The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount?

The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount?

a)250mL
b)300mL
c)100mL
d)500mL


Answer: d)500mL

After teaching a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful?

After teaching a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful?

a)"Postpartum psychosis usually appears soon after the woman comes home."
b)"Postpartum psychosis usually involves psychotropic drugs but not hospitalization."
c)"Postpartum depression develops gradually, appearing within the first 6 weeks."
d)"Postpartum blues usually resolves by the fourth or fifth postpartum day."


Answer: c)"Postpartum depression develops gradually, appearing within the first 6 weeks."

In preparing for a class in teaching women and their partners, which of the following would be the most important to emphasize as helping to prevent postpartum complications?

In preparing for a class in teaching women and their partners, which of the following would be the most important to emphasize as helping to prevent postpartum complications?

a)Adequate follow-up with their health care provider
b)Handwashing
c)Ensure proper hydration
d)Limiting contact with outsiders for the first week


Answer: b)Handwashing

Quickly determining the cause of postpartum hemorrhaging enables effective treatment. A nurse using the 5T's tool will recognize which of the following as being a potential cause of postpartum hemorrhage? (Select all that apply.)

Quickly determining the cause of postpartum hemorrhaging enables effective treatment. A nurse using the 5T's tool will recognize which of the following as being a potential cause of postpartum hemorrhage? (Select all that apply.)

a)Technique of delivery
b)Time
c)Thrombin
d)Tone
e)Tissue


Answer:


c)Thrombin
d)Tone
e)Tissue

A 35-year-old G2, P2 client presents to her postpartum appointment with vague complaints. The nurse suspects postpartum depression after the client expresses all except which of the following?

A 35-year-old G2, P2 client presents to her postpartum appointment with vague complaints. The nurse suspects postpartum depression after the client expresses all except which of the following?

a)Feels like eating all the time
b)Change in sleep
c)Appears detached from infant
d)Lack of energy and motivation


Answer: a)Feels like eating all the time

A 17-year-old nulliparous client presents in active labor. It is discovered that she received no prenatal care. Which of the following would be important to collect first?

A 17-year-old nulliparous client presents in active labor. It is discovered that she received no prenatal care. Which of the following would be important to collect first?

a)Urinalysis
b)HIV status
c)STI status
d)Coagulation studies


Answer: d)Coagulation studies

The nurse is assisting a client in completing the Postpartum Depression Screening Scale tool to assess for postpartum depression. Which of the following is least likely to be screened with this tool?

The nurse is assisting a client in completing the Postpartum Depression Screening Scale tool to assess for postpartum depression. Which of the following is least likely to be screened with this tool?

a)Emotional liability
b)Family and social support system
c)Guilt
d)Cognitive impairment


Answer: b)Family and social support system

Every postpartum client has the potential of hemorrhage. While assessing a client's status, the nurse recognizes which of the following would not be used as an indicator of possible hemorrhage?

Every postpartum client has the potential of hemorrhage. While assessing a client's status, the nurse recognizes which of the following would not be used as an indicator of possible hemorrhage?

a)Estimated amount of blood loss
b)Uterine tone
c)Signs of shock
d)Vital signs


Answer: c)Signs of shock

A 27-year-old G1, P1 woman arrives in the emergency department accompanied by her husband and new infant, crying, confused, and with possible hallucinations. The nurse recognizes this could possibly be postpartum psychosis as it can appear approximately when?

A 27-year-old G1, P1 woman arrives in the emergency department accompanied by her husband and new infant, crying, confused, and with possible hallucinations. The nurse recognizes this could possibly be postpartum psychosis as it can appear approximately when?

a)Within 2 months of giving birth
b)Within 5 months of giving birth
c)Within 4 months of giving birth
d)Within 3 months of giving birth


Answer: d)Within 3 months of giving birth

Various medications are available to help control hemorrhage in the postpartum client. When reviewing the client's history, the nurse notes she has a history of asthma. Which of the following medications would be contraindicated in her case?

Various medications are available to help control hemorrhage in the postpartum client. When reviewing the client's history, the nurse notes she has a history of asthma. Which of the following medications would be contraindicated in her case?

a)Hemabate
b)Cytotec
c)Methergine
d)Pitocin


Answer: a)Hemabate

In reviewing the postpartum G3, P3 woman's history the nurse notes it is positive for obesity and smoking. The nurse recognizes this client is at risk for which of the following complications?

In reviewing the postpartum G3, P3 woman's history the nurse notes it is positive for obesity and smoking. The nurse recognizes this client is at risk for which of the following complications?

a)Postpartum Hemorrhage
b)Uterine Atony
c)Deep venous thrombosis
d)Metritis


Answer: c)deep venous thrombosis

The nurse recognizes that the postpartum period is a time of rapid changes for each client. Which of the following is believed to be the cause of postpartum affective disorders?

The nurse recognizes that the postpartum period is a time of rapid changes for each client. Which of the following is believed to be the cause of postpartum affective disorders?

a)Medications used during labor and delivery
b)Lack of social support from family or friends
c)Drop in estrogen and progesterone levels after birth
d)Preexisting conditions in the client


Answer: c)Drop in estrogen and progesterone levels after birth

After teaching a class on ways to decrease the postpartum complication of thrombotic conditions, the nurse recognizes more teaching is needed when one of the participants states:

After teaching a class on ways to decrease the postpartum complication of thrombotic conditions, the nurse recognizes more teaching is needed when one of the participants states:

a)"Using passive range-of-motion exercises in bed sounds easy enough."
b)"At least, I don't have to give up smoking for this one."
c)"He has to do the deep breathing exercises with me."
d)"I can drink more, so I don't get dehydrated."


Answer: b)"At least, I don't have to give up smoking for this one."

Disseminated intravascular coagulation is a life-threatening condition that the nurse recognizes can occur as a complication secondary to which of the following primary conditions? (Select all that apply.)

Disseminated intravascular coagulation is a life-threatening condition that the nurse recognizes can occur as a complication secondary to which of the following primary conditions? (Select all that apply.)

a)Septicemia
b)Abruptio placenta
c)Isoimmunization
d)Ectopic pregnancy
e)Severe preeclampsia

Answer:


a)Septicemia
b)Abruptio placenta
e)Severe preeclampsia

When treating a postpartum woman for hemorrhage, the nurse will prepare the client for a blood transfusion once the estimates of blood loss reach which level?

When treating a postpartum woman for hemorrhage, the nurse will prepare the client for a blood transfusion once the estimates of blood loss reach which level?

a)1,000mL
b)1,500mL
c)1,750mL
d)1,250mL


Answer: b)1,500mL

Which of the following instructions would the nurse include in the teaching plan for a postpartum woman with mastitis?

Which of the following instructions would the nurse include in the teaching plan for a postpartum woman with mastitis?

a)"Limit the amount of fluid you drink so your breasts don't get much fuller."
b)"Stop breast-feeding until the pain and swelling subside."
c)"Try applying warm compresses to your breasts to encourage the milk to be released."
d)"You'll need to take this medication to stop the milk from being produced."


Answer: c)"Try applying warm compresses to your breasts to encourage the milk to be released."

Effective nursing management involves many aspects and being aware of subtle changes in the client. Which of the following should alert the nurse to a potential infection in the client?

Effective nursing management involves many aspects and being aware of subtle changes in the client. Which of the following should alert the nurse to a potential infection in the client?

a)Temperature of 37.5% C or higher after the first 12 hours after childbirth
b)Temperature of 39% C or higher after the first 48 hours after childbirth
c)Temperature of 38.5% C or higher after the first 36 hours after childbirth
d)Temperature of 38% C or higher after the first 24 hours after childbirth


Answer: d)Temperature of 38% C or higher after the first 24 hours after childbirth

The nurse recognizes that any client may develop postpartum hemorrhage and frequent assessments are conducted to ensure this is not happening. Which of the following is the most common cause of postpartum hemorrhage?

The nurse recognizes that any client may develop postpartum hemorrhage and frequent assessments are conducted to ensure this is not happening. Which of the following is the most common cause of postpartum hemorrhage?

a)Distended bladder
b)Uterine lacerations
c)Uterine Atony
d)Placenta Previa


Answer: c)Uterine atony

Retention of placental fragments commonly leads to hypertension.

Retention of placental fragments commonly leads to hypertension.

a) False
b) True


Answer: b) True

A Hispanic woman who gave birth several hours ago is experiencing postpartum hemorrhage. She had a cesarean birth and received deep, general anesthesia. She has a history of postpartum hemorrhage with her previous births. The blood is a dark red. Which of the following causes of the hemorrhage is most likely in this client?

A Hispanic woman who gave birth several hours ago is experiencing postpartum hemorrhage. She had a cesarean birth and received deep, general anesthesia. She has a history of postpartum hemorrhage with her previous births. The blood is a dark red. Which of the following causes of the hemorrhage is most likely in this client?

a) Cervical laceration
b) Uterine atony
c) Retained placental fragment
d) Disseminated intravascular coagulation


Answer: b)Uterine atony

When planning care for a postpartum patient, the nurse is aware the most common site for postpartum infection is which of the following?

