1. Due to the effects of cyclic ovarian changes in the breast, when is the best time for breast self- examination (BSE)?
a. Between 5 and 7 days after menses ceases
b. Day 1 of the endometrial cycle
c. Midmenstrual cycle
d. Any time during a shower or bath
ANS: A
The physiologic alterations in breast size and activity reach their minimal level approximately 5 to 7 days after menstruation ceases. Therefore, BSE is best performed during this phase of the menstrual cycle. Day 1 of the endometrial cycle is too early to perform an accurate BSE. After the midmenstrual cycle, breasts are likely to become tender and increase in size, which is not the ideal time to perform BSE. Lying down after a shower or bath with a small towel under the shoulder of the side being examined is appropriate teaching for BSE. A secondary BSE may be performed while in the shower.
2. Individual irregularities in the ovarian (menstrual) cycle are most often caused by what?
a. Variations in the follicular (preovulatory) phase
b. Intact hypothalamic-pituitary feedback mechanism
c. Functioning corpus luteum
d. Prolonged ischemic phase
ANS: A
Almost all variations in the length of the ovarian cycle are the result of variations in the length of the follicular phase. An intact hypothalamic-pituitary feedback mechanism would be regular, not irregular. The luteal phase begins after ovulation. The corpus luteum is dependent on the ovulatory phase and fertilization. During the ischemic phase, the blood supply to the functional endometrium is blocked, and necrosis develops. The functional layer separates from the basal layer, and menstrual bleeding begins.
3. How would the physiologic process of the sexual response best be characterized?
a. Coitus, masturbation, and fantasy
b. Myotonia and vasocongestion
c. Erection and orgasm
d. Excitement, plateau, and orgasm
ANS: B
Physiologically, according to Masters (1992), sexual response can be analyzed in terms of two processes: vasocongestion and myotonia. Coitus, masturbation, and fantasy are forms of stimulation for the physical manifestation of the sexual response. Erection and orgasm occur in
two of the four phases of the sexual response cycle. Excitement, plateau, and orgasm are three of the four phases of the sexual response cycle.
4. Which action would be inappropriate for the nurse to perform before beginning the health history interview?
a. Smile and ask the client whether she has any special concerns.
b. Speak in a relaxed manner with an even, nonjudgmental tone.
c. Make the client comfortable.
d. Tell the client her questions are irrelevant.
ANS: D
The woman should be assured that all of her questions are relevant and important. Beginning any client interaction with a smile is important and assists in putting the client at ease. If the nurse speaks in a relaxed manner, then the client will likely be more relaxed during the interview. The clients comfort should always be ensured before beginning the interview.
5. The nurse guides a woman to the examination room and asks her to remove her clothes and put on an examination gown with the front open. The woman replies, I have special undergarments that I do not remove for religious reasons. Which is the most appropriate response from the nurse?
a. You cant have an examination without removing all your clothes.
b. Ill ask the physician to modify the examination.
c. Tell me about your undergarments. Ill explain the examination procedure, and then we can discuss how you can comfortably have your examination.
d. I have no idea how we can accommodate your beliefs.
ANS: C
Explaining the examination procedure reflects cultural competence by the nurse and shows respect for the womans religious practices. The nurse must respect the rich and unique qualities that cultural diversity brings to individuals. The examination can be modified to ensure that modesty is maintained. In recognizing the value of cultural differences, the nurse can modify the plan of care to meet the needs of each woman. Telling the client that her religious practices are different or strange is inappropriate and disrespectful to the client.
6. A woman arrives at the clinic for her annual examination. She tells the nurse that she thinks she has a vaginal infection, and she has been using an over-the-counter cream for the past 2 days
to treat it. How should the nurse initially respond?
a. Inform the woman that vaginal creams may interfere with the Papanicolaou (Pap) test
for which she is scheduled.
b. Reassure the woman that using vaginal cream is not a problem for the examination.
c. Ask the woman to describe the symptoms that indicate to her that she has a vaginal infection.
d. Ask the woman to reschedule the appointment for the examination.
ANS: C
An important element of the health history and physical examination is the clients description of any symptoms she may be experiencing. The best response is for the nurse to inquire about the symptoms the woman is experiencing. Women should not douche, use vaginal medications, or
have sexual intercourse for 24 to 48 hours before obtaining a Pap test. Although the woman may need to reschedule a visit for her Pap test, her current symptoms should still be addressed.
7. Preconception and prenatal care have become important components of womens health. What is the guiding principal of preconception care?
a. Ensure that pregnancy complications do not occur.
b. Identify the woman who should not become pregnant.
c. Encourage healthy lifestyles for families desiring pregnancy.
d. Ensure that women know about prenatal care.
ANS: C
Preconception counseling guides couples in how to avoid unintended pregnancies, how to identify and manage risk factors in their lives and in their environment, and how to identify healthy behaviors that promote the well-being of the woman and her potential fetus.
Preconception care does not ensure that pregnancy complications will not occur. In many cases, problems can be identified and treated and may not recur in subsequent pregnancies. For many women, counseling can allow behavior modification before any damage is done, or a woman can make an informed decision about her willingness to accept potential hazards. If a woman is seeking preconception care, then she is likely aware of prenatal care.
8. Ovarian function and hormone production decline during which transitional phase?
a. Climacteric
b. Menarche
c. Menopause
d. Puberty
ANS: A
The climacteric phase is a transitional period during which ovarian function and hormone production decline. Menarche is the term that denotes the first menstruation. Menopause refers only to the last menstrual period.Puberty is a broad term that denotes the entire transitional period between childhood and sexual maturity.
9. Which statement indicates that a client requires additional instruction regarding BSE?
a. Yellow discharge from my nipple is normal if Im having my period.
b. I should check my breasts at the same time each month, after my period.
c. I should also feel in my armpit area while performing my breast examination.
d. I should check each breast in a set way, such as in a circular motion.
ANS: A
Discharge from the nipples requires further examination from a health care provider. The breasts should be checked at the same time each month. The armpit should also be examined. A circular motion is the best method during which to ascertain any changes in the breast tissue.
10. A blind woman has arrived for an examination. Her guide dog assists her to the examination room. She appears nervous and says, Ive never had a pelvic examination. What response from the nurse would be most appropriate?
a. Dont worry. It will be over before you know it.
b. Try to relax. Ill be very gentle, and I wont hurt you.
c. Your anxiety is common. I was anxious when I first had a pelvic examination.
d. Ill let you touch each instrument that Ill use during the examination as I tell you how it will be used.
