NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2, Exams of Nursing

Download NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2 and more Exams Nursing in PDF only on Docsity! NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU 1. 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: A. Eat foods high in calories and fat B. Lie down for at least 20 minutes after meals C. Eat carbohydrates such as cereals, rice, and pasta Correct D. Consume primarily soups and liquids at mealtimes Rationale: Low-fat foods and easily digested carbohydrates such as fruit, breads, cereals, rice, and pasta provide important nutrients and help prevent a low blood glucose level, which can cause nausea. Soups and other liquids should be taken between meals to avoid distending the stomach and triggering nausea. Sitting upright after meals reduces gastric reflux. Additionally, food portions should be small and foods with strong odors should be eliminated from the diet, because food smells often incite nausea. A nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate infusion to prevent eclampsia. Which finding indicates to the nurse that the medication is effective? E. Clonus is present. Incorrect F. Magnesium level is 10 mg/dL. NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU G. Deep tendon reflexes are absent. H. The client experiences diuresis within 24 to 48 hours. Correct Rationale: Magnesium sulfate is effective in preventing seizures (eclampsia) if diuresis occurs within 24 to 48 hours of the start of the infusion. As part of the therapeutic response, renal perfusion is increased and the client is free of visual disturbances, headache, epigastric pain, clonus (the rapid rhythmic jerking motion of the foot that occurs when the client’s lower leg is supported and the foot is sharply dorsiflexed), and seizure activity. Hyperreflexia indicates cerebral irritability. Clonus is normally not present. The therapeutic magnesium level is 4 to 8 mg/dL. Reflexes range from 1+ to 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: I. Vitamin K J. Protamine sulfate Incorrect K. Calcium gluconate Correct L. Naloxone hydrochloride NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU S. Wash the infant’s scalp daily, using only tepid water T. Shampoo the infant’s scalp, avoiding the anterior fontanel area Rationale: Seborrheic dermatitis, a chronic inflammation of the scalp or other areas of the skin, is characterized by yellow, scaly, oily lesions. It sometimes results when parents do not wash over the anterior fontanel carefully for fear that they will hurt the infant. Treatment includes the application of oil (e.g., mineral oil) to the area to help soften the lesions followed by gentle removal of the scaly lesions with a comb before the head is shampooed. The nurse should teach the mother how to shampoo the scalp and explain that she will not damage the fontanel with normal gentle shampooing. The A nurse is monitoring a client who was given an epidural opioid for a cesarean birth. The nurse notes that the client’s oxygen saturation on pulse oximetry is 92%. The nurse first: U. Notifies the registered nurse V. Documents the findings W. Instructs the client to take several deep breaths Correct X. Administers 100% oxygen by way of face mask Incorrect NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU 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 NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU the deep breaths fail to increase the oxygen saturation level, the registered nurse is notified and may prescribe oxygen. 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: Y. To perform a vaginal douche Z. To come to the clinic for a checkup Incorrect AA. That this is an indication of an infection AB. That this is a normal postpartum occurrence Correct 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 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: AC. A rubella vaccine must be administered immediately NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU AI. Encourage the intake of oral fluids Correct AJ. Tell the client that antibiotics will be prescribed Rationale: A temperature of 38° C (100.4° F) is common during the 24 hours after childbirth. It may be the result of dehydration or normal postpartum leukocytosis. If the increased temperature persists for longer than 24 hours or exceeds 38° C, infection is a possibility, and the fever is reported to the registered nurse. Because the client delivered her baby just 12 hours ago, the most appropriate nursing action is to encourage the intake of oral fluids. 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 AK. Has the client void before the uterine assessment AL. Tells the woman to bear down during fundal message AM. Simultaneously provides pressure over the lower uterine segment Correct AN. Asks the client to take slow, deep breaths during fundal assessment Incorrect NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU 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. A nurse is monitoring a client after vaginal delivery notes a constant trickle of bright-red blood from the client’s vagina. In which order would the nurse perform the following actions? Assign the number 1 to the first action and the number 5 to the last. Incorrect A. Assessing the client’s fundus B. Checking the client’s vital signs C. Changing the client’s peripads D. Contacting the physician