Chemistry Practice Question

3. A nurse is providing teaching about the expected effects of magnesium sulfate to a client who is at 28 weeks gestation and has preeclampsia. Which of the following responses by the nurses is appropriate? a. "This medication improves tissue perfusion." b. "This medication increases cardiac output." c. "This medication stabilizes the fetal heart rate." d. "This medication prevents seizures."

d. "This medication prevents seizures."

A nurse is assessing a client during her first prenatal visit the client reports March 20th us her last menstrual.. Use Niagele's rule to calculate the estimated date of delivery. Use the mmdd format with four numerals and no spaces or punctuation.

1225

A nurse is preparing to perform a fundal massage for a postpartum client with hearing seeing uterine atony. in which order should the nurse plan to perform the following actions? (molded steps into the box on the right. Placing them in order of performance use all steps )

1. Ask the client to lie on her back in with her knees flexed 2. Position one hand around the top of the client's when fundus in one hand just above the client's symphysis pubis 3. rotate the upper hand to massage that clients uterus while using slight downward pressure to compress the fundus 4. observe the client's perineum for the passage of clots and the amount of bleeding

45. A nurse is assessing the results of a non-stress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing? A. 3 fetal movements perceived by the client in a 20-minute testing period B. No late deceleration in the fetal heart rate loaded with 3 uterine contractions of 60 seconds in duration within a 10-minute testing period C. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client D. an increase in fetal heart rate to 150 / minute above Baseline of 140 minute lasting 10 seconds in response to fetal movement with a 40 minute testing period

D. an increase in fetal heart rate to 150 / minute above Baseline of 140 minute lasting 10 seconds in response to fetal movement with a 40 minute testing period

A nurse in a provider's office is assessing a client at her first antepartum visit. The client states that the first day of her last menstrual period was March 8. Use Nagele's rule to calculate the est. date of delivery. March 8, minus 3 months plus 7 days and 1 year equals an estimated date of delivery of

December 15

A nurse on the labor and delivery unit is caring for a client who is at 33 weeks of gestation and was admitted with placenta previa. Which of the following interventions should the nurse include in the client's plan of care? a. A non-stress test twice weekly b. Administration of magnesium sulfate c. Routine vaginal exams d. Ambulation as tolerated

a. A non-stress test twice weekly

A nurse is caring for a client who is receiving prenatal care and is at her 24-week appointment. Which of the following laboratory tests should the nurse plan to conduct? a. 1 hour glucose tolerance test b. rubella titer c. Group B strep culture d. blood type and Rh

a. 1 hour glucose tolerance test

A nurse is planning care immediately following birth for a newborn who has Myelomeningocele that is cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care? a. Administer broad-spectrum antibiotics b. cleanse the site with Povidone iodine c. monitor the rectal temperature every 4 hours d. prepare for surgical closure after 72 hours

a. Administer broad-spectrum antibiotics

A nurse in a postpartum unit is caring for several clients. Which of the following tasks should the nurse delegate to assistive personnel? a. Help the client with perineal care b. Check the saturation of the perineal pad c. Provide the client with a dose of magnesium hydroxide d. Demonstrate to a client how to change a diaper

a. Help the client with perineal care

A nurse is assessing a newborn was exposed to cocaine in utero. Which of the following findings should the nurse expect? a. High-pitched cry b. Hypotonicity c. increased head circumference d. decreased startle response

a. High-pitched cry

A nurse is caring for a client who is receiving oxytocin to induce labor. The nurse should discontinue the oxytocin if which of the following occurs a. Six contractions in 10 mins ( contractions > 90 secs) b. Moderate variability of the fetal heart rate c. Nonrepetitive.early decals d. Contractions last 60 secs

a. Six contractions in 10 mins ( contractions > 90 secs)

