Chapter 07: Nursing Management of Pain During Labor and Birth
MULTIPLE CHOICE
- A nurse is teaching a childbirth preparation class. The group is discussing individual expression of labor pain. What statement is accurate about a patient’s expression of pain?
| a. | It reduces the patient’s perception of pain. |
| b. | It is intensified by the vertex position of the fetus. |
| c. | It is influenced by culture. |
| d. | It can be completely controlled by nonpharmacological techniques. |
ANS: C
Culture influences how women feel about birth and what is an acceptable response to pain.
DIF: Cognitive Level: Comprehension REF: Page 161 OBJ: 3
TOP: Cultural Influences on Pain KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- What chemical substance(s) produced in the body acts as a natural pain reliever?
| a. | Endorphins |
| b. | Morphine |
| c. | Codeine |
| d. | Atropine |
ANS: A
Endorphins are natural body substances that are similar to morphine and may explain why laboring women need smaller doses of analgesia.
DIF: Cognitive Level: Knowledge REF: Page 160 OBJ: 1
TOP: Endorphins KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- A nurse instructs a woman’s labor coach to comfort her by firmly pressing on her lower back. What is this technique?
| a. | Sacral pressure |
| b. | Distraction |
| c. | Effleurage |
| d. | Conscious relaxation |
ANS: A
Sacral pressure refers to firm pressure against the lower back to relieve some of the pain of back labor.
DIF: Cognitive Level: Knowledge REF: Page 160, Box 7-1
OBJ: 6 TOP: Nonpharmacological Pain Management
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- A woman who is 6 cm dilated has the urge to push. What will the nurse instruct the woman to do during the contraction?
| a. | Use slow-paced breathing. |
| b. | Hold her breath and push. |
| c. | Blow in short breaths. |
| d. | Use rapid-paced breathing. |
ANS: C
If a laboring woman feels the urge to push before the cervix is fully dilated, then she is taught to blow in short breaths to avoid bearing down.
DIF: Cognitive Level: Application REF: Page 163 OBJ: 4
TOP: Stair-Step Breathing Pattern KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- Several hours into labor, a woman complains of dizziness, numbness, and tingling of her hands and mouth. What does the nurse recognize these symptoms signify?
| a. | Hypertension |
| b. | Anxiety |
| c. | Anoxia |
| d. | Hyperventilation |
ANS: D
Hyperventilation is sometimes a problem if a woman is breathing rapidly.
DIF: Cognitive Level: Comprehension REF: Page 164, Box 7-2
OBJ: 4 TOP: Hyperventilation
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- What is the most appropriate nursing action to take when a laboring woman hyperventilates?
| a. | Help her breathe into her cupped hands. |
| b. | Place her flat on her back. |
| c. | Initiate oxygen at 2 liters via mask. |
| d. | Notify the doctor. |
ANS: A
Measures to combat hyperventilation include breathing into cupped hands or a paper bag or holding breath for a few seconds. All of these techniques decrease PCO2.
DIF: Cognitive Level: Application REF: Page 164, Box 7-2
OBJ: 4 TOP: Nonpharmacological Pain Management
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
- A woman in the transition phase of labor requests a narcotic analgesic medication for pain relief. What should the nurse explain regarding giving a narcotic analgesic medication at this stage of labor?
| a. | It can cause medication given at later stages to be ineffective. |
| b. | It will have no complications for the mother or infant. |
| c. | It may result in respiratory depression to the newborn. |
| d. | It will speed up labor and increase pain. |
ANS: C
The risk of narcotic analgesics is that they cross the placenta and can cause fetal respiratory depression.
DIF: Cognitive Level: Comprehension REF: Page 164-165
OBJ: 7 TOP: Opioids KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
- What would the nurse guide a labor coach to do to comfort a woman tensing her muscles with contractions?
| a. | Offer warm liquids to the patient. |
| b. | Encourage the patient to pant. |
| c. | Engage the patient in conversation. |
| d. | Assist the patient to the knee-chest position. |
ANS: B
Panting relaxes the abdominal wall and distracts the patient. It would not be helpful to offer fluids or to attempt conversation during contractions. Walking intensifies contractions.
DIF: Cognitive Level: Application REF: Page 163 OBJ: 4
TOP: Panting KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- A woman in labor will receive general anesthesia prior to cesarean section. The nurse reminds the patient that food and fluids need to be restricted for several hours prior to delivery. What will this prevent?
| a. | Nausea and vomiting |
| b. | Vomiting and aspiration |
| c. | Abdominal cramping |
| d. | Intestinal obstruction |
ANS: B
The major adverse effect of general anesthesia is aspiration of stomach contents.
DIF: Cognitive Level: Comprehension REF: Page 166, Table 7-2
OBJ: 7 TOP: General Anesthesia
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
- What assessment should be taken immediately after the anesthesiologist administers an epidural block to a laboring woman?
| a. | Bladder for distention |
| b. | Blood pressure |
| c. | Sensation in the lower extremities |
| d. | Intravenous fluid flow rate |
ANS: B
Blood pressure is checked every 5 minutes when the epidural block is first begun. Bladder assessment is also important but not an initial assessment.
DIF: Cognitive Level: Application REF: Page 166, Table 7-2
OBJ: 6 TOP: Epidural Block
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
- A woman in labor has had an epidural block for pain relief. The nurse will be assessing carefully for what associated side effect of this type of regional anesthesia?
| a. | Reduced fetal heart rate |
| b. | Long, intense contractions |
| c. | Sudden leg cramps |
| d. | Bladder distention |
ANS: D
A side effect of an epidural block is urine retention because the anesthesia interferes with the woman’s ability to have an urge to void. The patient may have to be catheterized.
DIF: Cognitive Level: Knowledge REF: Page 166, Table 7-2
OBJ: 7 TOP: Epidural Block
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
- Which narcotic antagonist is used to reverse narcotic-induced respiratory depression?
| a. | Hydroxyzine (Vistaril) |
| b. | Phenobarbital |
| c. | Naloxone (Narcan) |
| d. | Nitrous oxide |
ANS: C
Naloxone (Narcan) is used to reverse respiratory depression caused by narcotics.
DIF: Cognitive Level: Knowledge REF: Page 165 OBJ: 7 | 8
TOP: Narcotic Antagonist KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Reduction of Risk
- The nurse is preparing a teaching plan for a woman receiving a subarachnoid block before delivery. What nursing action will be included in this plan to prevent the associated side effect of this type of anesthesia?
| a. | Restrict oral fluids. |
| b. | Keep legs flexed. |
| c. | Walk with assistance as soon as possible. |
| d. | Lie flat for several hours. |
ANS: D
The woman would be advised to remain flat for several hours after the block to decrease the chance of postspinal headache.
DIF: Cognitive Level: Application REF: Page 166, Table 7-2
OBJ: 7 TOP: Subarachnoid Block
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
- A woman requests a pudendal block to manage her labor pain. What statement by the woman indicates a need for further explanation about the pudendal block?
| a. | “I’m having a contraction. Can I get the pudendal block now?” |
| b. | “I’ll get the pudendal block right before I deliver.” |
| c. | “The nurse midwife will insert the needles into my vagina.” |
| d. | “It takes a few minutes after the medicine is administered to make me feel numb.” |
ANS: A
The pudendal block does not block pain from contractions and is given just before birth.
