Perry: Maternal Child Nursing Care, 4

th
Edition
Chapter 5: Health Assessment
Test Bank
M!T"P!E CH#"CE
1. The two primary functions of the ovary are:
a. Normal female development and sex hormone release.
b. Ovulation and internal pelvic support.
c. Sexual response and ovulation.
d. Ovulation and hormone production.
ANS: D
The two functions of the ovaries are ovulation and hormone production. The presence of
ovaries does not uarantee normal female development. The ovaries produce estroen!
proesterone! and androen. Ovulation is the release of a mature ovum from the ovary"
the ovaries are not responsible for interval pelvic support. Sexual response is a feedbac#
mechanism involvin the hypothalamus! anterior pituitary land! and the ovaries.
Ovulation does occur in the ovaries.
$TS: 1 D%&: 'onitive (evel: )nowlede *+&: ,-
O./: 'lient Needs: 0ealth $romotion and 1aintenance
TO$: Nursin $rocess: Assessment
2. The uterus is a muscular! pear3shaped oran that is responsible for:
a. 'yclic menstruation. c. &ertili4ation.
b. Sex hormone production. d. Sexual arousal.
ANS: A
The uterus is an oran for reception! implantation! retention! and nutrition of the fertili4ed
ovum" it also is responsible for cyclic menstruation. 0ormone production and fertili4ation
occur in the ovaries. Sexual arousal is a feedbac# mechanism involvin the
hypothalamus! the pituitary land! and the ovaries.
$TS: 1 D%&: 'onitive (evel: )nowlede *+&: ,,
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TO$: Nursin $rocess: Assessment
5. 6ni7ue muscle fibers ma#e the uterine myometrium ideally suited for:
a. 1enstruation. c. Ovulation.
b. The birth process. d. &ertili4ation.
ANS: .
The myometrium is made up of layers of smooth muscle that extend in three directions.
These muscles assist in the birth process by expellin the fetus! liatin blood vessels
after birth! and controllin the openin of the cervical os.
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:. The hormone responsible for maturation of mammary land tissue is:
a. +stroen. c. $rolactin.
b. Testosterone. d. $roesterone.
ANS: D
$roesterone causes maturation of the mammary land tissue! specifically acinar
structures of the lobules. +stroen increases the vascularity of the breast tissue.
Testosterone has no bearin on breast development. $rolactin is produced after birth and
released from the pituitary land. %t is produced in response to infant suc#lin and
emptyin of the breasts.
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TO$: Nursin $rocess: Assessment
;. .ecause of the effect of cyclic ovarian chanes on the breast! the best time for breast self3
examination <.S+= is:
a. &ive to > days after menses ceases. c. 1idmenstrual cycle.
b. Day 1 of the endometrial cycle. d. Any time durin a shower or bath.
ANS: A
The physioloic alterations in breast si4e and activity reach their minimal level about ; to
> days after menstruation stops. Therefore! all women should perform .S+ durin this
phase of the menstrual cycle.
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TO$: Nursin $rocess: $lannin
,. 1enstruation is periodic uterine bleedin:
a. That occurs every 2- days.
b. %n which the entire uterine linin is shed.
c. That is reulated by ovarian hormones.
d. That leads to fertili4ation.
ANS: '
1enstruation is periodic uterine bleedin that is controlled by a feedbac# system
involvin three cycles: endometrial! hypothalamic3pituitary! and ovarian. The averae
lenth of a menstrual cycle is 2- days! but variations are normal. Durin the endometrial
cycle! the functional two thirds of the endometrium is shed. (ac# of fertili4ation leads to
menstruation.
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O./: 'lient Needs: 0ealth $romotion and 1aintenance
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TO$: Nursin $rocess: Assessment
>. %ndividual irreularities in the ovarian <menstrual= cycle are most often caused by:
a. ?ariations in the follicular <preovulatory= phase.
b. An intact hypothalamic3pituitary feedbac# mechanism.
c. A functionin corpus luteum.
d. A proloned ischemic phase.