ANS: D
The client who is visually impaired needs to be oriented to the examination room and needs a full explanation of what the examination entails before the nurse proceeds. Telling the client that the examination will be over quickly diminishes the clients concerns. The nurse should openly and directly communicate with sensitivity. Women who have physical disabilities should be respected and involved in the assessment and physical examination to the full extent of their abilities. Telling the client that she will not be hurt does not reflect respect or sensitivity.
Although anxiety may be common, the nurse should not discuss her own issues nor compare them to the clients concerns.
11. Which female reproductive organ(s) is(are) responsible for cyclic menstruation?
a. Uterus
b. Ovaries
c. Vaginal vestibule
d. Urethra
ANS: A
The uterus is responsible for cyclic menstruation and also houses and nourishes the fertilized ovum and the fetus. The ovaries are responsible for ovulation and the production of estrogen. The vaginal vestibule is an external organ that has openings to the urethra and vagina. The urethra is not a reproductive organ, although it is found in the area.
12. Which body part both protects the pelvic structures and accommodates the growing fetus during pregnancy?
a. Perineum
b. Bony pelvis
c. Vaginal vestibule
d. Fourchette
ANS: B
The bony pelvis protects and accommodates the growing fetus. The perineum covers the pelvic structures. The vaginal vestibule contains openings to the urethra and vagina. The fourchette is formed by the labia minor.
13. Which phase of the endometrial cycle best describes a heavy, velvety soft, fully matured endometrium?
a. Menstrual
b. Proliferative
c. Secretory
d. Ischemic
ANS: C
The secretory phase extends from the day of ovulation to approximately 3 days before the next menstrual cycle. During this secretory phase, the endometrium becomes fully mature again.
During the menstrual phase, the endometrium is shed. The proliferative phase is a period of rapid growth. During the ischemic phase, the blood supply is blocked and necrosis develops.
14. Which part of the menstrual cycle includes the stimulated release of gonadotropin-releasing hormone (GnRH) and follicle-stimulating hormone (FSH)?
a. Menstrual phase
b. Endometrial cycle
c. Ovarian cycle
d. Hypothalamic-pituitary cycle
ANS: D
The cyclic release of hormones is the function of the hypothalamus and pituitary glands. The menstrual cycle is a complex interplay of events that simultaneously occur in the endometrium, hypothalamus, pituitary glands, and ovaries. The endometrial cycle consists of four phases: menstrual phase, proliferative phase, secretory phase, and ischemic phase. The ovarian cycle remains under the influence of FSH and estrogen.
15. What fatty acids (classified as hormones) are found in many body tissues with complex roles in many reproductive functions?
a. GnRH
b. Prostaglandins (PGs)
c. FSH
d. Luteinizing hormone (LH)
ANS: B
PGs affect smooth muscle contraction and changes in the cervix. GnRH is part of the hypothalamic-pituitary cycle, which responds to the rise and fall of estrogen and progesterone. FSH is part of the hypothalamic-pituitary cycle, which responds to the rise and fall of estrogen and progesterone. LH is part of the hypothalamic-pituitary cycle, which responds to the rise and fall of estrogen and progesterone.
16. Which information regarding substance abuse is important for the nurse to understand?
a. Although cigarette smoking causes a number of health problems, it has little direct effect on maternity-related health.
b. Women, ages 21 to 34 years, have the highest rates of specific alcohol-related problems.
c. Coffee is a stimulant that can interrupt body functions and has been related to birth defects.
d. Prescription psychotherapeutic drugs taken by the mother do not affect the fetus; otherwise, they would not have been prescribed.
ANS: B
Although a very small percentage of childbearing women have alcohol-related problems, alcohol abuse during pregnancy has been associated with a number of negative outcomes. Cigarette smoking impairs fertility and is a cause of low-birth-weight infants. Caffeine consumption has not been related to birth defects. Psychotherapeutic drugs have some effect on the fetus, and that risk must be weighed against their benefit to the mother.
17. As part of their participation in the gynecologic portion of the physical examination, which approach should the nurse take?
a. Take a firm approach that encourages the client to facilitate the examination by following the physicians instructions exactly.
b. Explain the procedure as it unfolds, and continue to question the client to get information in a timely manner.
c. Take the opportunity to explain that the trendy vulvar self-examination is only for women at risk for developing cancer.
d. Help the woman relax through the proper placement of her hands and proper breathing during the examination.
ANS: D
Breathing techniques are important relaxation techniques that can help the client during the examination. The nurse should encourage the client to participate in an active partnership with the health care provider. Explanations during the procedure are fine, but many women are uncomfortable answering questions in the exposed and awkward position of the examination. Vulvar self-examination on a regular basis should be encouraged and taught during the examination.
18. Which statement best describes Kegel exercises?
a. Kegel exercises were developed to control or reduce incontinent urine loss.
b. Kegel exercises are the best exercises for a pregnant woman because they are so pleasurable.
c. Kegel exercises help manage stress.
d. Kegel exercises are ineffective without sufficient calcium in the diet.
ANS: A
Kegel exercises help control the urge to urinate. Although these exercises may be fun for some, the most important factor is the control they provide over incontinence. Kegel exercises help manage urination, not stress. Calcium in the diet is important but not related to Kegel exercises.
19. The microscopic examination of scrapings from the cervix, endocervix, or other mucous membranes to detect premalignant or malignant cells is called what?
a. Bimanual palpation
b. Rectovaginal palpation
c. Papanicolaou (Pap) test
d. Four As procedure
ANS: C
The Pap test is a microscopic examination for cancer that should be regularly performed, depending on the clients age. Bimanual palpation is a physical examination of the vagina. Rectovaginal palpation is a physical examination performed through the rectum. The four As procedure is an intervention to help a client stop smoking.
20. Which questionnaire would be best for the nurse to use when screening an adolescent client for an eating disorder?
a. Four Cs
b. Dietary Guidelines for Americans
c. SCOFF screening tool
d. Dual-energy x-ray absorptiometry (DEXA) scan
ANS: C
A screening tool specifically developed to identify eating disorders uses the acronym SCOFF. Each question scores 1 point. A score of 2 or more indicates that the client may have anorexia nervosa or bulimia. The letters represent the following questions:
Do you make yourself Sick because you feel too full?
Do you worry about loss of Control over the amount that you eat?
Have you recently lost more than One stone (14 pounds) in a 3-month period? Do you think that you are too Fat, even if others think you are thin?
Does Food dominate your life?