DIF: Cognitive Level: Comprehension REF: Page 166, Table 7-2
OBJ: 7 TOP: Pudendal Block
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- An 18-year-old primigravida is 4 cm dilated and her contractions are 5 minutes apart. She received little prenatal care and had no childbirth preparation. She is crying loudly and shouting, “Please give me something for the pain. I can’t take the pain!” What is the priority nursing diagnosis?
| a. | Pain related to uterine contractions |
| b. | Knowledge deficit related to the birth experience |
| c. | Ineffective coping related to inadequate preparation for labor |
| d. | Risk for injury related to lack of prenatal care |
ANS: A
The most important issue for this woman, at this time, is effective pain management.
DIF: Cognitive Level: Analysis REF: Page 170, Nursing Care Plan 7-1
OBJ: 3 TOP: Pain as a Priority
KEY: Nursing Process Step: Nursing Diagnosis
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- The nurse who encourages the gate control theory of pain control would advise a woman in labor and her partner to use which nonpharmacological method of pain management?
| a. | Slow abdominal breathing |
| b. | Guided relaxation |
| c. | Listening to music |
| d. | Massage |
ANS: D
According to the gate control theory, stimulating large-diameter nerve fibers temporarily interferes with conduction of impulses through small-diameter fibers. Massage is a technique that stimulates large-diameter fibers and “closes the gate.”
DIF: Cognitive Level: Analysis REF: Page 159 OBJ: 5
TOP: Gate Control KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- When a pregnant woman arrives at the labor suite, she tells the nurse that she wants to have an epidural for delivery. What is a contraindication to an epidural block?
| a. | Abnormal clotting |
| b. | Previous cesarean delivery |
| c. | History of migraine headaches |
| d. | History of diabetes mellitus |
ANS: A
An epidural block is not used if a woman has abnormal blood clotting.
DIF: Cognitive Level: Comprehension REF: Page 166, Table 7-2 | Page 168
OBJ: 7 TOP: Epidural Block
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
- The nurse coaches the primigravida not to bear down until the cervix is completely dilated. What may premature bearing down cause?
| a. | Increased use of oxygen |
| b. | Cervical laceration |
| c. | Uterine rupture |
| d. | Compression of the cord |
ANS: B
Bearing down against a cervix that is not dilated can cause edema and laceration to the cervix.
DIF: Cognitive Level: Comprehension REF: Page 163 OBJ: 3
TOP: Cervical Laceration KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
- What is the Dick-Read method of childbirth preparation based on?
| a. | Mild sedation throughout labor |
| b. | Relaxation techniques |
| c. | Skin stimulation |
| d. | Deep massage |
ANS: B
The Dick-Read method depends on the use of relaxation techniques to reduce the discomforts of labor.
DIF: Cognitive Level: Knowledge REF: Page 161 OBJ: 5
TOP: Dick-Read Method KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- The nurse is instructing a Lamaze class on abdominal breathing and tells a patient that her baseline respiratory rate is 22 breaths per minute. What should be the patient’s rate while performing slow breathing?
ANS: B
The range of respirations should be no lower than half of the base rate and no more rapid than double the base rate.
DIF: Cognitive Level: Comprehension REF: Page 160, Box 7-1
OBJ: 5 TOP: Lamaze Method
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- What is the least amount of sensation that one perceives as pain?
| a. | Tolerance |
| b. | Threshold |
| c. | Level |
| d. | Abatement |
ANS: B
Pain threshold is the least amount of sensation that one perceives as pain. Thresholds are different for each individual.
DIF: Cognitive Level: Knowledge REF: Page 159 OBJ: 1
TOP: Pain Threshold KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- The nurse is caring for a laboring patient who is not reporting pain. What sign would alert the nurse of the need for pain relief?
| a. | Frequently asking for ice chips |
| b. | Facial grimacing |
| c. | Changing positions in bed |
| d. | Covering her face with her hands |
ANS: B
Facial grimacing may be an indicator of unexpressed pain.
DIF: Cognitive Level: Comprehension REF: Page 164 OBJ: 3
TOP: Nonverbal Pain Expressing KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- A patient who received an epidural block asks why her blood pressure is taken so often. What is the nurse’s best response to explain the frequent blood pressure assessments?
| a. | They ensure that unsafe levels of hypertension do not occur. |
| b. | They help assess for the need for further pain relief. |
| c. | They monitor the progress of labor. |
| d. | They ensure adequate placental perfusion. |
ANS: D
The hypotension that accompanies an epidural block may cause inadequate perfusion of the placenta, leading to fetal hypoxia.
DIF: Cognitive Level: Comprehension REF: Page 166, Table 7-2
OBJ: 7 TOP: Disadvantage of Epidural Block
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
- A laboring patient requests hot and cold applications be applied to her abdomen for pain control. How will this intervention act to control pain?
| a. | By increasing endorphin production |
| b. | By facilitating effacement and dilation |
| c. | By producing increasing pain tolerance |
| d. | By stimulation of large nerve fibers |
ANS: D
The gate control theory explains how pain impulses reach the brain for interpretation. It supports several nonpharmacological methods of pain control. According to this theory, pain is transmitted through small-diameter nerve fibers. However, the stimulation of large-diameter nerve fibers temporarily interferes with the conduction of impulses through small-diameter fibers. Techniques to stimulate large-diameter fibers and “close the gate” to painful impulses include massage, palm and fingertip pressure, and heat and cold applications.
DIF: Cognitive Level: Comprehension REF: Page 159, 162
OBJ: 3 TOP: Nonpharmacological Pain Relief
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- When caring for the laboring patient, the nurse determines that the fetus is located in the right occiput posterior (ROA). What will the nurse anticipate?
| a. | Urinary retention |
| b. | Severe lower back pain |
| c. | A shorter labor process |
| d. | Nausea |
ANS: B
If the fetal occiput is in a posterior pelvic quadrant, each contraction pushes it against the mother’s sacrum, resulting in persistent and poorly relieved back pain (back labor). Labor is often longer with this fetal position.
DIF: Cognitive Level: Application REF: Page 161 OBJ: 3
TOP: Maternal Condition KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
MULTIPLE RESPONSE
- What typical types of classes are available to help expectant parents prepare for parenthood? (Select all that apply.)
| a. | Infant care |
| b. | Breastfeeding |
| c. | Gestational diabetes |
| d. | Sources of financial aid |
| e. | Yoga |
ANS: A, B, C
Prenatal classes include such topics as infant care, breastfeeding, gestational diabetes, exercising, and sibling and grandparent preparation. Yoga and financial information are not traditional content for prenatal instruction.
DIF: Cognitive Level: Knowledge REF: Page 157-158, Health Promotion
OBJ: 2 TOP: Prenatal Classes
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
- What breathing techniques would the nurse teach the prenatal patient to help her focus during labor in order to reduce pain? (Select all that apply.)
| a. | First stage breathing |
| b. | Abdominal breathing |
| c. | Fourth stage breathing |
| d. | Modified pace breathing |
| e. | Patterned paced breathing |
ANS: A, B, D, E
First stage breathing includes the techniques of modified pace breathing and patterned paced breathing, which are types of abdominal breathing techniques. These patterns of breathing will help a woman in labor to focus and reduce pain perception. The fourth stage of labor is the woman’s recovery stage and does not require a breathing technique.
DIF: Cognitive Level: Comprehension REF: Page 163 OBJ: 5
TOP: Breathing Exercises KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- How does the pain of childbirth differ from other types of pain? (Select all that apply.)
| a. | Childbirth pain is part of a normal process. |
| b. | Childbirth pain seldom needs narcotic relief. |
| c. | Position changes relieve pain and facilitate delivery. |
| d. | Childbirth pain declines following birth. |
| e. | Childbirth pain is self-limited. |
ANS: A, C, D, E
Childbirth pain differs from other types of pain because it is part of a normal, natural, and expected process, can be relieved by change of position, declines immediately following birth, and is self-limiting. Childbirth pain requires pharmacological management with narcotics in many cases.