A nurse is caring for a client who is in the second stage of labor. Which of the following manifestations should the nurse expect? a. The client delivers the newborn b. The client expels the placenta c. The client beings having regular contractions d. The client experiences gradual dilation of the cervix

a. The client delivers the newborn

A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect? a. facial petechiae b. Periauricular papillomas c. Telangiectic nevi d. Erythema toxicum

a. facial petechiae

A nurse is providing prenatal teaching to a client who practices of vegan diet and is trying to increase intake on vitamin 12. Which of the following foods should the nurse recommend? a. fortified soy milk b. brown rice c. fresh citrus fruits d. raw carrots

a. fortified soy milk

A nurse is caring for a client who is in the latent phase of the first stage of Labor and is in pain. Which of the following nursing interventions is appropriate to reduce pain? Select all that apply a. have a client sit in a tub of warm water b. ambulate the client in the hallway c. apply counter pressure to the sacral area d. administer 70% nitrous oxide mixed with oxygen e. perform Leopold's maneuver

a. have a client sit in a tub of warm water b. ambulate the client in the hallway c. apply counter pressure to the sacral area

67. Nurse is caring for a client who has hyperemesis gravidarum. Which of the following laboratory results should the nurse anticipate ? a. urine ketones b. rapid plasma reagin c. Prothrombin time d. urine culture

a. urine ketones

A nurse in the antepartum clinic is teaching a client who is at 28 weeks of gestation and has preeclampsia. Which of the following instructions should the nurse include in the teaching a. "Limit your fluid intake to four 8-ounce glasses per day." - 6 to 8, 8oz glasses of water a day b. "Count your baby's movements daily." c. "Reduce your calcium intake to less than 1 gram per day." d. "Alternate arms each time you check your blood pressure."

b. "Count your baby's movements daily."

A nurse is preparing to administer methylergonovine 0.2 mg orally to a client who is 2 hour postpartum and has a boggy uterus. For which of the following assessment findings should the nurse withhold the medication? a. Respiratory rate 14/min b. Blood pressure 142/92 mm Hg c. Urine output 100 mL in 3 hr d. Pulse 58/min

b. Blood pressure 142/92 mm Hg

A nurse is caring for a client who is postpartum and experiencing hypovolemic shock. Which of the following findings should the nurse expect? a. Respiratory rate 18/min - inc rr b. Cool, clammy skin c. Urinary output 30 mL/hr - little/no uo

b. Cool, clammy skin

A nurse is assessing the reflexes of a term newborn. After placing the newborn in the supine position which of the following methods should the nurse use to elicit the moro reflex? a. Touch the newborn cheek w/ a finger b. Make a loud noise above the newborn c. Turn the newborn's head to one side d. Tap the newborn's forehead with a finger

b. Make a loud noise above the newborn

A nurse is providing teaching to the parents of a newborn about the plastibell circumcision technique. Which of the following info should the nurse include? a. Yellow exudate will form at the surgical site in 24 Hours b. Notify the provider if the end of your baby penis appears dark red c. Make sure the newborn's diaper is snug d. The Plastibell will be removed 4 hrs after the procedure

b. Notify the provider if the end of your baby penis appears dark red

A nurse is providing discharge teaching to a client following tubal ligation. Which of the following statements by the client indicates an understanding of the teaching? a. Premenstrual tension will no longer be present. b. Ovulation will remain the same c. Hormone replacements will be needed following this procedure d. My monthly menstrual period will be shorter

b. Ovulation will remain the same

A nurse manager in a newborn nursery is reviewing infection control procedures with a group of newly hired nurses. Which of the following instructions should the nurse manager include in the teaching? a. Allow parents to enter the nursery if they are wearing a mask b. Place newborn bassinets at least 3 feet apart c. Place the newborn's foot on a sterile field during a heelstick d. Maintain airborne precautions in the nursery

b. Place newborn bassinets at least 3 feet apart

A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take? a. Instruct the client to avoid urinary elimination until after administration b. Verify that the informed consent is obtained prior to administration c. Allow the medication to reach room temp prior to administration d. Place the client in a semi fowler's position for 1 hr after administration

b. Verify that the informed consent is obtained prior to administration

A nurse is caring for a client who is 1 day postpartum following the birth of her first baby. The client's partner states they been having nightmares that we are homeless and the baby starving. Which of the following is appropriate response by nurse a. I know your worries but everything is going to be okay b. What do you think it'll be like to be responsible for a baby? c. Why would you worry about being homeless when you have a good job d. This is just the beginning of the worrying you will do as a parent

b. What do you think it'll be like to be responsible for a baby?