The 4 Cs are used to determine cultural competence. Dietary Guidelines for Americans provide nutritional guidance for all, not only for those with eating disorders. The DEXA scan is used to determine bone density.
21. The unique muscle fibers that constitute the uterine myometrium make it ideally suited for what?
a. Menstruation
b. Birth process
c. Ovulation
d. Fertilization
ANS: B
The myometrium is made up of layers of smooth muscle that extend in three directions. These muscles assist in the birth process by expelling the fetus, ligating blood vessels after birth, and controlling the opening of the cervical os.
22. Which hormone is responsible for the maturation of mammary gland tissue?
a. Estrogen
b. Testosterone
c. Prolactin
d. Progesterone
ANS: D
Progesterone causes maturation of the mammary gland tissue, specifically acinar structures of the lobules. Estrogen increases the vascularity of the breast tissue. Testosterone has no bearing on breast development. Prolactin is produced after birth and released from the pituitary gland; it is produced in response to infant suckling and an emptying of the breasts.
23. What is the goal of a long-term treatment plan for an adolescent with an eating disorder?
a. Managing the effects of malnutrition
b. Establishing sufficient caloric intake
c. Improving family dynamics
d. Restructuring client perception of body image
ANS: D
The treatment of eating disorders is initially focused on reestablishing physiologic homeostasis. Once body systems are stabilized, the next goal of treatment for eating disorders is maintaining adequate caloric intake. Although family therapy is indicated when dysfunctional family relationships exist, the primary focus of therapy for eating disorders is to help the adolescent cope with complex issues. The focus of treatment in individual therapy for an eating disorder involves restructuring cognitive perceptions about the individuals body image.
24. A 62-year-old woman has not been to the clinic for an annual examination for 5 years. The recent death of her husband reminded her that she should come for a visit. Her family physician has retired, and she is going to see the womens health nurse practitioner for her visit. What should the nurse do to facilitate a positive health care experience for this client?
a. Remind the woman that she is long overdue for her examination and that she should come in annually.
b. Carefully listen, and allow extra time for this womans health history interview.
c. Reassure the woman that a nurse practitioner is just as good as her old physician.
d. Encourage the woman to talk about the death of her husband and her fears about her own death.
ANS: B
The nurse has an opportunity to use reflection and empathy while listening, as well as ensure an open and caring communication. Scheduling a longer appointment time may be necessary because older women may have longer histories or may need to talk. A respectful and reassuring approach to caring for women older than age 50 years can help ensure that they continue to seek health care. Reminding the woman about her overdue examination, reassuring the woman that she has a good practitioner, and encouraging conversation about the death of her husband and her own death are not the best approaches.
25. During a health history interview, a woman states that she thinks that she has bumps on her labia. She also states that she is not sure how to check herself. The correct response by the nurse would be what?
a. Reassure the woman that the examination will reveal any problems.
b. Explain the process of vulvar self-examination, and reassure the woman that she should become familiar with normal and abnormal findings during the examination.
c. Reassure the woman that bumps can be treated.
d. Reassure her that most women have bumps on their labia.
ANS: B
During the assessment and evaluation, the responsibility for self-care, health promotion, and enhancement of wellness is emphasized. The pelvic examination provides a good opportunity for the practitioner to emphasize the need for regular vulvar self-examination. Providing reassurance to the woman concerning the bumps would not be an accurate response.
26. Which statement regarding female sexual response is inaccurate?
a. Women and men are more alike than different in their physiologic response to sexual arousal and orgasm.
b. Vasocongestion is the congestion of blood vessels.
c. Orgasmic phase is the final state of the sexual response cycle.
d. Facial grimaces and spasms of the hands and feet are often part of arousal.
ANS: C
The final state of the sexual response cycle is the resolution phase after orgasm. Men and women are surprisingly alike. Vasocongestion causes vaginal lubrication and engorgement of the genitals. Arousal is characterized by increased muscular tension (myotonia).
27. A client at 24 weeks of gestation says she has a glass of wine with dinner every evening. Why should the nurse counsel her to eliminate all alcohol intake?
a. Daily consumption of alcohol indicates a risk for alcoholism.
b. She is at risk for abusing other substances as well.
c. Alcohol places the fetus at risk for altered brain growth.
d. Alcohol places the fetus at risk for multiple organ anomalies.
ANS: C
No period during pregnancy is safe to consume alcohol. The documented effects of alcohol consumption during pregnancy include fetal mental retardation, learning disabilities, high activity level, and short attention span. The fetal brain grows most rapidly in the third trimester and is vulnerable to alcohol exposure during this time. Abuse of other substances has not been linked to alcohol use.
28. Which statement by the client indicates that she understands BSE?
a. I will examine both breasts in two different positions.
b. I will examine my breasts 1 week after my menstrual period starts.
c. I will examine only the outer upper area of the breast.
d. I will use the palm of the hand to perform the examination.
ANS: B
The woman should examine her breasts when hormonal influences are at their lowest level. The client should be instructed to use four positions: standing with arms at her sides, standing with arms raised above her head, standing with hands pressed against hips, and lying down. The entire breast needs to be examined, including the outer upper area. The client should use the sensitive pads of the middle three fingers.
29. What is the primary reason why a woman who is older than 35 years may have difficulty achieving pregnancy?
a. Personal risk behaviors influence fertility.
b. Mature women have often used contraceptives for an extended time.
c. Her ovaries may be affected by the aging process.
d. Prepregnancy medical attention is lacking.
ANS: C
Once the mature woman decides to conceive, a delay in becoming pregnant may occur because of the normal aging of the ovaries. Older adults participate in fewer risk behaviors than younger adults. The past use of contraceptives is not the problem. Prepregnancy medical care is both available and encouraged.
30. What is the most dangerous effect on the fetus of a mother who smokes cigarettes while pregnant?
a. Genetic changes and anomalies
b. Extensive central nervous system damage
c. Fetal addiction to the substance inhaled
d. Intrauterine growth restriction
ANS: D
The major consequences of smoking tobacco during pregnancy are low-birth-weight infants, prematurity, and increased perinatal loss. Cigarettes will not normally cause genetic changes or extensive central nervous system damage. Addiction to tobacco is not usually a concern related to the neonate.
MULTIPLE RESPONSE
1. What are the two primary functions of the ovary? (Select all that apply.)
a. Normal female development
b. Ovulation
c. Sexual response
d. Hormone production
e. Sex hormone release
ANS: B, D
The two functions of the ovaries are ovulation and hormone production. The presence of ovaries does not guarantee normal female development. The ovaries produce estrogen, progesterone, and androgen. Ovulation is the release of a mature ovum from the ovary. Sexual response is a feedback mechanism involving the hypothalamus, anterior pituitary gland, and ovaries.