DIF: Cognitive Level: Comprehension REF: Page 159 OBJ: 3
TOP: Childbirth Pain KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- Which are nonpharmacological forms of pain relief? (Select all that apply.)
| a. | Skin stimulation |
| b. | Diversion and distraction |
| c. | Breathing techniques |
| d. | Exercise |
| e. | Yoga |
ANS: A, B, C
Skin stimulation, diversion and distraction, and breathing techniques are the bases of nonpharmacological pain control. Although exercise and practices such as yoga and Pilates are beneficial, they are not means of pain control.
DIF: Cognitive Level: Knowledge REF: Page 160, Box 7-1 | Page 162
OBJ: 5 TOP: Nonpharmacological Pain Control
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- Which position(s) and exercise(s) will the nurse teach as beneficial in combating discomfort in the later stages of pregnancy? (Select all that apply.)
| a. | Leg lifts |
| b. | Pelvic rock |
| c. | Tailor sitting |
| d. | Sit-ups |
| e. | Shoulder curling |
ANS: B, C, E
Pelvic rock, tailor sitting, and shoulder curling are beneficial to the muscles that will have to adapt to the extra weight and changed posture of later pregnancy. Leg lifts and sit-ups are not beneficial because they both increase intraabdominal pressure.
DIF: Cognitive Level: Comprehension REF: Page 158, Chapter 4
OBJ: 6 TOP: Helpful Exercises
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse is providing a conference on nonpharmacological pain control methods. What major advantages of nonpharmacological pain control methods will the nurse include in the presentation? (Select all that apply.)
| a. | They sedate the mother. |
| b. | They do not slow labor. |
| c. | They do not dull the excitement of the birth experience. |
| d. | They do not have the potential to cause allergic reactions. |
| e. | They do not have to be delayed until labor is well established. |
ANS: B, C, D, E
All the options mentioned are benefits of nonpharmacological pain control methods with the exception of sedating the mother.
DIF: Cognitive Level: Knowledge REF: Page 161 OBJ: 4
TOP: Advantages of Nonpharmacological Pain Control
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- The nurse is caring for a woman with epidural anesthesia for pain control during a vaginal delivery. A risk for injury related to epidural anesthesia has been identified by the nursing staff. What interventions are appropriate for the nurse to implement related to this diagnosis? (Select all that apply.)
| a. | Assess leg movement and sensation before ambulating. |
| b. | Administer antibiotic as ordered. |
| c. | Observe for signs of impending birth. |
| d. | Provide sacral pressure as needed. |
| e. | Assess fetal position frequently. |
ANS: A, C
To prevent the risk for injury related to epidural anesthesia the nurse should asses for movement, sensation, and leg strength before ambulating, ambulate cautiously with an assistant, assist the woman to change positions regularly, and observe for signs that birth may be near: increase in bloody show, perineal bulging, and/or crowning.
DIF: Cognitive Level: Application REF: Page 172 OBJ: 8
TOP: Epidural Anesthesia KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
- The physician has ordered Fentanyl (Sublimaze) for a woman in labor and has asked the nurse to provide patient education. What will the nurse include in the educational plan? (Select all that apply.)
| a. | Onset is slow. |
| b. | Duration is short. |
| c. | Administration is by mouth. |
| d. | No known side effects. |
| e. | It is not the same drug as sufentanil. |
ANS: B, E
Fentanyl has a rapid onset and short duration of action. Fentanyl, sufentanil, and alfentanil are not the same drugs. Fentanyl can cause respiratory depression but less than meperidine. It is not administered by mouth.
DIF: Cognitive Level: Comprehension REF: Page 165, Table 7-1
OBJ: 8 TOP: Narcotic Analgesia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
COMPLETION
- The amount of pain a person is willing to endure is referred to as ______________ ______________.
ANS:
pain tolerance
Pain tolerance is the amount of pain a person is willing to endure. Pain threshold is the point at which pain is perceived. Pain threshold is relatively consistent from person to person, but pain tolerance differs greatly.
DIF: Cognitive Level: Knowledge REF: Page 159 OBJ: 1
TOP: Pain Tolerance KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The massage technique that stimulates the large-diameter fibers in order to block impulses from the small-diameter fibers is ____________________.
ANS:
effleurage
Effleurage stimulates the large-diameter fibers and blocks the pain impulses from the small-diameter fibers.
DIF: Cognitive Level: Comprehension REF: Page 159, Figure 7-3 | Page 162
OBJ: 6 TOP: Effleurage KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- The ______________ ___________, also called the psychoprophylactic method, is the basis of most childbirth preparation classes in the United States.
ANS:
Lamaze method
The Lamaze method, also called the psychoprophylactic method, is the basis of most childbirth preparation classes in the United States.
DIF: Cognitive Level: Knowledge REF: Page 161 OBJ: 5
TOP: Childbirth Preparation KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
Chapter 09: The Family After Birth
MULTIPLE CHOICE
- The nurse is assessing a newborn. What sign of hypoglycemia does the nurse record?
| a. | Increased nasal mucus |
| b. | Increased temperature |
| c. | Active muscle movements |
| d. | High-pitched cry |
ANS: D
There are many signs of hypoglycemia in the newborn. One is a high-pitched cry.
DIF: Cognitive Level: Comprehension REF: Page 219 OBJ: 9
TOP: Signs of Hypoglycemia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
- What would the nurse expect to find when assessing the fundus of the uterus immediately after delivery?
| a. | Well-contracted with its upper border at or just below the umbilicus |
| b. | Well-contracted with its upper border three or four fingerbreadths above the umbilicus |
| c. | Relaxed with its upper border level with the umbilicus |
| d. | Relaxed with its upper border two or three fingerbreadths below the umbilicus |
ANS: A
Immediately after the placenta is expelled, the uterine fundus can be felt as a firm mass, about the size of a grapefruit, at the level of the umbilicus.
DIF: Cognitive Level: Comprehension REF: Page 200 OBJ: 2
TOP: Fundus Assessment KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- What statement made by a new mother indicates she needs additional information about breastfeeding?
| a. | “I let the baby nurse 10 to 15 minutes on the first breast and then switch to the other breast.” |
| b. | “The baby needs to nurse at least 5 minutes on the breast to get the hindmilk.” |
| c. | “The baby has been nursing every 2 to 3 hours.” |
| d. | “If the baby gets fussy between feedings, I give her a bottle of water.” |
ANS: D
Supplemental feedings of formula or water should not be offered to a healthy newborn who is breastfeeding.
DIF: Cognitive Level: Comprehension REF: Page 223-227
OBJ: 14 TOP: Breastfeeding—Supplemental Feedings
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- After delivery, the nurse’s assessment reveals a soft, boggy uterus located above the level of the umbilicus. What is the most appropriate nursing intervention?
| a. | Notify the physician. |
| b. | Massage the fundus. |
| c. | Initiate measures that encourage voiding. |
| d. | Position the patient flat. |
ANS: B
A poorly contracted uterus should be massaged until firm to prevent hemorrhage.
DIF: Cognitive Level: Application REF: Page 202 OBJ: 9
TOP: Boggy Uterus KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- What type of lochia will the nurse assess initially after delivery?
| a. | Serosa |
| b. | Rubra |
| c. | Alba |
| d. | Vaginalis |
ANS: B
The initial vaginal discharge after delivery is called lochia rubra. It is red and moderately heavy. Lochia rubra lasts for up to 3 days postpartum.
