Question

A) Hemoglobin and hematocrit
B) Urine for culture
C) Fetal ultrasound
D) Fundal height measurement

Answer 1

D
 Feedback:
 On every follow-up visit, fundal height measurements are performed to evaluate fetal growth and gestation. Hemoglobin and hematocrit, as part of a complete blood count, would be done on the initial visit and then repeated if the woman's status indicates a need for doing so. Urine is checked for protein, glucose, ketones, and nitrites. A culture would be done if there are signs and symptoms of an infection. Fetal ultrasound can be done at any time during the prenatal period, but it is not done at every visit.

Answer 2

B
 Feedback:
 The primary focus of perinatal education is to provide information and support to clients and their families to foster a more active role in the upcoming birth. It also includes preparation for breast-feeding, infant care, transition to new parenting roles, relationships skills, family health promotion, and sexuality. Some methods of childbirth education focus on pain-free childbirth. Information provided in childbirth education classes helps to minimize anxiety and provide the couple with control over the situation, but elimination of anxiety or total control is unrealistic.

Answer 3

C
 Feedback:
 Chadwick's sign refers to the bluish coloration of the cervix and vaginal mucosa. Hegar's sign refers to softening of the isthmus. Goodell's sign refers to softening of the cervix. Homans' sign indicates pain on dorsiflexion of the foot.

Answer 4

A
 Feedback:
 Douching while pregnant is contraindicated because the force of the irrigating fluid could cause the solution to enter the cervix and lead to uterine infection. In addition, douching alters the pH of the vagina, leading to an increased risk of vaginal bacterial growth. The alkalinity, purchase type, or temperature of the solution does not matter. The pregnant patient should not douche.

Answer 5

A
 Feedback:
 Sexual activity is permissible during pregnancy unless there is a history of vaginal bleeding, placenta previa, risk of preterm labor, multiple gestation, incompetent cervix, premature rupture of membranes, or presence of infection. Rupture of membranes or premature labor is unlikely since the woman's pregnancy has been uneventful so far. Alternative sexual positions may be necessary as the woman's abdomen increases in size.

Answer 6

C
Feedback
A To avoid cross-contamination, medication should never be shared.
B The child should remain home from school until 24 hours after receiving
medication.
C Care should be taken to avoid touching the tip of the ointment tube or dropper to
the eye to avoid contamination of the medication.
D The child should not wear contact lenses until treatment is completed.

Answer 7

A, B, C, E
 Feedback:
 The 2020 National Health Goals for pregnancy include objectives to abstain from social and binge alcohol intake, avoid smoking, receive prenatal care, and abstain from illicit drugs. Seeking alternative care approaches is not a 2020 National Health Goal for pregnancy.

Answer 8

B
Feedback
A Hypertension is not a symptom of increased intraocular pressure.
B Preventing coughing, straining, vomiting, and touching the operative site are all
measures directed toward avoiding increased intraocular pressure.
C The head of the bed should be raised slightly and the eye placed in a position that
is not dependent to prevent increasing intraocular pressure.
D Steroids, antibiotics, and mydriatics may be used after the surgery.

Answer 9

A
 Feedback:
 A patient may become pregnant with an intrauterine device (IUD) in place. If this occurs, it needs to be removed to prevent infection during pregnancy. The fetus does not need to be aborted, and the patient will not spontaneously abort because the IUD is in place. The IUD cannot remain in place because of the risk for infection.

Answer 10

A
 Feedback:
 Pain on urination is a symptom of a urinary infection, potentially serious because these are associated with preterm birth. This statement indicates that additional patient teaching is needed. The patient should call the doctor with any vaginal bleeding. A sudden rush of fluid indicates the membranes have ruptured. Once a day vomiting is not uncommon during the first trimester of pregnancy.

Answer 11

D
Feedback
A The patch should always be applied directly to the child's face, not to eyeglasses.
B The patch should be left in place even when the child is sleeping.
C Covering the "bad" eye will not contribute to strengthening it. The "good" eye
should be patched.
D The "good" eye is patched to force the child to use the "bad" eye, thus
strengthening the muscles.

Answer 12

D
 Feedback:
 The diagonal conjugate is the measurement between the anterior surface of the sacral prominence and the posterior surface of the symphysis pubis. The ischial tuberosity diameter measurement is the distance between the ischial tuberosities or the transverse diameter of the outlet and is made at the medial and lowermost aspect of the ischial tuberosities at the level of the anus. Measurements are not made from the posterior surface of the sacrum and the axis of the ischial tuberosities or the interior surface of the sacral prominence and the posterior surface of the symphysis pubis.

Answer 13

A
 Feedback:
 Gravida is defined as a woman who has been pregnant. Para is defined as the number of pregnancies that have reached viability, regardless of whether the infants were born alive. The patient was pregnant three times. The patient delivered two live births. The aborted fetus is not included in the para count. The patient was not pregnant four times.

Answer 14

A, B, C, E
 Feedback:
 Urine is tested for proteinuria, glycosuria, nitrites, and pyuria. All of these can be done by means of test strips. The nurse will not test the patient's urine for drug levels as part of a routine prenatal visit.

Answer 15

B
Feedback
A Once the patch is in place, it should remain there for the prescribed number of
hours.
B The patch should be securely applied to the face. Parents often apply the eye
patch to the child's eyeglasses.
C Patching alone will not straighten the eye.
D The amount of time the child wears the eye patch is not negotiable. Parents
should learn strategies for dealing with resistant behaviors.

