1. A nurse suspects that the laboring client may have been physically abused by her partner. What is the most appropriate intervention by the nurse?

a. Confront the partner

b. Question the client in front of her partner

c. Contact hospital security to monitor the partner

d. Collaborate with the interprofessional team to make a referral to social services

d.

Collaborating with others in the health care team, and the provider to make a referral to social services will create a plan, and provide support for the client. Additionally, by law, the nurse or nursing supervisor must report the suspected abuse to the

2. Accompanied by her father, a primiparous 15-year-old client arrives for her first prenatal visit at 30 weeks’ gestation. Her father refuses to leave the room. He tells the nurse that the girl is shy, and that he will answer the questions for her. What should concern the nurse the most about this situation? 

a. The possibility of preterm labor with an adolescent pregnancy 

b. Lack of prenatal care until this visit 

c. Possible child abuse or domestic violence 

d. Difficulties of an overprotective parent in dealing with his daughter

c.

Generally, a father would be somewhat uncomfortable staying in a room while his pregnant daughter is examined. If he insists on staying during the history and physical examination, the nurse should gently but firmly ask him to wait in another room. If the nurse suspects possible child abuse or domestic violence, the father may not want the girl to be alone with the nurse, fearing that she might reveal the abuse or violence. The possibility of preterm labor and lack of prenatal care should be considered, but they are not the primary concerns in this situation. An overprotective parent can be supported and taught how to let go of a child as time goes by. Referral to a social worker may be warranted.

A 25-year-old primiparous client arrives for her first prenatal visit at 10 weeks’ gestation. She seems nervous and has many questions. What is the most important intervention by the nurse? 

a. Address the client’s concerns while taking a comprehensive history 

b. Ask the client to undress to prepare for the physical examination 

c. Reassure the client that all her questions will be answered during the visit. 

d. Tell the client there’s nothing to worry about. The health care provider will take good care of her.

c.

Providing initial reassurance helps set the client’s mind at ease. Assessing the client’s concerns while taking a history would be appropriate only if the client wrote down her questions in advance. Asking this client to immediately disrobe could make the client even more nervous. The client should be treated as a partner in her care rather than being told that her health care provider will take care of everything.

4. A nurse is discussing a healthy diet with a prima gravida client. The client states that she doesn’t consume much milk or other dairy, even though she knows they are important. What advice should the nurse give this client? 

a. .“ The prenatal vitamins that are recommended will satisfy all dietary requirements.” 

v. “ You could supplement your diet with 1,800 mg of over-the-counter calcium tablets.” 

c. “ You should consume other non-dairy foods that are high in calcium.” 

d. “ After the first trimester, calcium intake isn’t significant because all fetal organ structures are formed.”

c.

Milk and dairy aren’t the only sources of calcium. Other foods that are high in calcium are considered an ideal source the mineral. While prenatal vitamins are generally recommended, they don’t satisfy all nutrient requirements. The calcium requirement for a pregnant woman is 1,300 mg/ day. Over-the-counter supplements are not always safe, and should be specifically recommended by the health care practitioner. While it’s true that all fetal organs are formed by the end of the first trimester, body development continues throughout pregnancy.

5. Which nursing intervention is priority for a pregnant adolescent during her first trimester? 

a. Schedule the client for a screening glucose tolerance test 

b. Refer the client to a dietitian for nutritional counseling 

c. Tell the client that she will most likely need a cesarean birth due to the head size of the fetus 

d. Assess the client for signs and symptoms of placenta previa

b.

Adolescents are at risk for delivering low-birth-weight neonates. Nutritional counseling should be a priority for these clients to ensure proper fetal development. A pregnant adolescent is not likely to deliver a macrosomic neonate. The final head size of the fetus is unknown at this time. Adolescents are not at increased risk for developing gestational diabetes or placenta previa.

6. The nurse is planning prenatal classes for pregnant adolescents intending to keep their babies. Which teaching strategy would be most effective for the adolescents?

a. Inviting mothers and daughters for one-to-one teaching sessions 

b. Preparing group sessions for teaching the pregnant adolescents together 

c. Offering open sessions for the pregnant adolescents and anyone else who wants to attend 

d. Designing poster boards that may be viewed individually in the school nurse’s office 

b.

Peer groups are important for adolescents, so utilizing group teaching sessions is the most effective teaching strategy.  a. Inviting mothers and daughters for individual teaching sessions may be effective for teaching the adolescent mothers, but less effective for the pregnant adolescents. C. Prenatal teaching, especially the topic of body changes with pregnancy, could threaten the adolescent’s self-esteem and body image if it is discussed in open sessions where anyone could attend. D. Poster boards could be an effective strategy for young adults, but not adolescents.

