This is the tonic neck reflex, but the head should turn toward the opposite arm, not the arm that is lifted.

Cognitive level: Comprehension

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Evaluation

Learning Outcome: 25.6 Describe the normal neurologic/neuromuscular characteristics and reflexes of the newborn considered in a newborn neurologic assessment.

 

Chapter 25_LO07_Q07

The nurse is working with a family that has just delivered their third child, at 33 weeks’ gestation. The mother tells the nurse, “This baby doesn’t turn his head and suck like the older two children did. Why?” The best response by the nurse is:

  1. “Every baby is different. This is just one variation of normal that we see on a regular basis.”
  2. “This baby might not have a rooting or sucking reflex because she is premature.”
  3. “When she is wide awake and alert, she will probably root and suck even if she is early.”
  4. “She may be too tired from the birthing process and need a couple days to recover.”

Correct Answer: 2

Rationale:

  1. Although each baby is unique and different from her siblings, this answer does not indicate that prematurity is the cause of the lack of root and suck reflexes.
  2. Preterm babies often have a poor or absent root and suck reflex. They also might not have a swallow reflex, and might require tube feedings temporarily.
  3. This statement is true of term infants, but this infant is preterm, and the prematurity is the cause of the lack of rooting and sucking.
  4. Although birth is stressful to newborns, and some require a day or two of recovery to become fully alert, this infant is preterm, and the prematurity is the cause of the lack of rooting and sucking.

Cognitive level: Comprehension

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Implementation

Learning Outcome: 25.7 Compare abnormal findings in a newborn neurologic assessment to possible causes and nursing responses.

 

Chapter 25_LO08_Q08

The nurse is planning an educational session for maternal–child health unit nurses to cross-train them for providing home-based care after discharge. Which statements indicate that additional teaching is required? “The behavioral assessment: (Select all that apply.)

  1. “Should be done as soon after birth as possible.”
  2. “Can be performed without input from parents.”
  3. “May be incomplete in a one-hour home visit.”
  4. “Includes orientation and motor activity.”
  5. “May detect neurological anomalies.”

Correct Answers: 1, 2

Rationale:

  1. The behavioral exam is not accurate until about the third day of life. Newborns have disorganized behavior in the first days after birth.
  2. Parental input is required to fully understand the infant’s behaviors that are not observed by the health care team.
  3. A full behavioral assessment requires seeing the infant in several sleep/alert stages, which is not likely to take place in a one-hour home visit.
  4. Orientation to visual and auditory clues and motor activity are portions of the behavioral assessment.
  5. This statement is true.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Evaluation

Learning Outcome: 25.8 Explain the components and methods of a behavioral assessment of the newborn.

 

Chapter 25_LO08_Q09

The student nurse attempts to take the vital sign of the newborn, but the newborn is crying. What nursing action would be appropriate?

  1. Place a gloved finger in the newborn’s mouth.
  2. Take the vital signs.
  3. Wait until the newborn stops crying.
  4. Place a hot water bottle in the isolette.

Answer: 1

Rationale:

  1. To soothe a newborn during assessment or other procedures, place a gloved finger into the newborn’s mouth.
  2. Crying will increase heart rate and respiratory rate, so vitals should not be taken when the newborn is crying.
  3. However, assessment of vitals needs to be done at regularly timed intervals, so waiting until the newborn stops crying might cause too long of a delay.
  4. A hot water bottle should not be placed next to the newborn, because of a potential risk for burns.

Cognitive Level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Assessment

Learning Outcome: 25.8 Explain the components and methods of a behavioral assessment of the newborn.

 

Chapter 25_LO08_Q10

The nurse wishes to demonstrate to a new family their infant’s individuality. Which assessment tool would be most appropriate for the nurse to use?

  1. Brazelton Neonatal Behavioral Assessment Scale
  2. Ballard Maturity Scale
  3. Dubowitz Gestational Age Scale
  4. Ortolani maneuver

Answer: 1

 

Rationale:

  1. The Brazelton Neonatal Behavioral Assessment Scale assesses the newborn’s state changes, temperament, and individual behavior patterns.
  2. The Ballard Maturity Scale assesses external physical characteristics and neurological or neuromuscular development.
  3. Dubowitz Gestational Age Scale assesses external physical characteristics and neurological or neuromuscular development.
  4. The Ortolani maneuver is an assessment technique that rules out the possibility of congenital hip dysplasia.

Cognitive Level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 25.8 Explain the components and methods of a behavioral assessment of the newborn.