A nurse is caring for four enter partum clients. Which of the following clients should the nurse assess first? a. A client who is at 7 weeks of gestation and reports urinary frequency b. a client who is at 32 weeks of gestation and reports seeing floating spots c. a client who is 38 weeks of gestation and reports leg cramps d. a client who is at 20 weeks of gestation and reports periodic numbness in her fingers

b. a client who is at 32 weeks of gestation and reports seeing floating spots

A nurse is caring for a newborn following delivery. Which of the following actions should the nurse take first? a. Apply prophylactic eye ointment b. apply identification bands to the newborn c. administer IM vitamin K d. obtain the newborn's weight

b. apply identification bands to the newborn

A nurse is assessing a client who is in preterm labor and has a new prescription or terbutaline 0.25 mg subcutaneous. For which of the following findings should the nurse Withhold the medication and Report to the provider? a. fasting blood glucose 75 mg / DL b. blood pressure 88/58 mmhg c. urinary output 40 ml /hr d. FHR 120/min

b. blood pressure 88/58 mmhg

A nurse is caring for a client who received epidural analgesia during labor and is 4 hours for spartum. Which of the following client reports should the nurse address first? a. Itching b. inability to void c. abdominal cramps d. tingling in the legs

b. inability to void

A nurse is caring for a client who has gestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse the client has hyperglycemia? a. double vision b. increased urination c. Sweating d. dizziness

b. increased urination

A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following information places the client at risk for infection? a. Placenta previa b. midline episiotomy c. gestational hypertension d. meconium stained fluid

b. midline episiotomy

A nurse is assessing a client who is 6 hours postpartum and has endometritis. Which of the following findings should the nurse expect? a. Scant lotia b. urine tenderness c. temperature 37.4 C ( 99.3 F) d. WBC 9,000/mm

b. urine tenderness

A nurse is caring for a client who was in active labor and has gonorrhea. Which of the following potential complications of Gonorrhea should the nurse monitor? a. oligo hydramnios b. vaginal laceration during birth c. excessive bleeding after birth d. chonoamniloitis

b. vaginal laceration during birth

A nurse is reviewing the medication prescriptions for a newborn who is 6 hr. old and whose mother is HBsAg-positive. The nurse should anticipate administering which of the following medications? a. Hep A vaccine b. Haemophilus influenzae type B vaccine c. Hep B immune globulin d. Hep A immune globulin

c. Hep B immune globulin

A nurse is caring for a client who is receiving oxytocin to induce labor. The nurse should discontinue the oxytocin if which of the following occurs? a. Contractions last 60 Seconds b. non-repetitive early decelerations c. 6 contractions in 10 minutes d. moderate variability of the fetal heart rate

c. 6 contractions in 10 minutes

A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider a. Cap succedaneum b. Milia c. Bulging fontanels d. Subconjunctival hemorrhage

c. Bulging fontanels

A nurse is providing teaching to a client who is receiving medroxyprogesterone IM for contraception. Which of the following statements by the client indicates an understanding of the teaching? a. I should discontinue this medication if I experience spotting b. I will need to return to the clinic in the next eight weeks for my next injection c. I should increase my calcium intake while taking this medication d. I will get two shots each time I receive this medication

c. I should increase my calcium intake while taking this medication

2. A nurse is assessing a client who has preeclampsia during a prenatal visit. Which of the following findings should the nurse report to the provider? a. Blood glucose 110mg/dL (130-140 is bad) b. DTR of 2+ (Bad if negative) c. Urine protein of 3+ (severe preeclampsia proteinuria > 3) d. Hemoglobin 13 g/dL (Norm 11-13)

c. Urine protein of 3+ (severe preeclampsia proteinuria > 3)

