Chapter 66 Exam - ATI and NCLEX

A nurse is discussing risk factors for urinary tract infections with a newly licensed nurse. Which of the following risk factors should the nurse include? (Select all that apply) (4)

1. Epidural anesthesia 2. Urinary bladder catheterization 3. Frequent pelvic examinations 4. History of UTIs - Cesarean birth places a client at risk for development of a UTI

A nurse is reinforcing teaching about external monitoring with a client who was recently admitted for induction of labor. Which of the following information should the nurse include?

External monitoring cannot measure intensity of contractions

A mother is breastfeeding her newborn baby and experiences breast engorgement. The nurse should encourage the mother to do which to provide relief of the engorgement?

Massage the breasts before feeding to stimulate let-down

A nurse is assisting in the care of a client who is in active labor. The nurse notes tachycardia on the external fetal monitor tracing. Which of the following conditions should the nurse identify as a potential cause of the heart rate?

Maternal fever - Tachycardia can be caused by maternal fever, infection, and chorioamnionitis

A client experiences a large gush of fluid from her vagina while walking in the hallway of the birthing unit. Which of the following actions should the nurse take first?

Monitor FHR for distress - The greatest risk to the client and fetus is umbilical cord prolapse, leading to fetal distress following rupture of membranes. The first action by the nurse is to monitor the FHR for manifestations of distress

The nurse is assisting with caring for a client with abruptio placentae. While caring for the client, the nurse notes that the client begins to develop signs of shock. The nurse should take which action first?

Turn the client onto her side

A nurse is reinforcing teaching with a client about the benefits of internal fetal heart monitoring. Which of the following statemetns should the nurse include? (Select all that apply) (3)

1. "It can detect abnormal fetal heart tones early." 2. "It allows for accurate readings despite maternal movement." 3. "It can measure uterine contraction intensity"

The nurse is collecting data from a client who has been diagnosed with placenta previa. Which findings should the nurse expect to note? Select all that apply. (2)

1. Bright red vaginal bleeding 2. Soft, relaxed, nontender uterus

A nurse is assisting with the care of a client who is at 40 weeks of gestation and experiencing contractions every 3 to 5 minutes and becoming stronger. A vaginal exam reveals that the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client asks for pain mediction. Which of the following acitons should the nurse take? (Select all that apply) (3)

1. Encourage use of patterned breathing techniques 2. Administer opioid analgesic medication 3. Suggest application of cold - Patterned breathing techniques can assist with pain management at this time - An opioid analgesic can be safely administered at this time. - A nonpharmacological approach, such as the application of cold, is an appropriate intervention at this time

Which findings indicate to the nurse that placental separation has occurred? Select all that apply. (3)

1. Lengthening of umbilical cord 2. Sudden trickle or spurt of blood 3. Fetal membranes are seen at the introitus

The nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. (4)

1. Rest during the acute phase 2. Wear a supportive, nonunderwire bra 3. Maintain a fluid intake of at least 3000 mL 4. Continue to breastfeed if the breasts are not too sore

A primigravida's membranes rupture spontaneously. Which action should the nurse take first?

Determine the fetal heart rate

The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. During admission, which action should the nurse take initially?

Determine the maternal and fetal vital signs

The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn. The nurse is monitoring for signs of placental separation knowing that which indicates that the placenta has separated?

A change in the uterine contour

The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that which routine labor procedure is contraindicated?

A manual pelvic examination

The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 cm dilted and is experiencing precipitous labor. Which is the priority nursing action?

Keep the client in a side-lying position

A nurse is reinforcing teaching with a client who is 1 week postpartum and breastfeeding. The client reports breast engorgement. Which of the following instructions should the nurse give to the client?

"Apply cold compresses between feedings." - The nurse hsould instruct the client to apply cold compresses to the breasts after feedings to help with breast engorgement

A nurse is discussing intermittent fetal heart monitoring with a newly licensed nurse. Which of the following statements should the nurse include?

"Auscultate the fetal heart rate immediately following rupture of membranes"

A postpartum client is getting ready for discharge. The nurse suspects that the client needs further teaching related to beastfeeding when she makes which statement?

"I don't need birth control because I will be breastfeeding."

A nurse is reinforcing discharge teaching with a postpartum client who had no immunity to varicella and received the varicella vaccine. Which of the following client statements indicates understanding of the teaching?

"I need a second vaccination at my postpartum visit" - A second varicella immunization is recommended at 4 to 8 weeks following delivery by cleints who had no history of immunity

A nurse is assisting with the care of a client in active labor. When last examined 2 hr ago, the client's cervix was 3 cm dialted, 100% effaced, membranes intact, and the fetus was at a -2 station. The client suddenly states her water broke. The monitor reveals a FHR of 80 to 85/min. The nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform first?

Apply finger pressure to the presenting part

A nurse is caring for a client who has postpartum psychosis. Which of the following acitons is the nurse's prioirity?

Ask the client if she has thoughts of harming herself of her infant.

A nurse is caring for a client who is in labor and is experiencing late decelerations in the FHR. Which of the following actions should the nurse take first?

Assist the client into the left-lateral position - The greatest risk to the fetus during late decelerations is uteroplacental insufficiency. The first action the nurse should take is place the client into the left-lateral position to increase uteroplacental perfusion.

After delivery the nurse checks the height of the uterine fundus. Which position of the fundus should the nurse expect to note?

At the level of the umbilicus

The nurse notes that the 4-hour postpartum client has cool, clammy skin and that she is restless and excessively thirsty. The nurse immediately notifies the registered nurse and then performs which action?