DIF: Cognitive Level: Knowledge REF: Page 202 OBJ: 4
TOP: Lochia Rubra KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- A woman will be discharged 48 hours after a vaginal delivery. When planning discharge teaching, the nurse would include what information about lochia?
| a. | Lochia should disappear 2 to 4 weeks postpartum. |
| b. | It is normal for the lochia to have a slightly foul odor. |
| c. | A change in lochia from pink to bright red should be reported. |
| d. | A decrease in flow will be noticed with ambulation and activity. |
ANS: C
A return to bright red lochia rubra may indicate a late postpartum hemorrhage and must be reported.
DIF: Cognitive Level: Application REF: Page 203 OBJ: 18
TOP: Hemorrhage KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- What instruction should the nurse teach the postpartum woman about perineal self-care?
| a. | Perform perineal self-care at least twice a day. |
| b. | Cleanse with warm water in a squeeze bottle from front to back. |
| c. | Remove perineal pads from the rectal area toward the vagina. |
| d. | Use cool water to decrease edema of the perineum. |
ANS: B
Cleansing from front to back prevents contamination from the rectal area.
DIF: Cognitive Level: Application REF: Page 204 OBJ: 2
TOP: Perineal Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- A postpartum woman is not immune to rubella. What will the nurse expect?
| a. | The rubella virus vaccine should be administered before discharge. |
| b. | The woman should receive the rubella virus vaccine at her 6-week postpartum checkup. |
| c. | The woman should be instructed not to get pregnant until she receives the rubella vaccine. |
| d. | No intervention is indicated at this time because the woman is not at risk for rubella. |
ANS: A
The woman who is not immune to rubella is immunized in the immediate postpartum period because there is no danger of her being pregnant.
DIF: Cognitive Level: Comprehension REF: Page 209 OBJ: 2
TOP: Rubella KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- Which statement indicates the new mother is breastfeeding correctly?
| a. | “I will alternate breasts when feeding the baby.” |
| b. | “I keep the baby on a 4-hour feeding schedule.” |
| c. | “I let the baby stay on the first breast only 5 minutes.” |
| d. | “I put only the nipple in the baby’s mouth when I am breastfeeding.” |
ANS: A
Alternating breasts for feeding increases milk production, particularly hindmilk, which has a higher protein and fat content.
DIF: Cognitive Level: Comprehension REF: Page 224, Table 9-4
OBJ: 14 TOP: Breastfeeding
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse is counseling a lactating mother about diet. What would the nurse include with this information?
| a. | Consume 500 more calories than her usual prepregnancy diet. |
| b. | Eat less meat and more fruits and vegetables. |
| c. | Drink 3 to 4 tall glasses of fluid daily. |
| d. | Eat 1000 more calories than her usual prepregnancy diet. |
ANS: A
To maintain nutrient stores while breastfeeding, the mother needs 500 additional calories each day over her prepregnancy diet.
DIF: Cognitive Level: Comprehension REF: Page 230 OBJ: 15
TOP: Breastfeeding—Maternal Nutrition
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- A woman asks about resumption of her menstrual cycle after childbirth. What should the nurse respond?
| a. | A woman will not ovulate in the absence of menstrual flow. |
| b. | Most nonlactating women resume menstruation about 2 months postpartum. |
| c. | Generally, a woman does not ovulate in the first few cycles after childbirth. |
| d. | The return of menstruation is delayed when a woman does not breastfeed. |
ANS: B
Menstrual periods resume in about 6 to 8 weeks if the woman is not breastfeeding.
DIF: Cognitive Level: Comprehension REF: Page 205 OBJ: 4
TOP: Return of Menses KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- In what situation will the physician order RhoGAM?
| a. | An unsensitized Rh-negative mother has an Rh-positive infant. |
| b. | An Rh-negative mother becomes sensitized. |
| c. | A sensitized infant has a rising bilirubin level. |
| d. | An unsensitized infant exhibits no outward signs. |
ANS: A
The Rh-negative woman should receive RhoGAM within 72 hours after the birth of an Rh-positive infant.
DIF: Cognitive Level: Analysis REF: Page 209 OBJ: 4
TOP: RhoGAM KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- After birth, the nurse quickly dries and wraps the newborn in a blanket. How does this action prevent heat loss?
| a. | Conduction |
| b. | Radiation |
| c. | Evaporation |
| d. | Convection |
ANS: C
Newborns lose heat quickly after birth as fluid evaporates from their bodies.
DIF: Cognitive Level: Comprehension REF: Page 216, Table 9-3
OBJ: 2 TOP: Thermoregulation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- What will the nurse’s instructions for a new mother to care for the infant’s umbilical cord include?
| a. | Keeping the area covered with a sterile dressing |
| b. | Dressing the stump with antibiotic ointment at every diaper change |
| c. | Fastening the diaper low to allow for air circulation |
| d. | Giving the newborn a daily tub bath until the cord falls off |
ANS: C
Diaper placement below the umbilical stump allows for drying by air circulation.
DIF: Cognitive Level: Application REF: Page 218-219, Skill 9-6
OBJ: 2 TOP: Umbilical Cord Care
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- A new mother states her preference to formula feed her newborn. What will the nurse planning discharge instructions tell her to help suppress lactation and promote comfort?
| a. | Wear a well-fitting bra continuously for several days. |
| b. | Stand in a warm shower, letting the water spray over the breasts. |
| c. | Express small amounts of milk from the breasts several times a day. |
| d. | Massage the breasts when they ache. |
ANS: A
When a mother does not wish to breastfeed, a snug bra worn around the clock can help alleviate discomfort from engorgement.
DIF: Cognitive Level: Application REF: Page 230 OBJ: 18
TOP: Suppression of Lactation KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- On the second postpartum day, a mother bathed her newborn for the first time. She tells the nurse, “I don’t think I did it right.” What postpartum psychological stage is this woman most likely in based on this comment?
| a. | Taking in |
| b. | Taking hold |
| c. | Letting go |
| d. | Settling down |
ANS: B
In phase 2, taking hold, the mother begins to initiate action and becomes interested in caring for the infant. In doing so, she may become critical of her performance.
DIF: Cognitive Level: Analysis REF: Page 212, Table 9-2
OBJ: 6 TOP: Postpartum Psychological Stages
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Physiological Adaptation
- A primipara tells the nurse, “My afterpains get worse when I am breastfeeding.” What is the most appropriate nursing response?
| a. | “I’ll get you some aspirin to relieve the cramping that you feel.” |
| b. | “Afterpains are more intense with your first baby.” |
| c. | “Breastfeeding releases a hormone that causes your uterus to contract.” |
| d. | “A change of position when you’re breastfeeding might help.” |
ANS: C
Breastfeeding mothers may have more afterpains because infant suckling causes the posterior pituitary to release oxytocin, which is a hormone that contracts the uterus.
DIF: Cognitive Level: Application REF: Page 201 OBJ: 2
TOP: Afterpains with Breastfeeding KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- A new mother has decided not to breastfeed her newborn. What information will the nurse include when planning to teach the mother about formula feeding?
| a. | Positioning the bottle so that the nipple is full of formula during the entire feeding |
| b. | Heating the infant formula in a microwave |
| c. | Burping the infant after 4 ounces and again when the bottle is empty |
| d. | Propping a bottle for a feeding |
ANS: A
The nipple of the bottle should be kept full of formula to reduce the amount of air the infant swallows.