7. The nurse conducts an admission interview of the hospitalized client. Which approach would best assess the client’s cultural needs? 

a. During introductions, address the cultural backgrounds of both the client and nurse. 

b. Ask with which specific culture the client identifies and if there are any cultural needs. 

c. Ask if the client needs any of the available culture specific services offered by the facility. 

d. Determine where the client lives and if the client has any social and religious affiliations.

b.

The best approach to identify an individual’s culture and cultural needs is to ask the person with an open-ended question that would allow the client to elaborate on the client’s culture and cultural needs.  a. The self-disclosure of the nurse is inappropriate and unnecessary. C. Asking the client if available culture-specific services are needed does not allow for open communication and can be a block to therapeutic communication because the client can answer with a yes or no response. D. Determining where the client lives and whether the client has any social or religious affiliations may not reflect the client’s cultural identification but rather the nurse’s interpretation. 

8. The nurse is using an interpreter when teaching the non–English-speaking Hispanic client. Which action by the nurse would be most inappropriate? 

a. Arrange the seating in a triangle. 

b. Keep statements and questions short. 

c. Maintain eye contact with the interpreter. 

d. Ask the client to explain back the information.

c.

The nurse should maintain eye contact with the client, not the interpreter.  a. Seating in a triangle would allow the nurse to look directly at the client while communicating but allow the client to see both the nurse and the interpreter. b. Short statements and questions will allow time for interpretation. d. Asking the client to explain back the information will help to ensure that the client understands what is being said.

9. The client of Hispanic ethnicity is newly diagnosed with type 2 DM. When creating a teaching plan for the client, which objective demonstrates culturally sensitive education? 

a. Discuss glycemic control of Hispanics 

b. Ensure that the client can perform glucose testing 

c. Discuss foods commonly eaten by Hispanics 

d. Teach about the complications of type 2 DM

 c.

The nurse demonstrates culturally sensitive education when including culturally appropriate foods within the Hispanic culture. Research shows that Hgb A1c, fasting plasma glucose, cholesterol/HDL ratio, and HDL improved after receiving culturally sensitive diabetes education.  a. Glycemic control is important, but only discussing the glycemic control of Hispanics can demonstrate cultural insensitivity.  b. Blood sugar testing is important but not related to cultural sensitivity. d. Learning about complications is important but not specifically related to cultural sensitivity.

10. The nurse is counseling the client who is trying to become pregnant. To promote fetal health when the client is unaware of a pregnancy, the nurse should stress the inclusion of which nutrient in daily food intake? 

a. Potassium 

b. Calcium 

c. Folic acid

d.  Sodium

c.

The nurse should educate the client about the need for adequate folic acid intake. Folic acid is important in preventing neural tube defects, especially during the first four weeks of fetal development.  a. Potassium is important in preventing leg cramps during pregnancy, but this is usually not an issue during the first four weeks of gestation. b. Calcium is important for fetal development of bones, teeth, heart, nerves, and muscles, but the fetus will take calcium from the mother. Calcium is more important to maternal health than fetal development. d. Sodium is important for maintaining optimal electrolyte balance but is typically ingested in more than adequate amounts in a typical diet.

11. The client, who is Chinese American and pregnant, is receiving nutritional counseling about the need for increased amounts of calcium in her diet. Which response by the nurse is most helpful when the client states she does not consume any dairy products? 

a. “Tell me how you perceive dairy products in your culture.” 

b. “Try having a glass of soy milk at each meal and at bedtime.” 

c. “Tell me about your intake of fortified tofu and leafy green vegetables.” 

d. “Rice milk fortified with calcium and nettle tea are good calcium choices.”

c.

Assessing the client’s intake of calcium-rich foods is the best response. Both fortified tofu and leafy green vegetables are high in calcium and are common foods consumed in the Chinese American diet.  a.  Although asking about the client’s perception of dairy products shows cultural sensitivity, the client has already stated she does not consume these. This statement is not the most helpful regarding helping the client to increase calcium intake in her diet.  b. The nurse is making a recommendation without further assessing the client’s dietary preferences. Soy milk should be calcium fortified; yet, according to research the calcium content can be as much as 85 percent less than the amount indicated on the product label. d. Both rice milk fortified with calcium and nettle tea are sources of calcium; however, the nurse is making an assumption that the client consumes these beverages.

12. The client tells the nurse, “Most days, I am so happy I am pregnant, but other days, I am not sure that I am ready to have a baby.” Which is the most accurate response from the nurse?

a. “This is such a happy time in your life. You need to be optimistic to feel happy.” 

b. “How does your spouse feel about the pregnancy? I hope he is happy about the baby.” 

c. “Feeling differently from day to day is normal. How do you feel today?” 

d. “Why do you feel this way? Is there something I can do to make it better for you?”

c.