When planning care for a postpartum patient, the nurse is aware the most common site for postpartum infection is which of the following?

a) Urinary
b) Breast
c) Integumentary
d) Reproductive


Answer: d)Reproductive

Samantha delivered her fourth child after protracted and difficult labor during which oxytocin was used to augment her contractions. The next day, her vaginal bleeding continues to be moderately heavy with numerous large clots. Palpating her fundus, you find that it is in the midline but boggy and above the level of the umbilicus. Fundal massage is indicated; what should you do first?

Samantha delivered her fourth child after protracted and difficult labor during which oxytocin was used to augment her contractions. The next day, her vaginal bleeding continues to be moderately heavy with numerous large clots. Palpating her fundus, you find that it is in the midline but boggy and above the level of the umbilicus. Fundal massage is indicated; what should you do first?

a) Ensure that her bladder is empty.
b) Place one hand over the symphysis pubis.
c) Insert uterine packing to control the hemorrhage.
d) Seek an order to obtain and administer an oxytocic.


Answer: b)Place one hand over the symphysis pubis.

Your patient delivered six hours ago. She calls you to her room complaining of pain "deep inside." You medicate her per orders with no relief attained. You check her vital signs and find they are markedly different then when the CNA charted them 30 minutes ago. What would you suspect?

Your patient delivered six hours ago. She calls you to her room complaining of pain "deep inside." You medicate her per orders with no relief attained. You check her vital signs and find they are markedly different then when the CNA charted them 30 minutes ago. What would you suspect?

a) Early postpartum hemorrhage
b) Late postpartum hemorrhage
c) Pelvic hematoma
d) Uterine laceration


Answer: c)Pelvic hematoma

Methylergonovine is ordered for a woman experiencing postpartum hemorrhage. The nurse monitors the woman closely for which of the following adverse effects?

Methylergonovine is ordered for a woman experiencing postpartum hemorrhage. The nurse monitors the woman closely for which of the following adverse effects?

a) Headache
b) Seizures
c) Uterine hyperstimulation
d) Flushing


Answer: b)Seizures

The majority of women who experience postpartum psychosis had no symptoms of mental illness before pregnancy.

The majority of women who experience postpartum psychosis had no symptoms of mental illness before pregnancy.

a) True
b) False


Answer: b)False

When teaching a postpartum woman about possible complications during this time, the nurse would include information about which of the following as a possible effect?

When teaching a postpartum woman about possible complications during this time, the nurse would include information about which of the following as a possible effect? 

a) Ineffectiveness of breast-feeding
b) Interference with the maternal-newborn attachment process
c) Delayed development of the newborn
d) Alteration in normal maternal hormonal function


Answer: b)Interference with the maternal-newborn attachment process

A nurse is caring for a client with a postpartum laceration. Which of the following nursing diagnoses would be most appropriate? Select all that apply.

A nurse is caring for a client with a postpartum laceration. Which of the following nursing diagnoses would be most appropriate? Select all that apply.

a) Ineffective tissue perfusion
b) Risk for disuse syndrome
c) Risk for injury
d) Impaired tissue integrity
e) Ineffective thermoregulation


Answer:

d)• Impaired tissue integrity
c)• Risk for injury
a)• Ineffective tissue perfusion

A nurse is assigned to care for a client experiencing early postpartum hemorrhage. The nurse is required to administer the prescribed methylergonovine maleate intramuscularly to the client. Which of the following conditions would the nurse identify as necessitating the cautious administration of this drug?

A nurse is assigned to care for a client experiencing early postpartum hemorrhage. The nurse is required to administer the prescribed methylergonovine maleate intramuscularly to the client. Which of the following conditions would the nurse identify as necessitating the cautious administration of this drug?

a) Respiratory problems
b) Low blood pressure
c) Mild fever
d) Cardiovascular disease


Answer: d)Cardiovascular disease

Within 24 hours of delivery, Diane begins to complain of pain in the pelvic region. Comfort measures and medication fail to eliminate the pain, her pulse is rapid, and her blood pressure, hematocrit, and hemoglobin are low. Her fundus is firm, however, and her lochia is dark red and flowing in only moderate amounts; no pooling is evident. You suspect

Within 24 hours of delivery, Diane begins to complain of pain in the pelvic region. Comfort measures and medication fail to eliminate the pain, her pulse is rapid, and her blood pressure, hematocrit, and hemoglobin are low. Her fundus is firm, however, and her lochia is dark red and flowing in only moderate amounts; no pooling is evident. You suspect

a) Deep-vein thrombosis
b) Retained placental fragments
c) Lacerations in the uterus
d) Deep pelvic hematoma


Answer: d)Deep pelvic hematoma

Uterine atony, or the inability of the uterus to effectively contract, has four major causes. What is one of them?

Uterine atony, or the inability of the uterus to effectively contract, has four major causes. What is one of them?

a) Disruption in fetal clotting mechanisms
b) Laceration of the placenta
c) Laceration of the cervix
d) Disruption of placental clotting mechanisms


Answer: c)Laceration of the cervix

Your patient is showing signs and symptoms of a pulmonary embolism. What should you do?

Your patient is showing signs and symptoms of a pulmonary embolism. What should you do?

a) Lay the patient flat and start oxygen.
b) Sit the patient up 90 degrees and call the RN.
c) Start oxygen at 2 to 3 liters per minute via nasal cannula.
d) Raise the head of the bed to at least 45 degrees.


Answer: d)Raise the head of the bed to at least 45 degrees.

The nurse is teaching a group of students about factors that place a pregnant woman at risk for infection in the postpartum period. Which of the following would the nurse be least likely to include?

The nurse is teaching a group of students about factors that place a pregnant woman at risk for infection in the postpartum period. Which of the following would the nurse be least likely to include?

a) Loss of protection with premature rupture of membranes
b) Increased vaginal acidity leading to growth of bacteria
c) Prolonged labor with multiple vaginal examinations to evaluate progress
d) Retained placental fragments


Answer: b)Increased vaginal acidity leading to growth of bacteria

Which measurement best describes delayed postpartum hemorrhage?

Which measurement best describes delayed postpartum hemorrhage?

a) Blood loss in excess of 1,000 ml, occurring 24 hours to 6 weeks after delivery
b) Blood loss in excess of 300 ml, occurring 24 hours to 6 weeks after delivery
c) Blood loss in excess of 800 ml, occurring 24 hours to 6 weeks after delivery
d) Blood loss in excess of 500 ml, occurring 24 hours to 6 weeks after delivery


Answer: d)Blood loss in excess of 500 ml, occurring 24 hours to 6 weeks after delivery

The nurse notes that a client's uterus which was firm after the fundal massage has become "boggy." Which intervention would the nurse do next?

The nurse notes that a client's uterus which was firm after the fundal massage has become "boggy." Which intervention would the nurse do next? 

a) Offer analgesics prescribed by primary care provider
b) Perform vigorous fundal massage for the client
c) Check for bladder distention, while encouraging the client to void
d) Use semi-Fowler's position to encourage uterine drainage


Answer: c)Check for bladder distention, while encouraging the client to void

Which woman should you suspect of having endometritis?

Which woman should you suspect of having endometritis?

a) A woman with diabetes who has delivered vaginally and develops tachycardia and a fever of 101.7 degrees on the third postpartum day. The next day, she appears ill; fever is 102.9 degrees; WBC is 31,500 cells/mm3; blood cultures are negative.
b) A woman with a history of infection and smoking who develops a temperature of 101 degrees on the fourth postpartum day. She reports severe perineal pain. The edges of the episiotomy have separated.
c) An obese woman who has a temperature of 100.4 degrees at 12 hours after delivery. Her lochia is moderate; vaginal cultures are negative.
d) A woman with PROM before delivery complains of severe burning with urination, malaise and severe temperature spikes on the seventh postpartum day. WBC is 21,850cells/mm3; temperature is 101 degrees; and her skin is pale and clammy.


Answer: a)A woman with diabetes who has delivered vaginally and develops tachycardia and a fever of 101.7 degrees on the third postpartum day. The next day, she appears ill; fever is 102.9 degrees; WBC is 31,500 cells/mm3; blood cultures are negative.

While assessing a postpartum woman, the nurse palpates a contracted uterus. Perineal inspection reveals a steady stream of bright-red blood trickling out of the vagina. The woman reports mild perineal pain. She just voided 200 mL of clear yellow urine. Which of the following would the nurse suspect?

While assessing a postpartum woman, the nurse palpates a contracted uterus. Perineal inspection reveals a steady stream of bright-red blood trickling out of the vagina. The woman reports mild perineal pain. She just voided 200 mL of clear yellow urine. Which of the following would the nurse suspect?

a) Uterine inversion
b) Uterine atony
c) Hematoma
d) Laceration


Answer: d)Laceration

After teaching a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful?

