Lesson 3 Health Promotion and Maintenance

Fetal movement count during the third trimester should be at least 5 movements per day.
T or F

F
In the third trimester, an awake, healthy fetus should move at least 3 times per hour. If the baby does not move, the mother should drink a glass of juice and then start a new count.

The fourth stage of labor is placental separation and expulsion.
T or F

F
The third stage of labor is placental separation and expulsion and lasts about 5 to 30 minutes. The fourth stage of labor is maternal adaptation, occurring 1 to 2 hours after birth.

When the fetus is active, its heart rate should increase by about 15 beats per minute.
T or F

T
When the fetus is active, its heart rate will accelerate by about 15 beats per minute above the baseline. Average fetal heart rate is about 130 BPM when near term.

Most pregnancy tests measure the level of estrogen in the woman's blood.
T or F

F
Pregnancy tests measure the hormone human chorionic gonadotropin (hCG) in the urine or in the blood. Levels can be first detected about 12 to 14 days after conception and peak in the first 8 to 11 weeks of pregnancy.

One of the first signs of pregnancy is Chadwick's sign, which is the softening of the cervix.
T or F

F
There are several findings of pregnancy during the first trimester. Increased vascularity in vagina is called Chadwick's sign; the increased vascularization and softness of uterine isthmus is Hegar's sign; and the softening of the cervix is Goodell's si

The nurse will give Rh immune globulin (RhoGAM�) to a Rh negative women after a miscarriage (spontaneous abortion).
T or F

T
RhoGAM� is administered to Rh negative women after any possible exposure to fetal blood, such as after each ectopic pregnancy, miscarriage, abortion, or amniocentesis. RhoGAM� will be given to help prevent problems associated with incompatible blood typ

Chloasma is the first milk the new mother produces.
T or F

F
Chloasma is a skin discoloration of pregnancy. The first breast milk is called colostrum. Colostrum is low in fat, high in carbohydrates, protein, and antibodies and easy for the newborn to digest.

The fetus receives more oxygenated blood when the laboring mother lies on her side.
T or F

T
Positioning the laboring mother on her (left) side usually results in a higher fetal oxygen saturation. Other measures to increase fetal oxygenation (and placental perfusion) include administering oxygen to the laboring woman.

A gravida 3, para 3 woman should be rushed to the delivery room once engagement has occurred.
T or F

F
Engagement means that the baby's head no longer floats freely, but has dropped down into the pelvis. In a multipara, engagement normally occurs about two weeks before birth.

An APGAR score of 2 for appearance means the newborn's fingers and toes are bluish in color.
T or F

F
The normal color all over for the newborn is pink; a pink baby earns a score of 2. A baby who is pink with pale blue toes/feet and fingers/hands will receive a score of 1 on the APGAR test.

A baby tapped briskly on the bridge of the nose will close both eyes.
T or F

T
Tapping on the glabella (flat bone between the eyebrows) causes a neurologically healthy baby to close both eyes. This is referred to as the glabellar reflex.

About 5 days after delivery, lochia is pink-brown in color.
T or F

T
Normal bleeding and discharge should be more watery and pink-brown colored (lochia serosa) about 3 to 5 days after delivery. It may take up to 2 to 4 weeks for discharge to taper off completely.

Common issues on the first postpartum day include afterpains and episiotomy discomfort and swelling.
T or F

T
The nurse should provide information about interventions that will help the new mother cope with the common physical and emotional changes she is experiencing. For example, the client can apply ice or a cold pack to the perineum and use a gentle squeeze

A woman cannot become pregnant when she is breastfeeding
T or F

F
Pregnancy can occur with unprotected intercourse at or before the first menstrual cycle after birth. Nurses should caution women to avoid pregnancy for the first three months after delivery to allow the body time to heal.

The safest time for the fetus is to give the mother analgesia when her cervix is dilated 8 to 10 centimeters.
T or F

F
The safest time to offer analgesia is when dilation is between 4 to 7 centimeters.