It is most therapeutic to acknowledge the client’s feelings and probe for more information on her thoughts and feelings about the pregnancy. a. Not all clients consider pregnancy a happy time in their lives, and the nurse should never tell the client how to feel. b. The nurse should not divert the client’s concerns away from self by bringing up the father’s adaptation to the pregnancy, even though paternal adaptation is related to maternal adaptation. d. The client may not be able to identify why she has the feelings she is experiencing or how the nurse can make her feel better. This response does not provide an avenue for further exploration of the client’s concerns.

13. The pregnant client and her significant other are attending childbirth classes. The client asks for guidance on preparing her school-aged child for the new baby’s birth. Which strategy might not be appropriate to suggest that the client use with her child? 

a.. Read books about bringing home a new baby. 

b. Think of unique names for the new baby. 

c. Help pack a bag for bringing the new baby home. 

d.  Explain how pregnancy occurred, if asked.

d.

Children younger than adolescents do not fully understand conception and pregnancy due to preoperational and concrete operational thinking. They are not usually asking for an explanation of sex during this time.   a. Engaging the child in activities such as reading books about bringing the new baby home helps the child to feel a part of the experience. b. Engaging the child in activities such as naming the new baby helps the child to feel a part of the experience. c. Engaging the child in activities such as packing a bag for the new baby’s coming home helps the child to feel a part of the experience.

14. The nurse is providing nutrition counseling to the client during her first prenatal clinical visit. Which statement, if made by the client, indicates that the client has an understanding of some of the nutritional requirements during pregnancy? 

a. “I can eat cheese as an alternative to milk, as I don’t care for milk.” 

b.  “I should be eating more at each meal because I’m eating for two.” 

c.  “I will need to limit my calories because I am already overweight.” 

d.  “I should limit myself to eating only three healthy meals per day.”

a.

Cheese is a milk product and is an alternative to milk. This statement indicates understanding of nutritional requirements regarding milk and milk products.  b. Caloric intake needs to increase by 300 kcal per day during pregnancy to meet increased metabolic needs. However, “I’m eating for two” is a common misconception and leads to caloric intake greater than necessary. c. Caloric intake needs to increase by 300 kcal per day and should not be limited during pregnancy. d. Nutritional snacks throughout the day can provide for steady blood glucose levels and decrease the nausea associated with pregnancy. A limit of only three meals per day may not provide the client with enough calories to meet increased metabolic needs or may cause the client to eat more at each meal and increase nausea and bloating.

15. The nurse is taking the health history of the 40-year-old pregnant client. Which identified medical conditions does not increase the client’s risk for complications during her pregnancy?

a. Diabetes mellitus type 2 

b. Previous full-term pregnancy 

c.  Controlled chronic hypertension 

d. New onset of iron-deficiency anemia

b.

2. Having a previous full-term pregnancy is not a risk factor for a current pregnancy.  a. DM is a risk factor for complications such as preeclampsia, eclampsia, dystocia, fetal macrosomia, recurrent monilial vaginitis and UTIs, ketoacidosis, congenital abnormalities, and others. c. Controlled chronic hypertension may become uncontrolled during pregnancy due to water retention and other factors related to pregnancy. It is a risk factor for complications such as preeclampsia, placental abruption, and fetal hypoxia. d. Iron-deficiency anemia is associated with an increased incidence of preterm birth, low-birthweight infants, and maternal and infant mortality.

16. The first-trimester pregnant client asks the nurse if the activities in which she participates are safe in the first trimester. Which activity should the nurse verify as a safe activity during the client’s first trimester? 

a. Hair coloring 

b. Hot tub use 

c. Pesticide use 

d. Sexual activity

d.

Sexual activity is not contraindicated in pregnancy unless a specific risk factor is identified.   a. Hair coloring should be avoided in the first trimester because the chemicals can be absorbed and pose a risk to the developing fetus. b. Hot tub use should be avoided because it increases the client’s body temperature. Maternal hyperthermia during the first trimester raises concerns about possible spontaneous abortion, CNS defects, and failure of neural tube closure. c. Exposure to pesticides during pregnancy increases the risk for preterm birth, intrauterine growth restriction, childhood developmental delays, and infertility later in adulthood. 

17. The pregnant client tells the nurse that she smokes two packs per day (PPD) of cigarettes, has smoked in other pregnancies, and has never had any problems. What is the nurse’s best response? 

a.  “I’m glad that your other pregnancies went well. Smoking can cause both maternal and fetal problems, and it is best if you could quit smoking.” 

b. You need to stop smoking for the baby’s sake. You could have a spontaneous abortion with this pregnancy if you continue to smoke.” 

c. “Smoking can lead to having a large baby, which can make delivery difficult. You may even need a cesarean section.” 

d.  “Smoking less would eliminate the risk for your baby, and you would feel healthier during your pregnancy.”

a.