DIF: Cognitive Level: Comprehension REF: Page 232, Skill 9-7
OBJ: 17 TOP: Formula Feeding
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
- In the recovery room, the nurse checks the newly delivered woman’s fundus following a cesarean section. How would the nurse proceed with this assessment?
| a. | Palpate from the midline to the side of the body. |
| b. | Palpate from the symphysis to the umbilicus. |
| c. | Palpate from the side of the uterus to the midline. |
| d. | Massage the abdomen in a circular motion. |
ANS: C
The fundus is checked gently by walking the fingers from the side of the uterus to the midline.
DIF: Cognitive Level: Application REF: Page 209 OBJ: 5
TOP: Postpartum Cesarean Assessment KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- The nurse instructed a postpartum woman about storing and freezing breast milk. What statement by the woman leads the nurse to determine that the teaching was effective?
| a. | “I can thaw frozen breast milk in the microwave.” |
| b. | “I’ll put enough breast milk for one day in a container.” |
| c. | “Breast milk can be stored in glass containers.” |
| d. | “Breast milk can be kept in the refrigerator for up to 3 months.” |
ANS: C
Breast milk can be safely stored in glass or clear hard plastic containers.
DIF: Cognitive Level: Comprehension REF: Page 229 OBJ: 14
TOP: Storing Breast Milk KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- What should the nurse implement for security purposes when bringing the infant from the nursery to the mother?
| a. | Ask, “Is this your band number?” |
| b. | Confirm room number of mother. |
| c. | Ask the mother to identify herself verbally. |
| d. | Check the band number of the infant with that of the mother. |
ANS: D
The nurse should check the band number of the infant with that of the mother by asking the mother to verbally read the number.
DIF: Cognitive Level: Application REF: Page 216-217
OBJ: 8 TOP: Security Identification Procedure
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- Below what blood glucose level is the newborn considered hypoglycemic?
| a. | Below 70 mg/dL |
| b. | Below 60 mg/dL |
| c. | Below 50 mg/dL |
| d. | Below 40 mg/dL |
ANS: D
A blood glucose level of less than 40 mg/dL is considered hypoglycemic. If the screening sample is below 40 mg/dL, a venous sample will be drawn. After the blood has been drawn, the infant should be fed to prevent a further drop.
DIF: Cognitive Level: Comprehension REF: Page 219 OBJ: 8
TOP: Hypoglycemia KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
- The nurse is caring for a woman of Middle Eastern descent on the first postpartum day. Education is provided regarding instruction on use of a sitz bath. What documentation best indicates that the woman has understood the provided instruction?
| a. | Patient correctly performed return demonstration. |
| b. | Patient indicated understanding by nodding head with instruction. |
| c. | Patient verbalizes “I understand.” |
| d. | Family member indicates patient understands procedure. |
ANS: A
The nurse may need an interpreter to understand and provide optimal care to the woman and her family. If possible, when discussing sensitive information the interpreter should not be a family member, who might interpret selectively. The interpreter should not be of a group that is in social or religious conflict with the patient and her family, an issue that might arise in many Middle Eastern cultures. It is also important to remember that an affirmative nod from the woman may be a sign of courtesy to the nurse rather than a sign of understanding or agreement.
DIF: Cognitive Level: Application REF: Page 200 OBJ: 3
TOP: Cultural Influences KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Cultural Awareness
- A woman has given birth to an unresponsive newborn that NICU staff are attempting to revive. The patient and her husband are grief stricken and request the child be baptized immediately. What is the nurse’s most appropriate action?
| a. | Contact the hospital chaplain. |
| b. | Request the couple’s clergy. |
| c. | Baptize the newborn. |
| d. | Ask the physician to baptize the newborn. |
ANS: C
If the condition of a newborn is poor, the parents may wish to have a baptism performed. The minister or priest is notified. However this is an emergency, so the nurse may perform the baptism by pouring water on the infant’s forehead while saying, “I baptize you in the name of the Father, and of the Son, and of the Holy Spirit.” If there is any doubt as to whether the infant is alive, the baptism is given conditionally: “If you are capable of receiving baptism, I baptize you in the name of the Father, and of the Son, and of the Holy Spirit.” The physician is attending to the patient’s immediate health needs.
DIF: Cognitive Level: Application REF: Page 213 OBJ: 7
TOP: Grieving Parents KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Grief and Loss
- A woman required a cesarean section for safe delivery of her newborn. She is planning to breastfeed and verbalized concern about pain. What is the best suggestion by the nurse?
| a. | “Consider formula feeding for the first few days.” |
| b. | “Pumping breast milk would be best for now.” |
| c. | “Take pain medication 30 to 40 minutes prior to nursing.” |
| d. | “Use the football hold when breastfeeding.” |
ANS: D
The best answer is to encourage use of the football hold to decrease pressure on the operative site. There is no indication for the woman to formula feed or pump. Some pain medications should not be taken when breastfeeding.
DIF: Cognitive Level: Application REF: Page 224-225, Figure 9-10
OBJ: 12 TOP: Breastfeeding
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
MULTIPLE RESPONSE
- Which assessments would lead the nurse to determine the gestational age of the infant as preterm? (Select all that apply.)
| a. | Thin, transparent skin |
| b. | Vernix only in the body creases |
| c. | Folded ear springs back slowly |
| d. | Breast tissue under the nipple |
| e. | Creases over entire sole |
ANS: A, C
The only signs of preterm are the thin skin and the slowly responding ear.
DIF: Cognitive Level: Application REF: Page 217 OBJ: 2
TOP: Gestational Age Assessment KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
- The nurse is giving a shower to a patient who had a cesarean section 2 days previously. What interventions should be included before, during, and after the shower? (Select all that apply.)
| a. | Leave abdominal dressing open to air. |
| b. | Position patient with back to water stream. |
| c. | Cover infusion site with rubber glove. |
| d. | Provide a shower chair. |
| e. | Confirm ambulation ability. |
ANS: B, C, D, E
The patient should be evaluated for ambulatory ability, and the abdominal dressing and infusion site should be covered with a waterproof cover. The patient should be provided a shower chair and positioned with her back to the water stream.
DIF: Cognitive Level: Application REF: Page 209-211
OBJ: 5 TOP: Postpartum Shower
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- What postpartum exercises should the nurse teach a patient who had a vaginal delivery yesterday? (Select all that apply.)
| a. | Abdominal tighteners |
| b. | Head lift |
| c. | Pelvic tilt |
| d. | Kegel exercises |
| e. | Leg lifts |
ANS: A, B, C, D
Exercises for postpartum involution such as abdominal tighteners, head lifts, pelvic tilts, and Kegel exercises are acceptable. Leg lifts are too strenuous early in the postpartum period.
DIF: Cognitive Level: Comprehension REF: Page 208 OBJ: 18
TOP: Postpartum Exercises KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- While instructing a new mother on formula preparations, the nurse would include what types? (Select all that apply.)
| a. | Ready-to-feed formula |
| b. | Concentrated liquid formula |
| c. | Powdered formula |
| d. | Cow’s milk |
| e. | Canned evaporated milk |
ANS: A, B, C
Formula choices are ready-to-use, concentrated liquid formula that will be diluted according to the infant’s needs and powdered formula that is mixed as needed. Cow’s milk and canned evaporated milk are unsuitable because they are nutritionally inadequate and stress the kidneys.