After teaching a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful?

a) "Postpartum blues usually resolves by the 4th or 5th postpartum day."
b) "Postpartum depression develops gradually, appearing within the first 6 weeks."
c) "Postpartum psychosis usually appears soon after the woman comes home."
d) "Postpartum psychosis usually involves psychotropic drugs but not hospitalization."


Answer: b)"Postpartum depression develops gradually, appearing within the first 6 weeks."

When working in a free clinic for children, the nurse observes a mother with her 2 week infant. Which of the following behaviors should the nurse bring to the attention of the health care provider?

When working in a free clinic for children, the nurse observes a mother with her 2 week infant. Which of the following behaviors should the nurse bring to the attention of the health care provider?

a) Talking to the infant and rocking the infant
b) Breastfeeding the infant in public
c) Non-responsive to the infant crying
d) Discussing her birth with another new mom


Answer: c)Non-responsive to the infant crying

Which complication is most likely responsible for a late postpartum hemorrhage?

Which complication is most likely responsible for a late postpartum hemorrhage?

a) Cervical laceration
b) Uterine subinvolution
c) Perineal laceration
d) Clotting deficiency


Answer: b)Uterine subinvolution

One of the primary assessments you, as a postpartum nurse, make every day is for postpartum hemorrhage. What do you assess the fundus for?

One of the primary assessments you, as a postpartum nurse, make every day is for postpartum hemorrhage. What do you assess the fundus for?

a) Consistency, location, and place
b) Content, lochia, place
c) Location, shape, and content
d) Consistency, shape, and location


Answer: d)Consistency, shape, and location

A postpartum woman is diagnosed as having endometritis. Which position would you expect to place her in based on this diagnosis?

A postpartum woman is diagnosed as having endometritis. Which position would you expect to place her in based on this diagnosis?

a) Trendelenburg.
b) On her left side.
c) Flat in bed.
d) Semi-Fowler's.


Answer: d)Semi-Fowler's.

A woman arrives at the office for her 4-week postpartum visit. Her uterus is still enlarged and soft, and lochial discharge is still present. Which of the following is the most likely nursing diagnosis for this patient?

A woman arrives at the office for her 4-week postpartum visit. Her uterus is still enlarged and soft, and lochial discharge is still present. Which of the following is the most likely nursing diagnosis for this patient?

a) Risk for fatigue related to chronic bleeding due to subinvolution
b) Risk for infection related to microorganism invasion of episiotomy
c) Risk for impaired breastfeeding related to development of mastitis
d) Ineffective peripheral tissue perfusion related to interference with circulation secondary to development of thrombophlebitis


Answer: a)Risk for fatigue related to chronic bleeding due to subinvolution

You are conducting discharge teaching with a postpartum woman. What would be an important instruction for this patient?

You are conducting discharge teaching with a postpartum woman. What would be an important instruction for this patient?

a) Call her caregiver if lochia moves from serosa to rubra.
b) Call her caregiver if lochia moves from rubra to serosa.
c) Call her caregiver if lochia moves from serosa to alba.
d) Call her caregiver if amount of lochia decreases.


Answer: a)Call her caregiver if lochia moves from serosa to rubra.

Which assessment on the third postpartal day would make you evaluate a woman as having uterine subinvolution?

Which assessment on the third postpartal day would make you evaluate a woman as having uterine subinvolution?

a) Her uterus is three finger widths under the umbilicus.
b) Her uterus is at the level of the umbilicus.
c) Her uterus is 2 cm above the symphysis pubis.
d) She experiences "pulling" pain while breastfeeding.


Answer: b)Her uterus is at the level of the umbilicus.

The nurse is caring for a patient within the first four hours of her cesarean birth. Which of the following nursing interventions would be appropriate to prevent thrombophlebitis?

The nurse is caring for a patient within the first four hours of her cesarean birth. Which of the following nursing interventions would be appropriate to prevent thrombophlebitis?

a) Roll a bath blanket or towel and place it firmly behind the knees
b) Assist client in performing leg exercises every two hours
c) Ambulate the client as soon as her vital signs are stable
d) Limit oral intake of fluids for the first 24 hours to prevent nausea


Answer: c)Ambulate the client as soon as her vital signs are stable

A woman is two weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101°F. She complains of abdominal pain and a "bad smell" to her lochia. The nurse recognizes that these symptoms are associated with which condition?

A woman is two weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101°F. She complains of abdominal pain and a "bad smell" to her lochia. The nurse recognizes that these symptoms are associated with which condition?

a) Endometritis
b) Episiotomy infection
c) Mastitis
d) Subinvolution


Answer: a)Endometritis

A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instructions in her discharge teaching?

A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instructions in her discharge teaching?

a) Shortness of breath is a common adverse effect of the medication
b) Wear knee-high stockings when possible
c) Avoid over-the-counter (OTC) salicylates
d) Avoid iron replacement therapy


Answer: c)Avoid over-the-counter (OTC) salicylates

It is discovered that a new mother has developed a puerperal infection. Which of the following is the most likely expected outcome that the nurse will identify for this patient related to this condition?

It is discovered that a new mother has developed a puerperal infection. Which of the following is the most likely expected outcome that the nurse will identify for this patient related to this condition?

a) Client's temperature remains below 100.4° F or 38° C orally
b) Fundus remains firm and midline with progressive descent
c) Lochia discharge amount is 6 inches or less on a perineal pad in 1 hour
d) Client maintains a urinary output greater than 30 mL per hour


Answer: a)Client's temperature remains below 100.4° F or 38° C orally

You administer methylergonovine (Methergine) 0.2 mg to a postpartal woman with uterine subinvolution. Which of the following assessments should you make prior to administering the medication?

You administer methylergonovine (Methergine) 0.2 mg to a postpartal woman with uterine subinvolution. Which of the following assessments should you make prior to administering the medication?

a) She can walk without experiencing dizziness.
b) Her blood pressure is below 140/90.
c) Her urine output is over 50 mL/h.
d) Her hematocrit level is over 45%.


Answer: b)Her blood pressure is below 140/90.

When diagnosed with a deep vein thrombosis, the nurse knows the patient will be treated with which medication?

When diagnosed with a deep vein thrombosis, the nurse knows the patient will be treated with which medication?

a) Non-steroidal inflammatory
b) Anticoagulants
c) Narcotic analgesics
d) Beta blockers


Answer: b)Anticoagulants

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism?

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism?

a) Group beta-hemolytic streptococci (GBS)
b) Streptococcus pyogenes
c) Staphylococcus aureus
d) Escherichia coli


Answer: c)Staphylococcus aureus

About 10 days following birth, a new mother visits her physician with localized symptoms of redness, swelling, warmth, and a hard inflamed vessel in one leg. The nurse should suspect which of the following conditions?

About 10 days following birth, a new mother visits her physician with localized symptoms of redness, swelling, warmth, and a hard inflamed vessel in one leg. The nurse should suspect which of the following conditions?

a) Subinvolution
b) Femoral thrombophlebitis
c) Mastitis
d) Uterine atony


Answer: b)Femoral thrombophlebitis

The nurse collects a urine specimen for culture from a postpartum woman with a suspected urinary tract infection. Which organism would the nurse most likely expect the culture to reveal?

The nurse collects a urine specimen for culture from a postpartum woman with a suspected urinary tract infection. Which organism would the nurse most likely expect the culture to reveal?

a) Escherichia coli
b) Staphylococcus aureus
c) Gardenerella vaginalis
d) Klebsiella pneumoniae


Answer: a)Escherichia coli

Which of the following is the most frequent reason for postpartum hemorrhage?

Which of the following is the most frequent reason for postpartum hemorrhage?

a) Endometritis.
b) Uterine atony.
c) Perineal lacerations.
d) Disseminated intravascular coagulation.


Answer: b)Uterine atony.

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which of the following conditions?

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which of the following conditions? 

a) Postpartum panic disorder
b) Postpartum depression
c) Postpartum psychosis
d) Postpartum blues


Answer: c)Postpartum psychosis

You are caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would you need to assess before the woman ambulates?

You are caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would you need to assess before the woman ambulates?

a) Height, level of orientation, support systems
b) Attachment, lochia color, complete blood cell count
c) Blood pressure, pulse, complaints of dizziness
d) Degree of responsiveness, respiratory rate, fundus location


Answer: c)Blood pressure, pulse, complaints of dizziness

Mrs. M. and her infant are being discharged home after an unplanned cesarean delivery. You explain to her that she is at a higher risk for postpartum infection than most patients. What is the major risk factor for a postpartum infection?

Mrs. M. and her infant are being discharged home after an unplanned cesarean delivery. You explain to her that she is at a higher risk for postpartum infection than most patients. What is the major risk factor for a postpartum infection?

a) Labor more than 12 hours long.
b) Labor less than 12 hours long.
c) A nonelective cesarean birth.
d) A planned cesarean birth.