The nurse is acknowledging that the client did not experience problems with her other pregnancies but is also informing the client that smoking can cause maternal and fetal problems during pregnancy. b. Telling the client to stop smoking for the baby’s sake is confrontational, making the client less likely to listen to the nurse’s teaching. Although spontaneous abortion is associated with tobacco use during pregnancy, the nurse is using a scare tactic rather than therapeutic communication. c. Smoking can lead to a fetus that is small for gestational age, not a large baby. d. Decreasing her smoking intake should be suggested; however, it does not eliminate the risk to the baby completely.

18. The nurse informs the pregnant client that her laboratory test indicates she has iron-deficiency anemia. Based on this diagnosis, the nurse should monitor this client for all these problems except?

a.  Susceptibility to infection

b.  Easily fatigued

c. Increased risk for preeclampsia

d.  Increased risk of diabetes 

d. Iron-deficiency anemia is not associated with an increased risk of diabetes. 

a.  Iron-deficiency anemia is associated with susceptibility to infection because oxygen is not transported effectively. b. Iron-deficiency anemia is associated with fatigue because oxygen is not transported effectively. c. Iron-deficiency anemia is associated with risk of preeclampsia because oxygen is not transported effectively. 

19. The nurse is caring for the pregnant client. The nurse identifies that the use of which street drug places the client at risk for placental abruption? 

a. Heroin 

b. Marijuana 

c. Oxycodone 

d. Cocaine

d.

The most commonly used drug that places the pregnant client at risk for placental abruption is cocaine. Stillbirth, preterm labor and birth, and small for gestational age are also associated with cocaine use during pregnancy.  a. Heroin use during pregnancy is associated with intrauterine growth restriction, spontaneous abortion, preterm labor and birth, and stillbirth. b. Marijuana use during pregnancy is primarily associated with intrauterine growth restriction. c. Oxycodone (OxyContin) is synthetic morphine, and its use during pregnancy is associated with intrauterine growth restriction, spontaneous abortion, preterm labor and birth, and stillbirth.

20. The 16-year-old asks the nurse how to calculate BMI. The client weighs 134 lb and is 5’3” tall. Together, the client and nurse calculate the client’s BMI rounded to the nearest tenth. What is the client’s BMI?

a. 28.4

b. 21.8

c. 26.8

d. 23.8

21. The nurse is planning an educational session for a group of parents with toddlers. Based on the leading causes of death in toddlers, the nurse should make which topic a priority? 

a.  Water safety and methods to prevent drowning. 

b.  Nutrition guidelines and age-appropriate foods. 

c. Use of labels to identify poisonous substances. 

d. Safety when outdoors and crossing the street.

a.

Drowning is the major cause of death in toddlers. Water safety and methods to prevent drowning should be addressed.  b. Although toddlers are picky eaters and choking is one of the major causes of death in toddlers, more toddlers die in drowning accidents and in MVAs than from choking. c. Although poisoning is a major cause of death in toddlers, more toddlers die in drowning accidents and MVAs. d. Unintentional pedestrian accidents are a major cause of death, but more toddlers die in drowning accidents and in MVAs than in pedestrian accidents.

22. One parent is present with the 14-year-old client who is to have an emergency appendectomy. The nurse has been asked to have the informed consent form signed. Which statement reflects the nurse’s best thinking about informed consent? 

a. A signed informed consent form ensures client knowledge of the risk and benefits of the procedure. 

b. Adolescents have the ability to make decisions for themselves and may sign the informed consent form. 

c. Both parents have legal rights regarding medical treatment. Without both parents present, the informed consent form may not be signed. 

d. The surgeon is responsible for obtaining informed consent and for explaining the surgical procedure, benefits, and potential risks.

d.

Obtaining informed consent should be done after determining that the client’s parents have a reasonable understanding of the information presented. The client’s parents should understand the procedure, risks, benefits, and alternatives to the recommended procedure. It is the responsibility of the surgeon to obtain informed consent for the medical procedure.

a. A signature on the consent form does not ensure client knowledge of risks and benefits. b. Minor children may not sign informed consent unless emancipated. c.. The consent of both parents is not required for a medical procedure. 

23. The 32-year-old has been trying to get pregnant for the past 10 years. The client consults a family planning clinic after being unsuccessful with the calendar and basal body temperature methods in determining the time of ovulation. Which statement by the nurse would be most appropriate? 

a. “Let me review the methods with you; maybe you have not been using them correctly.” 

b.  “Have you considered that you might not be ovulating and that adoption is an option?” 

c. “Test kits are available that will detect an enzyme in cervical mucus that signals ovulation.” 

d. “If your spouse wears restrictive underwear, this can reduce your chance of conception.”

c.

