Managing Care Quality and Safety
1. A primigravid client at 10 weeks’ gestation complaining of not feeling well with nausea
and vomiting, urinary frequency, and fatigue.
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117.
The health care provider at a prenatal clinic has ordered multivitamins for a woman who is 3 months’ pregnant. The client calls the nurse to report that she has gone to the pharmacy to fi ll her prescription but is unable to buy it as it costs too much. The nurse should refer the client to:■ 1. The charge nurse.
■ 2. The hospital fi nance offi ce.
■ 3. Her hospital social worker.
■ 4. Her insurance company.
Answers, Rationales, and Test Taking Strategies
The answers and rationales for each question fol- low below, along with keys ( ) to the client need (CN) and cognitive level (CL) for each question. Use these keys to further develop your test-taking skills.
For additional information about test-taking skills and strategies for answering questions, refer to pages 10–21, and pages 25–26 in Part 1 of this book.
The Preconception Client
1.
1. Plan B is a series of contraceptive pills sim- ilar in composition to birth control pills that have been used for the past 30 years. Plan B is the brand name for levonorgestrel 0.75 mg. Pills are most effective if taken immediately after unprotected intercourse and then again 12 hours later. Males can purchase this contraceptive as long as they are over 18 years of age. Common side effects include nau- sea, breast tenderness, vertigo, and stomach pain.CN: Physiological adaptation;
CL: Evaluate
2.
3. Birth control plans are infl uenced primarily by whether the mother is breast- or bottle-feeding her infant. The maternal milk supply must be well estab- lished prior to the initiation of most hormonal birth control methods. Low dose oral contraceptives would be the exception. Use of estrogen/progesterone based pills and progesterone only pills are commonly initi- ated from 4 to 6 weeks postpartum because the milk supply is well established by this time. Prior experi- ences with birth control methods have an impact on the method chosen as does the preferences of the cli- ent’s partner; however, they are not the most infl uen- tial factors. A history of blood clots or thrombophle- bitis is the second most important factor as several methods will be eliminated because of their potential to place the client at risk for clotting disorders.CN: Pharmacological and parenteral therapies; CL: Analysis
3.
4. The nurse determines that the client has understood the instructions when the client says that she will notify her physician if she notices discharge or bleeding because this may be symptom- atic of underlying disease. Ideally, breast self-exam- ination should be performed about 1 week after the onset of menses because hormonal infl uences on breast tissue are at a low ebb at this time. The client should perform breast self-examination on the same day each month only if she has stopped menstruat- ing (as with menopause). The client’s breasts should mirror each other. If one breast is signifi cantly larger than the other, or if there is “pitting” of breast tissue, a tumor may be present.CN: Reduction of risk potential;
CL: Evaluate
4.
3. For a client with a menstrual cycle of 28 days, ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle. Stated another way, the menstrual period begins about 2 weeks after ovulation has occurred.Ovulation does not usually occur during the menses component of the cycle when the uterine lining is being shed. In most women, the ovum survives for about 12 to 24 hours after ovulation, during which time conception is possible. The basal body tem- perature rises 0.5° to 1.0° F when ovulation occurs.
Although some women experience some pelvic discomfort during ovulation (mittelschmerz), severe or unusual pain is rare. After ovulation, the cervical mucus is thin and copious.
CN: Health promotion and maintenance;
CL: Create
5.
1. The nurse should instruct the client to take a mild analgesic, such as ibuprofen, if menstrual pain or “cramps” are present. The client should also eat foods rich in iron and should continue moderate exercise during menstruation, which increases ab- dominal tone. Avoiding cold foods will not decrease dysmenorrhea. Sexual intercourse is not prohibited during menstruation, but the male partner should wear a condom to prevent exposure to blood.CN: Health promotion and maintenance;
CL: Apply
6.
1. Under ideal conditions, sperm can reach the ovum in 15 to 30 minutes. This is an important point to make with adolescents who may be sexu- ally active. Many people believe that the time in- terval is much longer and that they can wait until after intercourse to take steps to prevent conception.Without protection, pregnancy and sexually transmit- ted diseases can occur. When using the abstinence or calendar method, the couple should abstain from intercourse on the days of the menstrual cycle when the woman is most likely to conceive. Using a 28-day
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cycle as an example, a couple should abstain from coitus 3 to 4 days before ovulation (days 10 through 14) and 3 to 4 days after ovulation (days 15 through 18). Sperm from a healthy male can remain viable for 24 to 72 hours in the female reproductive tract. If the female client ovulates after coitus, there is a possibil- ity that fertilization can occur. Before fertilization, the ovum and sperm each contain 23 chromosomes.