A nurse is performing a heel stick on a newborn. Which of the following actions should the nurse take? a. Place an ice pack on the newborn's heel 5 min before the procedure b. Cleanse the newborn's heel with an alcohol swab after the procedure c. Use an automatic puncture device on the heel d. Puncture the heel on the inner aspect of the foot

c. Use an automatic puncture device on the heel

34. A nurse is conducting a class for a group of clients about birth control. Which of the following information should the nurse include in the teaching? a. You should have an annual exam to assess your diaphragm b. Your fertility will return 6 months after your provider removes your IUD - c. You should use spermicide 3 hrs. prior to sexual intercourse d. You will not need to use birth control for 1 month after receiving emergency contraception

c. You should use spermicide 3 hrs. prior to sexual intercourse

68. A nurse is providing teaching about the expected effects of magnesium sulfate to a client was at 28 weeks of gestation and has preeclampsia. Which of the following responses by the nurse is appropriate? a. This medication stabilizes the fetal heart rate b. this medication improves tissue perfusion c. this medication prevents seizures d. this medication increases cardiac output

c. this medication prevents seizures

7. A nurse is providing discharge instructions to a client who is postpartum and has engorged breasts. Which of the following nonpharmacological comfort measures should the nurse include in the teaching? a. Wear nipple shields during the feeding b. Use a breast binder for 2 days c. Use plastic-lined breast pads d. Apply cabbage leaves after feedings

d. Apply cabbage leaves after feedings

A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion. The nurse notes a respiratory rate of 8/min and absent DTR's. Which of the following medications should the nurse administer a. Phytonadione b. Acetylcysteine c. Protamine Sulfate d. Calcium gluconate - antidote

d. Calcium gluconate - antidote

5. A nurse manager is revising a maternal unit policy to ensure proper identification of newborns. Which of the following should the nurse include in the policy? a. Check the newborn's identification using the crib card. (Verify Wrist/ankle band w/ mom's ID band) b. Replace the infant's identification band after his name has been recorded. c. Require visitors to wear an identification band. (Mom & dad) d. Obtain an imprint of the infant's feet prior to taking him to the nursery.

d. Obtain an imprint of the infant's feet prior to taking him to the nursery.

A nurse is caring for a client who is 6 weeks of gestation and reports nausea and vomiting. Which of the following Recommendations should the nurse make? a. avoid Eating snacks before bedtime b. eat high-fat snack before getting out of bed c. drink additional liquids with each meal d. consume food served at cool temperatures

d. consume food served at cool temperatures

35. A nurse is performing an assessment of a newborn's but Bensky reflex. Which of the following findings should the nurse expect? a. Flexion of the forearm b. extension of the leg c. Downward curl of the toes d. dorsiflexion of the greater toes

d. dorsiflexion of the greater toes

A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion for severe preeclampsia. Which of the following findings should the nurse report to the provider? a. DTR 2+ (+ 4 is normal) b. Absence of clonus c. Facial flushing d. urine output 20 mL/hr

d. urine output 20 mL/hr

61. A nurse is caring for a newborn immediately following birth and notes a large amount of mucus in the newborn's mouth. Identify the sequence when performing suction with a bulb syringe. (move steps into box on the right) PUT IN ORDER 1. Compress the bulb syringe 2. Place the bulb syringe in the newborn's mouth 3. Use the bulb syringe to suction the newborn's nose 4. Assess the newborn for reflex bradycardia

1. Compress the bulb syringe 2. Place the bulb syringe in the newborn's mouth 3. Use the bulb syringe to suction the newborn's nose 4. Assess the newborn for reflex bradycardia

A nurse is preparing to administer metronidazole 2 g PO to a client who has pelvic inflammatory disease. Available is metronidazole 500 mg tablets. How many tablets should .the nurse administer? (Round to nearest whole number)

4 tablets

A nurse in a clinic is preparing to measure the fundal height of a client who is pregnant. Which of the following actions should the nurse take? a. Lay the tape measure horizontally over the middle of the client's abdomen b. Place the client in a left-lateral position to obtain the measurement c. Ensure that the client has a full bladder before taking the measurement (empty) d. Measure from the upper border of the symphysis pubis to the upper border of the fundus.

Measure from the upper border of the symphysis pubis to the upper border of the fundus.

54. A nurse in a clinic is caring for a client who is in her second trimester of pregnancy. The client expresses concerns about preparing her 2-year old child for a new a sibling. Which of the following is anappropriate response by the nurse? a. "Move your toddler to his new bed 2 months before the baby comes home." b. "Let your toddler see you carrying the baby into the home for the first time." (have someone else carry the baby so you can hug the child first) c. "Avoid bringing your toddler to prenatal visits." d. "Require scheduled interactions between the toddler and the baby."

a. "Move your toddler to his new bed 2 months before the baby comes home."