ANS: A
Almost all variations in the lenth of the ovarian cycle are the result of variations in the
lenth of the follicular phase. An intact hypothalamic3pituitary feedbac# mechanism is
reular! not irreular. The luteal phase beins after ovulation. The corpus luteum depends
on the ovulatory phase and fertili4ation. Durin the ischemic phase the blood supply to
the functional endometrium is bloc#ed! and necrosis develops. The functional layer
separates from the basal layer! and menstrual bleedin beins.
$TS: 1 D%&: 'onitive (evel: 'omprehension *+&: >5
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TO$: Nursin $rocess: Assessment
-. $rostalandins are produced in most orans of the body! includin the uterus. Other
source<s= of prostalandins is@are:
a. Ovaries. c. 1enstrual blood.
b. .reast mil#. d. The vaina.
ANS: '
1enstrual blood is a potent source of prostalandins. $rostalandins are produced in
most orans of the body and in menstrual blood. The ovaries! breast mil#! and vaina are
neither orans nor a source of prostalandins.
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A. $hysioloically sexual response can be characteri4ed by:
a. 'oitus! masturbation! and fantasy. c. +rection and orasm.
b. 1yotonia and vasoconestion. d. +xcitement! plateau! and orasm.
ANS: .
$hysioloically! accordin to 1asters <1AA2=! sexual response can be analy4ed in terms of
two processes: vasoconestion and myotonia. 'oitus! masturbation! and fantasy are forms
of stimulation for the physical manifestation of the sexual response. +rection and orasm
occur in two of the four phases of the sexual response cycle. +xcitement! plateau! and
orasm are three of the four phases of the sexual response cycle.
$TS: 1 D%&: 'onitive (evel: )nowlede *+&: >:
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TO$: Nursin $rocess: Assessment
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Test .an#
19. .efore beinnin the health history interview! the nurse should perform all actions
except:
a. Smile and as# the client whether she has any special concerns.
b. Spea# in a relaxed manner with an even! nonBudmental tone.
c. 1a#e the client comfortable.
d. Tell the client her 7uestions are irrelevant.
ANS: D
The woman should be assured that all of her 7uestions are relevant and important.
Smilin and as#in about special concerns! spea#in in a relaxed manner! and ma#in
the client comfortable are all appropriate actions for the nurse to perform before
beinnin the health history.
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TO$: Nursin $rocess: Assessment
11. The nurse uides a woman to the examination room and as#s her to remove her clothes
and put on an examination own with the front open. The woman states! C% have special
underarments that % do not remove for reliious reasons.D The most appropriate response
from the nurse would be:
a. CEou canFt have an examination without removin all your clothes.D
b. C%Fll as# the doctor to modify the examination.D
c. CTell me about your underarments. %Fll explain the examination procedure! and
then we can discuss how you can have your examination comfortably.D
d. CGhatH %Fve never heard of such a thinI That sounds different and strane.D
ANS: '
This statement reflects cultural competence by the nurse and shows respect for the
womanFs reliious practices. The nurse must respect the rich and uni7ue 7ualities that
cultural diversity brins to individuals. %n reconi4in the value of these differences! the
nurse can modify the plan of care to meet the needs of each woman.
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TO$: Nursin $rocess: $lannin
12. A ,23year3old woman has not been to the clinic for an annual examination for ; years.
The recent death of her husband reminded her that she should come for a visit. 0er
family doctor has retired! and she is oin to see the womenFs health nurse practitioner
for her visit. To facilitate a positive health care experience! the nurse should:
a. *emind the woman that she is lon overdue for her examination and that she
should come in annually.
b. (isten carefully and allow extra time for this womanFs health history interview.
c. *eassure the woman that a nurse practitioner is Bust as ood as her old doctor.
d. +ncourae the woman to tal# about the death of her husband and her fears about
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her own death.
ANS: .
The nurse has an opportunity to use reflection and empathy while listenin and to ensure
open and carin communication. Schedulin a loner appointment time may be necessary
because older women may have loner histories or may need to tal#. A respectful and
reassurin approach to carin for women over ae ;9 can help ensure that they continue
to see# health care. *emindin the woman about her overdue examination! reassurin the
woman that she has a ood practitioner! and encourain conversation about the death of
her husband and her own death are not the best approaches with women in this ae roup.