E. Documenting the findings The correct order is: F. Assessing the client’s fundus G. Checking the client’s vital signs H. Contacting the physician I. Changing the client’s peripads J. Documenting the findings NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU Rationale: A constant trickle of bright-red blood may indicate abnormal bleeding and requires immediate attention. The nurse first checks the client’s fundus. Once it has NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU 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 NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU 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 A pregnant woman reports to the clinic complaining of loss of appetite, weight loss, and fatigue, and tuberculosis is suspected. A sputum culture reveals Mycobacterium tuberculosis. The nurse, providing instructions to the mother regarding therapeutic management of the disease, tells the mother that: A. The infant must be isolated from the mother after birth B. Maternal medication will not be started until the baby is born C. The infant will require medication therapy immediately after birth D. The mother may need to take isoniazid (INH), pyrazinamide, and rifampin (Rifadin) for a total of 9 m nths Correct NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU 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 the fetal presenting part is: E. At +1 station F. At –1 station G. At zero station Correct H. Stationed at the bottom of the coccyx 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. A nurse performing an assessment of a pregnant client is preparing to take the client’s blood pressure. The nurse positions the client: NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU I. Supine, on the left side J. Supine, on the right side NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU present. The nurse understands that this sign is indicative of: AK. The presence of fetal movement NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU AL. A high risk for spontaneous abortion AM. An increase in vascularity and hyptertrophy of the cervix Correct AN. The presence of human chorionic gonadotropin (hCG) in the urine 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. 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? AO. 4 weeks AP. 6 weeks AQ. 8 weeks AR. 12 weeks Correct NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU Rationale: Fetal heart sounds can be heard with the use of a Doppler ultrasound stethoscope by 12 weeks of gestation and can be heard with a fetoscope by 18 to 20 weeks of gestation. The gestational times of 4, 6, and 8 weeks are incorrect because the fetal heart sounds cannot be heard with a Doppler ultrasound stethoscope this early A nurse is assisting a midwife who is assessing a client for ballottement. Which action does the nurse anticipate that the midwife will employ to test for ballottement? AS. Assessing the cervix for thinning AT. Auscultating for fetal heart sounds AU. Performing a sudden tap on the cervix Correct AV. Palpating the abdomen for fetal movement Rationale: Near midpregnancy, a sudden tap on the cervix during a vaginal exam may cause the fetus to rise in the amniotic fluid and then rebound to its original position, a phenomenon known as ballottement. The examiner feels the rebound when the fetus falls back down. Ballottement has no relationship to cervical assessment findings, fetal heart sounds, or external palpation of fetal movement. 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: AW. Requires vigorous resuscitation NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU 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? BE. Maintaining strict asepsis BF. Monitoring the maternal vital signs BG. Administering oxygen as prescribed Correct BH. 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. A nurse teaches a new mother how to perform umbilical cord care and how to recognize the signs of a cord infection. Which of the following findings does the nurse tell the mother is an indicator of infection? BI. A darkened, drying cord BJ. Edema at the base of the cord Correct BK. A brownish-black cord with pinkness around the base NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU BL. A brownish-black cord with some moistness at the base Rationale: Symptoms of a cord infection include purulent drainage or redness or edema at the base of the cord. If symptoms of infection occur, the mother should be instructed to notify the healthcare provider, because antibiotics are necessary. The cord begins to dry shortly after birth. It turns a brownish black within 2 to 3 days and falls off within 10 A licensed practical nurse is performing assessments every 30 minutes on a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings would prompt the LPN to contact the registered nurse? BM. Urine output of 20 mL BN. Deep tendon reflexes of 2+ BO. Respirations of 10 breaths/min Correct BP. Fetal heart tone of 116 beats/min 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 A licensed practical nurse (LPN) is monitoring a client in the third trimester of pregnancy who has a diagnosis of severe NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU Rationale: Discomfort and pain associated with true labor contractions typically begin in the lower abdomen and back, then radiate over the entire abdomen. Mild, irregular contractions and a