After fertilization, the conceptus contains 46 chromo- somes unless there is a chromosomal abnormality.
CN: Health promotion and maintenance;
CL: Evaluate
7.
3. The symptothermal method is a natural method of fertility management that depends on knowing when ovulation has occurred. Because regu- lar menstrual cycles can vary by 1 to 2 days in either direction, the symptothermal method requires daily basal body temperature assessments plus close moni- toring of cervical mucus changes. The method relies on abstinence during the period of ovulation, which occurs approximately 14 days before the beginning of the next cycle. Abstinence from coitus for 5 days after menses is unnecessary because it is unlikely that ovulation will occur during this time period (days 1 through 10). Typically, the failure rate for this method is between 10% and 20%. Although a condom may increase the effectiveness of this method, most clients who choose natural methods are not interested in chemical or barrier types of family planning.CN: Health promotion and maintenance;
CL: Create
8.
2. Before advising a client about oral con- traceptives, the nurse needs to assess the client for signs and symptoms of hypertension. Clients who have hypertension, thrombophlebitis, obesity, or a family history of cerebral or cardiovascular accident are poor candidates for oral contraceptives. In addi- tion, women who smoke, are older than 40 years of age, or have a history of pulmonary disease should be advised to use a different method. Iron-defi ciency anemia, dysmenorrhea, and acne are not contrain- dications for the use of oral contraceptives. Iron- defi ciency anemia is a common disorder in young women. Oral contraceptives decrease the amount of menstrual fl ow and thus decrease the amount of iron lost through menses, thereby providing a benefi cial effect when used by clients with anemia. Low-dose oral contraceptives to prevent ovulation may be ef- fective in decreasing the severity of dysmenorrhea (painful menstruation). Dysmenorrhea is thought to be caused by the release of prostaglandins in response to tissue destruction during the ischemic phase of the menstrual cycle. Use of oral contracep- tives commonly improves facial acne.CN: Reduction of risk potential;
CL: Analyze
9.
4. The nurse determines that the client needs further instruction when the client says that one of the adverse effects of oral contraceptive use is ovarian cancer. Some studies suggest that ovar- ian and endometrial cancer are reduced in women using oral contraceptives. Other adverse effects of oral contraceptives include weight gain, nausea, headache, breakthrough bleeding, and monilial infections. The most serious adverse effect is throm- bophlebitis.CN: Pharmacological and parenteral therapies; CL: Evaluate
10.
1. The typical failure rate of a condom is approximately 12% to 14%. Adding a spermicide can decrease this potential failure rate because it offers additional protection against pregnancy.Natural skin condoms do not offer the same protec- tion against sexually transmitted diseases caused by viruses as latex condoms do. Unlike latex condoms, natural skin (membrane) condoms do not prevent the passage of viruses. Most condom users report decreased penile gland sensitivity. However, some users do report an increased sensitivity or aller- gic reaction (such as a rash) to latex, necessitating the use of another method of family planning or a switch to a natural skin condom.
CN: Health promotion and maintenance;
CL: Apply
11.
2. The teaching plan should include a cau- tion that a diaphragm should not be used if the client develops acute cervicitis, possibly aggravated by contact with the rubber of the diaphragm. Some studies have also associated diaphragm use with in- creased incidence of urinary tract infections. Douch- ing after use of a diaphragm and intercourse is not recommended because pregnancy could occur. The diaphragm should be inspected and washed with mild soap and water after each use. A diaphragm should be left in place for at least 6 hours but no longer than 24 hours after intercourse. More spermi- cidal jelly or cream should be used if intercourse is repeated during this period.CN: Reduction of risk potential;
CL: Create
12.
4. The client would need additional instruc- tions when she says that she can still use the same diaphragm if she gains or loses 20 lb. Gaining or losing more than 15 lb can change the pelvic and vaginal contours to such a degree that the dia- phragm will no longer protect the client against pregnancy. The diaphragm can be used for 2 to 3 years if it is cared for and well protected in its case.The client should be refi tted for another diaphragm after pregnancy and delivery of a newborn be- cause weight changes and physiologic changes of
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pregnancy can alter the pelvic and vaginal contours, thus affecting the effectiveness of the diaphragm.