Answer 16

C
Feedback
A This response is false reassurance and blocks communication.
B A 13-year-old adolescent is old enough to comprehend explanations and is
entitled to receive the pertinent information regarding her health.
C The nurse should be knowledgeable and honest in answering questions about
procedures.
D Patients, especially teenagers, do not appreciate health care providers who do not
treat them with honesty and respect.

Answer 17

B
Feedback
A Stuttering is not normal after age 5 years.
B If stuttering persists after 5 years of age, the child should be seen by the
physician and referred to a speech therapist.
C Early diagnosis and intervention are important to correct speech disorders.
D Early diagnosis and treatment of stuttering are critical in assisting the child to
develop as normally as possible.

Answer 18

A
Feedback
A Any surgical procedure leaves the patient vulnerable to infection.
B There is no data in the scenario to validate this conclusion.
C There is no data in the scenario to support this nursing diagnosis.
D Usually eye surgeries are relatively painless.

Answer 19

A, B, D, E
 Feedback:
 A number of 2020 National Health Goals speak directly to the importance of prenatal care to include increasing the proportion of pregnant women who attend a series of prepared childbirth classes, increasing the proportion of women of childbearing potential who have an intake of at least 400 mcg of folic acid from fortified foods or dietary supplements before pregnancy, increasing the proportion of mothers who achieve a recommended weight gain during their pregnancies, and making sites for prenatal care "family friendly" or maximally receptive to women and families. Strategies to avoid intimate partner violence will not help the nurse achieve the 2020 National Health Goals for prenatal care.

Answer 20

B
Feedback
A Damage caused by inflammation or obstruction usually causes a temporary and
reversible hearing loss.
B When hearing loss is caused by malformations, auditory nerve damage, or
infection, the loss is usually permanent.
C A central type of hearing loss usually causes difficulties in differentiating sounds
and problems with auditory memory, and it is reversible.
D A combination of conductive and sensorineural loss. Conductive loss is often
reversible, whereas sensorineural is permanent.

Answer 21

B
 Feedback:
 The patient is taking herbal remedies and over-the-counter medications, many of which can be teratogenic to the developing fetus. This is the most appropriate nursing diagnosis for the nurse to select for this assessment finding. There is no enough information to determine if the fetus is at risk because of the patient's lifestyle choices. The patient has not asked for specific information so health-seeking behavior diagnoses would not be appropriate for the patient at this time.

Answer 22

C
 Feedback:
 Breast changes may be one of the first things women notice in pregnancy. Any supernumerary nipples may become darker and enlarge in size. There is no information to support that supernumerary nipples fade with menopause or bleed. There is also no information to support that supernumerary nipples are genetic in origin.

Answer 23

A
Feedback
A Chemical eye burns are an ocular emergency and best managed by immediate
irrigation of the eye(s) with water or normal saline solution.
B Topical steroids usually are applied after irrigation.
C Caring for a frightened child is very difficult. Pain medication may help the child
cope with the situation, but the initial care is irrigation.
D Further treatment may include the use of medications to dilate the pupils to
decrease the risk of adhesions.

Answer 24

C
Feedback
A Maintaining separate towels and washcloths will prevent the other family
members from acquiring the infection.
B If the infection proliferates, the physician should be contacted.
C The antibiotic should be continued for the full prescription.
D The child should be kept home from school or day care until the child receives
the antibiotic for 24 hours.

Answer 25

A, B, C
 Feedback:
 Interventions to reduce lower lumbar backache associated with pregnancy include pelvic rocking exercises, walking with the head high, and resting and elevating the feet. The patient should be instructed to limit the use of high heels. Twisting the spine is not recommended to help with a lumbar backache.

Answer 26

D
Feedback
A Coughing, straining, or vomiting can increase intraocular pressure
postoperatively.
B Nystagmus and strabismus are clinical signs of a cataract. Color deficiency is not
a sign.
C A cataract usually does not cause double vision.
D A cataract is an opacity of the lens or loss of transparency of the lens.

Answer 27

C
 Feedback:
 The patient should be instructed to eat foods that are high in folic acid such as spinach, asparagus, and legumes. Adding spinach every day to the evening salad indicates that teaching about folic acid nutrition has been effective. Oranges, milk, cabbage, and cauliflower are not food items that will specifically influence the folic acid level.

Answer 28

D
 Feedback:
 The growing fetus has large needs for glucose, amino acids, and lipids, placing demands on maternal glucose stores. During the first half of pregnancy, much of the maternal glucose is diverted to the growing fetus. The pancreas continues to function during pregnancy. However, the placental hormones can affect maternal insulin levels. The demand for glucose by the fetus during pregnancy is high, but it is not necessarily used more rapidly. Placental hormones, not the woman's dietary intake, play a major role in glucose metabolism during pregnancy.

Answer 29

B
 Feedback:
 The statement that the patient needs to get back to work after delivery could indicate that the patient feels the pregnancy is robbing her of financial stability or ruin chances of a promotion. Desiring to lose weight after pregnancy does not indicate that the patient is not adjusting emotionally to being pregnant. The statements about parental support do not indicate that the patient is not adjusting emotionally to being pregnant.