NCLEX Remediation Course Session 4 Exam 3 - Focus on Maternity Exam with Verified Answers, Exams of Nursing

Download NCLEX Remediation Course Session 4 Exam 3 - Focus on Maternity Exam with Verified Answers and more Exams Nursing in PDF only on Docsity! 1/132 NCLEX Remediation Course Session 4 Exam 3 - Focus on Maternity Exam with Verified Answers & Rationales 2023 Session 4 Exam 3 - Focus on Maternity Exam Due Dec 30 at 11:59pm Points 98 Questions 98 Available Dec 23 at 12am - Jan 4, 2022 at 11:59pm 13 days Time Limit 150 Minutes Attempt History Attempt Time Score LATEST Attempt 1 93 minutes 93.67 out of 98 Score for this quiz: 93.67 out of 98 Submitted Dec 28 at 10:12pm This attempt took 93 minutes. 2/132 A home care nurse is instructing a client with hyperemesis gravidarum about measures to ease the nausea and vomiting. The nurse tells the client to: Eat foods high in calories and fat Correct! Eat carbohydrates such as cereals, rice, and pasta Lie down for at least 20 minutes after meals Consume primarily soups and liquids at mealtimes 1 / 1 pts Question 1 5/132 Question 3 1 / 1 pts A client with preeclampsia who is receiving magnesium sulfate in an intravenous infusion exhibits signs of magnesium toxicity. The nurse immediately prepares for the administration of: Correct! Calcium gluconate Protamine sulfate Naloxone hydrochloride Vitamin K 6/132 A nurse instructs a pregnant client about foods that are high in folic acid. Which item does the nurse tell the client is the best source of folic acid? Steak Correct! Lima beans 1 / 1 pts Question 4 Rationale: Calcium gluconate is the antidote to magnesium sulfate because it antagonizes the effects of magnesium at the neuromuscular junction. It should be readily available whenever magnesium is administered. Vitamin K is the antidote in cases of hemorrhage induced by the administration of oral anticoagulants such as warfarin sodium (Coumadin). Protamine sulfate is the antidote in cases of hemorrhage induced by the administration of heparin. Naloxone hydrochloride is administered to treat opioid- induced respiratory depression. Test-Taking Strategy: Focus on the subject of the question, the treatment for magnesium toxicity. Specific knowledge regarding antidotes and the process of elimination will assist in directing you to the correct option. Review common antidotes if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Gahart, B., & Nazareno, A. (2015). 2015 Intravenous medications (31st ed., p. 773). St. Louis: Mosby. 7/132 A nurse is providing instructions to a mother of an infant with seborrheic dermatitis (cradle cap) about treatment of the condition. The nurse tells the mother to: Wash the infant’s scalp daily, using only tepid water 1 / 1 pts Question 5 Chicken Milk Rationale: The best sources of folic acid are liver; kidney, pinto, lima, and black beans; and fresh dark-green leafy vegetables. Other good sources of folic acid are orange juice, peanuts, refried beans, and peas. Milk is high in calcium. Chicken and steak are high in protein. Test-Taking Strategy: Use the process of elimination and focus on the subject, the best source of folic acid. Eliminate the options that are comparable or alike in that they are high in protein. Next eliminate milk, recalling that milk is high in calcium. Review the foods high in folic acid if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Nutrition Giddens Concepts: Nutrition, Reproduction HESI Concepts: Metabolism – Nutrition, Sexuality, Reproduction Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 282-283). St. Louis: Elsevier. Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., pp. 114, 119). St. Louis: Mosby. 10/132 A client who delivered a healthy newborn 11 days ago calls the clinic and tells the nurse that she is experiencing a white vaginal discharge. The nurse tells the client: To come to the clinic for a checkup Correct! That this is a normal postpartum occurrence 1 / 1 pts Question 7 Rationale: If the client has been given an epidural opioid, the nurse should monitor the client’s respiratory status closely. If the oxygen saturation falls below 95%, the nurse instructs the client to take several deep breaths to increase the level. Although the finding would be documented, action is required to increase the oxygen saturation level. It is not necessary to contact the health care provider. If the deep breaths fail to increase the oxygen saturation level, the health care provider is notified and may prescribe oxygen. Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Noting the oxygen saturation level will assist you in eliminating this option. Noting the strategic word “first” will direct you to the correct option. Review care of the client after a cesarean birth if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Giddens Concepts: Clinical Judgment, Gas Exchange HESI Concepts: Clinical Decision-Making/Clinical Judgment, Oxygenation/Gas Exchange Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 430-431). St. Louis: Elsevier. 11/132 Question 8 1 / 1 pts That this is an indication of an infection To perform a vaginal douche Rationale: For the first 3 days following childbirth, lochia consists almost entirely of blood, with small particles of decidua and mucus, and is called lochia rubra because of its red color. The amount of blood decreases by about the fourth day, and which time the lochia changes from red to pink or brown-tinged; this stage is called lochia serosa. By about the 11th day, the erythrocyte component of lochia has decreased and the discharge becomes white or cream- colored. This final stage is known as lochia alba. Lochia alba contains leukocytes, decidual cells, epithelial cells, fat, cervical mucus, and bacteria. It is present in most women until the third week after childbirth but may persist for as long as 6 weeks. Lochia alba is a normal finding during the postpartum course, and no intervention is required, so the other options are incorrect. Test-Taking Strategy: Use your knowledge of expected postpartum findings to answer the question. Recalling the normal expected occurrences in regard to vaginal discharge will direct you to the correct option. Also, noting that the incorrect options are comparable or alike will direct you to the correct option. Review normal postpartum findings in regard to lochia if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Giddens Concepts: Clinical Judgment, Reproduction HESI Concepts: Clinical Decision-Making/Clinical Judgment, Sexuality/Reproduction Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 435). St. Louis: Elsevier. 12/132 A rubella antibody screen is performed in a pregnant client, and the results indicate that the client is not immune to rubella. The nurse tells the client that: A rubella vaccine must be administered immediately Correct! A rubella vaccine must be administered after childbirth She will not contract rubella if she is exposed to the disease She does not need to be concerned about being exposed to rubella 15/132 A nurse is assessing the uterine fundus of a client who has just delivered a baby and notes that the fundus is boggy. The nurse massages the fundus, and then presses to expel clots from the uterus. To prevent uterine inversion during this procedure, the nurse: Correct! Simultaneously provides pressure over the lower uterine segment Tells the woman to bear down during fundal message Asks the client to take slow, deep breaths during fundal assessment Has the client void before the uterine assessment 16/132 A nonstress test is performed, and the health care provider documents “accelerations lasting less than 15 seconds throughout fetal movement.” The nurse interprets these findings as: Normal 1 / 1 pts Question 11 Rationale: After massaging a boggy fundus until it is firm, the nurse presses the fundus to expel clots from the uterus. The nurse must also keep one hand pressed firmly just above the symphysis (over the lower uterine segment) the entire time. Removing the clots allows the uterus to contract properly. Providing pressure over the lower uterine segment prevents uterine inversion. Having the client void before uterine assessment will not prevent uterine inversion. Telling the woman to bear down while the nurse performs fundal message and asking the client to take slow, deep breaths during fundal assessment also will not prevent uterine inversion. Test-Taking Strategy: Use the process of elimination, focusing on the subject, prevention of uterine inversion. Visualizing each of the actions in the options and relating the action to the subject of the question will direct you to the correct option. Review fundal assessment and massage if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Giddens Concepts: Reproduction, Safety HESI Concepts: Sexuality/Reproduction, Safety Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 442, 668). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 1 / 1 pts Question 12 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 16/132 Reactive Inconclusive Correct! Nonreactive Rationale: A reactive nonstress test is a normal, or negative, result and indicates a healthy fetus. The result requires two or more fetal heart rate accelerations of at least 15 beats/min lasting at least 15 seconds from the beginning of the acceleration to the end, in association with fetal movement, during a 20-minute period. A nonreactive test is an abnormal test, showing no accelerations or accelerations of less than 15 beats/min or lasting less than 15 seconds during a 40-minute observation. An inconclusive result is one that cannot be interpreted because of the poor quality of the fetal heart rate recording. Test-Taking Strategy: Use the process of elimination. Eliminate a reactive nonstress test and a normal nonstress test first because they are comparable or alike. To select from the remaining options, note the relationship between “less than 15 seconds” in the question and “nonreactive” in the correct option. If you had difficulty answering this question, review the interpretation of nonstress test results. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Maternity/Antepartum Giddens Concepts: Clinical Judgment, Reproduction HESI Concepts: Clinical Decision-Making/Clinical Judgment, Sexuality/Reproduction Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 309). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 19/132 A nurse is reviewing the records of the clients admitted to the maternity unit during the past 24 hours. Which clients does the nurse recognize as being at risk for the development of disseminated intravascular coagulation (DIC)? Select all that apply. 1 / 1 pts Question 14 Rationale: The pregnant woman needs a well-balanced diet high in iron and protein and adequate in calories for weight gain. Iron supplements that are taken during pregnancy tend to cause constipation. Constipation causes the client to strain during defecation, inadvertently performing the Valsalva maneuver, which causes blood to rush to the heart and overload the cardiac system. The pregnant woman, then, should increase her intake of fluids and fiber. An unlimited intake of sodium (pretzels, cheese, nachos) could cause overload of the circulating blood volume and contribute to the cardiac condition. Test-Taking Strategy: Use the process of elimination and note that the client has a history of cardiac disease. Recalling the concepts of care of the client with cardiac disease and noting that the question involves a client who is pregnant will direct you to the correct option. Review dietary requirements and examples of foods containing those requirements for a cardiac client who is pregnant if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Maternity/Antepartum Giddens Concepts: Nutrition, Reproduction HESI Concepts: Metabolism – Nutrition, Sexuality, Reproduction Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 281, 616). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 20/132 A client with diabetes mellitus who delivered a 10-lb (4.5 kg) baby Correct! A client with septicemia A client with mild preeclampsia A client who delivered 12 hours ago and has lost 475 mL of blood Correct! A client who had a cesarean section because of abruptio placentae Rationale: DIC is a pathologic form of clotting that is diffuse and consumes large amounts of clotting factors, including platelets, fibrinogen, prothrombin, and factors V and VII. In the obstetric population, DIC occurs as a result of abruptio placentae, amniotic fluid embolism, dead fetus syndrome (in which the fetus has died but is retained in utero for at least 6 weeks), severe preeclampsia, septicemia, cardiopulmonary arrest, or hemorrhage. A loss of 475 mL is not considered hemorrhage .A mild case of preeclampsia is not a risk factor for DIC. It is not unusual for a client with diabetes mellitus to deliver a large baby, and this condition is unrelated to DIC. Test-Taking Strategy: Use the process of elimination and focus on the subject, the client at risk for DIC. Thinking about the pathophysiology of DIC and the conditions listed in the options will assist in answering correctly. Review the risk factors associated with DIC if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Maternity/Intrapartum Giddens Concepts: Reproduction, Perfusion HESI Concepts: Sexuality/Reproduction, Perfusion/Clotting Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 578). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 21/132 Question 15 1 / 1 pts A delivery room nurse is preparing a client for a cesarean delivery. The client is placed on the delivery room table, and the nurse positions the client: Prone In the Trendelenburg position Correct! Supine with a wedge under the right hip In a semi-Fowler position 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 24/132 A nurse provides instructions to a breastfeeding mother who is experiencing breast engorgement about measures for treating the problem. The nurse tells the mother to: 1 / 1 pts Question 18 Correct! Dark-red lochia rubra Lochia alba Rationale: When the perineum is assessed, the lochia is checked for amount, color, and the presence of clots. The color of the lochia during the fourth stage of labor (1 to 4 hours after birth) is dark red (rubra). This is an expected occurrence until the third day after delivery. Then, from days 4 through 10, the discharge is brownish pink (serosa). Alba is a white discharge that occurs on days 11 to 14. Test-Taking Strategy: Use the process of elimination. Noting that the question refers to a client who gave birth 1 hour ago will direct you to the correct option. Review postpartum assessment findings and the types of lochia if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Maternity/Postpartum Giddens Concepts: Clinical Judgment, Reproduction HESI Concepts: Assessment, Sexuality/Reproduction Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 360, 441). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 25/132 Apply heat packs to the breasts for 15 to 20 minutes between feedings to reduce swelling Take a cool shower just before breastfeeding Correct! Gently massage the breasts during breastfeeding to help empty the breasts Avoid breastfeeding during the night time hours to ensure adequate rest Rationale: Gently massaging the breasts during breast feeding will help empty the breasts. The mother should not avoid breastfeeding during the night; instead, she should breastfeed every 2 hours or pump the breasts. The nurse instructs the woman to apply ice packs, not heat packs, to the breasts between feedings to reduce swelling. It may be helpful for the mother to stand in a warm shower just before feeding to foster relaxation and letdown. Test-Taking Strategy: Focus on the subject, breast engorgement, and think about its characteristics. Use the process of elimination and visualize each of the descriptions in the options to identify the measure that will be helpful. If you had difficulty answering the question, review the measures for breast engorgement. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Maternity/Postpartum Giddens Concepts: Client Education, Tissue Integrity HESI Concepts: Teaching and Learning/Patient Education, Tissue Integrity Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 542). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 26/132 Question 19 1 / 1 pts When, during the normal postpartum course, would the nurse expect to note the fundal assessment shown in the figure? 4 days after delivery When the client’s bladder is full Correct! Immediately after delivery The day after delivery 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 29/132 Encouraging the client to ambulate every 30 minutes Monitoring the oxytocin (Pitocin) infusion closely Preparing the client for amniotomy Correct! Providing pain relief Rationale: Management of hypertonic uterine dysfunction depends on the cause. Relief of pain is the primary intervention in promoting a normal labor pattern. Therapeutic management of hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate labor progression. The client with hypertonic uterine dysfunction would be encouraged to rest, not to ambulate every 30 minutes. Test-Taking Strategy: Use the process of elimination, focusing on the strategic words “hypertonic” and “priority.” This, plus knowledge of the management of this condition, should direct you to the correct option. Also eliminate the options that are therapeutic measures for hypotonic uterine dysfunction and would stimulate labor (i.e., oxytocin augmentation and amniotomy). If you had difficulty with this question, review the management of hypertonic uterine dysfunction. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Giddens Concepts: Care Coordination, Clinical Judgment HESI Concepts: Clinical Decision-Making/Clinical Judgment, Collaboration/Managing Care – Care Coordination Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 636-637). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 30/132 Question 22 1 / 1 pts A nurse is preparing to care for a client experiencing dystocia. To which intervention does the nurse give priority? Changing the client’s position Correct! Monitoring fetal status Providing comfort measures Informing the client’s partner of the progress of the labor 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 31/132 A postpartum client asks a nurse when she may safely resume sexual activity. The nurse tells the client that she may resume sexual activity: When her normal menstrual period has resumed ou Answered After the 6-week health care provider checkup orrect Answer In 2 to 4 weeks 0 / 1 pts Question 23 Rationale: The priority intervention is monitoring fetal status. Once this is done, the nurse provides maternal comfort measures, including positioning the client, because this may decrease anxiety and hasten the progression of labor. Keeping the client’s partner informed of the progress of the labor is also an important aspect of client care during labor but is not an immediate priority. Test-Taking Strategy: Note the strategic word “priority.” Use Maslow’s Hierarchy of Needs theory and your knowledge of the ABCs (airway, breathing, and circulation) to answer the question. Remember that physiological needs are the priority. Review priority nursing interventions for the client with dystocia if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Giddens Concepts: Care Coordination, Reproduction HESI Concepts: Collaboration/Managing Care – Care Coordination, Sexuality/Reproduction Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 609, 636). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 34/132 A nurse midwife performs an assessment of a pregnant client and documents the station of the fetal head as it is reflected in the figure below. The nurse reviews the assessment findings and determines that 1 / 1 pts Question 25 Rationale: More than one medication may be used to prevent the growth of resistant organisms in the pregnant woman with tuberculosis. Treatment must be continued for a prolonged period. The preferred treatment for the pregnant woman is isoniazid plus rifampin for a total of 9 months. Ethambutol is added initially if drug resistance is suspected. Pyridoxine (vitamin B6) is often administered with isoniazid to prevent fetal neurotoxicity. The infant will be tested at birth and may be started on preventive isoniazid therapy. Skin testing of the infant should be repeated at 3 months, and isoniazid may be stopped if the result remains negative. If the result is positive, the infant should receive isoniazid for at least 6 months. If the mother’s sputum is free of organisms, the infant does not need to be isolated from the mother while in the hospital. Test-Taking Strategy: Knowledge regarding the therapeutic management of the mother with tuberculosis and that of the infant is required to answer this question. Eliminate the options containing the closed-ended words “must,” “not,” and “immediately.” If you had difficulty with this question, review treatment measures for the mother with tuberculosis. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Maternity/Antepartum Giddens Concepts: Client Education, Infection HESI Concepts: Infection, Teaching and Learning/Patient Education Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 631). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 35/132 the fetal presenting part is: At +1 station At –1 station Correct! At zero station Stationed at the bottom of the coccyx 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 36/132 A nurse performing an assessment of a pregnant client is preparing to take the client’s blood pressure. The nurse positions the client: Correct! In a sitting position with the arm in a horizontal position at heart level Supine, on the right side Supine, on the left side Lying down with the arm in a horizontal position at heart level 1 / 1 pts Question 26 Rationale: Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. It is measured in centimeters and is noted as a negative number above the line, a positive number below the line, and zero at the line. Test-Taking Strategy: Knowing that station is measured in centimeters, with the ischial spines as a reference point, will assist you in answering this question. Focus on the figure and note that the fetal head is at zero station. Review station if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Maternity/Antepartum Giddens Concepts: Clinical Judgment, Reproduction HESI Concepts: Assessment, Sexuality/Reproduction Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 330-331). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 39/132 A nurse teaching a pregnant client about the expectations and complications of pregnancy is describing Braxton Hicks contractions. The nurse tells the client these contractions: Correct! Are a common occurrence of pregnancy Must be reported to the health care provider Indicate that labor has started Necessitate bed rest for the remainder of the pregnancy 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 40/132 A nurse is assisting a health care provider in performing a physical examination of a client who has just been told that she is pregnant. The health care provider tells the nurse that the Goodell sign is present. The nurse understands that this sign is indicative of: The presence of fetal movement 1 / 1 pts Question 29 Rationale: Braxton Hicks contractions are irregular, painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. Because Braxton Hicks contractions are a normal finding experienced by many pregnant women during pregnancy, the other options represent inaccurate assumptions and an unnecessary intervention. Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike (i.e., labor has started and the health care provider must be contacted). To select from the remaining options, recall that Braxton Hicks contractions may occur throughout pregnancy; this will direct you to the correct option. If you had difficulty with this question, review the physiology of Braxton Hicks contractions. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum Giddens Concepts: Client Education, Reproduction HESI Concepts:Sexuality/Reproduction, Teaching and Learning/Patient Education Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 234, 328). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 41/132 A nurse performing an assessment of a pregnant client prepares to auscultate the fetal heart sounds, using a Doppler ultrasound stethoscope. By which week of gestation are fetal heart sounds audible with the use of this device? 1 / 1 pts Question 30 The presence of human chorionic gonadotropin (hCG) in the urine A high risk for spontaneous abortion Correct! An increase in vascularity and hyptertrophy of the cervix Rationale: In the early weeks of pregnancy, the cervix becomes more vascular and slightly hypertrophic; this is referred to as the Goodell sign. The edematous appearance of the cervix will be noted during pelvic examination by the examiner. hCG is noted in maternal urine in a urine pregnancy test. The Goodell sign does not indicate the presence of fetal movement or a risk for spontaneous abortion. Test-Taking Strategy: Knowledge regarding the Goodell sign is required to answer this question. It is necessary to know that the sign consists of increased vascularity and hypertrophy of the cervix. If you had difficulty with this question, review the changes in the cervix that occur during pregnancy. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Maternity/Antepartum Giddens Concepts: Clinical Judgment, Reproduction HESI Concepts: Assessment, Sexuality/Reproduction Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 244). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 44/132 Question 32 1 / 1 pts After the delivery of a newborn, a nurse performs an initial assessment and determines that the Apgar score is 8. The nurse interprets this score as indicating that the infant: Requires some resuscitative intervention Is having difficulty adjusting to extrauterine life Correct! Is adjusting well to extrauterine life Requires vigorous resuscitation Rationale: One of the earliest indicators of successful adaptation of the newborn infant is the Apgar score. Scoring ranges from 0 to 10. A score of 7 to 10 indicates that the infant should have no difficulty adjusting to extrauterine life. A score of 4 to 6 indicates moderate difficulty that may require some resuscitative intervention. A score of 0 to 3 indicates severe distress and the need for vigorous resuscitation. Test-Taking Strategy: Recall that the Apgar score ranges from 0 to 10. Noting that the question addresses a score of 8 will direct you to the correct option. Also note that the incorrect options are comparable or alike in that each indicates a problem with the newborn. If you had difficulty with this question, review this assessment test. Level of Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Analysis Content Area: Newborn Giddens Concepts: Clinical Judgment, Development HESI Concepts: Assessment, Developmental Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. p. 247). St Louis: Mosby. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 45/132 Question 33 1 / 1 pts A nurse teaching a pregnant client about measures to strengthen the pelvic floor instructs the client to: Drink at least 2 quarts of fluid per day Walk half a mile 3 times a week Correct! Perform Kegel exercises in 10 repetitions, three times per day Perform pelvic tilt exercises in 10 repetitions, three times per day Rationale: Kegel exercises strengthen the pelvic floor (pubococcygeal muscle). The increased tone of this muscle is beneficial during pregnancy and afterward. Walking is a general healthy measure but does not specifically strengthen the pelvic floor. Fluid intake is an indicator of hydration, which is important for normal physiological function. Pelvic tilt exercises ease backache. Test-Taking Strategy: Use the process of elimination and focus on the subject, ways to strengthen the pelvic floor. This focus will direct you to the correct option. Remember that Kegel exercises help strengthen the pelvic floor muscles. If you had difficulty with this question, review the purpose of Kegel exercises. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Maternity/Antepartum Giddens Concepts: Client Education, Reproduction HESI Concepts:Sexuality/Reproduction, Teaching and Learning/Patient Education Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 448). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 46/132 Question 34 1 / 1 pts A nurse is caring for a client in labor who has sickle cell anemia. Which intervention does the nurse implement to help prevent a sickling crisis? Maintaining strict asepsis Correct! Administering oxygen as prescribed Monitoring the maternal vital signs Placing a wedge under the client’s hip Rationale: Oxygen is administered continuously during labor to the client with sickle cell anemia to help ensure adequate oxygenation and prevent sickling. Maintaining asepsis, monitoring vital signs, and placing a wedge under the hip are interventions required of all clients, with or without sickle cell anemia. Although they are appropriate nursing interventions, they are not used to prevent sickling crisis. Test-Taking Strategy: Use the process of elimination, focusing on the subject, prevention of sickling crisis. Also, use your knowledge of the ABCs (airway, breathing, and circulation). The correct option involves oxygenation. Review care of the client in labor who has sickle cell anemia if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Giddens Concepts: Reproduction, Perfusion HESI Concepts: Sexuality/Reproduction, Perfusion/Clotting Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 622). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 49/132 A nurse is monitoring a client in the third trimester of pregnancy who has a diagnosis of severe preeclampsia. Which finding would prompt the nurse to contact the health care provider? Periods of fetal movement followed by quiet periods 1 / 1 pts Question 37 Urine output of 20 mL Rationale: Magnesium sulfate depresses the respiratory rate. If the rate is 12 breaths/min or slower, continuation of the medication must be reassessed. Acceptable urine output is 30 mL/hr or more. Urine output of 20 mL in 30 minutes is adequate. Deep tendon reflexes of 2+ are normal. The fetal heart tone is within normal limits for a resting fetus. Test-Taking Strategy: Note the strategic words “contact the health care provider.” Use the process of elimination, noting the assessment finding that is abnormal and requires further intervention. Also, use your knowledge of the ABCs (airway, breathing, and circulation) to identify the correct option. Review assessment findings in preeclampsia and the effects of magnesium sulfate if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum Giddens Concepts: Collaboration, Clinical Judgment HESI Concepts: Clinical Decision-Making/Clinical Judgment, Collaboration/Managing Care – Care Coordination Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 594-595). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 50/132 1 / 1 pts Question 38 Enlargement of the breasts Correct! Diaphoresis and tachycardia Complaint of feeling hot Rationale: Disseminated intravascular coagulation (DIC) is a complication of preeclampsia. Physical examination reveals unusual bleeding, spontaneous bleeding from the woman’s gums or nose, or the presence of petechiae around a blood pressure cuff placed on the woman’s arm. Excessive bleeding may occur from a site of slight trauma such as a venipuncture site, an intramuscular or subcutaneous injection site, a nick sustained during shaving of the perineum or abdomen, or injury inflicted during insertion of a urinary catheter. Tachycardia and diaphoresis indicate impending shock as a result of blood loss. Breast enlargement, fetal movement with rest periods, and complaints of feeling hot are all normal occurrences in the last trimester of pregnancy. Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they are normal occurrences in pregnancy. Review the complications associated with severe preeclampsia if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Maternity/Antepartum Giddens Concepts: Collaboration, Clinical Judgment HESI Concepts: Clinical Decision-Making/Clinical Judgment, Collaboration/Managing Care – Care Coordination Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 578, 597). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 51/132 A pregnant client is seen in the clinic for the first time. This is the client’s first pregnancy, and the client tells the nurse that she has diabetes mellitus. The nurse provides instruction to the client regarding health care during pregnancy. Which statements by the client indicate the need for further instruction? Select all that apply. “I need to report signs of infection to my health care provider.” “My insulin requirements may change while I’m pregnant.” “I need to follow the prescribed diabetic diet.” Correct! “I’ll come back for a prenatal visit every month during my first trimester.” Correct! “I need to limit my exercise while I’m pregnant.” 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 54/132 A nurse provides information about the treatment for hypoglycemia to a client with gestational diabetes who will be taking insulin. The nurse tells the client that if signs and symptoms of hypoglycemia occur, she must immediately: Contact the health care provider Correct! Check her blood glucose level Drink 8 oz (240 ml) of diet soda Lie down 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 55/132 Question 41 1 / 1 pts Rationale: If signs and symptoms of hypoglycemia occur, the client should immediately check the blood glucose level. The results will determine the required treatment. If the blood glucose is less than 60 mg/dL (3.3 mmol/L), the client should immediately eat or drink something that contains 10 to 15 g of simple carbohydrate. Examples include a half cup (4 oz [120 ml]) of unsweetened fruit juice, a half cup (4 oz [120 ml]) of regular (not diet) soda, 5 or 6 LifeSavers candies, 1 tablespoon of honey or corn (Karo) syrup; 1 cup (8 oz [240 ml]) of milk; or 2 or 3 glucose tablets. The blood glucose is tested again 15 minutes after intake of the carbohydrate. If the glucose level is still below 60 mg/dL (3.3 mmol/L), the client should eat or drink another 10 to 15 g of simple carbohydrate. The blood glucose is tested once again 15 minutes after intake of the carbohydrate, and the health care provider is notified immediately if it is still below 60 mg/dL (3.3 mmol/L), because further intervention is necessary. Lying down will not increase the blood glucose level and will delay necessary intervention. Test-Taking Strategy: Use the process of elimination and note the strategic word “immediately.” Remember that if hypoglycemia is suspected, a blood glucose test is needed to confirm its occurrence and then treatment measures must be taken immediately. Review the treatment measures for hypoglycemia if you had difficulty with this question. Level of Cognitive Ability: Applying Client’s Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Maternity/Antepartum Giddens Concepts: Client Education, Glucose Regulation HESI Concepts: Teaching and Learning/Patient Education, Glucose Regulation Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 614). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 56/132 A nurse is reviewing the criteria for early discharge of a newborn infant. Which, if noted in the infant, would indicate that the criteria for early discharge have been met? Select all that apply. Correct! Vital signs are documented as normal. Correct! The infant has passed 1 stool. The infant has shown no evidence of jaundice in the first 6 hours of life. The infant has completed one successful feeding. Correct! The infant has urinated. Rationale: Criteria for early discharge in the newborn infant include no evidence of significant jaundice in the 24 hours after birth. The infant should have urinated and passed at least one stool, completed at least two successful feedings, and have normal vital signs for at least 12 hours. Test-Taking Strategy: Note the strategic words “have been met.” Read each option carefully and think about the expected assessment findings for a newborn. This will direct you to the correct options. Review the criteria for early discharge of a newborn if you are unfamiliar with them. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Priority Concepts: Content Area: Newborn Giddens Concepts: Clinical Judgment, Evidence HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-Based Practice/Evidence Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. p. 287). St Louis: Mosby. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 59/132 0.67 / 1 pts Question 44 Applies strong traction on the cord when signs of separation occur Correct! Instructs the mother to push when signs of separation have occurred Pulls on the umbilical cord as the mother bears down Rationale: To assist in the delivery of the placenta, the woman is instructed to push when signs of separation have occurred. If possible, the placenta should be expelled by means of maternal effort during a uterine contraction. Alternate compression and elevation of the fundus plus minimal controlled traction on the umbilical cord may be used to facilitate delivery of the placenta and amniotic membranes. Test-Taking Strategy: Use the process of elimination. Noting the strategic word “initially” and recalling that the placenta is attached to the uterine wall will direct you to the correct option. Pulling on the umbilical cord and placing excess traction on the cord when signs of separation occur may put the client at risk for uterine inversion. Review the procedure for placental delivery if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Giddens Concepts: Clinical Judgment, Caregiving HESI Concepts: Clinical Decision-Making/Clinical Judgment, Cargiving Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 355). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 60/132 Question 45 1 / 1 pts A client is admitted to the hospital for an emergency cesarean delivery. Contractions are occurring every 15 minutes, the client has a temperature of 100° F (37.8° C), and the client reports that she last ate 2 hours ago. The client also states that “everything happened so fast" and that she has had no preparation for the cesarean delivery. Which action should the nurse take first? Giving acetaminophen to lower the client’s temperature Correct! Reporting the time of last food intake to the health care provider Continuing to time the contractions Beginning teaching about the cesarean delivery A multigravida woman with a history of multiple cesarean births is admitted to the maternity unit in labor. The client is experiencing excessively strong contractions, and the nurse monitors the client closely for uterine rupture. Which assessment findings are indicative of complete uterine rupture? Select all that apply. Correct! Maternal tachypnea Correct! Fetal bradycardia Correct! Maternal complaint of sudden sharp abdominal pain ou Answered Excessive vaginal bleeding Increased uterine contractions 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 61/132 A nurse assists a pregnant client who is in the second trimester into lithotomy position on the examining table in the obstetrician’s office. The client suddenly becomes dizzy, lightheaded, nauseated, and pale. The nurse immediately: Checks the client’s blood pressure, pulse, and respirations Calls the health care provider to see the client 1 / 1 pts Question 46 Rationale: The nurse should report the time of last food intake to the health care provider. General anesthesia may be used for an emergency cesarean delivery. Gastric contents are very acidic and can produce chemical pneumonitis if aspirated. Continued monitoring and client instruction are correct nursing actions but are of lesser priority than reporting the time of last oral intake. Giving acetaminophen is incorrect because it requires a health care provider’s prescription. Test-Taking Strategy: Note the strategic word “first” and use your knowledge of the ABCs — airway, breathing, and circulation — to find the correct option, which pertains to breathing (maintaining an open airway). Review client preparation for an emergency cesarean delivery if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Giddens Concepts: Care Coordination, Safety HESI Concepts: Collaboration/Managing Care – Care Coordination, Safety Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 428). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 64/132 Question 48 1 / 1 pts Rationale: Priority nursing care of the woman in precipitous labor includes promotion of fetal oxygenation and maternal comfort. A side-lying (lateral Sims) position enhances placental blood flow and reduces the effects of aortocaval compression. Added benefits of this position are slowing of rapid fetal descent and minimization of perineal tearing. The lateral Sims position also places less stress on the perineum. Because the upper leg is supported, the perineum can be better visualized as well. The other options are not the most optimal positions. Test-Taking Strategy: Focus on the subject, a client in precipitous labor. Recalling that precipitous labor is one in which birth occurs within 3 hours of the onset of labor and visualizing each position in the options will direct you to the correct option. Review care of the client in precipitous labor if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Giddens Concepts: Caregiving, Perfusion HESI Concepts: Caregiving, Perfusion/Clotting Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 350, 642- 643). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 65/132 1 / 1 pts Question 49 A nurse is caring for a postpartum client who had a low-lying placenta. The nurse assesses the client most closely for: Seizures A vaginal hematoma Infection Correct! Hemorrhage Rationale: The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, making this site more prone to bleeding. The client with a low-lying placenta is not at greater risk for seizures, postpartum infection, or vaginal hematoma. Test-Taking Strategy: Focus on the client’s diagnosis, a low-lying placenta. Recalling the anatomy and physiology of the lower segment of the uterus will direct you to the correct option. Review the complications associated with a low-lying placenta if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Maternity/Postpartum Giddens Concepts: Clinical Judgment, Perfusion HESI Concepts: Assessment, Perfusion/Clotting Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 440, 583, 671). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 66/132 A nurse working in a prenatal clinic is reviewing the records of several clients scheduled for prenatal visits today. Which client does the nurse identify as being at risk for abruptio placentae? Select all that apply. A 36- year-old A primipara A client who exercises regularly Correct! A pack-a-day smoker Correct! A hypertensive client Rationale: The cause of abruptio placentae is unknown, but several risk factors have been identified. Maternal use of cocaine, which causes vasoconstriction of the endometrial arteries, is a leading cause. Other risk factors include hypertension, cigarette smoking, abdominal trauma, and a history of previous premature separation of the placenta. Test-Taking Strategy: Note the strategic words “at risk” and focus on the subject, abruptio placentae. The correct options identify situations that could be harmful. Review the risk factors for abruptio placentae if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Maternity/Antepartum Giddens Concepts: Clinical Judgment, Perfusion HESI Concepts: Assessment, Perfusion/Clotting Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 585). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 69/132 Performing such exercises in the postpartum period may result in stress urinary incontinence Correct! Alternating contraction and relaxation of the muscles of the perineal area should be practiced The exercises should be delayed for 1 month to allow healing Rationale: Postpartum exercises may be started soon after birth, although the woman should be encouraged to begin with simple exercises and gradually progress to more strenuous ones. Abdominal exercises are postponed until approximately 4 weeks after a cesarean birth. Kegel exercises (alternated contraction and relaxation of the muscles of the perineal area) are extremely important in strengthening the muscle tone of the perineal area after vaginal birth. Kegel exercises help restore the muscle tone that is often lost as pelvic tissues are stretched and torn during pregnancy and birth. Women who maintain muscle strength may benefit years later, experiencing continued urinary continence. Test-Taking Strategy: Use the process of elimination. Note the relationship between the word “vaginally” in the question and “perineal area” in the correct option. Review the purpose and benefit of Kegel exercises if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Maternity/Postpartum Giddens Concepts: Client Education, Mobility HESI Concepts: Mobility, Teaching and Learning/Patient Education Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 448, 794). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 70/132 1 / 1 pts Question 53 Question 52 1 / 1 pts A nurse is assessing the respiratory rate of a newborn. Which finding would the nurse document as normal? 20 breaths/min 70 breaths/min 25 breaths/min Correct! 50 breaths/min Rationale: The normal respiratory rate for a newborn infant is 30 to 60 breaths/min. All of the other options are outside the normal range. Test-Taking Strategy: Knowledge regarding the normal respiratory rate of a newborn is required to answer this question. If you are unfamiliar with the normal ranges for newborn vital signs, review this content. Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Newborn Giddens Concepts: Clinical Judgment, Gas Exchange HESI Concepts: Assessment, Oxygenation/Gas Exchange Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. p. 254). St Louis: Mosby. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 71/132 A nurse is monitoring a newborn who has been admitted to the nursery. The nurse notes that the anterior fontanel measures 4 cm across and bulges when the infant is at rest. Based of this observation, what is the appropriate nursing action? Reassessing the fontanel in 30 minutes Documenting the finding Correct! Notifying the health care provider Assessing the infant’s blood pressure 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 74/132 1 / 1 pts Question 56 Correct! Bowel sounds heard over the chest Excessive oral secretions Hiccupping and spitting up after a meal Rationale: Clinical manifestations associated with CDH include diminished or an absence of breath sounds on the affected side, bowel sounds heard over the chest, cardiac sounds heard on the right side of the chest, and respiratory distress, including dyspnea, cyanosis, nasal flaring, tachypnea, retractions, and a scaphoid abdomen, that develops soon after birth. The presence of excessive oral secretions is a clinical manifestation of esophageal atresia and tracheoesophageal fistula. Hiccups and spitting up after meals are clinical manifestations of gastroesophageal reflux. A hiatal hernia may be evidenced by coughing, wheezing, and short periods of apnea. Test-Taking Strategy: Specific knowledge of the pathophysiology associated with CDH and knowledge that CDH is a neonatal emergency will direct you to the correct option. If you had difficulty with this question, review the characteristics of congenital diaphragmatic hernia. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Newborn Giddens Concepts: Clinical Judgment, Development HESI Concepts: Assessment, Developmental Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 1210-1211). St Louis: Mosby. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 75/132 A woman being seen in the prenatal clinic and complains of morning sickness that continues throughout the day. What does the nurse tell the client to do to overcome this discomfort? Eliminate the morning meal Drink fluids with meals Eat fatty or spicy foods only at the noontime meal Correct! Eat dry crackers every 2 hours to prevent an empty stomach 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 76/132 A client in the third trimester of pregnancy is complaining of urinary frequency, and the nurse instructs the client in measures to alleviate the discomfort. Which statement by the client indicates an understanding of these self-care measures? 1 / 1 pts Question 57 Rationale: Morning sickness, which is common during the first trimester of pregnancy, is associated with an increased level of human chorionic gonadotropin (hCG) and changes in carbohydrate metabolism. Morning sickness most often occurs when the pregnant woman arises (hence the name), although a few women experience it throughout the day. Self-care measures include eating dry crackers or toast before getting out of bed, eating dry crackers every 2 hours to prevent an empty stomach, eating small frequent meals, avoiding fatty or spicy foods, consuming fluids separately from meals, and rising slowly from a lying or sitting position to help prevent orthostatic hypotension. The client should not eliminate meals. Test-Taking Strategy: Use the process of elimination. Noting the strategic words “continues throughout the day” and their relationship to “every 2 hours” will direct you to the correct option. Review measures to relieve morning sickness if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Maternity/Antepartum Giddens Concepts: Client Education, Hormonal Regulation HESI Concepts: Nutrition, Teaching and Learning/Patient Education Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 252-253). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 79/132 Question 59 1 / 1 pts A woman in labor suddenly experiences chest pain and dyspnea, and the nurse suspects the presence of amniotic fluid embolism (AFE). The nurse immediately: Correct! Administers oxygen to the woman Notifies the family Attaches a cardiac monitor to the woman Prepares the client for intubation 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 80/132 After a vaginal delivery, a woman suddenly begins to complain of severe pelvic pain and extreme fullness in the vagina, and the nurse suspects uterine inversion. The nurse immediately prepares to: Correct! Assist in repositioning the uterus through the vagina into a normal position 1 / 1 pts Question 60 Rationale: Supportive interventions are instituted immediately to maintain cardiac and respiratory function, and oxygen is a necessary supportive therapy. The woman is intubated, and positive end expiratory pressure (PEEP) may be prescribed. The family should be notified; however, the nurse would first administer the oxygen, then prepare for intubation. A cardiac monitor may be needed, but this is not the initial action. Test-Taking Strategy: Use your knowledge of the ABCs — airway, breathing, and circulation — to answer the question. This will easily direct you to the correct option. If you are unfamiliar with the care of a woman in labor with amniotic fluid embolism (AFE), review this content. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Giddens Concepts: Clinical Judgment, Clotting HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion/Clotting References: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 662). St. Louis: Elsevier. Mosby’s Dictionary of medicine, nursing & health professionals (2013) 9th ed., p. 81 ). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 81/132 Administer oxytocin (Pitocin) Perform fundal massage Insert a Foley catheter Rationale: Uterine inversion occurs when the uterus turns completely or partially inside out, usually during the third stage of labor. The health care provider tries to replace the uterus, by way of the vagina, in a normal position. If this is not possible, laparotomy with replacement is performed. A hysterectomy may be required. Two intravenous lines are established to allow rapid fluid and blood replacement. A tocolytic medication or general anesthesia usually is needed to relax the uterus enough to replace it. To help ensure that the inverted fundus is not trapped in the cervix, oxytocin is not given until the uterus has been repositioned. Fundal massage should be avoided if possible, but, if it is prescribed, it should be conducted very carefully. A Foley catheter may be inserted to keep the bladder empty so that the uterus can contract well, but this is not the immediate action. Test-Taking Strategy: Use the process of elimination and note the strategic word “immediately.” Note the relationship between the words “uterine inversion” in the question and the option in which the uterus is repositioned, through the vagina, in its normal place. Review nursing interventions for the client with uterine inversion if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Giddens Concepts: Caregiving, Clinical Judgment HESI Concepts: Clinical Decision-Making/Clinical Judgment, Caregiving Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 661-662). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 84/132 A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 19, 2017. Using Nagele’s Rule, the nurse calculates the estimated date of delivery as: Correct! June 26, 2018 1 / 1 pts Question 63 Fetal heart monitor Rationale: The fetal heartbeat can be heard with the use of a fetoscope at 18 to 20 weeks’ gestation. When an electronic Doppler ultrasound device is used, the fetal heartbeat can be detected as early as 10 weeks’ gestation. An adult stethoscope will not adequately produce the fetal heartbeat. A fetal heart monitor is used during labor or in other situations when the fetal heart rate requires continuous monitoring. Test-Taking Strategy: Use the process of elimination. Eliminate an adult stethoscope first by focusing on the subject, fetal heart rate. To select from the remaining options, note the words “gestational week 12,” which will direct you to the correct option. If you had difficulty with this question, review the methods of assessing the fetal heart rate. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Maternity/Antepartum Giddens Concepts: Clinical Judgment, Development HESI Concepts: Assessment, Developmental Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 367-368). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 85/132 A pregnant client is positive for HIV. The client asks the nurse whether her newborn will contract the virus. The appropriate response is: 1 / 1 pts Question 64 June 12, 2018 May 26, 2018 May 12, 2018 Rationale: Accurate use of Nagele’s Rule requires that the woman have a regular 28-day menstrual cycle. It is calculated by subtracting 3 months from the first day of the LMP, adding 7 days, and then adding 1 year to that date. First day of the LMP: September 19, 2017; subtract 3 months: June 19, 2017; add seven days: June 26, 2017; add 1 year: June 26, 2018. Test-Taking Strategy: Knowledge regarding the use of Nagele’s Rule is required to answer this question. Use this rule to calculate the estimated date of delivery. Review Nagele’s Rule if you had difficulty with this question. Level of Cognitive Ability: Understanding Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Maternity/Antepartum Giddens Concepts: Clinical Judgment, Development HESI Concepts: Assessment, Developmental Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 247). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 86/132 1 / 1 pts Question 65 “The newborn will have signs of HIV at birth if the virus has been transmitted.” “Yes, the newborn will also have the virus.” Correct! “The newborn does have a risk of contracting the infection.” “HIV can only be transmitted through sexual contact.” Rationale: An infant born to an HIV-positive mother is at risk for contracting the infection. The modes of transmission are sexual, parenteral, and perinatal. Characteristically the newborn is asymptomatic at birth, but signs and symptoms in an infected child usually become obvious during the first year of life. Therefore the remaining options are incorrect. Test-Taking Strategy: Use the process of elimination. Simply knowing that the infant born to an HIV-positive mother is at risk for contracting the infection will direct you to the correct option. Review the risks associated with pregnancy in an HIV-positive woman if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum Giddens Concepts: Infection, Reproduction HESI Concepts: Infection, Sexuality/Reproduction Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 403, 716-717). St Louis: Mosby. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 89/132 A nurse is caring for a client receiving an intravenous infusion of oxytocin to stimulate labor. Which finding would prompt the nurse to stop the infusion? 1 / 1 pts Question 67 Rationale: Dehydration will precipitate sickling of the red blood cells in the person with sickle cell disease. Sickling can lead to life- threatening consequences, such as an interruption of blood flow to the respiratory system and placenta, for the pregnant woman and fetus. Therefore a low fluid intake is the priority. Although the client’s complaints of poor appetite and occasional dizziness on standing require attention, they are not the priority in this situation. The client’s concerns about being able to care for her baby may be a priority after delivery, depending on the specific client situation at the time. Test-Taking Strategy: Use Maslow's Hierarchy of Needs theory to prioritize, remembering that physiological needs come first. Using this principle, eliminate the option involving the client’s concern about her inability to care for her baby. To select from the remaining options, use your knowledge of sickle cell anemia to select the correct option. In this case, the potential outcome, sickling, means that the client’s deficient fluid volume is the priority. Review sickle cell anemia if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Maternity/Antepartum Giddens Concepts: Caregiving, Perfusion HESI Concepts: Caregiving, Perfusion/Clotting Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 622-623). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 1 / 1 pts Question 68 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 90/132 The presence of three contractions every 10 minutes Correct! Nonreassuring fetal heart rate pattern Soft uterine tone palpated between contractions Contractions every 3 minutes Rationale: The goal of labor augmentation is to achieve three good-quality contractions (of appropriate intensity and duration) in a 10-minute period. The uterus should return to resting tone between contractions, and there should be no evidence of fetal distress. If a nonreassuring fetal heart rate pattern is detected, the oxytocin infusion is stopped. A nonreassuring fetal heart rate pattern is associated with fetal hypoxia. Test-Taking Strategy: Use the process of elimination and your knowledge of the ABCs (airway, breathing, and circulation). Eliminate the options that are comparable or alike (i.e., contractions every 3 minutes and occurrence of three contractions every 10 minutes). The correct option, of the two that remain, is the one that indicates a problem with circulation. Review the expected outcomes and the signs of complications associated with oxytocin infusion if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 417). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 1 / 1 pts Question 69 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 91/132 A nurse is assessing a woman in labor and notes the presence of accelerations on the fetal monitor tracing. Which action should the nurse perform in response to this observation? Taking the mother’s vital signs Calling the health care provider Correct! Documenting the finding Repositioning the mother Rationale: Accelerations are transient increases in the fetal heart rate, normally caused by fetal movement or accompanying contractions. Accelerations are a sign of fetal well-being and adequate oxygen reserve. No intervention besides documentation is necessary in this situation. Test-Taking Strategy: Use the process of elimination. Recalling that the presence of accelerations indicates fetal well-being will direct you to the correct option. Review the description of accelerations if you are unfamiliar with this content. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Giddens Concepts: Clinical Judgment, Perfusion HESI Concepts: Assessment, Clinical Decision-Making/Clinical Judgment Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 373-374). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 94/132 1 / 1 pts Question 71 Increasing the rate of the oxytocin (Pitocin) infusion Preparing for immediate birth Rationale: Late decelerations are a result of uteroplacental insufficiency stemming from decreased blood flow and oxygen transfer to the fetus during uterine contractions. This causes hypoxemia; therefore oxygen is necessary, making the administration of oxygen the correct choice. Late decelerations are considered an ominous sign but do not necessarily require immediate birth of the baby. The oxytocin infusion should be discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia, because the medication stimulates contractions, leading to increased uteroplacental insufficiency. Although the finding needs to be documented, documentation is not the priority action in this situation. Test-Taking Strategy: Note the strategic word “priority” in the question. Use your knowledge of the ABCs — airway, breathing, and circulation — to answer the question. This will direct you to the correct option, the one that addresses oxygen. Review content on late decelerations if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Giddens Concepts: Clinical Judgment, Perfusion HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 375-376). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 95/132 Placental abruption is suspected in a client who is experiencing vaginal bleeding. On assessment, which finding would the nurse expect to note? Correct! Uterine tender to palpation Abdomen soft to palpation Lack of uterine irritability or tetanic contractions Uterine contractions every 3 to 5 minutes Rationale: Vaginal bleeding in a pregnant client is most often caused by placenta previa or a placental abruption. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board-like on palpation as the blood penetrates the myometrium, causing uterine irritability and maternal tenderness. A normal uterine contraction pattern is unusual in the presence of a placental abruption. A sustained tetanic contraction may occur if the client is in labor and the uterine muscle cannot relax. Test-Taking Strategy: Focus on the diagnosis, placental abruption. Remember that uterine pain and tenderness occurs with an abruption. Review the characteristics of placental abruption if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Maternity/Antepartum Giddens Concepts: Clinical Judgment, Perfusion HESI Concepts: Assessment, Perfusion Reference: Hammond, B., & Zimmermann, P. (2013) Sheehy’s Manual of Emergency Care (7th ed., p. 466). St. Louis: Elsevier. 12/30/21, 7:46 PM Session 4 Exam 3 - Focus on Maternity Exam: NCLEX Remediation Course Nov 2021 https://jerseycollege.instructure.com/courses/2491/quizzes/27609 96/132 Question 72 1 / 1 pts A postpartum nurse instructs a new mother in how to bathe her newborn. Which statement by the mother indicates a need for further instruction? “I need to sponge-bathe him until the cord falls off.” Correct! “I should bathe him after a feeding.” “I should check the temperature of the water before using it to bathe him.” “I need to keep him covered as much as possible while I’m giving him a bath.”