- (Topic 2)
A client is in early labor. Her fetus is in a left occipitoanterior (LOA) position; fetal heart sounds are best auscultated just:

1. A. Below the umbilicus toward left side of mother??s abdomen
2. B. Below the umbilicus toward right side of mother??s abdomen
3. C. At the umbilicus
4. D. Above the umbilicus to the left side of mother??s abdomen

Correct Answer: A
(A) LOA identifies a fetus whose back is on its mother??s left side, whose head is the presenting part, and whose back is toward its mother??s anterior. It is easiest to auscultate fetal heart tones (FHTs) through the fetus??s back. (B) The identified fetus??s back is on its mother??s left side, not right side. It is easiest to auscultate FHTs through the fetus??s back.
(C) In an LOA position, the fetus??s head is presenting with the back to the left anterior side of the mother. The umbilicus is too high of a landmark for auscultating the fetus??s heart rate through its back. (D) This is the correct auscultation point for a fetus in the left sacroanterior position, where the sacrum is presenting, not LOA.

- (Topic 4)
A 10-month-old infant??s mother says that he takes fresh whole milk eagerly, but that when she offered him baby foods at 6 months of age, he pushed them out of his mouth. Because he has gained weight appropriately, she has quit trying to get him to eat other foods. The nurse??s response is based on the knowledge that:

1. A. Milk intake should be limited to no more than four 8-oz bottles per day and should be followed by iron-enriched cereal or other solid foods or juices
2. B. Milk is an excellent food and will meet his nutritional needs adequately until he is ready to eat solid foods
3. C. It is acceptable to continue to give him whole milk and to delay giving solid foods as long as he takes a vitamin supplement daily
4. D. He should be started on iron-enriched cereal, meat, vegetables, fruits, and juices prior to bottle feed
5. E. Milk intake should be limited to 1 qt/day

Correct Answer: D
(A) If the infant is given the bottle first, he will be less likely to be hungry enough to eat the solid foods. (B) Milk is deficient in iron, vitamin C, zinc, and fluoride. It does not provide an adequate diet. (C) The vitamin supplement will help, but the infant needs an iron supplement. (D) Giving the solid food when the infant is hungriest will increase the likelihood that he will eat. The more solid food he takes, the less milk he will desire.

- (Topic 7)
The following nursing diagnosis is written for a comatose client with cirrhosis of the liver and secondary splenomegaly—High risk for injury: Increased susceptibility to bleeding related to:

1. A. Increased absorption of vitamin K
2. B. Thrombocytopenia due to hypersplenism
3. C. Diminished function of the Kupffer cells
4. D. Increased synthesis of the clotting factors

Correct Answer: B
(A) There is a decreased absorption of vitamin K with cirrhosis of the liver. This decrease impairs blood coagulation and the formation of prothrombin. (B) Thrombocytopenia, an
increased destruction of platelets, occurs secondary to hypersplenism. (C) A diminished function of the Kupffer cells occurs with cirrhosis of the liver, causing the client to become more susceptible to infections. (D) A decrease in the synthesis of fibrinogen and clotting factors VII, IX, and X occurs with cirrhosis of the liver and increases the susceptibility to bleeding.

- (Topic 3)
An elective saline abortion has been performed on a 3- week primigravida. Following the procedure, the nurse should be alert for which early side effect?

1. A. Water satiety
2. B. Thirst
3. C. Edema
4. D. Diabetes insipidus

Correct Answer: B
(A) If the client is experiencing water satiety, there is no more desire for water. (B) Absorption of saline into circulation rather than into amniotic sac increases serum sodium and desire for water. (C) Edema can be a late side effect caused by water intoxication. (D) Diabetes insipidus occurs as a result of deficient antidiuretic hormone.

- (Topic 5)
A female client is exhibiting signs of respiratory distress. Which of the following signs indicate a possible pneumothorax?

1. A. Crackles or rales on the affected side
2. B. Bradypnea and bradycardia
3. C. Shortness of breath and sharp pain on the affected side
4. D. Increased breath sounds on the affected side

Correct Answer: C
(A) With a pneumothorax, air occupies the pleural space. Crackles or rales are heard with increased fluid or secretions and would not be present with air in the space. (B) With a pneumothorax, the client would experience tachypnea and tachycardia to compensate for the decrease in oxygenation. (C) Symptoms of pneumothorax include shortness of breath, sharp pain on the affected side with movement or coughing, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. (D) With a pneumothorax, breath sounds would be decreased on the affected side (indicates air in the pleural space).