2. Which statements regarding menstruation (periodic uterine bleeding) are accurate? (Select all that apply.)
a. Menstruation occurs every 28 days.
b. During menstruation, the entire uterine lining is shed.
c. Menstruation begins 7 to 10 days after ovulation.
d. Menstruation leads to fertilization.
e. Average blood loss during menstruation is 50 ml.
ANS: A, B, E
Menstruation is the periodic uterine bleeding that is controlled by a feedback system involving three cycles: the endometrial cycle, the hypothalamic-pituitary cycle, and the ovarian cycle. The average length of a menstrual cycle is 28 days; however, variations are normal. During the endometrial cycle, the functional two thirds of the endometrium is shed. The average blood loss is 50 ml with a normal range of 20 to 80 ml. Menstruation occurs 14 days after ovulation. The lack of fertilization leads to menstruation.
3. Women of all ages will receive substantial and immediate benefits from smoking cessation. The process is not easy, and most people have attempted to quit numerous times before achieving success. Which organizations provide self-help and smoking cessation
materials? (Select all that apply.)
a. Leukemia and Lymphoma Society
b. March of Dimes
c. American Cancer Society
d. American Lung Association
e. Easter Seals
ANS: B, C, D
The March of Dimes, the American Lung Association, and the American Cancer Society have self-help materials available. The Leukemia and Lymphoma Society support research for these two types of cancer. Easter Seals is best known for its work with disabled children.
4. Many pregnant teenagers wait until the second or third trimester to seek prenatal care. What should the nurse recognize as reasons for this delay? (Select all that apply.)
a. Lack of realization that they are pregnant
b. Uncertainty as to where to go for care
c. Continuing to deny the pregnancy
d. Desire to gain control over their situation
e. Wanting to hide the pregnancy as long as possible
ANS: A, B, C, E
These reasons are all valid explanations why teens delay seeking prenatal care. An adolescent often has little to no understanding of the increased physiologic needs that a pregnancy places on her body. Once care is sought, it is often sporadic, and many appointments are usually missed.
The nurse should formulate a diagnosis that assists the pregnant teen to receive adequate prenatal care. Planning for her pregnancy and impending birth actually provides some sense of control for the teen and increases her feelings of competency. Receiving praise from the nurse when she attends her prenatal appointments will reinforce the teens positive self-image.
MULTIPLE CHOICE
1. Which principle of teaching should the nurse use to ensure learning in a family situation?
a. Motivate the family with praise and positive feedback.
b. Learning is best accomplished with the lecture format.
c. Present complex subject material first while the family is alert and ready to learn.
d. Families should be taught using medical jargon so they will be able to understand the technical language used by physicians.
ANS: A
Praise and positive feedback are particularly important when a family is trying to master a frustrating task such as breastfeeding. A lively discussion stimulates more learning than a straight lecture, which tends to inhibit questions. Learning is enhanced when the teaching is structured to present the simple tasks before the complex material. Even though a family may understand English fairly well, they may not understand the medical terminology or slang terms that are used.
2. Which nursing intervention is an independent function of the nurse?
a. Administering oral analgesics
b. Requesting diagnostic studies
c. Teaching the client perineal care
d. Providing wound care to a surgical incision
ANS: C
Nurses are now responsible for various independent functions, including teaching, counseling, and intervening in nonmedical problems. Interventions initiated by the physician and carried out by the nurse are called dependent functions. Administrating oral analgesics is a dependent function; it is initiated by a physician and carried out by a nurse. Requesting diagnostic studies is a dependent function. Providing wound care is a dependent function; it is usually initiated by the physician through direct orders or protocol.
3. Which most therapeutic response to the clients statement, Im afraid to have a cesarean birth should be made by the nurse?
a. Everything will be OK.
b. Dont worry about it. It will be over soon.
c. What concerns you most about a cesarean birth?
d. The physician will be in later and you can talk to him.
ANS: C
The response, What concerns you most about a cesarean birth focuses on what the client is saying and asks for clarification, which is the most therapeutic response. The response, Everything will be ok is belittling the clients feelings. The response, Dont worry about it. It will be over soon will indicate that the clients feelings are not important. The response, The physician will be in later and you can talk to him does not allow the client to verbalize her feelings when she wishes to do that.
4. Which action should the nurse take to evaluate the clients learning about performing infant
care?
a. Demonstrate infant care procedures.
b. Allow the client to verbalize the procedure.
c. Routinely assess the infant for cleanliness.
d. Observe the client as she performs the procedure.
The clients correct performance of the procedure under the nurses supervision is the best proof of her ability. Demonstration is an excellent teaching method, but not an evaluation method. During verbalization of the procedure, the nurse may not pick up on techniques that are incorrect. It is not the best tool for evaluation. Routinely assessing the infant for cleanliness will not ensure that the proper procedure is carried out. The nurse may miss seeing that unsafe techniques being used.
5. A nurse is reviewing teaching and learning principles. Which situation is most conducive to learning?
a. An auditorium is being used as a classroom for 300 students.
b. A teacher who speaks very little Spanish is teaching a class of Hispanic students.
c. A class is composed of students of various ages and educational backgrounds.
d. An Asian nurse provides nutritional information to a group of pregnant Asian women.
ANS: D
A clients culture influences the learning process; thus, a situation that is most conducive to learning is one in which the teacher has knowledge and understanding of the clients cultural beliefs. A large class is not conducive to learning. It does not allow questions, and the teacher cannot see nonverbal cues from the students to ensure understanding. The ability to understand the language in which teaching is done determines how much the client learns. Clients for whom English is not their primary language may not understand idioms, nuances, slang terms, informed usage of words, or medical terms. The teacher should be fluent in the language of the student.
Developmental levels and educational levels influence how a person learns best. For the teacher to present the information in the best way, the class should be at the same level.
6. Which is the step of the nursing process in which the nurse determines the appropriate interventions for the identified nursing diagnosis?
a. Planning
b. Evaluation
c. Assessment
d. Intervention
ANS: A
The third step in the nursing process involves planning care for problems that were identified during assessment. The evaluation phase is determining whether the goals have been met. During the assessment phase, data are collected. The intervention phase is when the plan of care is carried out.