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O./: 'lient Needs: $sychosocial %nterity
TO$: Nursin $rocess: $lannin
15. Durin a health history interview! a woman states that she thin#s that she has CbumpsD on
her labia. She also states that she is not sure how to chec# herself. The correct response
would be to:
a. *eassure the woman that the examination will not reveal any problems.
b. +xplain the process of vulvar self3examination to the woman and reassure her that
she should become familiar with normal and abnormal findins durin the
examination.
c. *eassure the woman that CbumpsD can be treated.
d. *eassure her that most women have CbumpsD on their labia.
ANS: .
Durin the assessment and evaluation the responsibility for self3care! health promotion!
and enhancement of wellness is emphasi4ed. The pelvic examination provides a ood
opportunity for the practitioner to emphasi4e the need for reular vulvar self3
examination. $rovidin reassurance to the woman concernin the CbumpsD would not be
an accurate response.
$TS: 1 D%&: 'onitive (evel: Application *+&: -1! -2
O./: 'lient Needs: $hysioloic %nterity TO$: Nursin $rocess: Assessment
1:. A woman arrives at the clinic for her annual examination. She tells the nurse that she
thin#s she has a vainal infection and she has been usin an over3the3counter cream for
the past 2 days to treat it. The nurseFs initial response should be to:
a. %nform the woman that vainal creams may interfere with the $apanicolaou <$ap=
test for which she is scheduled.
b. *eassure the woman that usin vainal cream is not a problem for the examination.
c. As# the woman to describe the symptoms that indicate to her that she has a vainal
infection.
d. As# the woman to reschedule the appointment for the examination.
ANS: '
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An important element of the history and physical examination is the clientFs description
of any symptoms she may be experiencin. Althouh vainal creams may interfere with
the $ap test! the best response is for the nurse to in7uire about the symptoms the client is
experiencin. Gomen should not douche! use vainal medications! or have sexual
intercourse for 2: to :- hours before obtainin a $ap test. Althouh the woman may need
to reschedule a visit for her $ap test! her current symptoms should still be addressed.
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1;. The transition phase durin which ovarian function and hormone production decline is
called:
a. The climacteric. c. 1enopause.
b. 1enarche. d. $uberty.
ANS: A
The climacteric is a transitional phase durin which ovarian function and hormone
production decline. Menarche is the term that denotes the first menstruation. Menopause
refers only to the last menstrual period. Puberty is a broad term that denotes the entire
transitional stae between childhood and sexual maturity.
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1,. Ghich statement would indicate that the client re7uires additional instruction about breast
self3examinationH
a. CEellow dischare from my nipple is normal if %Fm havin my period.D
b. C% should chec# my breasts at the same time each month! li#e after my period.D
c. C% should also feel in my armpit area while performin my breast examination.D
d. C% should chec# each breast in a set way! such as in a circular motion.D
ANS: A
Dischare from the nipples re7uires further examination from a health care provider. C%
should chec# my breasts at the same time each month! li#e after my period!D C% should
also feel in my armpit area while performin my breast examination!D and C% should
chec# each breast in a set way! such as in a circular motionD all indicate successful
learnin.
$TS: 1 D%&: 'onitive (evel: Analysis *+&: >1
O./: 'lient Needs: 0ealth $romotion and 1aintenance
TO$: Nursin $rocess: Assessment
1>. A 293year3old client calls the clinic to report that she has found a lump in her breast. The
nurseFs best response is:
a. CDonFt worry about it. %Fm sure itFs nothin.D
b. CGear a tiht bra! and it should shrin#.D
c. C1any women have benin lumps and bumps in their breasts. 0owever! to ma#e
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sure that itFs benin! you should come in for an examination by your physician.D
d. C'hec# it aain in 1 month and call me bac# if itFs still there.D
ANS: '
Try to ease the clientFs fear! but provide a time for a thorouh evaluation of the lump
because it may indicate abnormal chanes in the breast. Discreditin the clientFs findins
may discourae her from continuin with breast self3examination. Gearin a tiht bra
may irritate the s#in and will not cause the lump to shrin#. Delayin treatment may allow
proliferation of abnormal cells.