Reflects back on life

Older Adult
Integrity vs. Despair (approximately age 65 years & older)

Explores independence & develops a sense of self

Adolescence
Identity vs. Role Confusion (approximately age 12-18 years)

Explores & develops close, committed relationships

Early Adulthood
Intimacy vs. Isolation (approximately age 18-40 years)

Develops a greater sense of personal control

Early Childhood
Autonomy vs. Shame & Doubt (approximately 18 months to 3 years)

Building careers & family

Adulthood
Generativity vs. Stagnation (approximately age 40-64 years)

Development of trust is based on quality of caregiver

Infant
Trust vs. Mistrust (approximately birth to 18 months)

Develops a sense of pride in accomplishments

School Age
Industry vs. Inferiority (approximately age 6-11 years)

Play, imagination & initiating activities with others

Preschool
Initiative vs. Guilt (approximately age 3-5 years)

Concepts attached to concrete situations

School Age
Piaget: Concrete Operations (approximately age 6-11 years)

Analyzes situation & uses abstract logic, reasoning

Adolescence
Piaget: Formal Operations stage of cognitive development (approximately age 11 years to adult)

The "good boy/girl" makes an effort to secure approval and be friendly with others

Kohlberg
Level 2: Conventional Morality - Stage 3: Conformity and Interpersonal Accord

Actions are based on satisfying one's own needs ("what's in it for me?")

Kohlberg
Level 1: Pre-Conventional Morality - Stage 2: Personal Reward Orientation

Uses magical thinking & imagination

Early Childhood
Piaget: Preoperational stage of cognitive development (approximately age 3-6 years)

Behavior is based on mutual benefit, reciprocity and utilitarian rules

Kohlberg
Level 3: Post-Conventional Morality - Stage 5: Social Contract

Use sucking, grasping, listening, looking to learn about the environment

Infant
Piaget: Sensorimotor stage (birth to 2 years)

Behavior is based on obedience and avoiding punishment

Kohlberg
Level 1: Pre-Conventional Morality - Stage 1: Punishment and Obedience

When you examine the mouth, you see that the soft palate is moist and pink with whitish spots.
When you examine the mouth, you see that the soft palate is moist and pink with whitish spots.
Abnormal finding(s)
Expected finding(s)

Abnormal finding(s)
The soft palate should be reddish pink; spots are a possible sign of infection

The client is able to stand on one foot, with eyes shut, for five seconds.
Abnormal finding(s)
Expected finding(s)

Expected finding(s)
Balancing on one foot, with eyes shut, is one sign of normal cerebellar function.

A 42 year-old breathes 30 times per minute.
Abnormal finding(s)
Expected finding(s)

Abnormal finding(s)
Normal respiratory rate in adolescents and adults is 12-20 breaths per minute.

You examine a client's breast and see a cluster of very tiny dimples near one nipple.
Abnormal finding(s)
Expected finding(s)

Abnormal finding(s)
There should be no dimples; in fact "orange peel" skin is a late sign of breast cancer.

Auscultation reveals bowel sounds in two of the four abdominal quadrants.
Abnormal finding(s)
Expected finding(s)

Abnormal finding(s)
Normally, you should hear bowel sounds in all four quadrants in a healthy client.

A 60 year-old male has a left scrotal sac that is slightly lower than the right.
Abnormal finding(s)
Expected finding(s)

Expected finding(s)
Asymmetry in the scrotum is normal, with the left usually larger or hanging lower than the right.

A client can tell you her name, but does not know the day of the week.
Abnormal finding(s)
Expected finding(s)

Abnormal finding(s)
Normal mental function includes orientation to person, place, and time.

A 5-month old has a sunken anterior fontanel.
Abnormal finding(s)
Expected finding(s)

Abnormal finding(s)
The fontanel should be flat; a sunken fontanel indicates possible dehydration.

An 84-year has decreased muscle strength in his bilateral upper extremities.
Abnormal finding(s)
Expected finding(s)

Expected finding(s)
A common age-associated change with the musculoskeletal system is the decline in muscle mass and strength.

The adolescent's spine is straight and posterior ribs are symmetrical when the client bends forward.
Abnormal finding(s)
Expected finding(s)

Expected finding(s)
The adolescent client should be assessed for scoliosis by asking the client to bend forward and touch his or her toes. The client's spine should be straight and without curvature or asymmetry.