 

Chapter 25_LO08_Q11

The parents of a newborn comment to the nurse that their infant seems to enjoy being held, and that holding the baby helps him calm down after crying. They ask the nurse why this happens. After explaining newborn behavior, the nurse assesses the parents’ learning. Which statement indicates that teaching was effective?

  1. “Some babies are easier to deal with than others.”
  2. “We are lucky to have a baby with a calm disposition.”
  3. “Our baby spends more time in the active alert phase.”
  4. “Cuddliness is a social behavior that some babies have.”

Answer: 4

Rationale:

  1. Easier or more difficult to deal with is a judgment, not part of an assessment.
  2. Describing an infant as having a calm disposition is a judgment, not part of an assessment.
  3. The active alert phase of the sleep-awake cycle is characterized by motor activity.
  4. The Brazelton Neonatal Behavioral Assessment Scale looks at: habituation, orientation to animate or inanimate visual or auditory stimuli, motor activity, self-quieting, cuddliness or social behaviors, and variations of each of these categories.

Cognitive level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Evaluation

Learning Outcome: 25.8 Explain the components and methods of a behavioral assessment of the newborn.

 

 

Chapter 25_LO9_Q12

The nurse is teaching a group of new parents about their infants. The infants are all 4 weeks of age or less. Which statement should the nurse include?

  1. “The baby will respond to you the most if you look directly into your baby’s eyes and talk to him.”
  2. “Each baby is different. Don’t try to compare your infant’s behavior to any other child’s behavior.”
  3. “If the sound level around your baby is high, the baby will wake up and be fussy or cry.”
  4. “If your baby is a cuddler, it is because you rocked and talked to him during your pregnancy.”

Correct Answer: 1

Rationale:

  1. Holding the baby en face and speaking softly obtains the most response from the baby, including eye contact, smiling, and vocalization.
  2. Although each infant is unique, there are certain predictable norms to observe for when assessing for neurological normality or impairment.
  3. Some infants will become overstimulated when excessive noise is present, but more will habituate to the sound and sleep.
  4. Cuddling is a social behavior that correlates with personality, but has not been linked to any prenatal activities.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 25.9 Describe the normal behavioral characteristics and normal variations of the newborn considered in a newborn behavioral assessment.

 

Chapter 25_LO10_Q13

The nurse is answering phone calls at the pediatric clinic. Which call should the nurse return first?

  1. 2-week-old infant who doesn’t make eye contact when talked to
  2. 1-week-old infant who sleeps through the noise of an older sibling
  3. 6-day-old infant who responds more to mother’s voice than to father’s voice
  4. 3-week-old infant who has begun to suck on the fingers of her right hand

Correct Answer: 1

Rationale:

  1. This is an abnormal finding. Infants who do not make eye contact when talked to could have an ophthalmic abnormality.
  2. This is habituation, and is an expected behavior.
  3. It is not unusual for an infant to respond more to the higher-pitched speech of its mother.
  4. Self-comforting behaviors such as sucking on fists, thumbs, or fingers are normal findings.

Cognitive level: Application

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 25.10 Compare abnormal findings in a newborn behavioral assessment and their possible causes and nursing responses.

 

Chapter 25_LO11_Q14

The nurse is assessing a newborn. The parents are present. Which statement is best?

  1. “Your infant was born with several reflexes. Some help her eat and protect her. I will show you what they look like.”
  2. “You will be most successful if you put your baby to breast when she has her eyes wide open and she is looking around.”
  3. “The muscle tone of your baby will increase as she gets older. You’ll notice her head lagging less in a few weeks.”
  4. “The umbilical cord stump will dry up and fall off in about two weeks. There might be a spot of blood when it falls off.”

Correct Answer: 2

Rationale:

  1. Although this is true, parents’ knowledge about reflexes is not critical to the survival of the infant.
  2. This statement is best because it is about the physical need of feeding. Infants feed best when they are in the active alert phase, characterized by quiet, eyes open, and looking calmly around.
  3. Although this statement is true, parents’ knowledge about neuromuscular development is not critical to the survival of the infant.
  4. Although this is true, parents’ knowledge about the cord falling off is not critical to the survival of the infant.

Cognitive level: Analysis

Category of Client Need: Health Promotion and Maintenance

Nursing Process: Planning

Learning Outcome: 25.11 Use the assessment procedure and results of the newborn physical, neurologic, and behavioral assessments to teach and involve parents in the care of the newborn.