$TS: 1 D%&: 'onitive (evel: Analysis *+&: >A
O./: 'lient Needs: $hysioloic %nterity TO$: Nursin $rocess: Assessment
1-. The female reproductive oran<s= responsible for cyclic menstruation is@are the:
a. 6terus. c. ?ainal vestibule.
b. Ovaries. d. 6rethra.
ANS: A
The uterus is responsible for cyclic menstruation. %t also houses and nourishes the
fertili4ed ovum and the fetus. The ovaries are responsible for ovulation and production of
estroen" the uterus is responsible for cyclic menstruation. The vainal vestibule is an
external oran that has openins to the urethra and vaina" the uterus is responsible for
cyclic menstruation. The urethra is not a reproductive oran! althouh it is found in the
area" the uterus is responsible for cyclic menstruation.
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1A. The body part that both protects the pelvic structures and accommodates the rowin
fetus durin prenancy is the:
a. $erineum. c. ?ainal vestibule.
b. .ony pelvis. d. &ourchette.
ANS: .
The bony pelvis protects and accommodates the rowin fetus. The perineum covers the
pelvic structures" the bony pelvis protects and accommodates the rowin fetus. The
vainal vestibule contains openins to the urethra and vaina" the bony pelvis protects
and accommodates the rowin fetus. The fourchette is formed by the labia minor" the
bony pelvis protects and accommodates the rowin fetus.
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TO$: Nursin $rocess: Assessment
29. A fully matured endometrium that has reached the thic#ness of heavy! soft velvet
describes the JJJJJ phase of the endometrial cycle.
a. 1enstrual c. Secretory
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b. $roliferative d. %schemic
ANS: '
The secretory phase extends from the day of ovulation to approximately 5 days before the
next menstrual cycle. Durin this phase the endometrium becomes fully mature. Durin
the menstrual phase the endometrium is bein shed" the endometrium is fully mature
aain durin the secretory phase. The proliferative phase is a period of rapid rowth! but
the endometrium becomes fully mature aain durin the secretory phase. Durin the
ischemic phase the blood supply is bloc#ed! and necrosis develops. The endometrium is
fully mature durin the secretory phase.
$TS: 1 D%&: 'onitive (evel: 'omprehension *+&: >5
O./: 'lient Needs: 0ealth $romotion and 1aintenance
TO$: Nursin $rocess: Assessment
21. The stimulated release of onadotropin3releasin hormone and follicle3stimulatin
hormone is part of the:
a. 1enstrual cycle c. Ovarian cycle
b. +ndometrial cycle d. 0ypothalamic3pituitary cycle
ANS: D
The menstrual! endometrial! and ovarian cycles are interconnected. 0owever! the cyclic
release of hormones is the function of the hypothalamus and pituitary lands.
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TO$: Nursin $rocess: Assessment
22. 'ertain fatty acids classified as hormones that are found in many body tissues and that
have roles in many reproductive functions are #nown as:
a. Konadotropin3releasin hormone <Kn*0=.
b. $rostalandins <$Ks=.
c. &ollicle3stimulatin hormone <&S0=.
d. (uteini4in hormone <(0=.
ANS: .
$Ks affect smooth muscle contraction and chanes in the cervix. Kn*0! &S0! and (0
are part of the hypothalamic3pituitary cycle! which responds to the rise and fall of
estroen and proesterone.
$TS: 1 D%&: 'onitive (evel: )nowlede *+&: >5
O./: 'lient Needs: 0ealth $romotion and 1aintenance
TO$: Nursin $rocess: Assessment
25. Ghich statement about female sexual response is NOT accurateH
a. Gomen and men are more ali#e than different in their physioloic response to
sexual arousal and orasm.
b. ?asoconestion is the conestion of blood vessels.
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c. The orasmic phase is the final state of the sexual response cycle.
d. &acial rimaces and spasms of hands and feet are often part of arousal.
ANS: '
The final state of the sexual response cycle is the resolution phase after orasm. 1en and
women are surprisinly ali#e. ?asoconestion causes vainal lubrication and
enorement of the enitals. Arousal is characteri4ed by increased muscular tension
<myotonia=.