Answer: c)A nonelective cesarean birth.

You are the nurse giving an educational presentation to the local Le Leche league chapter. One woman asks you about mastitis. What would be your best response?

You are the nurse giving an educational presentation to the local Le Leche league chapter. One woman asks you about mastitis. What would be your best response?

a) Risk factors include frequent feeding.
b) Risk factors include complete emptying of the breast
c) Risk factors include nipple piercing.
d) Risk factors include breast pumps.


Answer: c)Risk factors include nipple piercing.

An Rh-positive client vaginally delivers a 6-lb, 10-oz neonate after 17 hours of labor. Which condition puts this client at risk for infection?

An Rh-positive client vaginally delivers a 6-lb, 10-oz neonate after 17 hours of labor. Which condition puts this client at risk for infection?

a) Method of delivery
b) Length of labor
c) Size of the neonate
d) Maternal Rh status


Answer: b)Length of labor

A postpartal woman with a thrombophlebitis tells you that her leg is very painful. Which of the following actions would be most appropriate to relieve this pain?

A postpartal woman with a thrombophlebitis tells you that her leg is very painful. Which of the following actions would be most appropriate to relieve this pain?

a) Urge her to walk to relieve muscle spasm.
b) Apply ice to her leg above the knee.
c) Massage the calf of her leg.
d) Keep covers off the leg.


Answer: d)Keep covers off the leg.

A fundal massage is sometimes performed on a postpartum woman. Which of the following is a reason for performing a fundal massage?

A fundal massage is sometimes performed on a postpartum woman. Which of the following is a reason for performing a fundal massage?

a) Uterine atony
b) Uterine contraction
c) Uterine prolapse
d) Uterine subinvolution



Answer: a)Uterine atony

Over 75% of women who give birth experience postpartum depression.

Over 75% of women who give birth experience postpartum depression.

a) True
b) False


Answer: b)False

When providing care for a postpartum patient at a 6 week check-up, which behavior would alert the nurse the patient may have postpartum psychosis?

When providing care for a postpartum patient at a 6 week check-up, which behavior would alert the nurse the patient may have postpartum psychosis?

a) Tearful during appointment
b) Talkative and asking questions
c) Restless and agitated, concerned with self
d) States being tired and happy at same time


Answer: c)Restless and agitated, concerned with self

Which of the following would lead the nurse to suspect that a postpartum woman has developed metritis? Select all that apply.

Which of the following would lead the nurse to suspect that a postpartum woman has developed metritis? Select all that apply.

a) Hematuria
b) Leukocytosis
c) Foul-smelling lochia
d) Pain on both sides of the abdomen
e) Flank pain

Answer:

b)• Leukocytosis
c)• Foul-smelling lochia
d)• Pain on both sides of the abdomen

Two weeks after their baby is born, Tom calls to report that his wife Sylvia is behaving strangely. She is extremely talkative and energetic and he has not observed her sleeping for more than an hour or two at a time. She is also forgetting to eat and neglecting her appearance, but worse, she seems to barely be aware of the baby's needs and appears surprised when Tom asks her about the child, "As if," Tom says, "she's forgotten that we even have a baby!" You tell him to bring her in right away, because you suspect Sylvia is suffering from what condition?

Two weeks after their baby is born, Tom calls to report that his wife Sylvia is behaving strangely. She is extremely talkative and energetic and he has not observed her sleeping for more than an hour or two at a time. She is also forgetting to eat and neglecting her appearance, but worse, she seems to barely be aware of the baby's needs and appears surprised when Tom asks her about the child, "As if," Tom says, "she's forgotten that we even have a baby!" You tell him to bring her in right away, because you suspect Sylvia is suffering from what condition?

a) Postpartum blues
b) Maladjustment
c) Postpartum psychosis
d) Postpartum depression


Answer: c)Postpartum psychosis

A nurse is assigned to care for a client with deep vein thrombosis who has to undergo anticoagulation therapy. Which of the following instructions should the nurse offer the client as a caution when the client receives anticoagulation therapy?

A nurse is assigned to care for a client with deep vein thrombosis who has to undergo anticoagulation therapy. Which of the following instructions should the nurse offer the client as a caution when the client receives anticoagulation therapy?

a) Sit with legs crossed over each other
b) Refrain from performing any leg exercises
c) Avoid products containing aspirin
d) Avoid prolonged straining during defecation


Answer: c)Avoid products containing aspirin

A nurse discovers a perineal hematoma in a woman who has recently given birth. Which of the following interventions should the nurse make in this case? (Select all that apply.)

A nurse discovers a perineal hematoma in a woman who has recently given birth. Which of the following interventions should the nurse make in this case? (Select all that apply.)

a) Perform fundal massage
b) Administer methotrexate
c) Estimate the size of the hematoma and report it
d) Apply an ice pack to the site
e) Administer an antibiotic
f) Administer a mild analgesic as prescribed


Answer:


f)• Administer a mild analgesic as prescribed
d)• Apply an ice pack to the site
c)• Estimate the size of the hematoma and report it

Which recommendation should be given to a client with mastitis who's concerned about breast-feeding her neonate?

Which recommendation should be given to a client with mastitis who's concerned about breast-feeding her neonate?

a) She should continue to breast-feed; mastitis won't infect the neonate
b) She should supplement feeding with formula until the infection resolves
c) She should stop breast-feeding until completing the antibiotic
d) She shouldn't use analgesics because they aren't compatible with breastfeeding


Answer: a)She should continue to breast-feed; mastitis won't infect the neonate

Which of the following instructions should the nurse offer a client as primary preventive measures to prevent mastitis?

Which of the following instructions should the nurse offer a client as primary preventive measures to prevent mastitis?

a) Avoid massaging the breast area
b) Apply cold compresses to the breast
c) Avoid frequent breastfeeding
d) Perform handwashing before breastfeeding


Answer: d)Perform handwashing before breastfeeding

Which of the following behaviors exhibited by a 4-hour postpartum woman requires further interventions by the nurse?

Which of the following behaviors exhibited by a 4-hour postpartum woman requires further interventions by the nurse?

a) Returns her son to the nursery because of fatigue.
b) Absent verbalization about the birthing process.
c) Cuddles her son close to her while feeding.
d) Tells visitors about her son and the labor.


Answer: b)Absent verbalization about the birthing process.

A client has had a cesarean birth. Which of the following amounts of blood loss would the nurse document as a postpartum hemorrhage in this client?

A client has had a cesarean birth. Which of the following amounts of blood loss would the nurse document as a postpartum hemorrhage in this client?

a) 250 ml.
b) 750 ml.
c) 500 ml.
d) 1000 ml.


Answer: d)1000 ml

When assessing a postpartum patient who was diagnosed with a cervical laceration which has been repaired, what sign should the nurse report as a possible development of hypovolemic shock?

When assessing a postpartum patient who was diagnosed with a cervical laceration which has been repaired, what sign should the nurse report as a possible development of hypovolemic shock?

a) Decreased respiratory rate
b) Warm and flushed skin
c) Elevated blood pressure
d) Weak and rapid pulse


Answer: b)Weak and rapid pulse

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first?

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first?

a) Assess the woman's fundus.
b) Begin an IV infusion of Ringer's lactate solution.
c) Call the woman's health care provider.
d) Assess the woman's vital signs.


Answer: a)Assess the woman's fundus.

A woman recovering from cesarean birth in the hospital and who was catheterized complains of a feeling of burning on urination and a feeling of frequency. Which of the following should be the next nursing action?

A woman recovering from cesarean birth in the hospital and who was catheterized complains of a feeling of burning on urination and a feeling of frequency. Which of the following should be the next nursing action?

a) Obtain a clean-catch urine specimen
b) Administer amoxicillin, as prescribed
c) Encourage her to drink large amounts of fluid
d) Suggest that she take an oral analgesic


Answer: a)Obtain a clean-catch urine specimen

Jerry, who is hypertensive and who received corticosteroids during pregnancy, delivered by cesarean and subsequently developed endometritis. Her incision is red, warm, and very sensitive to touch, and she remains febrile despite antibiotic therapy. What is the most important aspect of post hospital care to teach her?

Jerry, who is hypertensive and who received corticosteroids during pregnancy, delivered by cesarean and subsequently developed endometritis. Her incision is red, warm, and very sensitive to touch, and she remains febrile despite antibiotic therapy. What is the most important aspect of post hospital care to teach her?

a) Proper perineal care
b) Wound care and hand washing
c) Use of warm compresses and sitz baths
d) Strict adherence to antibiotic therapy


Answer: b)Wound care and hand washing

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage?

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage?

a) Moderate amount of lochia rubra
b) Uterine atony
c) Thrombophlebitis
d) Hemoglobin level of 12 g/dl


Answer: b)Uterine atony

In which time period would the nurse most likely expect a client who has delivered twins to experience late postpartum hemorrhage?