A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B streptococcus �-hemolytic (GBS). The client is multigravida and multipara with no history of GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse? a. "We need to know if you are positive for GBS at the time of delivery." b. "There was no indication of GBS in your earlier prenatal testing." c. "You didn't report any symptoms of GBS during your pregnancy." d. "Your previous deliveries were all negative for GBS."

a. "We need to know if you are positive for GBS at the time of delivery."

A nurse is providing teaching about expected changes during pregnancy to a client who is at 24 weeks of gestation. Which of the following information should the nurse include? a. "You should expect your uterus to double in size." b. "Your stomach will empty rapidly." c. "Your nipples will become lighter in color." d. "You should anticipate nasal stuffiness."

a. "You should expect your uterus to double in size."

A nurse in a prenatal Clinic is reviewing the laboratory results for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take? (Click on the exhibit button for additional information about the client. There are three tabs that contain separate categories of data.) a. Administer ceftriaxone IM b. administer rubella vaccine c. obtain a maternal serum alpha-fetoprotein specimen d. obtain a blood culture

a. Administer ceftriaxone IM

A nurse is caring for a client who has bladder distention following a vaginal birth. Which of the following actions should the nurse take first? a. Assist the client to the bathroom b. Offer the client a sitz bath c. Insert a urinary catheter

a. Assist the client to the bathroom

A nurse is planning care for a full term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care? a. Avoid using lotion or ointment on the newborn's skin b. Dress the newborn in lightweight clothing - (diaper only) c. Keep the newborn supine throughout treatment d. Measure the newborns temp q8hrs

a. Avoid using lotion or ointment on the newborn's skin

A nurse is providing dietary teaching to a client who is 32 weeks of gestation and has cholelithiasis. Which of the following foods should the nurse recommend for the client to include in her diet? a. Baked chicken b. whole milk c. french fries d. bacon cheeseburger

a. Baked chicken

A nurse is caring for a client who is in active labor and has gonorrhea. For which of the following potential complications of gonorrhea should the n urse monitor? a. Chorioamnionitis b. Vaginal laceration during birth c. Excessive bleeding after birth - i think, b/c the site said bleeding can occur, ATI just said PID "pelvic inflammatory disease" d. Oligohydramnios

a. Chorioamnionitis

A nurse is caring for a client who is active labor & is receiving oxytocin via IV infusion. The nurse has applied an internal fakfe heart monitor & recognizes an early deceleration of the fetal heart rate tracing. Which of the following actions should the nurse take a. Continue to monitor the client b. Discontinue oxytocin c. Administer 8L/min per mask d. Assists the client to lay on her right side

a. Continue to monitor the client

10. A nurse is observing an adolescent client who is offering her newborn a bottle while he is lying in the bassinet. When the nurse offers to pick the newborn up and place him in the client's arms, the mother states, "No, the baby is too tired to be held." Which of the following actions should the nurse take? a. Demonstrate how to hold the newborn and allow the client to practice b. Persuade the client to breastfeed the newborn to promote bonding c. Offer to take the newborn to the nursery to finish his feeding d. Insist that the mother pick up the newborn to feed him

a. Demonstrate how to hold the newborn and allow the client to practice

A nurse is caring for a preterm newborn immediately after delivery. Which of the following actions should the nurse takes first? a. Dry the infant under a radiant warmer b. Weigh the infant c. Take the infant's temp d. Obtain the infant's blood glucose level

a. Dry the infant under a radiant warmer

A nurse on the postpartum unit is reviewing prevention of new diaper rash with a client. Which of the following statements indicates an understanding of the teaching? a. I will allow the diaper area to dry before applying clean diaper b. I will clean the diaper area with a scented baby wipe c. I will apply a thin layer of tail to the diaper area twice a day d. I will wash the diaper area with an antibacterial soap with each diaper change