MSC: Client Needs: Safe and Effective Care Environment
7. Which goal is most appropriate for the collaborative problem of wound infection?
a. The client will not exhibit further signs of infection.
b. Maintain the clients fluid intake at 1000 mL/8 hr.
c. The client will have a temperature of 98.6 F within 2 days.
d. Monitor the client to detect therapeutic response to antibiotic therapy.
In a collaborative problem, the goal should be nurse-oriented and reflect the nursing interventions of monitoring or observing. Monitoring for complications such as further signs of infection is an independent nursing role. Intake and output is an independent nursing role.
Monitoring a clients temperature is an independent nursing role.
8. Which nursing intervention is correctly written?
a. Force fluids as necessary.
b. Observe interaction with the infant.
c. Encourage turning, coughing, and deep breathing.
d. Assist to ambulate for 10 minutes at 8 AM, 2 PM, and 6 PM.
ANS: D
Interventions might not be carried out if they are not detailed and specific. Force fluids is not specific; it does not state how much. Encouraging the client to turn, cough, and breathe deeply is not detailed and specific. Observing interaction with the infant does not state how often this procedure should be done.
9. The client makes the statement: Im afraid to take the baby home tomorrow. Which response by the nurse would be the most therapeutic?
a. Youre afraid to take the baby home?
b. Dont you have a mother who can come and help?
c. You should read the literature I gave you before you leave.
d. I was scared when I took my first baby home, but everything worked out.
ANS: A
This response uses reflection to show concern and open communication. The other choices are blocks to communication. Asking if the client has a mother who can come and help blocks further communication with the client. Telling the client to read the literature before leaving does not allow the client to express her feelings further. Sharing your feelings about your experience with a new baby blocks further communication with the client.
10. The nurse is writing an expected outcome for the nursing diagnosisacute pain related to trauma of tissue, secondary to vaginal birth, as evidenced by client stating pain of 8 on a scale of
10. Which is a correctly stated expected outcome for this problem?
a. Client will state that pain is a 2 on a scale of 10.
b. Client will have a reduction in pain after administration of the prescribed analgesic.
c. Client will state an absence of pain 1 hour after administration of the prescribed analgesic.
d. Client will state that pain is a 2 on a scale of 10, 1 hour after the administration of the prescribed analgesic.
ANS: D
The outcome should be client-centered, measurable, realistic, and attainable and have a time frame. Client stating that pain is now 2 on a scale of 10 lacks a time frame. Client having a
reduction in pain after administration of the prescribed analgesic lacks a measurement. Client stating an absence of pain 1 hour after the administration of prescribed analgesic is unrealistic.
11. Which nursing diagnosis should the nurse set as a priority for a laboring client?
a. Risk for anxiety related to upcoming birth
b. Risk for imbalanced nutrition related to NPO status
c. Risk for altered family processes related to new addition to the family
d. Risk for injury (maternal) related to altered sensations and positional or physical changes
ANS: D
The nurse should determine which problem needs immediate attention. Risk for injury is the problem that has the priority at this time because it is a safety problem. Risk for anxiety, imbalanced nutrition, and altered family processes are not the priorities at this time.
12. Regarding advanced roles of nursing, which statement is true with regard to clinical practice?
a. Family nurse practitioners (FNPs) can assist with childbirth care in the hospital setting.
b. Clinical nurse specialists provide primary care to obstetric clients.
c. Neonatal nurse practitioners provide emergency care in the postbirth setting to high-risk infants.
d. A certified nurse midwife (CNM) is not considered to be an advanced practice nurse.
ANS: C
Neonatal NPs provide care for the high-risk neonate in the birth room and in the neonatal intensive care unit, as needed. FNPs do not participate in childbirth care but can take care of uncomplicated pregnancies and postbirth care outside of the hospital setting. CNSs work in hospital settings but do not provide primary care services to clients. A CNM is an advanced practice nurse who receives additional certification in the specific area of midwifery.
13. You are taking care of a couple postbirth who are very eager to learn about bathing techniques that they can use for their newborn. Which teaching technique could the nurse use to facilitate parents learning about giving a bath to their newborn infant?
a. Provide direct, step-by-step demonstration to each parent separately to foster individual retention and comprehension.
b. Present information to parents prior to discharge so that the information will be current.
c. Have each parent bathe the newborn each time the infant comes to the room and provide commentary after the skill repetition.
d. Demonstrate bathing techniques on the newborn infant with parents in attendance.
ANS: D
Demonstration of bathing techniques is a form of role modeling that would enhance teaching and learning outcomes. Presenting the information at the time of discharge will not allow for identification of concerns and/or evaluation of whether the skill has been acquired. Although it may be advantageous to have each parent bathe their newborn, this action would not be advised in terms of time management and safety related to maintenance of core temperature.
14. Which statement is true regarding the shortage of nurses in the United States?
a. There are a larger proportion of younger nurses in the workforce as compared with older nurses.
b. As a result of decreased RN-to-client ratios, there is a decrease in client mortality in the clinical setting.
c. Increased needs for baccalaureate nurses are not being met by current enrollment.
d. There are adequate classroom and clinical facilities for training RNs.
ANS: C
According to an Institute of Medicine (IOM) report, by the year 2020, there will only be 50% of RNs with baccalaureate degrees. The required demand is at 80%. There are a larger proportion of older nurses in the workforce based on current research by the IOM. Increased RN-to-client ratios has resulted in decreased client mortality in the clinical setting. There are limitations of classroom and clinical facilities to train new nurses adequately.
15. A hospital has achieved Magnet status. Which indicators would be consistent with this type of certification?
a. There is stratification of communication in a directed manner between nursing staff and administration.
b. There is increased job satisfaction of nurses, with a low staff turnover rate.
c. Physicians are certified in their respective specialty areas.
d. All nurses have baccalaureate degrees and certification in their clinical specialty area.
ANS: B
Magnet status is a certification offered by the ANCC (American Nurses Credentialing Center) in which hospitals apply based on designated criteria that consider nurse job satisfaction, staff patterns, strength, quality of nursing staff, and open communication. It is not based on physician status. Although the expectation is that at least 80% of the nurses will have baccalaureate degrees, most hospitals that achieve Magnet status have 50% of RNs at that level. Also, certification is not required for all nurses at this point. The expectation with Magnet status is that nurses will continue to expand their knowledge by earning additional degrees and certification.