In which time period would the nurse most likely expect a client who has delivered twins to experience late postpartum hemorrhage?

a) 24 to 48 hours after delivery
b) 6 weeks to 3 months after delivery
c) 24 hours to 6 weeks after delivery
d) 6 weeks to 6 months after delivery


Answer: c)24 hours to 6 weeks after delivery

When assessing the patient for postpartum hemorrhage the nurse monitors which of the following every hour?

When assessing the patient for postpartum hemorrhage the nurse monitors which of the following every hour?

a) Vital signs
b) Complete blood count
c) Urine volume excreted
d) Pad count


Answer: d)Pad count

A nurse is assessing vital signs for a postpartum patient 48 hours after delivery. The vital signs are: T 101.2°F; HR 82; RR 18; BP 125/78. How will the nurse interpret the vital signs?

A nurse is assessing vital signs for a postpartum patient 48 hours after delivery. The vital signs are: T 101.2°F; HR 82; RR 18; BP 125/78. How will the nurse interpret the vital signs?

a) Shock
b) Normal vital signs
c) Infection
d) Dehydration


Answer: c)Infection

The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching?

The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching?

a) Symptoms include fever, chills, malaise, and localized breast tenderness
b) The most common pathogen is group A beta-hemolytic streptococci
c) Mastitis usually develops in both breasts of a breast-feeding client
d) A breast abscess is a common complication of mastitis


Answer: a)Symptoms include fever, chills, malaise, and localized breast tenderness

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts?

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts?

a) Applying warm compresses
b) Administering bromocriptine (Parlodel)
c) Restricting fluids
d) Applying ice


Answer: d)Applying ice

When monitoring a postpartum client 2 hours after delivery, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially?

When monitoring a postpartum client 2 hours after delivery, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially?

a) Administering ergonovine (Ergotrate)
b) Massaging the fundus firmly
c) Notifying the primary health care provider
d) Performing bimanual compressions


Answer: b)Massaging the fundus firmly

Which situation should concern the nurse treating a postpartum client within a few days of delivery?

Which situation should concern the nurse treating a postpartum client within a few days of delivery?

a) The client would like to watch the nurse give the baby her first bath
b) The client feels empty since she delivered the neonate
c) The client would like the nurse to take her baby to the nursery so she can sleep
d) The client is nervous about taking the baby home


Answer: b)The client feels empty since she delivered the neonate

A postpartal woman is developing a thrombophlebitis in her right leg. Which of the following assessments would you make to detect this?

A postpartal woman is developing a thrombophlebitis in her right leg. Which of the following assessments would you make to detect this?

a) Ask her to raise her foot and draw a circle.
b) Dorsiflex her right foot and ask if she has pain in her calf.
c) Bend her knee and palpate her calf for pain.
d) Blanch a toe and count the seconds it takes to color again.


Answer: b)Dorsiflex her right foot and ask if she has pain in her calf.

A postpartal woman calls you into her room because she is having a very heavy lochia flow containing large clots. Your first action would be to

A postpartal woman calls you into her room because she is having a very heavy lochia flow containing large clots. Your first action would be to

a) Assess her blood pressure.
b) Palpate her fundus.
c) Have her turn to her left side.
d) Assess her perineum.


Answer: b)Palpate her fundus.

The nurse is assessing the breast of a woman who is 1 month postpartum. The woman is complaining of a painful area on one breast with a red area. The nurse notes a local area on one breast, red and warm to touch. Which of the following should the nurse suspect is the potential diagnosis?

The nurse is assessing the breast of a woman who is 1 month postpartum. The woman is complaining of a painful area on one breast with a red area. The nurse notes a local area on one breast, red and warm to touch. Which of the following should the nurse suspect is the potential diagnosis?

a) Mastitis
b) Engorgement
c) Plugged milk duct
d) Breast yeast


Answer: a)Mastitis

On the third day postpartum, which temperature is internationally defined as a postpartal infection?

On the third day postpartum, which temperature is internationally defined as a postpartal infection?

a) 99.6°F (37.5°C)
b) 100.4°F (38°C)
c) 102.4°F (39.1°C)
d) 104.2°F (40.1°C)


Answer: b)100.4°F (38°C)

A nurse is assigned to care for a client with a uterine prolapse. Which of the following would be most important for the nurse to assess when determining the severity of the prolapse?

A nurse is assigned to care for a client with a uterine prolapse. Which of the following would be most important for the nurse to assess when determining the severity of the prolapse?

a) Uterine bleeding present
b) Foul smelling lochia
c) Pain in the lower abdomen
d) Uterine protrusion into the vagina


Answer: a)Uterine protrusion into the vagina

Which of the following would the nurse use to monitor the effectiveness of intravenous anticoagulant therapy for a postpartum woman with deep vein thrombosis?

Which of the following would the nurse use to monitor the effectiveness of intravenous anticoagulant therapy for a postpartum woman with deep vein thrombosis?

a) Activated partial thromboplastin time
b) Prothrombin time
c) Platelet level
d) Fibrinogen level


Answer: a)Activated partial thromboplastin time

Which of the following assessments would lead you to believe a postpartal woman is developing a urinary complication?

Which of the following assessments would lead you to believe a postpartal woman is developing a urinary complication?

a) Her perineum is obviously edematous on inspection.
b) At 8 hours post delivery she has voided a total of 100 mL in four small voidings.
c) She has voided a total of 1000 mL in two voidings, each spaced 1 hour apart.
d) She tells you she is extremely thirsty.


Answer: b) At 8 hours post delivery she has voided a total of 100 mL in four small voidings.

The nurse caring for a toddler immediately after a fall from a grocery cart will avoid moving which body area as the child is examined?

The nurse caring for a toddler immediately after a fall from a grocery cart will avoid moving which body area as the child is examined?

a) Clavicle
b) Head and neck
c) Lower extremities
d) Torso


Answer: b)Head and neck

Muscular dystrophy is a result of which cause?

Muscular dystrophy is a result of which cause?

a) Gene mutation
b) Chromosomal aberration
c) Genetic and environmental factors
d) Unknown nongenetic origin


Answer: a)Gene mutation

A child is to undergo testing for suspected muscular dystrophy and is scheduled for the following tests. Which test would the nurse identify as most important to be completed first?

A child is to undergo testing for suspected muscular dystrophy and is scheduled for the following tests. Which test would the nurse identify as most important to be completed first?

a) Electromyogram
b) Nerve conduction velocity
c) Muscle biopsy
d) Creatine kinase


Answer: d)Creatine kinase

Which statement about cerebral palsy would be accurate?

Which statement about cerebral palsy would be accurate?

a) "Cerebral palsy is a condition that doesn't get worse."
b) "Cerebral palsy means there will be many disabilities."
c) "Cerebral palsy is a condition that runs in families."
d) "Cerebral palsy occurs because of too much oxygen to the brain."


Answer: a)"Cerebral palsy is a condition that doesn't get worse."

When a child is suspected of having muscular dystrophy, a nurse should expect which muscles to be affected first?

When a child is suspected of having muscular dystrophy, a nurse should expect which muscles to be affected first?

a) Muscles of the foot
b) Muscles of the hip
c) Muscles of respiration
d) Muscles of the hand


Answer: b)Muscles of the hip

The nurse is teaching the parents of a female child with a myelomeningocele how to perform clean intermittent catheterization. The nurse determines that the teaching was effective when the parents return demonstrate the procedure and state which of the following?

The nurse is teaching the parents of a female child with a myelomeningocele how to perform clean intermittent catheterization. The nurse determines that the teaching was effective when the parents return demonstrate the procedure and state which of the following?

a) "Before inserting the catheter, we need to wipe her labia with normal saline from back to front."
b) "We need to apply some petroleum jelly to her labia and the catheter before we attempt to insert it."
c) "When the urine stops flowing, we should press on the lower belly to ensure the bladder is empty."
d) "We need to insert the catheter about 6 inches so that we make sure the catheter is in the bladder."


Answer: c)+"When the urine stops flowing, we should press on the lower belly to ensure the bladder is empty."

The child with a surgically repaired myelomeningocele has a neurogenic bladder. How will the nurse best explain this problem to the parents?

The child with a surgically repaired myelomeningocele has a neurogenic bladder. How will the nurse best explain this problem to the parents?

a) "Old urine remains in the bladder because of poor emptying or overfilling, putting your child at risk for urinary tract infection."
b) "Your child dribbles urine because the bladder either is overactive, pushing urine out, or is not active enough, becoming overfilled and causing urine to leak."
c) "While your child is young, urine leaking from the bladder will not be a problem because diapering is expected."
d) "Your child cannot properly control holding urine or emptying the bladder. "


Answer: a)"Old urine remains in the bladder because of poor emptying or overfilling, putting your child at risk for urinary tract infection."

The nurse is caring for an infant with a myelomeningocele who has paralysis of the lower extremities. Which action would be most appropriate to help reduce friction resulting from this paralysis?