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TO$: Nursin $rocess: Assessment
2:. As part of their participation in the ynecoloic portion of the physical examination!
nurses should:
a. Ta#e a firm approach that encouraes the client to facilitate the examination by
followin the physicianFs instructions exactly.
b. +xplain the procedure as it unfolds and continue to 7uestion the client to et
information in a timely manner.
c. Ta#e the opportunity to explain that the trendy vulvar self3examination is only for
women at ris# for cancer.
d. 0elp the woman relax throuh proper placement of her hands and proper breathin
durin the examination.
ANS: D
.reathin techni7ues are important relaxation techni7ues that can help the client durin
the examination. The nurse should encourae the client to participate in an active
partnership with the care provider. +xplanations durin the procedure are fine! but many
women are uncomfortable answerin 7uestions in the exposed and aw#ward position of
the examination. ?ulvar self3examination on a reular basis should be encouraed and
tauht durin the examination.
$TS: 1 D%&: 'onitive (evel: Application *+&: -9
O./: 'lient Needs: Safe and +ffective 'are +nvironment
TO$: Nursin $rocess: %mplementation
2;. The microscopic examination of scrapins from the cervix! endocervix! or other mucous
membranes to detect premalinant or malinant cells is called:
a. .imanual palpation. c. A $apanicolaou <$ap= test.
b. *ectovainal palpation. d. A four As procedure.
ANS: '
The $ap test is a microscopic examination for cancer that should be performed reularly!
dependin on the clientFs ae. .imanual palpation is a physical examination of the
vaina. *ectovainal palpation is a physical examination performed throuh the rectum.
The four As is an intervention procedure to help a client stop smo#in.
$TS: 1 D%&: 'onitive (evel: )nowlede *+&: -5
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O./: 'lient Needs: $hysioloic %nterity TO$: Nursin $rocess: %mplementation
2,. As a irl proresses throuh development! she may be at ris# for a number of ae3related
conditions. Ghile preparin a 213year3old client for her first adult physical examination
and $apanicolaou <$ap= test! the nurse is aware of excessiveness shyness. The youn
woman states that she will not remove her bra because! CThere is somethin wron with
my breasts" one is way bier.D Ghat is the best response by the nurse in this situationH
a. C$lease reschedule your appointment until you are more prepared.D
b. C%t is o#ay" the provider will not do a breast examination.D
c. C% will explain normal rowth and breast development to you.D
d. CThat is unfortunate" this must be very stressful for you.D
ANS: '
Durin adolescence one breast may row faster than the other. Discussion reardin this
aspect of rowth and development with the client will reassure her that there may be
nothin wron with her breasts. &emale teenaers usually enter the health system for
screenin <$ap tests bein at ae 21 or 5 years after first sexual activity=. Situations such
as these can produce reat stress for the teenaer! and the nurse and health care provider
should treat her carefully. As#in her to reschedule will li#ely result in the clientFs not
returnin for her appointment at all. A breast examination at her ae is part of the
complete physical examination. Eoun women should be tauht about normal breast
development and bein doin breast self3examinations. This response is inappropriate.
Althouh this shows empathy on the part of the nurse and ac#nowledes the clientLs
stress! it will not correct the clientFs deficient #nowlede related to normal rowth and
development.
$TS: 1 D%&: 'onitive (evel: Application *+&: >9
O./: 'lient Needs: 0ealth $romotion and 1aintenance
TO$: Nursin $rocess: Dianosis
T$E%&A!'E
1. Diethylstilbestrol <D+S= was a dru commonly used to prevent miscarriae and
premature birth between 1A5- and 1A>1. 1ost nurses who provide ynecoloic care are
aware of the increased ris# of adenocarcinoma to the vaina and cervix for the dauhters
of women who used D+S. &ortunately there were no #nown side effects to their sons.
ANS: &
Sons of women who too# D+S have an increased ris# of noncancerous epididymal cysts.
Krandsons of these women are 29 times more li#ely to have hypospadias.
$TS: 1 D%&: 'onitive (evel: Application *+&: -5
O./: 'lient Needs: $hysioloic %nterity TO$: Nursin $rocess: $lannin
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