16. Which of the following indicates a nurses role as a researcher?
a. Reading peer-reviewed journal articles
b. Working as a member of the interdisciplinary team to provide client care
c. Helping client to obtain home care post-discharge from the hospital
d. Delegating tasks to unlicensed personnel to allow for more teaching time with clients
ANS: A
A nurse in a researcher role should look to improve her or his knowledge base by reading and reviewing evidence-based practice information as found in peer-reviewed journals. Working as a member of the interdisciplinary team to provide client care indicates that the nurse is working as a collaborator. Helping the client to obtain home care post-discharge from the hospital indicates that the nurse is working as a client advocate. Delegating tasks to unlicensed personnel to allow for more teaching time with clients indicates that the nurse is working as a manager.
17. A 16-year-old primipara has just completed her first prenatal visit with the health care provider. The nurse is preparing to teach her about nutrition during pregnancy. What must the nurse include in the patients teaching plan?
a. Provide her with pictures of dairy products.
b. Ask her, Are you ready to hear this information now?
c. Read directly from the pamphlet prepared for teen mothers.
d. Provide a comfortable and warm setting after she has put on her street clothes.
ANS: D
The nurse must structure teaching for teens in a way that suits them best. For teaching to be most effective, the physical environment must be comfortable and distractions to learning must be kept at a minimum. Pictures, videos, and computer-based materials are more effective teaching tools for younger clients. Patients must have an attitude of readiness and openness for the teaching to be effective. However, if the environment is not conducive to learning, efforts for effective teaching will be minimized.
18. The nurse states to the newly pregnant patient, Tell me how you feel about being pregnant. Which communication technique is the nurse using with this patient?
a. Clarifying
b. Paraphrasing
c. Reflection
d. Structuring
ANS: A
The nurse is attempting to follow up and check the accuracy of the patients message. Paraphrasing is restating words other than those used by the patient. Reflection is verbalizing comprehension of what the patient has said. Structuring takes place when the nurse has set guidelines or set priorities.
19. The pregnant woman tells the nurse, I think something may be wrong with my pregnancy. Which statement by the nurse demonstrates therapeutic communication?
a. Most women worry; I felt the same way when I was pregnant.
b. Tell me more about what concerns you about this pregnancy.
c. That is a very common concern, but your pregnancy will turn out just fine.
d. You should focus on taking care of yourself and not worry so much.
ANS: B
Questioning is a therapeutic communication technique in which additional information is elicited by using open-ended questions. The remaining options are examples of three behaviors that block communicationinappropriate self-disclosure, providing false reassurance, and giving advice.
MULTIPLE RESPONSE
20. The nurse is formulating a nursing care plan for a postpartum client. Which actions by the nurse indicate use of critical thinking skills when formulating the care plan? (Select all that apply).
a. Using a standardized postpartum care plan
b. Determining priorities for each diagnosis written
c. Writing interventions from a nursing diagnosis book
d. Reflecting and suspending judgment when writing the care plan
e. Clustering data during the assessment process according to normal versus abnormal
ANS: B, D, E
Critical thinking focuses on appraisal of the way the individual thinks, and it emphasizes reflective skepticism. Determining priorities, reflecting and suspending judgment, and clustering data are actions that indicate the use of critical thinking. Using a standardized care plan and writing interventions from a nursing diagnosis book do not show that reflection about the clients individual care is being done.
21. The nurse is teaching a group of nursing students about behaviors that can block or open lines of communication. Which behaviors open the lines of communication? (Select all that apply).
a. Sitting at the bedside
b. Leaning forward with arms relaxed
c. Acknowledging the clients comments or feelings
d. Self-disclosing about your personal birth experience
e. Holding a laptop computer in front of your body during an interview
ANS: A, B, C
Behaviors that open the lines of communication can be described as attending behaviors, which convey the nurses interest and a sincere desire to understand. Acknowledging the clients comments or feelings is an attending behavior. Nonverbal behaviors are just as powerful as spoken words. The nurse should convey an open attitude, such as sitting at the bedside and leaning forward with arms relaxed while listening. Self-disclosing is inappropriate and closes lines of communication. Holding a laptop on your lap during the interview process is putting a barrier between the nurse and client.
MULTIPLE CHOICE
1. A pregnant woman tells the nurse that she got relief from nausea when she had a therapy that involves pressure and massage on meridian sites. What type of therapy does this describe?
a. Acupuncture
b. Acupressure
c. Aromatherapy
d. Ayurveda ANS: B
Acupressure uses finger pressure and massage on the meridian sites. It can be used during pregnancy to control nausea, backache, and pain. It has been useful for minor postpartum problems such as constipation.
2. Which child should not receive massage therapy?
a. 15-year-old with a fractured femur
b. 12-year-old with diabetes mellitus
c. 8-year-old with Down syndrome
d. 17-year-old with an eating disorder ANS: C
Children with Down syndrome are prone particularly to cervical spine anomalies and may be injured by massage therapy.
3. A pregnant woman wishes to use aromatherapy during her labor and delivery. What is the most appropriate essential oil for the nurse to recommend?
a. Juniper
b. Wintergreen
c. Thyme
d. Citrus ANS: D
Citrus is one essential oil that has been shown to be useful during labor and delivery.
4. A parent asks the nurse, What is guided imagery? Which statement is the most accurate response?
a. It is a technique where the patient focuses on an image to relieve stress.
b. It involves using water to promote relaxation.
c. The patient enters a hypnotic state of sleep to promote relaxation.
d. It helps the patient recognize tension in the muscles with responses on an electronic machine. ANS: A
In guided imagery, by focusing on a specific image, stress reduction and improved performance can result.
5. A woman taking St. Johns wort and ginseng daily is scheduled to have a hysterectomy in 3 weeks. What instruction should the nurse provide?
a. The herbs are not likely to cause any problems during the surgery.
b. The St. Johns wort must be stopped prior to surgery, but she can continue the ginseng.
c. The ginseng should be stopped 1 week before surgery.
d. She should discontinue taking both herbs 2 weeks before surgery. ANS: D
Both St. Johns wort and ginseng can cause problems during surgery, and their use should be discontinued 2 weeks before surgery.
6. Which herb can the nurse suggest to be used for discomforts associated with menopause, such as hot flashes?
a. Evening primrose oil
b. Echinacea
c. Milk thistle
d. Black cohosh ANS: D
Black cohosh diminishes hot flashes by reducing luteinizing hormone. It also reduces joint pain and other menopausal discomforts.
7. What is the difference between complementary therapy and alternative therapy?
a. Complementary therapy must be administered by a medical doctor.
b. Complementary therapy is administered with conventional therapy.
c. Complementary therapy replaces conventional therapy.
d. Complementary therapy is administered to a group of patients at the same time. ANS: B
Complementary therapy is administered with conventional therapy, such as massage with muscle relaxants for low back pain.