The clinic nurse is performing the intake assessment for a 74 year-old male. The client has a history of benign prostatic hypertrophy (BPH) and reports having trouble voiding. After the client uses the bathroom to void, how would the nurse best assess the

Scan the bladder using a portable ultrasound scanner
Urinary retention and incomplete bladder emptying can result from urethral obstruction, as seen in BPH. The nurse can palpate the area from the umbilicus towards the symphysis pubis; an empty bladder re

While performing an initial assessment on a newborn following a breech delivery, the nurse suspects hip dislocation. Which of these findings is most suggestive of this abnormality?
Negative Ortolani response
Irregular hip symmetry
Flexion of lower extremi

Irregular hip symmetry
Early assessment of irregular hip symmetry alerts the nurse and the provider to a correctable congenital hip dislocation. The leg is shortened on the affected side. One check for hip dislocation is the Ortolani click; if it is found

The nurse is giving the pneumovax vaccination to clients in a community health clinic. The nurse should not administer the vaccine to which of the following clients?
The client who had chemotherapy for cancer four days ago
The client who reports feeling a

The client who had chemotherapy for cancer four days ago
Immunization with this vaccine is contraindicated with clients that are immunosuppressed. The pneumovax vaccine is to be given at least a week apart from other vaccines. The other two options do not

A newborn born prematurely is to be fed breast milk through a nasogastric tube. Why is breast milk preferred over formula for premature infants?
Has less fatty acids
Contains less lactose
Is higher in calories/ounce
Provides antibodies

Provides antibodies
Breast milk is ideal for the preterm baby who needs additional protection against infection through maternal antibodies. It is also much easier to digest. Therefore, less residual is left in the infant's stomach.

A nurse is observing children playing in the hospital playroom. The nurse should expect to see 4 year-old children playing in which manner?
Alone with hand-held computer games
With their own toys alongside with other children
Competitive board games with

Cooperatively with other preschoolers
Cooperative or associative play is typical of the preschool period. School-age children would play board games, toddlers engage in side-by-side or parellel play, and adolescents would be more likely to play the hand-h

A client is in the third month of her first pregnancy. During the interview, she tells a nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of these nursing interventions is best at this time?
Refer the clien

Request the RN to counsel the woman to consent to HIV screening
The client's behavior places her at high risk for HIV. While it would be a good idea to draw blood to test for STDs, this can't be done without informed consent of the client. Since the woman

The client is an adult who was recently diagnosed with type 1 diabetes. Which action would be the best strategy for a nurse to use when reinforcing insulin injection techniques?
Ask the client questions during practice sessions
Listen to client's verbaliz

Observe a return demonstration
Because injecting insulin is a psychomotor skill, observing a return demonstration is the best strategy to know or evaluate whether the client has learned the proper technique.

The school nurse is observing a group of children. The nurse should be aware that which of these psychosocial needs are more commonly found in adolescents?
Independence, confidence, narcissism
Social competencies, respect, sense of humor
Attention, compet

Privacy, autonomy, peer interaction
Adolescents display the need for privacy, autonomy, and peer interaction concurrent with an evolving sense of identity.

According to Piaget, which finding indicates that a child has attained the stage of concrete operations?
Thinks in mental images or word pictures
Reasons that homework is time-consuming yet necessary
Explores the environment with the use of sight and move

Makes the moral judgment that "stealing is wrong"
The stage of concrete operations is depicted by logical thinking and moral judgments. This stage is associated with school-aged children from ages 7 to about 11. It is a time when children develop transiti

A nurse is working with family members of an 80 year-old client newly diagnosed with Alzheimer's disease. Which intervention would be helpful?
Have the family feed the client
Demonstrate an active-passive exercise routine
Assist the family to bathe the cl

Role play communication strategies
Because Alzheimer's disease is a progressive chronic illness that challenges caregivers, the nurse can be of great assistance in helping the family to identify changes in language, as well as ways to communicate with the