It is most appropriate for the nurse to suggest an ovulation test kit. These are available over the counter and are easy to use and considered reliable. The kit can detect the presence of guaiacol peroxidase, the enzyme in cervical mucus that signals ovulation 6 days beforehand   a. Offering to review the methods is not the most appropriate response because the client has been unsuccessful for 10 years. b. Suggesting adoption is premature because other options to test ovulation are still untried.. d.  Providing information about a male’s restrictive underwear reducing the chance of conception does not address the problem of determining the time of ovulation.

24. The nurse is assessing the appropriateness of a self-help group for the 20-year-old client

a. recently diagnosed with an eating disorder. The nurse should initially obtain which information? The average age of the self-help group’s membership 

b. The ratio of clients to involved health care professionals 

c. How compatible the group’s meeting schedule is with the client’s expectations 

d.  The composition of the self-help group’s membership and similarity with the client

d.

A group that has clients who are similar is more likely to promote positive adaptive responses among its clients.  a. The average age of members may affect the client’s comfort with the group, but it is not the initial consideration. b. This statement reflects a consideration that may affect the client’s comfort with the group as well as its management of clients, but it is not the initial consideration. c. This statement reflects a consideration that may affect the client’s comfort with the group and ultimate attendance, but it is not the initial consideration.

25. The nurse at a community health care clinic is teaching parents about measures to take to prevent and manage obesity in children. The nurse determines that the parents need additional teaching if they indicate that they will implement which measure?. 

a. Use foods as a reward. 

b. Offer options of healthy foods. 

c. Avoid eating at fast-food restaurants. 

d. Establish consistent times for meals and snacks.

a.

Parents can implement several measures to prevent and manage obesity in their children. These measures include not using food as a reward; establishing consistent times for meals and snacks, and not allowing eating in-between; offering only healthy food options; minimizing trips to fast-food restaurants; keeping unhealthy food out of the house; acting as a role model for children; encouraging the child to do fun, physical activities with the family; and praising the child for making appropriate food choices and increasing physical activity levels. Obesity places a client at risk for hypertension, hyperlipidemia, myocardial infarction, stroke, diabetes mellitus, cancer, and other health conditions.

26. A 9-year-old child is scheduled for an electromyelogram. To prepare the child for this procedure, what should the nurse do first? 

a. Wait until just before the test to tell the child what will be done. 

b.  Ask the child to draw a picture of the body structures involved. 

c. Show the child the equipment that will be used in the test. 

d.  Verbally explain what will be done during the test.

 b.

Before teaching a school-age child about a medical or nursing procedure, it is best to become familiar with the child’s knowledge level. The nurse can then begin by explaining about the body structure involved in the procedure. Children of this age should be told about the unknown procedures far enough in advance for them to prepare for what is going to happen to them. Showing the child the equipment and explaining what is going to be done during the test should be done after the child is allowed to express what he knows about what is going to happen to him.

27. Ovulation occurs how many days before the next menstrual period?

a. 7 days

b. 3 days

c. 14 days

d. 21 days

28. The nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy. Which statement by the client indicates a need for further instructions? 

a.  “I should wear panty hose.” 

b. “I should wear support hose.” 

c.“I should wear flat nonslip shoes that have good support.” 

d.  “I should wear knee-high hose, but I should not leave them on longer than 8 hours.”

d.

Varicose veins often develop in the lower extremities during pregnancy. Any constrictive clothing, such as knee-high hose, impedes venous return from the lower legs and places the client at risk for developing varicosities. The client should be encouraged to wear support hose or panty hose. Flat nonslip shoes with proper support are important to assist the pregnant woman to maintain proper posture and balance and to minimize falls.

29. The nurse is choosing age-appropriate age-appropriate toys for a toddler. Which toy is the best choice for this age? 

a.  Puzzle 

b. Toy soldiers 

c. Large stacking blocks 

d. A card game with large pictures

c.

Toddlers like to master activities independently, such as stacking blocks. Because toddlers do not have the developmental ability to determine what could be harmful, toys that are safe need to be provided. A puzzle and toy soldiers provide objects that can be placed in the mouth and may be harmful for a toddler. A card game with large pictures may require cooperative play, which is more appropriate for a school-age child.

30. The parents leave the child’s hospital room after visiting their 2-year-old. Which finding by the nurse poses the most immediate and serious safety threat to the child? 

a. Coloring book and crayons left in the crib 

b. A doll with movable eyes left in the crib 

c. A mobile hanging from the top of the crib 

d. The crib rail that was left halfway down

d. Related to the immediate risk compared to the more prolong possible risk.

31. New parents are asked to sign the consent for their son to be circumcised. They ask for the nurse's opinion of the procedure. How should the nurse respond?

a. "You should talk to the physician about this if you have any questions."

b.  "Let's talk about it because there are advantages and disadvantages."

c. "It is a safe procedure and it is best for male infants to be circumcised.”

d.  "Although it may be a somewhat painful experience for the baby, I would allow it if I were you."

b.