lack of changes in the cervix are findings associated with false labor. A firm uterus is present when contractions occur. NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU FP. Contractions that begin in the lower abdomen and back and radiate over the entire abdomen Correct A nurse is preparing to assess the fetal heartbeat in a pregnant woman who is at gestational week 12. Which piece of equipment does the nurse use to assess the fetal heartbeat? FQ. Fetoscope FR. Adult stethoscope NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU FS. Electronic Doppler Correct FT. Fetal heart monitor 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, 2013. Using Nagele’s Rule, the nurse calculates the estimated date of delivery as: FU. May 26, 2014 FV. June 12, 2014 FW. June 26, 2014 Correct FX. May 12, 2014 NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU 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. NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU A pregnant client is positive for HIV. The client asks the nurse whether her newborn will contract the virus. The appropriate response is: FY. “Yes, the newborn will also have the virus.” FZ. “HIV can only be transmitted through sexual contact.” GA. “The newborn does have a risk of contracting the infection.” Correct GB. “The newborn will have signs of HIV at birth if the virus has been transmitted.” A delivery room nurse performing an initial assessment on a newborn notes that the ears are low set. In light of this finding, which nursing action is appropriate initially? GC. Notifying the physician Correct NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU 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, 2013; subtract 3 months: June 19, 2013; add seven days: June 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. NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU would prompt the nurse to stop the infusion? GK. Contractions every 3 minutes GL. Nonreassuring fetal heart rate pattern Correct GM. Soft uterine tone palpated between contractions GN. The presence of three contractions every 10 minutes A licensed practical nurse (LPN) is monitoring a woman in labor and notes the presence of accelerations on the fetal monitor tracing. Which action should the LPN take in response to this observation? GO. Contacting the registered nurse GP. Documenting the finding Correct GQ. Repositioning the mother NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU 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. NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU GR. Taking the mother’s vital signs A nurse assessing a pregnant woman in labor notes the presence of early decelerations on the fetal monitor tracing. Which of the following situations would the nurse suspect in light of this observation? GS. Umbilical cord compression GT. Pressure on the fetal head during a contraction Correct GU. Adequate pacemaker activity of the fetal heart GV. Uteroplacental insufficiency during a contraction A nurse caring for a client in the active stage of labor assesses the fetal status and notes a late deceleration on the monitor strip. In light of this finding, which nursing action is the priority? NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU 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. Rationale: Early decelerations, which result from pressure on the fetal head during a contraction, are not associated with fetal compromise and require no intervention. Variable decelerations suggest umbilical cord compression. Late decelerations are an ominous pattern in labor because they suggest uteroplacental insufficiency during a contraction. "Short-term variability" refers to the difference between successive heartbeats, indicating that the natural pacemaker activity of the fetal heart is working properly. NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU GW. Documenting the finding GX. Preparing for immediate birth GY. Administering oxygen by way of face mask Correct GZ. Increasing the rate of the oxytocin (Pitocin) infusion Placental abruption is suspected in a client who is experiencing vaginal bleeding. On assessment, which of the following findings would the nurse expect to note? HA. Abdomen soft to palpation HB. Uterine tender to palpation Correct NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU 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. NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU HM. Limit maternal activity HN. Turn the client on her side Correct HO. Monitor maternal vital signs HP. Provide emotional support to reduce anxiety A multigravida asks a nurse when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted as early as: HQ. 8 to 10 weeks of gestation HR. 11 to 13 weeks of gestation HS. 14 to 16 weeks of gestation Correct HT. 18 to 20 weeks of gestation NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU Rationale: With a client in shock, the goal is to increase perfusion to the placenta. The immediate nursing action would be to turn the client on her side. This would increase blood flow to the placenta by relieving pressure from the gravid uterus on the great vessels. The remaining options are also interventions that would be implemented, but only after this immediate action had been taken. Rationale: A maternal 1-hour blood glucose test may be prescribed as a screen for gestational diabetes. If it is increased (140 mg/dL or greater), a 3-hour glucose- tolerance test may be recommended to confirm the presence of gestational diabetes. Oral hypoglycemics and insulin would not be prescribed solely on the basis of an increased maternal 1-hour glucose level. Additionally, oral hypoglycemic agents are contraindicated during pregnancy. A result of NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU A 1-hour oral glucose tolerance test is performed on a pregnant client, with a result of 155 mg/dL. The nurse tells the client that: HU. Daily NPH insulin will be needed HV. Her glucose level is within normal limits HW. A daily oral hypoglycemic agent will be prescribed HX. A 3-hour glucose tolerance test will likely be performed to confirm gestational diabetes Correct A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. The nurse tells the client that: HY. She must be retested in 1 week NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU Rationale: The first recognition of fetal movements by the multigravida may occur as early as the 14th to 16th week of gestation. The primigravida may not notice these sensations until week 18 or later. Therefore the other options are incorrect. Rationale: A hepatitis B screen is performed to detect the presence of antigens in maternal blood. If antigens are present, the infant should receive hepatitis immune globulin and a vaccine soon after birth. Repeating the screen and prescribing liver function tests are incorrect measures and are unnecessary. NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU HZ. Liver function tests will be prescribed IA. A repeat hepatitis screen will be performed during the pregnancy IB. The infant should receive both the vaccine and hepatitis immune globulin soon after birth Correct A client in the first trimester of pregnancy arrives at the clinic and reports that she has been experiencing vaginal bleeding. Threatened abortion is suspected, and the nurse provides instructions to the client regarding care. Which statement by the client indicates the need for further instruction? IC. “I need to stay in bed for the rest of my pregnancy.” Correct ID. “I need to avoid having sex until the bleeding has stopped.” IE. “I need to watch for stuff that looks like tissue coming from my vagina.” NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU during pregnancy.” Rationale: It is important for the nurse to obtain additional information from the client. The nurse is using the therapeutic communication tool of validation and clarification to obtain more information about the client’s diet. The other options will block communication. The statement regarding harm to the baby devalues the client and shows disapproval. Informing the physician is avoiding the issue, and telling the client 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: CD. Lie down CE. Contact the physician CF. Drink 8 oz of diet soda CG. Check her blood glucose level Correct 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, the client should immediately eat or drink something that contains 10 to 15 g of simple carbohydrate. Examples include a half cup (4 oz) of unsweetened fruit juice, a half cup (4 oz) of regular (not diet) soda, 5 or 6 LifeSavers candies, 1 tablespoon of honey or corn (Karo) syrup; 1 cup (8 oz) of milk; or NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU intake of the carbohydrate. If the glucose level is still below 60 mg/dL, 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 physician is notified immediately if it is still below 60 mg/dL, because further intervention is necessary. Lying down will not increase the blood glucose level and will delay necessary A nurse is reviewing the criteria for early discharge of a newborn infant. Which of the following, if noted in the infant, would indicate that the criteria for early discharge have been met? Select all that apply. CH. The infant has urinated. CI. The infant has passed 1 stool. CJ. Vital signs are documented as normal. Correct CK. The infant has completed one successful feeding. CL. The infant has shown no evidence of jaundice in the first 6 hours of life. NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU Correct Correct NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU 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. A client admitted to the maternity unit 12 hours ago has been experiencing strong contractions every 3 minutes but has remained at station 0. The fetal heart rate on admission was 140 beats/min and regular. The fetal heart rate is slowing, and a CM. Preparing to induce labor CN. Turning the client on her left side CO. Preparing the client for a cesarean delivery Correct CP. Continuing to monitor the fetal heart rate pattern Rationale: Dystocia, failure of labor to progress, and a persistent nonreassuring fetal heart rate pattern are indications of the need for cesarean delivery. Induction of labor is not indicated in this case because the client has been in labor for 12 hours without progress and signs of fetal distress are present. Placing the client on her left side will increase oxygen to the uterus by relieving pressure on the aorta and the inferior vena cava. However, this intervention would be implemented with any client in labor, not specifically with a client experiencing dystocia. Monitoring the fetal heart rate pattern is also appropriate for any client in labor and is not the appropriate nursing action in Immediately after the delivery of a newborn infant, the nurse prepares to deliver the placenta. The nurse initially: CQ. Pulls on the placenta as it enters the vaginal canal NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU DC. Giving acetaminophen (Tylenol) to lower the client’s temperature NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU Rationale: The nurse should report the time of last food intake to the physician. 