The nurse is asked about chiropractic treatment for illnesses. The nurse should know that it focuses on which approach?
Spinal column manipulation
Electrical energy fields
Exercise of joints
Mind-body balance

Spinal column manipulation
The underlying theory of chiropractic medicine is that interference with transmission of mental or electrical impulses between the brain and the body organs produces diseases. Such interference is caused by misalignment of the v

A newly pregnant woman asks the nurse what to expect in the early stages of pregnancy. The major developmental task that a woman must accomplish during the first trimester of pregnancy is the acceptance of which issue?
The pregnancy and the physical chang

The pregnancy and the physical changes that are involved
During the first trimester the maternal focus is directed toward acceptance of the pregnancy and adjustment to the minor discomforts. Ambivalence is a normal, expected emotion. You should be able to

A 75 year-old client is admitted with the diagnosis of possible dehydration. The nurse should understand that older adults are at risk for dehydration due to which of the following factors?
Weakened urinary sphincter
Reduction in lean body mass
Decreased

Decreased sensation of thirst
Older adults do not drink because they do not feel as thirsty as younger people. Other risk factors for minimal ingestion of fluids in older adults may include fear of incontinence, inability to drink fluids independently or

Parents are asking for information about how they will know if their toddler is ready for toilet training. What should the nurse understand before reinforcing information about toilet training?
The child learns voluntary sphincter control through repetiti

Myelination of the spinal cord is completed during the toddler years
Voluntary control of the sphincter muscles can be gradually achieved due to the complete myelination of the spinal cord, which occurs sometime between the ages of 18 to 24 months. The ot

A healthy 18 year-old is entering college in the fall. Which immunization would the health care provider recommend prior to college? (Select all that apply.)
Meningococcal conjugate vaccine (MCV4)
Shingles vaccine
Pneumococcal polysaccharide vaccine (PPSV

Meningococcal conjugate vaccine (MCV4)
Tetanus, Diphtheria, Pertussis vaccine (Tdap)
Seasonal influenza vaccine
Human papillomavirus (HPV) vaccine
Adults older than age 50 should get the shingles vaccine. The PPSV23 is given to adults older than age 65. (

A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third admission for asthma in seven months. She describes how she doesn't really like having to use her medications all the time. Which of the follow

Lung remodeling and permanent changes in lung function
While an asthma attack is an acute event from which lung function essentially returns to normal, chronic under-treated asthma can lead to lung remodeling and permanent changes in lung function. Increa

A nurse who works in a high school is reinforcing information to a group of unwed pregnant students. What is the most important action the nurse should stress so that each girl can deliver a healthy child?
Get adequate sleep and frequent rest
Keep in cont

Maintain good nutrition
Nurses can play a pivotal role in reinforcing nutritional education. Weight gain during pregnancy is one of the strongest predictors of infant birth weight. Pregnant teens who gain between 26 and 35 pounds have the lowest incidence

During the physical inspection of a client, the nurse notes a pulsating mass in the client's periumbilical area. Which action is appropriate for the nurse to take to gather more data about the mass?
Percuss the area
Auscultate the area
Measure the length

Auscultate the area
Auscultation of the abdomen will find a bruit, which will confirm the presence of an abdominal aneurysm. The other actions would be contraindicated because placing pressure on the area might cause the aneurysm to leak or rupture.

A client referred for a mammography asks the nurse about the cancer risks from radiation exposure. What is an appropriate response by the nurse?
"The radiation from a mammography is equivalent to one hour of sun exposure."
"A chest x-ray gives you more ra

The radiation from a mammography is equivalent to one hour of sun exposure."
A client would have to have numerous procedures during the course of a year to be at risk for cancer. The correct response is concise and gives the client a point of reference.

The geriatric social worker is working with the nurse to assess the client's ability to perform instrumental activities of daily living (IADL). Which of the following skills are considered instrumental activities of daily living? (Select all that apply.)

Ability to take medications
Ability to write checks
Ability to cook meals
Activities of daily living (ADLs) are basic self-care tasks, such as feeding, toileting, grooming, bathing, putting on clothes. Instrumental activities of daily living (IADLs) are s