The client should use a spermicidal jelly or cream before inserting the diaphragm.
CN: Reduction of risk potential;
CL: Evaluate
13.
1,2,3,5,6. The pregnancy requirement for folic acid is 600 micrograms/day. Major sources of folic acid include leafy green vegetables, straw- berries and oranges, beans, particularly black and kidney beans, sunfl ower seeds, and lentils. Milk and fats contain no folic acid.CN: Health promotion and maintenance;
CL: Apply
14.
1. Another method of contraception is needed until all sperm has been cleared from the body. The number of ejaculates for this to occur varies with the individual and laboratory analysis is required to determine when that has been ac- complished. Vasectomy is considered a permanent sterilization procedure and requires microsurgery for anastomosis of the vas deferens to be completed.Studies have shown that there is no connection between cardiac disease in males and vasectomy.
There is no need for follow-up once verifi cation there is no sperm in the system.
CN: Physiological adaptation; CL: Create
15.
1. Tubal ligation, a female sterilization pro- cedure, involves ligation (tying off) or cauterization of the fallopian tubes through a small abdominal incision (laparotomy). Reversal of a tubal ligation is not easily done, and the pregnancy success rate after reversal is about 30%. After a tubal ligation, the cli- ent may engage in intercourse 2 to 3 days after the procedure. The ovaries are not generally removed during a tubal ligation. An oophorectomy involves removal of one or both ovaries.CN: Health promotion and maintenance;
CL: Evaluate
16.
2. The basal body temperature method requires that the client take her temperature each morning before getting out of bed, preferably at the same time each day before eating or any other activity. Just before the day of ovulation, the tem- perature falls by 0.5° F. At the time of ovulation, the temperature rises 0.4° to 0.8° F because of increased progesterone secretion in response to the luteiniz- ing hormone. The temperature remains higher for the rest of the menstrual cycle. The client should keep a diary of about 6 months of menstrual cycles to calculate “safe” days. There is no mucus for the fi rst 3 or 4 days after menses, and then thick, sticky mucus begins to appear. As estrogen increases, the mucus changes to clear, slippery, and stretchy. This condition, termed spinnbarkeit, is present duringovulation. After ovulation, the mucus decreases in amount and becomes thick and sticky again until menses. Because the ovum typically survives about 24 hours and sperm can survive up to 72 hours, couples must avoid coitus when the cervical mucus is copious and for about 3 to 4 days before and after ovulation to avoid a pregnancy.
CN: Health promotion and maintenance;
CL: Apply
17.
4. By the end of the fi rst visit, the couple should be able to identify potential causes and treatment modalities for infertility. If their evalua- tion shows that a treatment or procedure may help them to conceive, the couple must then decide how to proceed, considering all of the various treatments before selecting one. Treatments can be diffi cult, painful, or risky. The fi rst visit is not the appropri- ate time to decide on a treatment plan because the couple needs time to adjust to the diagnosis of infer- tility, a crisis for most couples. Although the couple may be in a hurry for defi nitive therapy, a thorough assessment of both partners is necessary before a treatment plan can be initiated. The success rate for achieving a pregnancy depends on both the cause and the effectiveness of the treatment, and in some cases it may be only as high as 30%. The couple may desire information about alternatives to treat- ment, but insuffi cient data are available to suggest that a specifi c treatment modality may not be suc- cessful. Suggesting that the couple consider adop- tion at this time may inappropriately imply that the couple has no other choice. If a specifi c therapy may result in a pregnancy, the couple should have time to consider their options. After a thorough evalua- tion, adoption may be considered by the couple as an alternative to the costly, time-consuming, and sometimes painful treatments for infertility.CN: Health promotion and maintenance;
CL: Analyze
18.
3. The client’s understanding of the procedure is demonstrated by the statement describing IVF as a technique that involves bypassing the blocked or absent fallopian tubes. The physician removes the ova by laparoscope- or ultrasound-guided transvagi- nal retrieval and mixes them with prepared sperm from the woman’s partner or a donor. Two days later, up to four embryos are returned to the uterus to increase the likelihood of a successful pregnancy.Supplemental progesterone, not estrogen, is given to enhance the implantation process. Gamete intrafal- lopian transfer (GIFT) and tubal embryo transfer have a higher pregnancy rate than IVF. However, these procedures cannot be used for clients who have blocked or absent fallopian tubes because the fertilized ova are placed into the fallopian tubes, subsequently entering the uterus naturally for implantation. In IVF, fertilization of the ova by the
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sperm occurs outside the client’s body. In GIFT, both ova and sperm are implanted into the fallopian tubes and allowed to fertilize within the woman’s body.
