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TEST BANK FOR EVOLVE RESOURCES IN MATERNA2
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TEST BANK FOR EVOLVE RESOURCES IN MATERNA2
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TEST BANK FOR EVOLVE RESOURCES INMATERNAL-CHILD NURSING, 6TH EDITION BY
MCKINNEY
1. A pregnant woman who is at term is admitted to the birthing unit in active labor.
The client has only progressed from 2cm to 3 cm in 8 hours. She is diagnosed with
hypotonic dystocia and the physician ordered Oxytocin (Pitocin) to augment her
contractions. Which of the following is the most important aspect of nursing
intervention at this time?
A. Timing and recording length of contractions.
B. Monitoring.
C. Preparing for an emergency cesarean birth.
D. Checking the perineum for bulging. - ANSWER A. The oxytocic effect of Pitocin
increases the intensity and durations of contractions; prolonged contractions will
jeopardize the safetyof the fetus and necessitate discontinuing the drug
2. A client who hallucinates is not in touch with reality. It is important for the nurse to:
A. Isolate the client from other patients.
B. Maintain a safe environment.
C. Orient the client to time, place, and person.
D. Establish a trusting relationship. - ANSWER B. It is of paramount importance to
prevent the client from hurting himself or herself or others.
3. The nurse is caring to a child client who has had a tonsillectomy. The child
complains of having dryness of the throat. Which of the following would the nurse
give to the child?
A. Cola with ice
B. Yellow noncitrus Jello
C. Cool cherry Kool-Aid
D. A glass of milk - ANSWER B. After tonsillectomy, clear, cool liquids should be
given. Citrus, carbonated, and hot or cold liquids should be avoided because they
may irritate the throat. Red liquids should be avoided because they give the
appearance of blood if the child vomits. Milk and milk products including pudding are
avoided because they coat the throat, cause the child to clear the throat, and
increase the risk of bleeding.
4. The physician ordered Phenylephrine (Neo-Synephrine) nasal spray to a 13-year-
old client. The nurse caring to the client provides instructions that the nasal spray
must be used exactly as directed to prevent the development of:
A. Increased nasal congestion.
B. Nasal polyps.
,C. Bleeding tendencies.
D. Tinnitus and diplopia. - ANSWER A. Phenylephrine, with frequent and continued
use, can cause rebound congestion of mucous membranes.
5. A client with tuberculosis is to be admitted in the hospital. The nurse who will be
assigned to care for the client must institute appropriate precautions. The nurse
should:
A. Place the client in a private room.
B. Wear an N 95 respirator when caring for the client.
C. Put on a gown every time when entering the room.
D. Don a surgical mask with a face shield when entering the room. - ANSWER B.
The N 95 respirator is a high-particulate filtration mask that meets the CDC
performance criteria for a tuberculosis respirator.
6. Which of the following is the most frequent cause of noncompliance to the medical
treatment of open-angle glaucoma?
A. The frequent nausea and vomiting accompanying use of miotic drug.
B. Loss of mobility due to severe driving restrictions.
C. Decreased light and near-vision accommodation due to miotic effects of
pilocarpine.
D. The painful and insidious progression of this type of glaucoma. - ANSWER
7. In the morning shift, the nurse is making rounds in the nursing care units. The
nurse enters in a client's room and notes that the client's tube has become
disconnected from the Pleurovac. What would be the initial nursing action?
A. Apply pressure directly over the incision site.
B. Clamp the chest tube near the incision site.
C. Clamp the chest tube closer to the drainage system.
D. Reconnect the chest tube to the Pleurovac. - ANSWER
8. Which of the following complications during a breech birth the nurse needs to be
alarmed?
A. Abruption placenta.
B. Caput succedaneum.
C. Pathological hyperbilirubinemia.
D. Umbilical cord prolapse. - ANSWER
9. The nurse is caring to a client diagnosed with severe depression. Which of the
following nursing approach is important in depression?
A. Protect the client against harm to others.
B. Provide the client with motor outlets for aggressive, hostile feelings.
C. Reduce interpersonal contacts.
D. Deemphasizing preoccupation with elimination, nourishment, and sleep. -
ANSWER
, 10. A 3-month-old client is in the pediatric unit. During assessment, the nurse is
suspecting that the baby may have hypothyroidism when mother states that her baby
does not:
A. Sit up.
B. Pick up and hold a rattle.
C. Roll over.
D. Hold the head up. - ANSWER
11. The physician calls the nursing unit to leave an order. The senior nurse had
conversation with the other staff. The newly hired nurse answers the phone so that
the senior nurses may continue their conversation. The new nurse does not knowthe
physician or the client to whom the order pertains. The nurse should:
A. Ask the physician to call back after the nurse has read the hospital policy manual.
B. Take the telephone order.
C. Refuse to take the telephone order.
D. Ask the charge nurse or one of the other senior staff nurses to take the telephone
order. - ANSWER
12. The staff nurse on the labor and delivery unit is assigned to care to a
primigravida in transition complicated by hypertension. A new pregnant woman in
active labor is admitted in the same unit. The nurse manager assigned the same
nurse to the second client. The nurse feels that the client with hypertension requires
one-to-one care. What would be the initial actionof the nurse?
A. Accept the new assignment and complete an incident report describing a shortage
of nursing staff.
B. Report the incident to the nursing supervisor and request to be floated.
C. Report the nursing assessment of the client in transitional labor to the nurse
manager and discuss misgivings about the new assignment.
D. Accept the new assignment and provide the best care. - ANSWER
13. A newborn infant with Down syndrome is to be discharged today. The nurse is
preparing to give the discharge teaching regarding the proper care at home. The
nurse would anticipate that the mother is probably at the:
A. 40 years of age.
B. 20 years of age.
C. 35 years of age.
D. 20 years of age. - ANSWER
14. The emergency department has shortage of staff. The nurse manager informs
the staff nurse in the critical care unit that she has to float to the emergency
department. What should the staff nurse expect under these conditions?
A. The float staff nurse will be informed of the situation before the shift begins.
B. The staff nurse will be able to negotiate the assignments in the emergency
department.
C. Cross training will be available for the staff nurse.
D. Client assignments will be equally divided among the nurses. - ANSWER
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