8. The nurse uses a diagram to show the location of meridians. How will the nurse explain the definition of meridians?
a. They are lymph nodes.
b. They are invisible pathways for energy.
c. They are lines that divide the body into 10 zones.
d. They are areas of skin that are specifically innervated. ANS: B
Meridians are invisible pathways through which energy travels to effect acupuncture treatment.
9. Which herbal remedy used by a patient taking warfarin should the nurse report to the physician?
a. Angelica (dong quai)
b. Chamomile
c. Ginseng
d. Kava-kava ANS: A
Angelica prolongs prothrombin time and will synergize the effect of the warfarin.
10. What should the nurse remind a parent who is considering homeopathic remedies for treatment of her childs asthma?
a. Should be drunk with large amounts of fluid
b. Can be taken with traditional Western medications
c. Can be enhanced by drinking hot tea
d. May contain mercury, alcohol, or arsenic ANS: D
Homeopathic remedies often contain mercury, alcohol, or arsenic and are taken sublingually. All Western medications should be stopped when the homeopathic therapy is begun. Caffeine drinks are to be avoided during homeopathic treatment.
11. The focus of acupressure is to restore the balance of what?
a. Chi
b. Shiatsu
c. Yin and yang
d. Ayurveda ANS: A
Acupressure is focused on the return of the balance of Chi to control disease processes.
12. A breastfeeding mother tells the nurse she is taking large doses of vitamin C to keep up her energy. What should the nurse warn that large doses of vitamin C can cause in an infant?
a. Diarrhea
b. Jaundice
c. Colic
d. Retinal damage ANS: C
Vitamin C can be passed on to a breastfeeding child through breast milk and can cause colic.
13. The pregnant patient with a stasis ulcer asks if she might be a candidate for hyperbaric oxygen therapy (HBOT). What is the nurses best response?
a. Yes. Hyperbaric oxygen therapy should have no harmful effect on your baby.
b. No. High amounts of oxygen in your system will cause changes in your babys heart.
c. Yes. Hyperbaric oxygen therapy is a much better option than using antibiotics.
d. No. Hyperbaric oxygen therapy may cause the placenta to separate from the uterine wall. ANS: B
High concentrations of oxygen in the mothers blood can cause closure of the ductus arteriosus and cause fetal death.
14. A patient is providing history information to the admitting nurse about treatment used for chronic pain. The patient reports she participates in a type of relaxation therapy that enables her to recognize tension in the muscles via responses on an electronic machine and visual electromyography responses. What type of therapy does the nurse record on admission record?
a. Guided imagery
b. Biofeedback
c. Hypnotherapy
d. Chiropractic care ANS: B
Biofeedback is a type of relaxation therapy that enables the patient to recognize tension in the muscles via responses on an electronic machine and visual electromyography responses. The process is also used by traditional health care providers for drug addiction and chronic pain control.
MULTIPLE RESPONSE
15. What conditions would a nurse expect to see treated with hyperbaric oxygen therapy (HBOT)? (Select all that apply.)
a. Wounds
b. Carbon monoxide poisoning
c. Hyperemesis gravidarum
d. Decompression illness
e. Pneumonia ANS: A, B, D
Hyperbaric oxygen therapy (HBOT) uses an airtight enclosure to provide compressed air or oxygen under increased pressure. HBOT is used to revive children with carbon monoxide poisoning, to aid wound healing, and to treat the diving syndrome known as decompression illness. HBOT is contraindicated during pregnancy, because the increased oxygen saturation can cause the ductus arteriosus to close, resulting in fetal death.
16. The nurse points out that light therapy is used in the treatment of patients with which disorder(s)? (Select all that apply.)
a. Digestive disorders
b. Seasonal affective disorder
c. Inflammatory diseases
d. Stress disorders
e. Jaundice ANS: B, E
Light therapy has proven effective in the treatment of persons with seasonal affective disorders. Light therapy is also used in the treatment of jaundiced babies.
17. What advantage(s) of alternative health care should the nurse outline when providing information to patients? (Select all that apply.)
a. Offering more patient control of health care
b. Offering a variety of health care advisors
c. Keeping patients from having to make decisions
d. Using natural products rather than chemical ones
e. Incorporating cultural beliefs and practices ANS: A, B, D, E
Alternative health care actually promotes the patients decision making in care.
18. Which approaches to care are combined with osteopathy? (Select all that apply.)
a. Manipulation therapy
b. Aroma therapy
c. Herbal application
d. Pressure point therapy
e. Traditional medicine ANS: A, D, E
COMPLETION
22. The practice of is a process of fascia pressure and stretching. ANS:
rolfing
Rolfing involves a process of stretching and placing pressure on the fascia to improve muscle and bone function.
19. is an ancient practice that involves concentrated fluid or the essence of specific herbs that are combined with steams or baths to inhale or bathe the skin.
ANS:
Aromatherapy
Aromatherapy is an ancient practice that involves concentrated fluid or the essence of specific herbs that are combined with steams or baths to inhale or bathe the skin.
20. In 1992 the National Institutes of Health (NIH) created the Office of Alternative Medicine to evaluate the various CAM therapies. It has since been renamed
the .
ANS:
National Center for Complementary and Alternative Medicine (NCCAM)
In 1992 the National Institutes of Health (NIH) created the Office of Alternative Medicine to evaluate the various CAM therapies. It has since been renamed the National Center for Complementary and Alternative Medicine (NCCAM). This Center serves as a public clearinghouse and resource for research concerning CAM therapies.
1. The perinatal nurse describes risk factors for placenta previa to the student nurse. Placenta previa risk factors include (select all that apply):
a. Cocaine use
b. Tobacco use
c. Previous caesarean birth
d. Previous use of medroxyprogesterone (Depo-Provera)
ANS: a, b, c Feedback
a. Placenta previa may be associated with risk factors including smoking, cocaine use, a prior history of placenta previa, closely spaced pregnancies, African or Asian ethnicity, and maternal age greater than 35 years.
b. Placenta previa may be associated with risk factors including smoking, cocaine use, a prior history of placenta previa, closely spaced pregnancies, African or Asian ethnicity, and maternal age greater than 35 years.
c. Placenta previa may be associated with conditions that cause scarring of the uterus such as a prior cesarean section, multiparity, or increased maternal age.
d. Previous use of medroxyprogesterone (Depo-Provera) is not a risk factor for placenta previa.
