Question 5351)
A pregnant 16-year-old asks the nurse if she should have an abortion. How should
the nurse respond initially?
A. “You should ask your parents for advice.”
B. “Abortion is the deliberate killing of a human being.”
C. “An abortion would let you finish growing up before you have children.”
D. “What are your feelings about abortion?”
Answer: D
Explanation: The nurse should initially encourage the client to formulate and express her thoughts and concerns.
The nurse should not try to impose her or his values on the client, as answers 2 and 3 do. Answer 1 tells the client
what to do and is not appropriate for an initial response, although discussing the issue with her parents should be
encouraged
Question 5352)
A 25-year-old woman is four months pregnant. She had rheumatic fever at age 15
and developed a systolic murmur. She reports exertional dyspnea. What instruction should the
nurse give her?
A. “Try to keep as active as possible, but eliminate any activity that you find tiring.”
B. “Carry on all your usual activities, but learn to work at a slower pace.”
C. “Avoid heavy housework, shopping, stair climbing, and all unnecessary physical effort.”
D. “Get someone to do your housework, and stay in bed or in a wheelchair.”
Answer: C
Explanation: The client reports exertional dyspnea. The answer relates to avoiding exertion or things requiring
extra effort. The data do not suggest that it is necessary at this point to stay in bed or in a wheelchair. Answers 1
and 2 do not relate to the data, which include exertional dyspnea.
Question 5353)
A pregnant woman comes for her sixth-month checkup and mentions to the nurse
that she is gaining so much weight that even her shoes and rings are getting tight. What should the
nurse plan to include in her care?
A. Teaching about the food pyramid and the importance of a well-balanced diet
B. Further assessment of her weight, blood pressure, and urine
C. Encouraging the use of a comfortable walking shoe with a medium heel
D. Reassurance that weight gain is normal as long as it does not exceed 25 lb
Answer: B
Explanation: Her symptoms suggest pregnancy-induced hypertension; particularly significant is the fact that her
rings are getting tight. Upper body edema is highly suggestive of PIH. The nurse should record her weight and note
how much weight has been gained in the last month. Monitoring blood pressure for elevation and checking urine
for protein will help to determine if this woman has PIH. Dietary teaching as described in answer 1 is important,
but the action relating to the data in the question is assessment for PIH. The advice in answer 3 regarding a
comfortable walking shoe is also appropriate for a pregnant woman but does not relate to the data in this question.
More important than total weight gain is the pattern of weight gain. A sudden increase in weight gain may indicate
fluid retention accompanying PIH, even if the total is not yet above 25 lbs.
Question 5354)
A 23-year-old woman, pregnant for the first time, is 39 weeks gestation. She is
admitted to the labor room with contractions every five minutes lasting 45 seconds. On vaginal
exam, she is noted to be completely effaced and 5-cm dilated. Station is 0. She asks the nurse for
pain medication. What is the best response for the nurse to make?
A. “I’ll ask your doctor for medication.”
B. “Can you hold out for a few more minutes? It’s too soon for you to have medication.”
C. “Pain medication will hurt your baby. We would rather not give you any unless absolutely necessary.”
D. “Can your husband help you with your breathing techniques?”
Answer: A
Explanation: Analgesia can usually be safely given after 5 cm of dilation and until one to two hours before delivery.
Answer 2 is not appropriate because according to the data given, the mother is a good candidate for some type of
analgesia. Answer 3 is not true. Pain medication too early may slow labor, and pain medication too late may
depress the baby’s respirations and heartbeat. Pain medication given appropriately is often very helpful during
labor. Answer 4 is not appropriate. It does not address the question that the client asked about pain medication.
Question 5355)
After several hours of active labor, a woman says to the nurse, “I have to push. I
have to push.” What is the best initial response for the nurse to make?
A. “Pull your knees up to your chest and hold on to them. Take a deep breath and push down as though you are
having a bowel movement.”
B. “Let me have the RN examine you before you start to push.”
C. “That means the baby is coming. I’ll take you into the delivery room now.”
D. “Women often feel that way during labor. Turn on your left side, and you will be more comfortable.”
Answer: B
Explanation: Before encouraging the mother to push, the nurse should determine that the mother has completed
transition and is fully dilated. She should not push before she is fully dilated. Answer 1 is a good description of
pushing. However, the woman should not push until she is fully dilated. Most women need to push for a while
before the baby is born. Answer 4 is a true statement; however, it is not the best response for the nurse to make.