The nurse is caring for an infant with a myelomeningocele who has paralysis of the lower extremities. Which action would be most appropriate to help reduce friction resulting from this paralysis?

a) Place a folded diaper in between the legs.
b) Place synthetic sheepskin under the infant's chest.
c) Place a pad beneath the diaper area and change frequently.
d) Place the child on a special care mattress.


Answer: a)Place a folded diaper in between the legs.

Women attending a health and wellness event ask the presenting nurse what is meant by "neural tube defect." Which is the accurate response?

Women attending a health and wellness event ask the presenting nurse what is meant by "neural tube defect." Which is the accurate response?

a) "Neural tube defect refers to abnormal development of the brain and spinal cord in the embryo."
b) "Neural tube defect refers to improper development of the digestive system in the fetus."
c) "Neural tube defect refers to abnormal development of the genitourinary system in the embryo."
d) "Neural tube defect refers to abnormal development of the brain and spinal cord in the fetus."


Answer: a)"Neural tube defect refers to abnormal development of the brain and spinal cord in the embryo."

A nurse is developing a teaching plan for the parents of a child with myasthenia gravis. Which of the following would the nurse include?

A nurse is developing a teaching plan for the parents of a child with myasthenia gravis. Which of the following would the nurse include?

a) Establishment of plans for rest periods
b) How to administer anticholinergic drugs
c) Signs and symptoms of infection
d) Ways to increase the temperature of the child's environment
e) Stress management techniques


Answer:

b)How to administer anticholinergic drugs
a)Establishment of plans for rest periods
c)Signs and symptoms of infection
e)Stress management techniques

The nurse is caring for an 8-month-old boy presenting with poor feeding, listlessness, and a weak cry. What assessment finding would lead the nurse to suspect a diagnosis of botulism?

The nurse is caring for an 8-month-old boy presenting with poor feeding, listlessness, and a weak cry. What assessment finding would lead the nurse to suspect a diagnosis of botulism?

a) Floppy extremities
b) Diminished gag reflex
c) Drooping eyelids
d) Inadequate sucking


Answer: b)Diminished gag reflex

A young child with Duchenne muscular dystrophy is placed on both prednisone and calcium. Parents view these two medications as rather "common" and question their importance for the child. What explanation by the nurse will be most helpful to the parents?

A young child with Duchenne muscular dystrophy is placed on both prednisone and calcium. Parents view these two medications as rather "common" and question their importance for the child. What explanation by the nurse will be most helpful to the parents?

a) "Prednisone will stimulate weight gain and appetite. Calcium is needed to ensure adequate supplies for the development of permanent teeth."
b) "Prednisone helps to keep muscle fibers strong and delays progression of the disease. Calcium protects against osteoporosis caused by both prednisone and lack of weight bearing."
c) "Prednisone will help protect his vulnerable respiratory tract from developing reactive airway disease. Calcium is needed to guard against muscle cramping."
d) "Prednisone will protect against nerve inflammation in his hips and legs. Calcium is necessary should dietary intake be insufficient to meet growth needs."


Answer: b)"Prednisone helps to keep muscle fibers strong and delays progression of the disease. Calcium protects against osteoporosis caused by both prednisone and lack of weight bearing."

What methods can a nurse use to evaluate extremity function in an 18-month-old? Select all that apply.

What methods can a nurse use to evaluate extremity function in an 18-month-old? Select all that apply.

a) Elicit from the parent a description of fine and gross motor activities.
b) Ask the child to squeeze the nurse's fingers simultaneously.
c) Have the child push against resistance with both feet.
d) Look for symmetric motion in the arms and legs.
e) Observe the child in developmentally appropriate play.



Answer:

e)Observe the child in developmentally appropriate play.
d)Look for symmetric motion in the arms and legs.
a)Elicit from the parent a description of fine and gross motor activities.

How would the nurse best describe Gowers' sign to the parents of a child with muscular dystrophy?

How would the nurse best describe Gowers' sign to the parents of a child with muscular dystrophy?

a) A waddling-type gait
b) The pelvis position during gait
c) Muscle twitching present during a quick stretch
d) A transfer technique


Answer: d)A transfer technique

A multidisciplinary team meeting is being called by the nurse to identify methods to reduce spasticity in a school-age child with cerebral palsy. Input from which discipline will not be needed at this gathering?

A multidisciplinary team meeting is being called by the nurse to identify methods to reduce spasticity in a school-age child with cerebral palsy. Input from which discipline will not be needed at this gathering?

a) Dietary
b) Surgery
c) Pharmacy
d) Orthotics


Answer: a)Dietary

A nurse is teaching the parents of a child who has been diagnosed with spina bifida. Which statement by the nurse would be the most accurate description of spina bifida?

A nurse is teaching the parents of a child who has been diagnosed with spina bifida. Which statement by the nurse would be the most accurate description of spina bifida?

a) "Its presence indicates that many areas of the central nervous system (CNS) may not develop or function adequately."
b) "It has little influence on the intellectual and perceptual abilities of the child."
c) "It's a complex neurologic disability that involves a collaborative health team effort for the entire first year of life."
d) "It's a simple neurologic defect that's completely corrected surgically within 1 to 2 days after birth."


Answer: a)"Its presence indicates that many areas of the central nervous system (CNS) may not develop or function adequately."

After teaching a group of students about medications commonly used for neuromuscular disorders, the nursing instructor determines that the teaching was successful when the students identify which agent as a centrally acting skeletal muscle relaxant?

After teaching a group of students about medications commonly used for neuromuscular disorders, the nursing instructor determines that the teaching was successful when the students identify which agent as a centrally acting skeletal muscle relaxant?

a) Baclofen
b) Botulin toxin
c) Lorazepam
d) Prednisone


Answer: a)Baclofen

Parents of a preschooler with cerebral palsy ask the nurse what the surgeon plans to implant in their child's body to control spasticity. What is the nurse's answer?

Parents of a preschooler with cerebral palsy ask the nurse what the surgeon plans to implant in their child's body to control spasticity. What is the nurse's answer?

a) Vagal nerve stimulator
b) Baclofen pump
c) Botulinum toxin
d) Central venous catheter


Answer: b)Baclofen pump

Which characteristic is true of cerebral palsy?

Which characteristic is true of cerebral palsy?

a) It's progressive.
b) It appears at birth or during the first 2 years of life.
c) It's reversible.
d) It results in mental retardation.


Answer: b)It appears at birth or during the first 2 years of life.

A child with cerebral palsy is referred for physical therapy. When describing the rationale for this therapy, the nurse would emphasize which of the following as the primary goal?

A child with cerebral palsy is referred for physical therapy. When describing the rationale for this therapy, the nurse would emphasize which of the following as the primary goal?

a) Development of gross motor movement
b) Enhance feeding capabilities
c) Development of fine motor skills
d) Promote optimal self-care ability


Answer: a)Development of gross motor movement

Which diagnostic measure is most accurate in detecting neural tube defects?

Which diagnostic measure is most accurate in detecting neural tube defects?

a) Presence of high maternal levels of albumin after 12th week of gestation
b) Significant level of alpha-fetoprotein present in amniotic fluid
c) Amniocentesis for lecithin-sphingomyelin (L/S) ratio
d) Flat plate of the lower abdomen after the 23rd week of gestation


Answer: b)Significant level of alpha-fetoprotein present in amniotic fluid

The nurse is assessing a child with spina bifida occulta. During the assessment, the parents say, "It's going to be so difficult taking care of our child. He'll never be able to walk." The nurse identifies which nursing diagnosis as the priority?

The nurse is assessing a child with spina bifida occulta. During the assessment, the parents say, "It's going to be so difficult taking care of our child. He'll never be able to walk." The nurse identifies which nursing diagnosis as the priority?

a) Impaired physical mobility related to spinal cord defect
b) Risk for injury related to lack of muscle control
c) Ineffective coping related to diagnosis of chronic condition
d) Deficient knowledge related to diagnosis and condition


Answer: d)Deficient knowledge related to diagnosis and condition

A nurse is preparing a presentation for a health fair focusing on prevention of congenital neuromuscular disorders. Which of the following would the nurse emphasize as most important in preventing neural tube defects?

A nurse is preparing a presentation for a health fair focusing on prevention of congenital neuromuscular disorders. Which of the following would the nurse emphasize as most important in preventing neural tube defects?

a) Maternal serum a-fetoprotein levels screening
b) Ultrasound screening at 16 weeks' gestation
c) Folic acid supplementation
d) Genetic testing for gene identification


Answer: c)Folic acid supplementation

The nurse is caring for a 10-year-old girl with myasthenia gravis. The nurse suspects myasthenic crisis based on which of the following?

The nurse is caring for a 10-year-old girl with myasthenia gravis. The nurse suspects myasthenic crisis based on which of the following?

a) Bradycardia
b) Tachycardia
c) Increased salivation
d) Sweating


Answer: b)Tachycardia

Which nursing diagnosis will the nurse prepare for the infant who is placed prone to protect the myelomeningocele repair site?