DIF: Cognitive Level: Comprehension REF: Page 231 OBJ: 17
TOP: Formula Choices KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
- The nurse is instructing a woman at 6 months postpartum on weaning her infant from breastfeeding. What interventions will the nurse suggest? (Select all that apply.)
| a. | Omit newborn’s favorite feeding first. |
| b. | Eliminate one feeding at a time. |
| c. | Expect the need for comfort feeding. |
| d. | Formula will need to be provided to substitute for feeding. |
| e. | Pump breasts in place of eliminated feeding. |
ANS: B, C, D
When weaning a newborn from breastfeeding, the mother should eliminate the favorite feeding last. One feeding should be eliminated at a time, and the need for comfort feeding should be expected. In younger infants formula will need to be substituted. The mother should not be instructed to pump in place of eliminated feeding or the breasts will continue to produce milk.
DIF: Cognitive Level: Comprehension REF: Page 230 OBJ: 16
TOP: Weaning KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
COMPLETION
- The nurse assesses a 6-inch stain of lochia rubra on a pad that was worn for 2 hours. The nurse would document this as a(n) ________________ amount of lochia.
ANS:
moderate
A 6-inch stain on a pad worn for 2 hours is regarded as a moderate amount of lochia discharge.
DIF: Cognitive Level: Application REF: Page 202, Skill 9-2
OBJ: 2 TOP: Estimating Lochia Discharge
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
- The nurse explains that the three infections that are contraindications to breastfeeding are _______________, _______________, and ________________.
ANS:
human immunodeficiency virus (HIV), hepatitis B, hepatitis C
Mothers who are HIV positive should not breastfeed because the virus can be transmitted through breast milk, as can the viruses that cause hepatitis B and C.
DIF: Cognitive Level: Comprehension REF: Page 222 OBJ: 13
TOP: Contraindication for Breastfeeding KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- The hormone responsible for milk production is ____________________.
ANS:
prolactin
During pregnancy, the woman secretes high levels of prolactin, the hormone that causes milk production. Following delivery, increased levels of prolactin lead to lactation.
DIF: Cognitive Level: Knowledge REF: Page 223 OBJ: 11
TOP: Prolactin KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The hormone responsible for milk “let-down” or ejection from the breasts is ____________.
ANS:
oxytocin
The milk “let-down” reflex is caused by the hormone oxytocin.
DIF: Cognitive Level: Knowledge REF: Page 223 OBJ: 11
TOP: Oxytocin KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- ____________ refers to changes that the reproductive organs, particularly the uterus, undergo after birth to return to their prepregnancy size and condition.
ANS:
Involution
Involution refers to changes that the reproductive organs, particularly the uterus, undergo after birth to return to their prepregnancy size and condition.
DIF: Cognitive Level: Knowledge REF: Page 200 OBJ: 1
TOP: Puerperium KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
Chapter 11: The Nurse’s Role in Women’s Health Care
MULTIPLE CHOICE
- The nurse is preparing a community education program on preventive health care for women. What common screening test will the nurse plan on explaining to the women attending the program?
| a. | Breast examination by a health professional |
| b. | Breast self-examination |
| c. | Breast biopsy |
| d. | Mammography |
ANS: D
Mammography is a screening test used to detect breast cancer.
DIF: Cognitive Level: Comprehension REF: Page 251 OBJ: 2
TOP: Mammography KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- The nurse reviews the procedure for breast self-examination (BSE) with a 25-year-old woman who has a family history of breast cancer. When reviewing the procedure, when will the nurse indicate as the best time for a woman to perform a breast self-examination?
| a. | A few days before her period |
| b. | During her menstrual period |
| c. | On the last day of menstrual flow |
| d. | One week after the beginning of her period |
ANS: D
The best time for BSE is 1 week after the beginning of the menstrual period.
DIF: Cognitive Level: Knowledge REF: Page 251 OBJ: 2
TOP: Breast Self-Exam KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- A woman asks the nurse, “How do oral contraceptives prevent pregnancy?” What will the nurse explain about the combination of estrogen and progesterone in oral contraceptives?
| a. | Makes cervical mucus hostile to sperm |
| b. | Prevents ovulation |
| c. | Prohibits implantation of the egg |
| d. | Acts as a barrier by destroying sperm |
ANS: B
Oral contraceptives contain a combination of estrogen and progesterone that suppresses ovulation.
DIF: Cognitive Level: Comprehension REF: Page 262 OBJ: 5
TOP: Oral Contraceptives KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- What should a woman expect after insertion of an intrauterine device (IUD)?
| a. | Menstrual flow will be lighter. |
| b. | Menstrual cramps will be eliminated. |
| c. | A string should be felt in the vagina. |
| d. | The device should be changed every 2 years. |
ANS: C
A woman should feel for the string periodically, especially after her period, to confirm the presence of the IUD.
DIF: Cognitive Level: Comprehension REF: Page 264 OBJ: 5
TOP: IUDs KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- What information will the nurse provide when educating a woman about the correct use of a diaphragm?
| a. | Use of a spermicidal cream or jelly is not recommended. |
| b. | Leave in place for at least 6 hours after intercourse. |
| c. | Remove immediately after intercourse for douching. |
| d. | It is effective for up to 48 hours if positioned properly. |
ANS: B
To act as a barrier, the diaphragm must be left in place for at least 6 hours after intercourse and can be left in place up to 24 hours.
DIF: Cognitive Level: Comprehension REF: Page 264-265
OBJ: 5 TOP: Diaphragm KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- The nurse is providing sexual education to a group of high school students. What will the nurse explain is the most effective choice of birth control for preventing pregnancy and sexually transmitted diseases?
| a. | Abstain from sex. |
| b. | Use the male condom. |
| c. | Use the female condom. |
| d. | Use the barrier method. |
ANS: A
Abstinence is 100% effective in preventing pregnancy and sexually transmitted diseases.
DIF: Cognitive Level: Comprehension REF: Page 262 OBJ: 5
TOP: Abstinence KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- On day 13 of a 28-day cycle, a woman’s basal body temperature is 36.5° C (97.7° F). What will her temperature measurement most likely be if ovulation takes place on day 14?
| a. | 35.9° C (96.7° F) |
| b. | 36.3° C (97.3° F) |
| c. | 36.7° C (98.1° F) |
| d. | 37.1° C (98.9° F) |
ANS: C
At the time of ovulation, body temperature will increase slightly, about 0.2° C (0.4° F).
DIF: Cognitive Level: Analysis REF: Page 261 OBJ: 6
TOP: Ovulation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse tells a woman who is trying to conceive to check her cervical mucus for changes. What will she expect the characteristic of cervical mucus to be a few days before ovulation?
| a. | Cloudy and tacky |
| b. | Scant and thick |
| c. | Thin and white |
| d. | Clear and slippery |
ANS: D
Within a few days of ovulation, cervical mucus will become clear and slippery to aid the passage of sperm into the cervix.
DIF: Cognitive Level: Knowledge REF: Page 261 OBJ: 6
TOP: Ovulation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse is discussing cervical mucus changes with a woman who wishes to use natural family planning methods. What information about cervical mucus at ovulation will the woman indicate to the nurse, demonstrating that learning has taken place?
| a. | Cervical mucus enhances the motility of the sperm. |
| b. | Cervical mucus indicates endometrial readiness for implantation. |
| c. | Cervical mucus facilitates movement of the ovum through the fallopian tube. |
| d. | Cervical mucus provides vaginal lubrication during intercourse. |
ANS: A
Around the time of ovulation, the slippery, clear cervical mucus enhances the motility of the sperm.