Checks the vital signs

A nurse is caring for a client who has been in lbaor for 12 hr, and her membranes are intact. The provider has decided to eprform an amniotomy in an effort to facilitate the progress of labor. The nurse performs a vaginal examination to ensure which of the following prior to the performance of the amniotomy?

Fetal engagement - Prior to an amniotomy, it is imperative that the fetus is engaged at 0 station and at the level of the maternal ischial spines to prevent prolapse of the umbilical cord

A nurse is reinforcing discharge teaching with a postpartum client following a cesarean birth. The client reports leaking urine every time she sneezes or coughs. Which of the following interventions should the nurse suggest to the client?

Kegel exercises - The nurse should suggest that the client perform Kegel exercises, which consist of the voluntary contraction and relaxation of the pubococcygeus muscle to strengthen the pelvic muscles. These exercises assist in decreasing postpartum urinary stress incontinence that occurs with sneezing and coughing

A nurse on a postpartum unit is contributing to the plan of care for a client who has thrombophlebitis. Which of the following interventions should the nurse recommend?

Measure leg circumferences - The nurse should measure the circumference of the leg to monitor for changes in the client's condition

A nurse is collecting data from a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of sadness. The nurse should identify these findings as an indication of which of the following conditions?

Postpartum blues - Postpartum blues are characterized by tearfulness, insomnia, lack of appetite, and feelings of sadness or inadequacies

The nurse is assisting with planning care for a postpartum woman who has small vulvar hematomas. To assist with reducing the swelling, the nurse should perform which action?

Prepare an ice pack for application to the area - The application of ice will reduce the swelling caused by hematoma formation in the vulvar area

The client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client's systolic blood pressure (BP) dropped 20 points, the diastolic BP dropped 10 points, and her pulse is 120 beats per minute. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. Based on this diagnosis, the nurse should plan which action?

Prepare the client for surgery

The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. Which lochia characteristic should the nurse expect to note?

Red

A nurse is reinforcing discharge instructions with a client who is 4 weeks postpartum. The nurse should instruct the client to contact her provider for which of hte following findings?

Sore nipple with cracks and fissures - The nurse should isntruct the client to contact the provider of sore nipples and cracks with fissures because this is an indication of mastitis, inflammation of the breast tissue

The client who is being prepared for a cesarean delivery is brought to the delivery room. To maintain the optimal perfusion of oxygenated blood to the fetus, the nurse should place the client in which position?

Supine position with a wedge under the right hip

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do which to help the woman process what has happened?

Support the mother in her reaction to the newborn

After episiotomy and the delivery of a newborn, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it is firm. Which determination should the nurse make?

The bright red bleeding is abnormal and should be reported

Leopold's maneuvers will be performed on a pregnant client. The clietn asks the nurse about the procedure. Which information should the nurse provide to the client abobut Leopold's maneuvers?

The maneuvers are a systematic method for palpating the fetus thorugh the maternal abdominal wall

The nurse is assigned to assist with caring for a client with abruptio placentae who is experiencing vaginal bleeding. The nurse collects data from the client, knowing that abruptio placentae is accompanied by which additional finding?

Uterine tenderness on palpation

The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly complains of chest pain and dyspnea. The nurse should initially check which item?

Vital signs

The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. Which description should the nurse give to the client?

The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day

A nurse is reinforcing teaching with a client who is breastfeeding and has mastitis. Which of the following statements should the nurse make?

"Completely empty each breast at each feeding or use a pump" - Instruct the client to completely empty each breast at each feeding to prevent milk stasis, which provides a medium for bacterial growth

The nurse suspects that the client has a pulmonary embolism. Which is the most important nursing action?

Administer oxygen by face mask, as prescribed

The nurse is assigned to care for the client after a cesarean section. To prevent thrombophlebitis, the nurse should encourage the woman to take which priority action?

Ambulate frequently - Stasis is believed to be a major predisposing factor for the development of thrombophlebitis. Because cesarean delivery poses a risk factor, the client should ambulate early and frequently to pormote circulation and prevent stasis

A nurse is inspecting the perineal pad of a client who is 24 hr postpartum. The pad is saturated with approximately 12 cm of dark-red discharge. Which of the following blood loss estimations should the nurse report to the charge nurse and document in the client's medical record?

Moderate - Moderate blood loss is greater than 10 cm. This is an expected finding 24 hr postpartum

A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings which is the priority nursing action?

Notify the registered nurse (RN) immediately

The nurse is caring for a postpartum client. At 4 hours postpartum, the client's temperature is 102F (38.9C). Which is the appropriate nursing action?

Notify the registered nurse (RN), who will then contact the primary health care provider (PHCP)

The nurse is caring for a client who is in labor. The nurse recheck the client's blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position?

Side-lying

The nurse is assigned to care for a client who is in early labor. When collecting data from the client, which should the nurse check first?

Baseline fetal heart rate

A nurse in the labor and delivery unit is assiting with the care ofa client in labor and applies an external fetal monitor and tocotransducer. The FHR is around 140/min. Contractions are occurring every 8 min and 30 to 40 seconds in duration. The RN performs a vaginal exam and finds the cervix is 2 cm dilated and 50% effaced, and the fetus is at a -2 station.

First stage, latent phase -In stage 1, latent phase, the cervix dilates from 0 to 3 cm, and contraction duration ranges from 30 to 45 seconds

The nurse is assisting with caring for a postpartum client who is experiencing uterine hemorrhage. When planning to meet the psychosocial needs of the client, the nurse should plan which action?

Keep the client and her family members informed of her progress