Which nursing diagnosis will the nurse prepare for the infant who is placed prone to protect the myelomeningocele repair site?

a) Disorganized infant behavior
b) Risk for impaired skin integrity
c) Peripheral neurovascular dysfunction
d) Risk for activity intolerance


Answer: b)Risk for impaired skin integrity

The nurse is caring for a 2-year-old boy with cerebral palsy (CP). The medical record indicates "hypertonicity and permanent contractures affecting both extremities on one side." Based on these findings, the nurse identifies this type of CP as which of the following?

The nurse is caring for a 2-year-old boy with cerebral palsy (CP). The medical record indicates "hypertonicity and permanent contractures affecting both extremities on one side." Based on these findings, the nurse identifies this type of CP as which of the following?

a) Athetoid or dyskinetic
b) Ataxic
c) Spastic diplegia
d) Spastic hemiplegia


Answer: d)Spastic hemiplegia

The nurse is caring for a newborn with facial nerve palsy from birth trauma. The mother is very upset and concerned about the child's prognosis. Which response by the nurse would be most appropriate?

The nurse is caring for a newborn with facial nerve palsy from birth trauma. The mother is very upset and concerned about the child's prognosis. Which response by the nurse would be most appropriate?

a) "Have you seen any signs of improvement?"
b) "This is the most common facial nerve palsy."
c) "In most cases treatment is not necessary, only observation."
d) "Was this from pressure resulting from forceps?"


Answer: c)"In most cases treatment is not necessary, only observation."

What reflex response will the nurse consider abnormal when assessing the 8-month-old infant?

What reflex response will the nurse consider abnormal when assessing the 8-month-old infant?

a) Plantar grasp
b) Babinski
c) Parachute
d) Brisk deep tendon


Answer: d)Brisk deep tendon

Which of the following strategies would be the first choice in attempting to maximize function in a child with muscular dystrophy?

Which of the following strategies would be the first choice in attempting to maximize function in a child with muscular dystrophy?

a) Motorized wheelchair
b) Manual wheelchair
c) Long leg braces
d) Walker


Answer: c)Long leg braces

Which condition would alert the nurse that a child may be suffering from muscular dystrophy?

Which condition would alert the nurse that a child may be suffering from muscular dystrophy?

a) Upper extremity spasticity
b) Hypertonia of extremities
c) Hyperactive lower extremity reflexes
d) Increased lumbar lordosis


Answer: d)Increased lumbar lordosis

The nurse caring for a client diagnosed with muscular dystrophy would expect which laboratory values to be most abnormal?

The nurse caring for a client diagnosed with muscular dystrophy would expect which laboratory values to be most abnormal?

a) Serum potassium
b) Sodium
c) Bilirubin
d) Creatinine


Answer: d)Creatinine

The nurse will prepare the 17-year-old with myasthenia gravis for which surgical procedure to treat the disorder?

The nurse will prepare the 17-year-old with myasthenia gravis for which surgical procedure to treat the disorder?

a) Thymectomy
b) Thyroidectomy
c) Splenectomy
d) Cholecystectomy


Answer: a)Thymectomy

Why does the nurse suspect cerebral palsy in the 8-month-old just assessed?

Why does the nurse suspect cerebral palsy in the 8-month-old just assessed?

a) The baby drools almost constantly.
b) The child does not crawl.
c) When startled, a strong Moro reflex is noted.
d) The child sits independently with a straight back.


Answer: c)When startled, a strong Moro reflex is noted.

The mother of a 3-year-old with a myelomeningocele is thinking about having another baby. The nurse should inform the woman that she should increase her intake of which acid?

The mother of a 3-year-old with a myelomeningocele is thinking about having another baby. The nurse should inform the woman that she should increase her intake of which acid?

a) Folic acid to 0.4 mg/day
b) Ascorbic acid to 4 mg/day
c) Folic acid above 0.4 mg/day
d) Ascorbic acid to 0.4 mg/day


Answer: c)Folic acid above 0.4 mg/day

The nurse is assessing a child with spastic cerebral palsy. Which of the following would the nurse expect to assess? Select all that apply.

The nurse is assessing a child with spastic cerebral palsy. Which of the following would the nurse expect to assess? Select all that apply.

a) Poor control of balance
b) Hemiplegia
c) Drooling
d) Hypertonicity
e) Exaggerated deep tendon reflexes
f) Dysarthria


Answer:


e)Exaggerated deep tendon reflexes
b)Hemiplegia
a)Poor control of balance
d)Hypertonicity

A nurse is caring for an infant with spinal muscle atrophy (SMA) type 1. What will the nurse note when assessing the child?

A nurse is caring for an infant with spinal muscle atrophy (SMA) type 1. What will the nurse note when assessing the child?

a) Enlarged head with low-set ears
b) Narrow chest and protuberant abdomen
c) Spastic upper and lower extremities
d) Lusty cry with voracious appetite


Answer: b)Narrow chest and protuberant abdomen

The nurse is caring for a 6-year-old boy with myelomeningocele. The nurse is teaching the mother how to promote appropriate bowel elimination and avoid constipation. Which response from the mother indicates a need for further teaching?

The nurse is caring for a 6-year-old boy with myelomeningocele. The nurse is teaching the mother how to promote appropriate bowel elimination and avoid constipation. Which response from the mother indicates a need for further teaching?

a) "He must have an adequate amount of fluid."
b) "I need to figure out his usual pattern for passing stool."
c) "I can palpate his abdomen to assess for constipation"
d) "My son's activity is too limited to stimulate his bowels."


Answer: d)"My son's activity is too limited to stimulate his bowels."

Which type of spinal neural tube defect does the nurse recognize as common and usually benign?

Which type of spinal neural tube defect does the nurse recognize as common and usually benign?

a) Myelomeningocele
b) Spina bifida
c) Meningocele
d) Spina bifida occulta


Answer: d)Spina bifida occulta

Other than providing direct care to children, what is the major role of nurses in the care of nearly all children with neuromuscular disorders?

Other than providing direct care to children, what is the major role of nurses in the care of nearly all children with neuromuscular disorders?

a) Consoling parents
b) Helping with specialized equipment
c) Coordinating care by specialists
d) Teaching children self-care


Answer: c)Coordinating care by specialists

Why will it be necessary for the nurse to be very supportive of parents' attempts to feed the infant with recently repaired myelomeningocele?

Why will it be necessary for the nurse to be very supportive of parents' attempts to feed the infant with recently repaired myelomeningocele?

a) Pain will interfere with the feeding process.
b) Nausea and vomiting often follow repair of the cystic mass.
c) Assuming the usual feeding position will be difficult.
d) The infant will have a poor sucking reflex.


Answer: c)Assuming the usual feeding position will be difficult.

A nurse is preparing a plan of care for an infant who has undergone surgery to repair a myelomeningocele. The nurse would include placing the infant in which position postoperatively?

A nurse is preparing a plan of care for an infant who has undergone surgery to repair a myelomeningocele. The nurse would include placing the infant in which position postoperatively? Select all that apply.

a) Left side lying
b) Supine
c) Semi-Fowler
d) Prone
e) Right side lying



Answer:

d)Prone
e)Right side lying
a)Left side lying

A nurse is conducting a physical examination of a 5-year-old boy with spinal muscular atrophy (SMA) type 2. What assessment findings would the nurse expect to find?

A nurse is conducting a physical examination of a 5-year-old boy with spinal muscular atrophy (SMA) type 2. What assessment findings would the nurse expect to find?

a) Loss of strength in ankle dorsiflexion
b) Pseudohypertrophy of the calves
c) Pectus excavatum
d) Loss of strength in hip extension


Answer: c)Pectus excavatum

A nurse is caring for a child with spina bifida. The child's mother asks the nurse what she did to cause the birth defect. Which statement would be the nurse's best response?

A nurse is caring for a child with spina bifida. The child's mother asks the nurse what she did to cause the birth defect. Which statement would be the nurse's best response?

a) "The cause is unknown and there are many environmental factors that may contribute to it."
b) "It's a common complication of amniocentesis."
c) "It has been linked to maternal alcohol consumption during pregnancy."
d) "Older age at conception is one of the major causes of the defect."


Answer: a)"The cause is unknown and there are many environmental factors that may contribute to it."

The nurse is caring for a 7-year-old with Guillain-Barré syndrome (GBS). Which of the following would be the most effective intervention to monitor for respiratory deterioration?

The nurse is caring for a 7-year-old with Guillain-Barré syndrome (GBS). Which of the following would be the most effective intervention to monitor for respiratory deterioration?

a) Pulse oximetry
b) Serial measurement of tidal volume
c) Ineffective cough
d) Diminished breath sounds


Answer: b)Serial measurement of tidal volume

The nurse is taking a health history of a 6-year-old girl with suspected dermatomyositis. During the physical examination, which of the following would help confirm the nurse's suspicions?