Question 5356)
A laboring woman is to be transferred to the delivery room. The nurse is
positioning her on the table when she has a very strong contraction and starts to bear down. What
should the nurse tell her to do?
A. Pant
B. Bear down strongly
C. Put her legs up in the stirrups
D. Ignore the contraction
Answer: A
Explanation: When it is not desirable for a woman to push, such as when moving from bed to table, she should be
instructed to pant. It is not possible for a woman to pant and push at the same time. The mother will probably be
unable to put her legs up in stirrups during a contraction. At this stage of labor, she will be unable to ignore
contractions.
Question 5357)
A 32-year-old, gravida 2, para 1, term 1, preterm 0, abortion 0, living 1, is
admitted to the labor room. Her previous delivery was a normal, spontaneous vaginal delivery
without complications. She has been having contractions for four hours at home. The registered
nurse examines her and determines that she is 4-cm dilated and 70% effaced. The fetus is in the
breech position. She calls for the nurse saying, “My water just broke!” What should the practical
nurse do initially?
A. Notify the physician
B. Do a vaginal exam.
C. Check the fetal heart rate
D. Prepare for delivery
Answer: C
Explanation: The practical nurse should initially check the fetal heart rate, and then the registered nurse (RN)
should perform a vaginal exam. A breech fetus is at high risk for a prolapsed cord when the membranes rupture.
Following assessment of the fetal heart rate, the RN will perform a vaginal exam. A woman with a breech
presentation may need a cesarean delivery. After the initial assessments, the physician will be notified because
this baby is in a breech position. The physician is not automatically notified when the membranes rupture.
Question 5358)
The fetus is in the breech position. Inspection of the amniotic fluid after the
membranes rupture shows a greenish-black cast to the fluid. What is the best interpretation of
this finding?
A. The baby is in acute distress.
B. The fluid is contaminated with feces from the mother
C. The mother has diabetes mellitus.
D. It may be normal since the baby is presenting breech
Answer: D
Explanation: Breech presentations frequently have amnioticstained fluid. Amniotic-stained fluid in a vertex
presentation is a sign of fetal distress. Maternal diabetes does not cause amniotic-stained fluid unless the fetus
happens to be in distress.
Question 5359)
A woman in labor does not continue to dilate. The physician decides to perform a
cesarean section. A healthy 7-lb, 12-oz baby boy is delivered. What is the most essential nursing
intervention in the immediate postpartum period?
A. Check the uterine fundus for firmness.
B. Assess the episiotomy for bleeding.
C. Assist the woman with accepting the necessity of having had a cesarean section.
D. Encourage fluid intake
Answer: A
Explanation: Checking the uterine fundus for hemorrhage is of highest priority. The placenta separates from the
uterus in a woman who has had a cesarean delivery just as it does in a vaginal delivery. Both types of deliveries
have a risk of postpartum hemorrhage. It is essential to keep the fundus firm for both types of deliveries. The
woman who had a cesarean delivery has no episiotomy. Assisting with emotional adjustment will be a part of
nursing care but is not the highest priority. Encouraging fluid intake is important but is not the highest priority.
Question 5360)
A woman, gravida 2, para 2, term 2, preterm 0, abortion 0, living 2, who has just
had an unexpected cesarean delivery asks the nurse if having a cesarean means that she cannot
have any more children. What is the best response for the nurse to give this mother?
A. “Many women are able to have another child after having had a cesarean delivery.”
B. “Since you have two healthy children, it would be better not to attempt another delivery.”
C. “Is it important for you to have more children?”
D. “That is a question you will have to discuss with your physician.”
Answer: A
Explanation: A cesarean delivery is not in itself a contraindication for another pregnancy. Many women can have a
vaginal delivery after a cesarean. The old rule of only two cesarean deliveries is no longer true. Remember that
this client had one vaginal delivery and one cesarean. Answer 2 does not give accurate information. Answer 3 does
not answer the question. Answer 4 contains some truth, but the nurse should be able to give general information
to this mother.
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