This response permits exploration of the parents' wishes and leads to assisting them in making their own decision. a. This response blocks further discussion; the nurse can answer some of the questions and refer those that cannot be answered to the practitioner. c. This is a value judgment; it denies the parents' right to decide.  d. This response might frighten the parents; it denies the parents their power of decision.

32. A client at 16 weeks' gestation arrives at the prenatal clinic for a routine visit. During the examination the nurse observes bruises on the client's face and abdomen. There are no bruises on her legs and arms. Further assessment is required to confirm:

a. Domestic abuse

b.  Hydatidiform mole

c. Excessive exercising

d. Thrombocytopenic purpura

a.

Domestic abuse is more likely to intensify during pregnancy and the attacks usually are directed toward the pregnant woman's abdomen.  b. A hydatidiform mole may be manifested by an unusually enlarged uterus for gestational age, hypertension, nausea and vomiting, and vaginal bleeding, not bruises on the face and abdomen. c. Excessive exercise may cause cardiovascular or pulmonary problems. It will not result in bruising.  d. Thrombocytopenic purpura and other bleeding disorders are manifested by bruises and petechiae on many areas of the body surface, not just the face and abdomen.

33. A 16-year-old girl at 28 weeks' gestation arrives at the prenatal clinic with her mother for a routine sonogram. Before the procedure, the girl requests that the nurse not reveal the fetus's gender if it should become apparent. Afterward the mother asks the nurse the sex of the fetus. Considering the mother-daughter relationship, the nurse's best response is:

a. "That information is not available at this time."

b. "I'm not allowed to divulge confidential information."

c. "Your daughter asked me not to give that information to anyone."

d. "The sex of the baby isn't the most important information to know at this time."

a.

This response supports the client's right to confidentiality without antagonizing the client's mother. b. Although this response protects the client's right to confidentiality, it may disrupt the relationship between the client and her mother.  c. Although this response protects the client's right to confidentiality, it may disrupt the relationship between the client and her mother.  d. This is a judgmental, nontherapeutic statement.

34. A 29-year-old pregnant client arrives at the hospital in active labor. The client is deaf and her husband is with her. Which intervention from the nurse expresses her ability to communicate with this patient? 

a. Use exaggerated lip movements to allow the client to read lips 

b. Mime what needs to be done in order to communicate 

c. Arrange for a sign language interpreter who can be present during the delivery 

d. Assess the communication ability of the patient and her husband and ask them what they would prefer

d.

When working with a deaf or hard of hearing patient, the nurse should first determine how the patient wants to communicate. Many deaf people have integrated into society by using ASL, lip reading, or other forms of communication, but the nurse will not know this patient’s choice of communication until they ask. Before getting an interpreter, the nurse should first find out the patient’s preference. Because the deaf community is not speaking a foreign language, they might be more comfortable with the printed word and lip reading rather than bringing an interpreter in during this private period of their life. If they read lips using exaggerated lip movements is like shouting in English at someone who speaks a different language..insulting.  Who would Mime birthing instructions? Throw out B.   For foreign languages C might be used but would you call an interpreter in if English is a second language or would you ask the patient first what they are comfortable with.  

35. What is the best nursing intervention to achieve the cooperation of an extremely anxious pregnant client during her first pelvic examination? 

a. Distract the client by asking her preference as to the sex of her infant

b.  Assist the practitioner so the client's examination can be completed quickly

c.  Explain the procedure and maintain eye contact while touching the client gently

d. Encourage the client to squeeze the nurse's hand, close her eyes, and hold her breath

c.

Doing this will help the client relax and will lessen discomfort.  a. This may distract the client but will not produce relaxation.  b. The client may become more anxious if the procedure is hurried.  d. This may make the client more anxious; holding the breath causes tightening of the perineum.

36. An active 19-year-old primigravida attends the prenatal clinic for the first time. She asks the nurse if she can continue playing tennis and go horseback riding while she is pregnant. How should the nurse reply?

a. "Continue your usual activities as long as you are comfortable."

b. "Horseback riding is acceptable, but only up to the last trimester"

c.  "Tennis is good exercise for you, but horseback riding is too strenuous."

d.  "Both of these sports have been found to be too strenuous for a pregnant woman."

a.

Any regular activity that was typical before pregnancy can be continued in pregnancy if there are no complications such as bleeding, cramps, or pain.  b. It is not necessary to stop riding after the second trimester unless the woman is uncomfortable or it is otherwise contraindicated.  c. A woman used to riding horses can continue; no exercise is too strenuous if it was done consistently before pregnancy.  d. Both activities are acceptable as long as the woman is accustomed to doing them.

37.While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially?

a. Activate the code blue or emergency system.

b. Do nothing because acrocyanosis is normal in the neonate

c. Immediately take the newborn's temperature according to hospital policy

d. Notify the physician of the need for a cardiac consult

b.

Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also called peripheral cyanosis), is a normal finding and shouldn't last more than 24 hours after birth. 

38. The nurse is providing nutrition counseling to a primigravida who is 10 weeks pregnant. Which meal choice stated by the client indicates she needs additional information? 

a. Black beans, wild rice, collard greens 

b. Dry cereal, milk, dried cranberries 

c. Tuna, broccoli, baked potato 

d. Beef strips, lentils, red peppers

c.

Tuna contains mercury and should be limited in pregnancy due to risk of mercury poisoning. The nurse should provide this additional information.  a. Black beans provide a good source of calcium, iron, and protein. Black beans, wild rice, and collard greens provide fiber. Collard greens provide a good source of calcium and folic acid. b. Dry cereal provides a good source of vitamin D, milk provides a good source of calcium, and dried cranberries provide a good source of calcium and iron. d. Beef provides a good source of protein and iron, lentils provide a good source of iron, and red peppers provide a good source of vitamin C.

39. The nurse is providing instructions to a Chinese-American client about the frequency and dosages of the take home medicines. When conducting the teaching, the client continuously turns away from the nurse. The nurse should do which of the following appropriate action?

a. Walk around the client so that the nurse can constantly face the client. 

b. Call the attention of the client by speaking loudly. 

c. Continue with the instructions, then confirming client's understanding. 

d. Hand over a written instruction and discuss only what the client doesn't understand.

c.

Most Chinese maintains a formal personal space with others, which is a form of respect. Most Chinese are uncomfortable with face-to-face communications, especially when eye contact is direct. If the client turns away from the nurse during a conversation, the most appropriate action is to continue with the instructions.  Option A: Walking around to the client so that the nurse faces the client is in direct conflict with the cultural practice. Option B: Calling the attention and speaking loudly is viewed as a rude gesture. Option D: Discussing only what the client cannot understand is not an acceptable practice of a nurse.

40. What is the daily consumption of folic acid level for pregnant women?

a. 400 mcg

b. 250 mcg

c. 800 mcg

d. 600 mcg

d.

600 mcg with all women planning or capable of pregnancy taking a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid while pregnant women should consume 600 mcg daily.

41. What speific negative connections does caffeine od 300 mg daily have during pregnancy?

                   a. causes fetal tachycardia

                   b. causes premature contractions

                   c. causes maternal hypertension.     

                   d. associated with low birth weight.

d.

Though caffeine is a central nervous system stimulant that increases heart rate, urine production in the kidneys, and secretion of acid in the stomach the concern during pregnancy is low birth weight.   Sources of caffeine include chocolate, soft drinks, tea, and coffee. A daily caffeine intake of more than 300 mg (about 4 cups of coffee) has been associated with low birth weight. 

42. All the vitamins are fat soluble except for…

                   a. Vitamin A

                   b. Vitamin K

                   c. Vitamin B

                   d. Vitamin D

c. 

Vitamin B: Eight of the water-soluble vitamins are known as the vitamin B-complex group: thiamin (vitamin B1), riboflavin (vitamin B2), niacin (vitamin B3), vitamin B6 (pyridoxine), folate (folic acid), vitamin B12, biotin and pantothenic acid.

43. Major concerns related to adolescent pregnancy include all except:

a. poor nutritional status

b. emotional and behavioral difficulties

c. lack of support systems

d. fragile pelvic 

d.

Major concerns related to adolescent pregnancy include poor nutritional status; emotional and behavioral difficulties; lack of support systems; increased risk of stillbirth; low-birth-weight infants; fetal mortality; cephalopelvic disproportion; and increased risk of maternal complications, such as hypertension, anemia, prolonged labor, and infections but not a fragile pelvis bone.

44. A 32-year-old multigravida returns to the clinic for a routine prenatal visit at 36 weeks’ gestation. The assessments during this visit include blood pressure, 140/ 90 mm Hg; pulse, 80 beats/ min; respiratory rate, 16 breaths/ min. What further information should the nurse obtain to determine if this client is becoming preeclamptic?

a.  headaches

b. blood glucose level

c. proteinuria

d. peripheral edema

c.

The two major defining characteristics of preeclampsia are blood pressure elevation of 140/ 90 mm Hg or greater and proteinuria. Because the client’s blood pressure meets the gestational hypertension criteria, the next nursing responsibility is to determine if she has protein in her urine. If she does not, then she may be having transient hypertension. The peripheral edema is within normal limits for someone at this gestational age, particularly because it is in the lower extremities. While the preeclamptic client may have significant edema in the face and hands, edema can be caused by other factors and is not part of the diagnostic criteria. Headaches are significant in pregnancy-induced hypertension but may have other etiologies. The client’s blood glucose level has no bearing on a preeclampsia diagnosis.