The nurse is taking a health history of a 6-year-old girl with suspected dermatomyositis. During the physical examination, which of the following would help confirm the nurse's suspicions?

a) Delayed capillary refill
b) Ptosis or altered eye movements
c) Red-purple rash on upper eyelids, knuckles, elbows, and knees
d) Tenting of skin


Answer: c)Red-purple rash on upper eyelids, knuckles, elbows, and knees

The nurse caring for a client with suspected muscular dystrophy would prepare her client for which diagnostic test?

The nurse caring for a client with suspected muscular dystrophy would prepare her client for which diagnostic test? 

a) Muscle biopsy
b) EEG
c) Assessment of ambulation
d) X-ray


Answer: a)Muscle biopsy

In caring for the child with Guillain-Barré syndrome, the nurse will provide much supportive care while watching carefully for signs of deterioration in which body system?

In caring for the child with Guillain-Barré syndrome, the nurse will provide much supportive care while watching carefully for signs of deterioration in which body system?

a) Urinary
b) Cardiovascular
c) Respiratory
d) Integumentary


Answer: c)Respiratory

Through which mechanism is Duchenne muscular dystrophy acquired?

Through which mechanism is Duchenne muscular dystrophy acquired?

a) Virus
b) Environmental toxins
c) Autoimmune factors
d) Heredity


Answer: d)Heredity

The nurse is caring for a child recently fitted with braces on both legs due to cerebral palsy (CP). Which of the following would the nurse emphasize in the discharge teaching?

The nurse is caring for a child recently fitted with braces on both legs due to cerebral palsy (CP). Which of the following would the nurse emphasize in the discharge teaching?

a) "It is very important to comply with the use of this brace."
b) "If the brace is painful, feel free to take it off."
c) "Check the skin that is covered by the braces for redness and breakdown."
d) "Please try and follow the therapist's on and off schedule."


Answer: c)"Check the skin that is covered by the braces for redness and breakdown."

A teenager has been admitted to the hospital with respiratory complications related to Duchenne muscular dystrophy. How can the nurse best provide support for the parents, who are the caretakers of this adolescent?

A teenager has been admitted to the hospital with respiratory complications related to Duchenne muscular dystrophy. How can the nurse best provide support for the parents, who are the caretakers of this adolescent?

a) Assume responsibility for the teen's daily care while accepting input from parents and the teen
b) Encourage the parents to assist their child with his activities of daily living while hospitalized
c) Teach the parents how to add chest physical therapy to the care they provide
d) Provide accommodations for both parents to room-in with their teen


Answer: a)Assume responsibility for the teen's daily care while accepting input from parents and the teen

The nurse caring for an infant with myelomeningocele before surgical intervention will prioritize care in what way?

The nurse caring for an infant with myelomeningocele before surgical intervention will prioritize care in what way?

a) Prevent cold stress using an Isolette and blankets
b) Cover the sac with a saline-moistened dressing
c) Change position from side to side hourly
d) Keep the mass uncovered and dry


Answer: b)Cover the sac with a saline-moistened dressing

The nurse receives a report on a child admitted with severe muscular dystrophy. The nurse suspects the child has been diagnosed with the most severe form of the disease, known as:

The nurse receives a report on a child admitted with severe muscular dystrophy. The nurse suspects the child has been diagnosed with the most severe form of the disease, known as:

a) facioscapulohumeral.
b) myotonia.
c) limb-girdle.
d) Duchenne's.


Answer: d)Duchenne's.

Which finding will cause the nurse to refer a 6-month-old child for further neuromuscular testing?

Which finding will cause the nurse to refer a 6-month-old child for further neuromuscular testing?

a) Head lag when pulled from supine to sitting
b) Bilaterally open rather than closed hands
c) Supporting own weight when placed in standing position
d) Equal withdrawal of lower extremities from pain


Answer: a)Head lag when pulled from supine to sitting

An infant has been born and diagnosed with a meningocele. Which action will the nurse incorporate into each contact with this infant?

An infant has been born and diagnosed with a meningocele. Which action will the nurse incorporate into each contact with this infant? 

a) Careful supine positioning
b) Listening for a shrill cry
c) Inspection of the cystic sac on the child's back for leakage
d) Auscultation for bowel sounds


Answer: c)Inspection of the cystic sac on the child's back for leakage

The pediatric nurse practitioner (PNP) records "positive Gowers' sign" after finishing the assessment of a young boy. How will the student nurse reading the PNP's note interpret this?

The pediatric nurse practitioner (PNP) records "positive Gowers' sign" after finishing the assessment of a young boy. How will the student nurse reading the PNP's note interpret this?

a) The head is held tilted with limited side-to-side motion.
b) The boy rises from the floor by walking his hands up his legs.
c) The boy has a large tan skin lesion on his torso.
d) Severe lordosis is evident in the lumbar spine.


Answer: b)The boy rises from the floor by walking his hands up his legs.

A client with muscular dystrophy has lost complete control of his lower extremities. He has some strength bilaterally in the upper extremities, but poor trunk control. Which mechanism would be the most important to have on the wheelchair?

A client with muscular dystrophy has lost complete control of his lower extremities. He has some strength bilaterally in the upper extremities, but poor trunk control. Which mechanism would be the most important to have on the wheelchair?

a) Wheelchair belt
b) Antitip device
c) Headrest support
d) Extended breaks


Answer: a)Wheelchair belt

A nurse who is discussing Duchenne muscular dystrophy characterizes it correctly using which descriptors?

A nurse who is discussing Duchenne muscular dystrophy characterizes it correctly using which descriptors?

a) Duchenne muscular dystrophy is a progressive disease of muscles and nerves that affects males and females equally.
b) Duchenne muscular dystrophy is diagnosed in boys who develop gait changes during the late school-age years.
c) Duchenne muscular dystrophy is a non progressive disorder that severely affects muscle function through spinal cord atrophy.
d) Duchenne muscular dystrophy causes progressive muscular weakness that ends in death.


Answer: d)Duchenne muscular dystrophy causes progressive muscular weakness that ends in death.

Which nursing diagnosis is most relevant in the first 12 hours of life for a neonate born with a myelomeningocele?

Which nursing diagnosis is most relevant in the first 12 hours of life for a neonate born with a myelomeningocele?

a) Impaired physical mobility
b) Constipation
c) Delayed growth and development
d) Risk for infection


Answer: d)Risk for infection

The nurse will teach parents of children with myelomeningocele to maintain an environment free of what element?

The nurse will teach parents of children with myelomeningocele to maintain an environment free of what element?

a) Latex
b) Cat dander
c) Peanuts
d) Alcohol ge


Answer: a)Latex

The young child has been diagnosed with Guillain-Barré syndrome and it is progressing in a classic manner. Rank the following sequence of events in the order that they typically occur.

The young child has been diagnosed with Guillain-Barré syndrome and it is progressing in a classic manner. Rank the following sequence of events in the order that they typically occur.

1. The child is having difficulty producing facial expressions.
2. The child reports numbness and tingling in his toes.
3. The child states that it is difficult to move his legs.
4. The child states that it is difficult to move his arms.



Answer:


2)The child reports numbness and tingling in his toes.
3)The child states that it is difficult to move his legs.
4)The child states that it is difficult to move his arms.
1)The child is having difficulty producing facial expressions.

Based on knowledge of the progression of muscular dystrophy, which activity would a nurse anticipate the client having difficulty with first?

Based on knowledge of the progression of muscular dystrophy, which activity would a nurse anticipate the client having difficulty with first?

a) Swallowing
b) Breathing
c) Sitting
d) Standing


Answer: d)Standing

What will be the nurse's next action after noting dimpling and a tuft of hair located in the lumbosacral area of the preschool child during examination?

What will be the nurse's next action after noting dimpling and a tuft of hair located in the lumbosacral area of the preschool child during examination?

a) Record and refer the finding for follow-up to the pediatrician
b) Move on to other assessments without calling attention to the difference
c) Snip the tuft of hair off close to the skin for hygienic reasons
d) Inspect for precocious hair growth in the genital and underarm areas


Answer: a)Record and refer the finding for follow-up to the pediatrician

The nurse is planning to teach the parents of a child with newly diagnosed muscular dystrophy about the disease. Which definition should she use to best describe this condition?

The nurse is planning to teach the parents of a child with newly diagnosed muscular dystrophy about the disease. Which definition should she use to best describe this condition?

a) Degeneration of muscle fibers
b) A demyelinating disease
c) Lesions of the brain cortex
d) Upper motor neuron lesions


Answer: a)Degeneration of muscle fibers

Given knowledge of muscular dystrophy, the nurse would expect to see which form of this condition most commonly in children?

Given knowledge of muscular dystrophy, the nurse would expect to see which form of this condition most commonly in children?

a) Limb-girdle
b) Becker's
c) Myotonic
d) Duchenne's


Answer: d)Duchenne's