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 (Tylenol) is incorrect because it requires 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: DD. Positions the client on her side Correct DE. Calls the physician to see the client DF. Places a cool washcloth on the client’s forehead DG. Checks the client’s blood pressure, pulse, and respirations Rationale: Supine hypotension may occur during the second and third trimesters when a woman is placed in the lithotomy position, in which the weight of the abdominal contents may compress the vena cava and aorta, causing a drop in blood pressure and a feeling of faintness. Other signs and symptoms include pallor, dizziness, breathlessness, tachycardia, nausea, clammy (damp, cool) skin, and sweating. The nurse would immediately position the woman on her side. Placing a cool washcloth on the client’s forehead or checking the client’s vital signs will not eliminate this problem. The physician must be contacted if the symptoms do not subside, but this would not be A nurse is caring for a client in precipitous labor. In which position NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU does the nurse place the client? DH. DI. DJ. DK. Correct 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 A nurse is caring for a postpartum client who had a low-lying placenta. The nurse assesses the client most closely for: DL. Seizures DM. Infection NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU client who has delivered a newborn vaginally. The nurse tells the client that: DY. The exercises should be delayed for 1 month to allow healing NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU 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. NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU DZ. Performing such exercises in the postpartum period may result in stress urinary incontinence EA. Alternating contraction and relaxation of the muscles of the perineal area should be practiced Correct EB. Abdominal exercises will be started while the client is in the hospital as a means of evaluating tolerance EC. 20 breaths/min ED. 25 breaths/min NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU EE. 50 breaths/min Correct EF. 70 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. A licensed practical nurse is monitoring a newborn who has been admitted to the nursery. The LPN notes that the anterior fontanel measures 4 cm across and bulges when the infant is at rest. In light of this observation, what is the most appropriate nursing action? EG. Notifying the registered nurse Correct EH. Documenting the finding EI. Assessing the infant’s blood pressure EJ. Reassessing the fontanel in 30 minutes NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU Rationale: The anterior fontanel, which is diamond shaped, is located on the top of the head. It should be flat and soft. It measures 1 to 4 cm, varying as a result of molding and individual differences. It normally closes by 12 to 18 months of age. Although the anterior fontanel may bulge slightly when the infant cries, bulging at rest may indicate increased intracranial pressure. If this is suspected, the registered nurse is notified. The NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU ER. Coughing, wheezing, and short periods of apnea 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 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? ES. Drink fluids with meals ET. Eliminate the morning meal EU. Eat fatty or spicy foods only at the noontime meal EV. Eat dry crackers every 2 hours to prevent an empty stomach Correct NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU 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 NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU 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 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? EW. “I need to drink at least 2000 mL of fluid a day.” Correct EX. “I should cut back on my fluid intake in the evening.” EY. “I need to avoid emptying my bladder so frequently.” EZ. “I should avoid drinking large amounts of fluids during the day.” Rationale: Urinary frequency is present in the first trimester and late in the third trimester because of the pressure exerted on the bladder by the enlarging uterus. Self- care measures for urinary frequency include frequent emptying of the bladder (every 2 hours) and drinking at least 2000 mL of fluid a day. Restricting fluid intake at any time is incorrect; it could lead to urinary stasis and fluid- volume deficit A licensed practical nurse (LPN) is assisting the registered nurse (RN) in assessing a pregnant client’s deep tendon reflexes and a reflex of 2+ is noted. Based on this finding, the LPN anticipates that the RN will take which action? FA. Document the finding Correct NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU B. 82.ID: 327528095 A nurse is told that a newborn with myelomeningocele will be admitted to the newborn nursery. In which