2. There is little consensus on the management of premenstrual dysphoric disorder (PMDD). However, nurses can advise women on several self-help modalities that often improve symptoms. The nurse knows that health teaching has been effective when the client reports that she has adopted a number of lifestyle changes, including (Select all that apply):
a. Regular exercise.
b. Improved nutrition.
c. A daily glass of wine.
d. Smoking cessation.
e. Oil of evening primrose.
ANS: A, B, D, E
These modalities may provide significant symptom relief in 1 to 2 months. If there is no improvement after these changes have been made, the patient may need to begin pharmacologic therapy. Women should decrease both their alcohol and caffeinated beverage consumption if they have PMDD.
3. A man smokes two packs of cigarettes a day. He wants to know if smoking is contributing to the difficulty he and his wife are having getting pregnant. The nurses most appropriate response is:
a. Your sperm count seems to be okay in the first semen analysis.
b. Only marijuana cigarettes affect sperm count.
c. Smoking can give you lung cancer, even though it has no effect on sperm.
d. Smoking can reduce the quality of your sperm.
ANS: D
Use of tobacco, alcohol, and marijuana may affect sperm counts. Your sperm count seems to be okay in the first semen analysis is inaccurate. Sperm counts vary from day to day and depend on emotional and physical status and sexual activity. A single analysis may be inconclusive. A minimum of two analyses must be performed several weeks apart to assess male fertility.
4. While evaluating a patient for osteoporosis, the nurse should be aware of what risk factor?
a. African-American race
b. Low protein intake
c. Obesity
d. Cigarette smoking
ANS: D
A Women at risk for osteoporosis are likely to be Caucasian or Asian.
B Inadequate calcium intake is a risk factor for osteoporosis.
C Women at risk for osteoporosis are likely to be small boned and thin. Obese women have higher estrogen levels as a result of the conversion of androgens in the adipose tissue.
Mechanical stress from extra weight also helps preserve bone mass.
D Smoking is associated with earlier and greater bone loss and decreased estrogen production.
5. A 21-year-old pregnant woman smokes 8 to 10 cigarettes per day. The clinic nurse reviews the patients diet with her and notes that she does not eat fruits or vegetables. Which action should the nurse recommend to this patient?
A. Cut down on smoking and eventually quit.
B. Eat non-produce sources of vitamin C.
C. Take an over-the-counter vitamin C supplement.
D. Try to drink one glass of orange juice daily. ANS: C
Food sources rich in vitamin C include produce such as red and green sweet peppers, oranges, kiwi fruit, grapefruit, strawberries, Brussels sprouts, cantaloupe, broccoli, sweet potatoes, tomato juice, cauliflower, pineapple, and kale. Most pregnant women are able to meet the recommended daily allowance (80 to 85 mg) by including at least one daily serving of citrus fruit or juice or vitamin Crich food source, but women who smoke need more (NIH, 2011). Although it is important for the woman to quit smoking, this alone will not help her meet her dietary need for Vitamin C. Because she does not eat the primary sources of this vitamin, an over-the-counter supplement would be her best option.
6. A woman in her second trimester continues to smoke a pack of cigarettes a day despite stating that she understands why smoking is bad for her and for her fetus. Which action by the nurse is best?
A. Assess the patient for past trauma and abuse.
B. Document the information in the patients chart.
C. Review prior teaching done regarding smoking.
D. Show photos of babies born with abnormalities. ANS: A
Research shows that women who continue to smoke during pregnancy often report high levels of trauma and abuse and higher levels of PTSD symptoms. Women who smoke as a coping mechanism are even more likely to smoke during pregnancy (Lopez, Konrath, & Seng, 2011).
The nurse should assess for these factors. Documentation is important, but is not the best answer because the nurse does not do anything to assist the patient; documentation alone is the answer only when the data are normal. Reviewing prior teaching may be helpful, but if the nurse does not help the patient address the core issue of smoking, this review will be unhelpful and a waste of time. Showing babies born with abnormalities is demeaning and could be interpreted as threatening.
7. The nurse advocates for smoking cessation during pregnancy and teaches pregnant women about the effects of tobacco exposure. Which of the following are potential harmful effects of prenatal tobacco use that the nurse should plan to include in the teaching? (Select all that apply.)
A. Continued childhood respiratory problems
B. Congenital diabetes
C. Gestational hypertension
D. Preterm labor and birth
E. Small-for-gestational-age infant ANS: A, D, E
Effects of tobacco use during pregnancy are well documented and predispose to premature rupture of the membranes, preterm labor, placental abruption, placenta previa, and infants who are small for gestational age. These effects continue well into childhood and are associated with upper respiratory problems, such as infections, asthma, and wheezing. Exposure to tobacco products is not associated with congenital diabetes or gestational hypertension.
1. A pregnant woman in the 36th week of gestation complains that her feet are quite swollen at the end of the day. After careful assessment, the nurse determines that this is an expected finding at this stage of pregnancy. Which intervention would be most appropriate for the nurse to suggest?
A) Limit your intake of fluids.
B) Eliminate salt from your diet.
C) Try elevating your legs when you sit.
D) Wear Spandex-type full-length pants.
2. ANS.C
When assessing a pregnant woman in her last trimester, which question would be most appropriate to use to gather information about weight gain and fluid retention?
A) Whats your usual dietary intake for a typical day?
B) What size maternity clothes are you wearing now?
C) How puffy does your face look by the end of a day?
D) How swollen do your ankles appear before you go to bed?
ANS.D
3. A pregnant client in her second trimester has a hemoglobin level of 11 g/dL. The nurse interprets this as indicating which of the following?
A) Iron-deficiency anemia
B) A multiple gestation pregnancy
C) Greater-than-expected weight gain
D) Hemodilution of pregnancy
4.
ANS.D
The nurse is teaching a pregnant woman about recommended weight gain. The woman has a prepregnancy body mass index of 26. The nurse determines that the teaching was successful when the woman states that she should gain no more than which amount during pregnancy?
A) 35 to 40 pounds
B) 25 to 35 pounds
C) 28 to 40 pounds
D) 15 to 25 pounds
5. ANS.D
A nurse is developing a teaching plan about nutrition for a group of pregnant women. Which of the following would the nurse include in the discussion? (Select all that apply.)
A) Keep weight gain to 15 lb
B) Eat three meals with snacking
C) Limit the use of salt in cooking
D) Avoid using diuretics
E) Participate in physical activity
ANS. B,D,E