CN: Reduction of risk potential;
CL: Evaluate
19.
4. The client is verbalizing concerns about death during childbirth, thus providing the nurse with an opportunity to gather additional data. Ask- ing the client about these concerns would be most helpful to determine the client’s knowledge base and to provide the nurse with the opportunity to answer any questions and clarify any misconcep- tions. Although the maternal mortality rate is low in the United States, maternal deaths do occur, even with modern technology. Leading causes of maternal mortality in the United States include embolism, pregnancy-induced hypertension, hemorrhage, ectopic pregnancy, and infection. Telling the client not to concern herself about what has happened in the past is not useful. It only serves to discount the client’s concerns and block further therapeutic communication. Also, postponing or ignoring the client’s need for a discussion about complications of pregnancy may further increase the client’s anxiety.CN: Health promotion and maintenance;
CL: Apply
20.
3. As ovulation approaches, cervical mucus is abundant and clear, resembling raw egg white.Ovulation generally occurs 14 days (plus or minus 2 days) before the beginning of menses. During the luteal phase of the cycle, which occurs after ovula- tion, the cervical mucus is thick and sticky, making it diffi cult for sperm to pass. Changes in the cervical mucus are related to the infl uences of estrogen and progesterone. Cervical mucus is always present.
CN: Health promotion and maintenance;
CL: Create
21.
1. To ensure maximum effectiveness, the condom should always be placed over the erect penis before coitus. Some couples fi nd condom use objectionable because foreplay may have to be inter- rupted to apply the condom. The penis, covered by the condom, should be withdrawn before the penis becomes fl accid. Otherwise sperm may escape from the condom, providing an opportunity for possible fertilization. Rather than having the condom pulled tightly over the penis before coitus, space should be left at the tip of the penis to allow the condom to hold the sperm. The client does not need a prescrip- tion for a condom with nonoxynol 9 because these are sold over the counter.CN: Reduction of risk potential;
CL: Apply
22.
3. With medroxyprogesterone acetate, irregular menstrual cycles and amenorrhea are com- mon adverse effects. Other adverse effects include weight gain, breakthrough bleeding, headaches, and depression. This method requires deep intramus- cular injections every 3 months. The fi rst injection should occur within 5 days after menses.CN: Reduction of risk potential;
CL: Evaluate
23.
4. Severe cramping and pain may occur as the device is passed through the internal cervical os. The insertion of the device is generally done when the client is having her menses, because it is unlikely that she is pregnant at that time. Com- mon adverse effects of IUDs are heavy menstrual bleeding and subsequent anemia, not amenorrhea.Uterine infection or ectopic pregnancy may occur.
The IUD has an effectiveness rate of 98%. Therefore, additional protection is not necessary to prevent pregnancy. IUDs generally are less costly than other forms of contraception because they do not require additional expense. Only one insertion is necessary, in comparison to daily doses of oral contraceptives or the need for spermicides in conjunction with diaphragm use.
CN: Reduction of risk potential;
CL: Apply
24.
1. The American Cancer Society recommends an annual mammography screening examination for all women after the age of 40. Some high-risk women may begin annual screening at an earlier age. Some women have never had a mammogram because of fear or misconceptions. Mammography should be scheduled after the client’s menses to reduce complaints of breast tenderness. Mammog- raphy screening is considered expensive, especially by low-income women. Although some discomfort is common because the breast is placed between two plates during the screening process, the procedure should not be considered extremely painful.CN: Health promotion and maintenance;
CL: Evaluate
25.
3. Small-boned, fair-skinned women of northern European descent are at the greatest risk for osteoporosis, not African American women. One cup of yogurt or 1.5 oz of hard cheese is the equivalent of one glass of milk. Women who do not eat dairy products, such as women who are lactose intoler- ant, should consider using calcium supplements.Inadequate lifetime intake of calcium is a major risk factor for osteoporosis. Estrogen therapy, or some of the newer medications that are not estrogen based, can greatly reduce the incidence of osteoporosis.
CN: Reduction of risk potential;
CL: Evaluate
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