DIF: Cognitive Level: Comprehension REF: Page 261 OBJ: 6
TOP: Cervical Mucus KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- In the week before her menstrual period, a woman experiences irritability, anxiety, and difficulty concentrating. What remedy might the nurse suggest to relieve these symptoms?
| a. | Drink tea or hot chocolate before going to bed. |
| b. | Take a daily folic acid and vitamin C supplement. |
| c. | Include complex carbohydrates and fiber in the diet. |
| d. | Avoid exercise when symptoms occur. |
ANS: C
A diet rich in complex carbohydrates and fiber is recommended for premenstrual dysmorphic disorder.
DIF: Cognitive Level: Application REF: Page 254 OBJ: 3
TOP: Premenstrual Dysmorphic Disorder
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse explains that the drug clomiphene (Clomid) is used in infertility treatment. What is the primary action of clomiphene (Clomid)?
| a. | Induces ovulation |
| b. | Reduces endometriosis |
| c. | Promotes implantation of a fertilized ovum |
| d. | Inhibits excess prolactin secretion |
ANS: A
Clomiphene (Clomid) induces ovulation. It may also increase sperm production, although this is an unlabeled use.
DIF: Cognitive Level: Knowledge REF: Page 272 OBJ: 7
TOP: Clomid KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- At her regular gynecological examination, a woman tells the nurse that she is concerned about osteoporosis. What suggestion can the nurse make to this patient?
| a. | Take a vitamin E supplement daily. |
| b. | Do isometric exercises that can be practiced every day. |
| c. | Include more dairy products and green, leafy vegetables in her diet. |
| d. | Try to limit her intake of caffeine. |
ANS: C
Foods rich in calcium include milk, dairy products, and green, leafy vegetables.
DIF: Cognitive Level: Application REF: Page 275 OBJ: 8
TOP: Prevention of Osteoporosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- A 48-year-old woman tells the nurse, “I missed my period last month. Am I in menopause?” The nurse knows that at which point is a woman considered to be menopausal?
| a. | Her periods have stopped for 1 year. |
| b. | Her periods have been irregular and light for 12 months. |
| c. | She has symptoms of vasomotor instability. |
| d. | She experiences symptoms of decreased estrogen, such as dyspareunia. |
ANS: A
When a woman’s menstrual periods have stopped for 1 year, she is considered menopausal.
DIF: Cognitive Level: Comprehension REF: Page 274 OBJ: 8
TOP: Menopause KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse is planning to teach a woman about perimenopause. What would the nurse include regarding lowered estrogen level?
| a. | It prevent osteoporosis. |
| b. | It decreases vaginal lubrication. |
| c. | It raises the level of low-density lipoproteins. |
| d. | It raises the level of high-density lipoproteins. |
ANS: C
Estrogen increases the amount of high-density lipoproteins that carry cholesterol from body cells to the liver for excretion. With lowered levels of estrogen, low-density lipoproteins increase, causing an increase in the incidence of heart attacks and strokes.
DIF: Cognitive Level: Knowledge REF: Page 274 OBJ: 8
TOP: Menopause KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- What side effect would the nurse instruct a woman to look for when starting hormone replacement therapy (HRT)?
| a. | Fatigue |
| b. | Headache |
| c. | Weight loss |
| d. | Amenorrhea |
ANS: B
Patients initiating HRT are reminded to have regular follow-up care and report headaches, vision changes, symptoms of thrombophlebitis, and cardiac symptoms.
DIF: Cognitive Level: Comprehension REF: Page 275 OBJ: 8
TOP: HRT KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- What will the nurse advise when a woman asks what she can do to reduce the discomfort of hot flashes?
| a. | “Aerobic exercise helps control hot flashes.” |
| b. | “Increase the amount of calcium and vitamin D in your diet.” |
| c. | “Dress in layers of cotton clothing.” |
| d. | “Drink plenty of fluids, particularly caffeinated beverages.” |
ANS: C
Cotton allows easier passage of air than synthetic fabrics. Layering allows the woman to take off or put on clothes when symptoms occur.
DIF: Cognitive Level: Application REF: Page 276, NCP 11-1
OBJ: 8 TOP: Prevention of Hot Flashes
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- Which statement made by the nurse would teach an adolescent using tampons how to prevent toxic shock syndrome (TSS)?
| a. | Super-absorbency tampons are effective for overnight absorption. |
| b. | Tampons should be changed at least every 4 hours. |
| c. | Gloves should be worn when changing tampons. |
| d. | TSS can be prevented by using a pad for the first 2 days of menstrual flow. |
ANS: B
Tampons should be changed every 4 hours because a blood-soaked tampon is an excellent environment for bacteria.
DIF: Cognitive Level: Comprehension REF: Page 255 OBJ: 4
TOP: TSS KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- What statement by a man considering a vasectomy indicates a need for further information?
| a. | “Sterility does not occur immediately after the procedure.” |
| b. | “We will need to use some form of birth control for about a month afterward.” |
| c. | “The procedure involves the use of local anesthesia.” |
| d. | “I’ll need to remain in the hospital for a few days.” |
ANS: D
A vasectomy takes about 20 minutes and is performed on an outpatient basis under local anesthesia.
DIF: Cognitive Level: Analysis REF: Page 268 OBJ: 5
TOP: Vasectomy KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- At her 6-week postpartum checkup, a woman states, “I am wondering about birth control. I used oral contraceptives before, and I’m breastfeeding now. Can I use the pill again?” What is the nurse’s best response?
| a. | “You should know that oral contraceptives increase your milk production.” |
| b. | “Oral contraceptives can be taken once lactation is well established.” |
| c. | “You don’t need to use any form of birth control as long as you are breastfeeding.” |
| d. | “Oral contraceptives are contraindicated for the lactating woman.” |
ANS: B
Oral contraceptives decrease breast milk production and are contraindicated until lactation is well established. Women who breastfeed their infants usually will not ovulate for 10 weeks and do not need contraception until that time.
DIF: Cognitive Level: Application REF: Page 263 OBJ: 5
TOP: Oral Contraceptives KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- A 17-year-old girl comes to the emergency department complaining of severe pain in her left lower quadrant. An ovarian cyst is suspected. The nurse knows that what confirms this diagnosis?
| a. | Laparotomy |
| b. | Oophorectomy |
| c. | Transvaginal ultrasound |
| d. | Hysteroscopy |
ANS: C
Diagnosis of an ovarian cyst is made by transvaginal ultrasound.
DIF: Cognitive Level: Analysis REF: Page 278 OBJ: 10
TOP: Ovarian Cysts KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
- A 21-year-old college student has come to see the nurse practitioner for treatment of a vaginal infection. Physical assessment reveals inflammation of the vagina and vulva, and vaginal discharge has a cottage cheese appearance. With what are these findings consistent?
| a. | Candidiasis |
| b. | Trichomoniasis |
| c. | Bacterial vaginosis |
| d. | Chlamydia |
ANS: A
The signs and symptoms of candidiasis include inflammation of the vagina and vulva and a cottage cheese appearance to the vaginal discharge.
DIF: Cognitive Level: Analysis REF: Page 257, Table 11-1
OBJ: 4 TOP: Candidiasis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- The nurse is providing an informational session on oral contraceptives. Which of the following decrease effectiveness of oral contraceptives?
| a. | Antihistamines for seasonal allergies |
| b. | Iron preparations for treatment of anemia |
| c. | Appetite suppressants for weight reduction |
| d. | Anticonvulsants for treatment of epilepsy |
ANS: D
Anticonvulsants decrease the effectiveness of oral contraceptives.