position does the nurse plan to place the infant? A. Prone Correct B. Supine C. On the back, in semi-Fowler D. On the back, in Trendelenburg NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU Rationale: A myelomeningocele is a neural tube defect caused by failure of the posterior neural tube to close. The meninges are exposed through the surface of the skin in a herniated sac that may be either healed or leaking. One major preoperative intervention is protection of the sac from injury to prevent its rupture and resultant risk of central nervous system infection. The infant should be positioned in a side-lying or prone position to prevent pressure on the sac until surgical repair can be performed. Supine positioning would increase pressure on the sac, thereby increasing the risk for sac rupture. Test-Taking Strategy: Focus on the newborn’s diagnosis and use the process of elimination. Eliminate the positions that are comparable or alike in that they involve placing the newborn on the back. If you had difficulty with this question, review care of a newborn with myelomeningocele. Level of Cognitive Ability: Applying NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU Integrated Process: Nursing Process/Implementation Content Area: Newborn References: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., p. 1473). St. Louis: Elsevier. Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal-child nursing care (4th Awarded 0.0 points out of 1.0 possible points. C. 83.ID: 327528075 A nurse is performing an assessment of a female client with suspected mittelschmerz. Which question does the nurse ask the client to elicit data specific to this disorder? A. “Do you have continuous heavy vaginal bleeding?” B. “Do you have pain at the beginning of your period?” C. “Do you have pain every time you have intercourse?” D. “Do you have sharp pain on the right or left side of your pelvis?” Correct Rationale: Mittelschmerz ("middle pain") refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation. The pain is due to growth of the dominant follicle within NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU D. 84.ID: 327529216 A nurse is conducting a home visit with a mother and her 1-week- old infant, who is at risk for acquired neonatal congenital syphilis. Which finding specific to this disease does the nurse look for while assessing the infant? A. Diarrhea B. Hypothermia C. Vigorous feeding D. A copper-colored rash Correct Rationale: Signs of congenital neonatal syphilis — including poor feeding, slight hyperthermia, and “snuffles” (copious clear serosanguinous mucous discharge from the nose) — may be nonspecific at first. By the end of the first week, however, a copper- colored maculopapular dermal rash is characteristically observed on the palms and soles, in the diaper area, and around the mouth and anus. Diarrhea is not specifically associated with this condition. Test-Taking Strategy: Specific knowledge regarding the signs and symptoms of acquired neonatal congenital syphilis in a 1-week-old infant is required to answer this question. If you had difficulty with NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU this question, review the signs of this infection. Level of Cognitive Ability: Analyzing Clients Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Newborn References: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., p. 1035). St. Louis: Elsevier. Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal-child nursing care (4th ed., pp. 749, 750). St. Louis: Elsevier. Awarded 0.0 points out of 1.0 possible points. E. 85.ID: 327528055 A nurse provides instruction regarding prenatal care to a client with a history of heart disease. The nurse tells the client that: A. It is best to lie supine for sleep B. Physical activity should be limited Correct NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU C. The amount of weight gained is not important NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU Rationale: Accelerations, shown in the correct answer, are brief temporary increases in the fetal heart rate of at least 15 beats/min from baseline and lasting at least 15 seconds. They are an indication of fetal well-being and an oxygenated fetal central nervous system. Variable decelerations do not have the uniform appearance of early or late decelerations. Early decelerations are decreases in the fetal heart rate to below baseline; late decelerations look similar to early decelerations but begin well after the contraction begins and return to baseline after the contraction ends. NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU Test-Taking Strategy: Use the process of elimination and your knowledge of the indications of fetal well-being. To answer this question correctly it is necessary to be able to interpret fetal heart rate patterns and identify those that indicate fetal well-being. If you had difficulty with this question, review fetal heart rate patterns. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Antepartum Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., Awarded 0.0 points out of 1.0 possible points. G. 87.ID: 327528049 A clinic nurse is developing a plan of care for a pregnant client with AIDS. Which problem does the nurse identify as the priority to be addressed in the plan of care? A. Poor hygiene B. Inverted nipples C. History of IV drug use Correct D. Intake of fewer than 6 glasses of fluid daily NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU Rationale: AIDS is a breakdown in immune function caused by a retrovirus known as human immunodeficiency virus, or HIV. The infected person contracts opportunistic infections or malignancies that ultimately are fatal. For this reason, the prevention of infection is a priority of nursing care. Although poor hygiene may affect the client’s risk for infection, addressing and helping the client cease her use of IV drugs, which is an immediate contributor to the risk for infections, is priority. Inverted nipples and intake of less than 6 glasses of fluid daily are not specifically related to this syndrome. Test-Taking Strategy: Note the strategic word “priority.” Recalling that AIDS affects the body’s immune system and remembering the factors that increase the risk for infections will direct you to the correct option. If you had difficulty with this question, review the priority concerns related to the client with AIDS. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU Maternal-child nursing care (4th ed., pp. 345, 346). St. Louis: Elsevier. NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU Awarded 0.0 points out of 1.0 possible points. I. 89.ID: 327528083 A nurse answers a call light in the room of a woman who was just admitted in early latent labor. The woman is lying flat on her back on the bed. The husband reports excitedly, “I think my wife is going into shock or something! She was just lying there, and then she turned so pale, and her hands are so clammy. She said she was dizzy and sick to her stomach.” The nurse notes on the noninvasive blood pressure monitor that the woman’s pulse is 58 beats/min and her blood pressure is 90/50 mm Hg. The nurse interprets these findings as indications that the woman is experiencing: A. Anxiety related to the onset of labor B. Progression from latent to active first-stage labor C. Hyperventilation related to excitement at her first labor experience D. Altered tissue perfusion related to hypotensive syndrome (vena cava syndrome) Correct Rationale: In a pregnant woman, the supine position adds gravity pressure to the inferior vena cava, which is already displaced and partially compressed by the full-term gravid uterus. The increased compression decreases cardiac output, leading to beginning tissue NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU hypoxia, which brings on the signs and symptoms described in the question. The signs and symptoms identified in the question are not indicative of progression to active first-stage labor. There is no information in the question to indicate that the client is experiencing hyperventilation or anxiety. Test-Taking Strategy: Use the process of elimination, focusing on the data in the question. Recognizing that there is no information in the question to indicate that the client is experiencing hyperventilation or anxiety will assist you in eliminating these options. To select from the remaining options, note that the pulse and blood pressure are low and remember the pathophysiology of hypotensive syndrome (vena cava syndrome), which will direct you to the correct option. Review the signs and symptoms of hypotensive syndrome (vena cava syndrome) if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Maternity/Intrapartum Reference: Lowdermilk, D., Perry, S., & Cashion, K. (2010). Maternity nursing (8th ed., p. 204). St. Louis: Mosby. NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU difficulty with this question, review the characteristics of normal and abnormal FHRs. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Maternity/Antepartum References: Lowdermilk, D., Perry, S., & Cashion, K. (2010). Maternity nursing (8th ed., p. 280). St. Louis: Mosby. McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., p. 398). St. Louis: Elsevier. Awarded 0.0 points out of 1.0 possible points. K. 91.ID: 327528667 A pregnant woman at 38 weeks’ gestation arrives at the emergency department, reporting bright-red vaginal bleeding but denying pain. On the basis of this information, the nurse determines that the client may be experiencing: A. Placenta previa Correct B. Abruptio placentae NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU C. Passage of the mucus plug NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU D. Rupture of the amniotic sac Rationale: The primary symptom of placenta previa is painless vaginal bleeding in the second or third trimester of pregnancy. Findings of abruptio placentae include dark- red vaginal bleeding and abdominal pain. A ruptured amniotic sac is characterized by findings such as watery vaginal drainage. Passage of the mucus plug is manifested as pink or as blood-tinged mucus. Test-Taking Strategy: Use the process of elimination. Focus on the data in the question and recall that painless vaginal bleeding occurs in placenta previa. If you had difficulty with this question, review the assessment signs associated with the conditions identified in the options. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Maternity/AntepartumAwarded 0.0 points out of 1.0 possible points. L. 92.ID: 327529231 A nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative, refusing any interventions until her husband arrives at the hospital. The nurse analyzes the client’s behavior as most likely the result of: A. Emotional immaturity NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU Rationale: Neonatal abstinence syndrome is the term given to the group of signs and symptoms associated with drug withdrawal in the neonate. Drug withdrawal causes a hyperactive response in the infant because of the increased central nervous system (CNS) stimulation. This hyperactive response and the signs and symptoms of drug withdrawal seem to be most apparent around 1 week of age. Sepsis, hypercalcemia, and intraventricular hemorrhage cause symptoms of CNS depression. Test-Taking Strategy: Use the process of elimination, focusing on the data in the question. Note the strategic word “hyperactive,” which indicates CNS stimulation and should direct you to the correct option. If you had difficulty with this question, review the signs and symptoms of drug withdrawal in the neonate. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Analysis Content Area: Newborn NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU Rationale: One contraindication to the administration of Rho(D) immune globulin is previous hypersensitivity to immune globulin. Rho(D) immune globulin is indicated when an Rh-negative client is exposed to Rh-positive fetal blood cells in any way, including amniocentesis. The other options are all indications for administering RhoGam. Test-Taking Strategy: Use the process of elimination and focus on the subject, a contraindication. Read each option carefully and note the word “hypersensitivity” in the correct option. Review the contraindications to and precautions for the administration of this medication if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU Reference: Lowdermilk, D., Perry, S., & Cashion, K. (2010). Maternity nursing (8th ed., pp. 785, 786). St. Louis: Mosby. Awarded 0.0 points out of 1.0 possible points. N. 94.ID: 327529233 Rho(D) immune globulin (RhoGam) is prescribed for a client after delivery. Before administering the medication, the nurse reviews the client’s history. Which of the following findings is a contraindication to administration of the medication? A. A previous hypersensitivity reaction to immune globulin Correct B. Delivery of an Rh-positive infant by an Rh-negative woman C. Amniocentesis in an Rh-negative woman carrying an Rh-positive fetus D. Known or suspected entry of Rh-positive fetal blood cells to the circulation of an Rh-negative woman NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU Rationale: One contraindication to the administration of Rho(D) immune globulin is previous hypersensitivity to immune globulin. Rho(D) immune globulin is indicated when an Rh-negative client is exposed to Rh-positive fetal blood cells in any way, including amniocentesis. The other options are all indications for administering RhoGam. Test-Taking Strategy: Use the process of elimination and focus on the subject, a contraindication. Read each option carefully and note the word “hypersensitivity” in the correct option. Review the contraindications to and precautions for the administration of this medication if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU Awarded 0.0 points out of 1.0 possible points. O. 95.ID: 327528063 A nurse is caring for a client experiencing hypotonic labor NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU you in answering correctly. Review the characteristics of hypotonic labor contractions and the psychosocial reactions associated with this disorder if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Analysis Content Area: Maternity/Intrapartum Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., pp. 666, 667). St. Louis: Elsevier. Awarded 0.0 points out of 1.0 possible points. P. 96.ID: 327528039 A nurse is reviewing the records of the clients admitted to the maternity unit during the past 24 hours. Which of the following clients does the nurse recognize as being at risk for the development of disseminated intravascular coagulation (DIC)? Select all that apply. M. A client with septicemia N. A client with mild preeclampsia NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU In orrect Correct NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU O. A client with diabetes mellitus who delivered a 10-lb baby Incorrect P. A client who had a cesarean section because of abruptio placentae Correct Q. A client who delivered 12 hours ago and has lost 475 mL of blood 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: R. Prone S. In a semi-Fowler position T. In the Trendelenburg position NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU 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. NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU U. Supine with a wedge under the right hip Correct A nurse is preparing to perform the Leopold maneuvers on a pregnant client. The nurse should first: V. Locate the fetal heart tone NURSING 240 TEST EXAM Q& AS WITH ALL ANSWERS 100% CORRECTLY/VERIFIED LATEST UPDATE 2023/2024 GRADED A+ A HOME CARE NURSE IS INSTRUCTING A CLIENT WITH HYPEREMESIS GRAVIDARU Rationale: The pregnant client is positioned so that the uterus is displaced laterally to prevent compression of the inferior vena cava, which causes decreased placental perfusion. This is accomplished by placing a wedge under the hip. Positioning for abdominal surgery necessitates a supine position. The Trendelenburg position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler or prone position is not practical for this type of abdominal surgery.