 45. What is the most appropriate teaching point to include in a health promotion teaching plan for parents of children age 5 to 14?

a. Causes of mechanical suffocation

b. Keeping all medications out of children’s reach

c. Storing firearms in locked cabinets.

d. Warning signs of violent crimes.

c. 

Storing firearms in locked cabinets.
Improper use of firearms is the fourth leading cause of death from injury in children 5 to 14.  Mechanical suffocation is the leading cause of death from injury in infants. Homicide is the second leading cause of death in 15 to 19 year olds. 
Poisoning causes a considerable number of injuries in children under 4 years of age.

46.  A 22-year-old client tells the nurse that she and her husband are trying to conceive a baby. When teaching the client about reducing the incidence of neural tube defects, the nurse would emphasize the need for increasing the intake of all the following foods except?

a. leafy green vegetables

b. strawberries

c. beans 

d. milk 

d.

The pregnancy requirement for folic acid is 400 to 800 mcg/ day. Major sources of folic acid include leafy green vegetables, strawberries and oranges, beans, particularly black and kidney beans, sunflower seeds, and lentils. Milk and fats contain no folic acid.

47. The 4-year-old is crying and hugging a teddy bear while being admitted to the pediatric unit. Which response by the nurse is best?

a. “Hello, my name is Chris. Come with me; I am going to show you to your new room.”

b. “I see that you are crying. Let’s go to the playroom, where you can meet other children.”

c. “Hi. You’re likely afraid. I see that you have your teddy bear. What’s your bear’s name?”

d.“Can I hold you and your teddy bear to take you to the room? You can put teddy to bed.”

c. 

Stating that the child is likely afraid and making reference to the stuffed animal acknowledge the child’s feelings as well as focus on a familiar object of security.  a. The nurse’s introduction and directions to the child do not acknowledge the child’s feelings and are an attempt to control the child. b. Diverting the child by taking the child to the playroom will not alleviate fear and anxiety. d. Asking the child questions that allow for a yes/no response is closed-ended questioning and, because of the child’s fear and anxiety, will likely get a “no” response.

48. The nurse is teaching the 8-year-old with precocious puberty about the child’s physiological changes. Which statement should be helpful in facilitating a positive body image for this child?

a. “You may want to dress like a teenager now that you are going through puberty.”

b. “Your body is maturing more rapidly than other children your age. You should make friends with children who are older than you.”

c. “The changes in your body are normal but occurring at an earlier age. Your friends will eventually have the same changes.”

d. “You are going to look older than your age. Tell others your age so they don’t ask you to do things that you are not ready to do.”

 c.

Reassuring the child that pubertal changes are normal, and that the child’s friends will eventually develop the same characteristics, should be helpful in facilitating a positive body image a. Dressing as a teenager reinforces that the child is different from peers the same age. b. Encouraging friendships with children who are older reinforces that the child is different from peers the same age.. d. Encouraging the child to inform others of his or her age reinforces that the child is different from peers the same age.

49. While in labor, the first-time mother informs the nurse that she wants to breastfeed her infant but is concerned about her ability to successfully breastfeed. Which intervention should the nurse plan to implement immediately after delivery to promote successful breastfeeding?

a. Have the mother rest for 1 to 2 hours after delivery before attempting to breastfeed

b. Provide privacy by allowing the mother and infant to be alone during the first feeding

c. Place the infant on the mother’s chest so that there is skin-to-skin contact between them

d. Feed the newborn a bottle of formula to stimulate bowel peristalsis before breastfeeding

c.

Skin-to-skin contact after birth leads to an eight-fold increase in spontaneous nursing and may be a critical component in breastfeeding success. For the first 30 minutes to one hour after birth, the infant is usually active, alert, and ready to breastfeed.  a. Allowing the mother to rest for 1 to 2 hours immediately after delivery would bypass the initial period of newborn activity. Thirty minutes after birth, newborn activity begins to decrease, and the newborn enters a period of deep sleep. b. Rather than privacy, most women appreciate having an experienced nurse with them for a first feeding to offer support and advice. Leaving the mother and infant alone during the first feeding does not help to promote successful breastfeeding. d. Supplemental bottle feedings for the breastfeeding infant are not recommended for normal, healthy newborns as they may lead to nipple confusion and decrease infant stimulation of the mother’s breast.

50. To increase quality and years of healthy life, Healthy People 2020 focuses on four areas. One of those areas is:

a.     Allowing people to continue current behaviors to reduce the stress of change.

b.     Focusing only on individual health changes that will lead to better communities.

c.      Creating social and physical environments that promote good health.

d.     Focusing on illness treatment to provide fast recuperation.

c.

Healthy People 2020 includes four goals, one of which is to create social and physical environments that promote good health for all. 
The other three include 
(1) attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; 
(2) achieve health equity, eliminate disparities, and improve the health of all groups; and 
(3) promote quality of life, healthy development, and healthy behaviors across all life stages.