DIF: Cognitive Level: Comprehension REF: Page 263 OBJ: 5
TOP: Oral Contraceptives KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- The nurse is instructing a man considering a vasectomy. What instruction will the nurse provide to address the postoperative time period?
| a. | Intercourse should be delayed for 6 weeks. |
| b. | Sperm will still be ejaculated for a month. |
| c. | Erections will be difficult to maintain. |
| d. | Monthly sperm counts for a year will be necessary. |
ANS: B
Because sperm are distal to the severed vas deferens, sperm will be in the ejaculate for about a month. A sperm count after that period of time should be performed to confirm the absence of sperm. Intercourse does not have to be delayed, but an alternate method of contraception should be used. Erections and sexual pleasure are not affected by a vasectomy.
DIF: Cognitive Level: Comprehension REF: Page 268 OBJ: 5
TOP: Vasectomy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- A woman diagnosed with endometriosis reports “painful intercourse.” What is the appropriate medical term for the nurse to document when describing this symptom?
| a. | Dyspnea |
| b. | Dysmenorrhea |
| c. | Dyspareunia |
| d. | Dysrhythmia |
ANS: C
Dyspareunia is the term for painful sexual intercourse. Dyspnea is shortness of breath. Dysmenorrhea is painful menstruation. Dysrhythmia is irregular heart rhythm.
DIF: Cognitive Level: Knowledge REF: Page 254 OBJ: 1
TOP: Dyspareunia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse is educating a woman diagnosed with Premenstrual Dysphoric Disorder (PMDD). What is the best type of diet for the nurse to recommend?
| a. | High protein, low fat |
| b. | High carbohydrate, high fiber |
| c. | Low calorie, low fat |
| d. | Low carbohydrate, high protein |
ANS: B
Treatment of PMDD includes a diet rich in complex carbohydrates and fiber (to lengthen effects of the carbohydrate meal).
DIF: Cognitive Level: Application REF: Page 254 OBJ: 3
TOP: PMDD KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
- The nurse instructs a woman taking oral contraceptives to report which possible side effects? (Select all that apply.)
| a. | Abdominal pain |
| b. | Weight gain |
| c. | Headache |
| d. | Eye or visual problems |
| e. | Speech disturbances |
ANS: A, C, D, E
The memory aid ACHES is helpful: Abdominal pain, Chest pain, Headaches, Eye problems, Speech disturbances. Weight gain is an expected side effect of oral contraceptives.
DIF: Cognitive Level: Comprehension REF: Page 263 OBJ: 5
TOP: Oral Contraceptives KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- What are anonymous sperm donors screened for? (Select all that apply.)
| a. | Particular physical features |
| b. | Genetic defects |
| c. | Infections |
| d. | High-risk behaviors |
| e. | Nationality |
ANS: B, C, D
Sperm donors are screened for genetic defects, infections, and high-risk behaviors. As an added precaution, the sperm are kept frozen for 6 months before the sample is used.
DIF: Cognitive Level: Comprehension REF: Page 272 OBJ: 6
TOP: Sperm Donors KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The nurse cautions that women with a history of which disorders are not candidates for HRT? (Select all that apply.)
| a. | Melanoma |
| b. | Estrogen-dependent breast cancer |
| c. | Hepatitis C |
| d. | Thromboembolic disease |
| e. | Hyperthyroidism |
ANS: A, B, C, D
Persons who are absolutely restricted from HRT are those with melanoma, estrogen-dependent breast cancers, chronic liver disorders, thromboembolic disease, and seizure disorders.
DIF: Cognitive Level: Comprehension REF: Page 275 OBJ: 9
TOP: HRT KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- The patient who has been dealing with urge incontinence tells the nurse that the symptoms have gotten worse lately. The nurse reminds the patient that which food(s) and drug(s) can increase incontinence? (Select all that apply.)
| a. | Antihypertensive drugs |
| b. | Coffee |
| c. | Alcohol |
| d. | Diuretics |
| e. | NSAIDs |
ANS: A, B, C, D
Foods and drugs that increase the symptoms of urge incontinence are antidepressants, angiotensin converting enzyme (ACE) inhibitors, caffeine, alcohol, and diuretics. NSAIDs do not increase incontinence.
DIF: Cognitive Level: Application REF: Page 278 OBJ: 10
TOP: Urge Incontinence KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- What might the nurse advise the woman with pelvic floor dysfunction to do for relief of the associated discomfort? (Select all that apply.)
| a. | Lie down with feet elevated. |
| b. | Practice Kegel exercises. |
| c. | Assume knee-chest position periodically. |
| d. | Perform leg lift exercises. |
| e. | Prevent constipation. |
ANS: A, B, C, E
Elevating the feet, performing Kegel exercises, assuming the knee-chest position, and preventing constipation will reduce the pelvic discomfort of pelvic floor dysfunction.
DIF: Cognitive Level: Application REF: Page 277 OBJ: 10
TOP: Pelvic Floor Dysfunction KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- A woman is prescribed to take alendronate (Fosamax) for osteoporosis postmenopause. What information will the nurse provide when educating this patient on alendronate (Fosamax)?
| a. | Drink 8 oz. of water following dosage. |
| b. | Lay down for 30 minutes after taking. |
| c. | This medication has no known side effects. |
| d. | Avoid weight-bearing exercises. |
ANS: A
Alendronate (Fosamax) may be prescribed. Esophageal and gastric irritation are common side effects of alendronate, and the woman should be instructed to drink 8 ounces of plain water and sit upright for 30 minutes after taking the drug and before eating a meal. Weight-bearing exercises such as walking, hiking, stair climbing, and dancing are advisable. High-impact exercises should be avoided.
DIF: Cognitive Level: Comprehension REF: Page 275 OBJ: 2 | 8
TOP: Osteoporosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- The nurse is caring for a patient planning to undergo a uterine fibroid embolization. What information can the nurse provide? (Select all that apply.)
| a. | It involves laser destruction of fibroids. |
| b. | It has fewer physiological effects than drug therapy. |
| c. | It is nonsurgical. |
| d. | It is associated with more psychological effects than surgery. |
| e. | It has a faster recovery time than surgery. |
ANS: B, C, E
Uterine fibroid embolization is a nonsurgical technique of treating uterine fibroids that involves fewer physiological effects than drug therapy, fewer psychological effects than surgery, and a faster recovery time than surgery. Myolysis is the laser or electrosurgical destruction of fibroids, and it also preserves fertility.
DIF: Cognitive Level: Comprehension REF: Page 278 OBJ: 11
TOP: Uterine Fibroid KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
COMPLETION
- The nurse outlines the process of ova being mixed with sperm and then the resulting embryos being returned to the mother’s uterus. This process of infertility treatment is ____________ ______________ _________________.
ANS:
in vitro fertilization
The in vitro fertilization technique mixes ova with sperm and deposits several of the resulting embryos in the mother’s uterus.
DIF: Cognitive Level: Knowledge REF: Page 273, Table 11-2
OBJ: 6 TOP: In Vitro Fertilization
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
- When intraabdominal pressure increases from laughing or sneezing in a woman with a cystocele, __________ ___________ results.
ANS:
stress incontinence
When intraabdominal pressure increases, such as with laughing, coughing, or sneezing, a woman with a cystocele is said to have stress incontinence.
DIF: Cognitive Level: Knowledge REF: Page 277 OBJ: 10
TOP: Cystocele KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- ______________________ is the presence of tissue that resembles endometrium outside the uterus.
ANS:
Endometriosis
Endometriosis is the presence of tissue that resembles endometrium outside the uterus.
DIF: Cognitive Level: Knowledge REF: Page 254 OBJ: 1
TOP: Endometriosis KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