a. I will allow the diaper area to dry before applying clean diaper

A nurse is planning care for a client who is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan? a. Increase the infusion rate every 30-60 min b. Maintain the client in a supine position c. Limit IV intake to 4 L per 24 hr d. Titrate the infusion rate by 4 milliunits/min

a. Increase the infusion rate every 30-60 min

A nurse is providing teaching about increasing dietary fiber to an antepartum client who reports constipation. Which of the following food selections has the highest fiber content per cup? a. Lentils b. Oatmeal c. Cabbage d. Asparagus

a. Lentils

A nurse is providing discharge instructions to a client who delivered a newborn via cesarean birth 4 days ago. The nurse should instruct the client to contact the provider for which of the following findings? a. Newborn has fewer than 4 wet diapers in 24hrs b. The newborn's cord stump is still attached after 1 week c. The newborn sleeps 16hrs a day d. The newborn has loose stools

a. Newborn has fewer than 4 wet diapers in 24hrs

A nurse is performing a physical examination of a term newborn upon admission to the nursery. In which order should the nurse perform the following assessments? (HEAD TO TOE) a. Observe the newborns respirations b. Auscultate the newborn's heart rate c. Auscultate the newborns abdomen d. Test the newborn's reflexes

a. Observe the newborns respirations b. Auscultate the newborn's heart rate c. Auscultate the newborns abdomen d. Test the newborn's reflexes

A nurse is providing nutritional guidance McClain was pregnant in follows a vegan diet. The client asks the nurse which foods she should eat to ensure adequate calcium intake. The nurse should instruct the client that which of the following Foods has the highest amount of calcium? a. One cup cooked broccoli b. One cup cubed avocado c. one medium potato d. one large banana

a. One cup cooked broccoli

A nurse is reviewing the laboratory findings of a client who is at 10 wks gestation. Which of the following findings should the nurse report to the provider a. Platelets 100,000 mm3 b. WBC count 10,000mm c. Hgb 12g/dL d. Creatinine 0.5mg/dL

a. Platelets 100,000 mm3

A nurse is planning care for a newborn who is large for gestational age due to maternal gestational diabetes mellitus. The nurse should recognize that the newborn is at risk for which of the following conditions (select all that apply) 3 a. Polycythemia b. Hypermagnesemia c. Hypoglycemia d. Hyperbilirubinemia e. Hypercalcemia - hypo

a. Polycythemia c. Hypoglycemia d. Hyperbilirubinemia

A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse report to the provider? (select all that apply) a. Respiratory rate 11/min b. Urine output 130 mL/4 hr c. deep tendon reflexes absent d. Fetal heart rate 120/min e. Flushing of the face

a. Respiratory rate 11/min c. deep tendon reflexes absent

A nurse is caring for a client who is at 32 weeks of gestation and has gestational diabetes mellitus. Which of the following findings should the nurse report to the provider? a. The client has a fundal height of 38 cm b. the client reports 12 fetal movements in 1 hour c. The client has a fasting blood glucose of 90 mg / DL d. the client has non pitting pedal edema

a. The client has a fundal height of 38 cm

A nurse is assessing a full term newborn 1 hr following a vaginal birth. Which of the following is an expected assessment finding? a. The newborn's head circumference is greater than the chest circumference b. The newborn exhibits apnea episodes of 30 seconds c. The newborn has a heart rate of 70/min while sleeping d. The newborn's anterior fontanelle bulges when he is quiet

a. The newborn's head circumference is greater than the chest circumference

A nurse is caring for a newborn. Which of the following assessment findings should indicate to the nurse that suctioning of the nasopharynx is needed? a. The newborn's pulse oximeter is 91% b. the newborns respiratory rate is 32 / minutes c. the newborn is beginning to cough d. the newborns respiratory rate is the regular

a. The newborn's pulse oximeter is 91%

A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching? a. Transmission can occur via the saliva and urine of the newborn (semen, cervical/vag secretions, breast milk, placental tissue, urine, feces, blood) b. Mothers will receive prophylactic treatment with acyclovir prior to delivery - (ganciclovir) c. Lesions are visible on the mother's genitalia d. This infection requires airborne precautions are initiated for the newborn (droplet)

a. Transmission can occur via the saliva and urine of the newborn (semen, cervical/vag secretions, breast milk, placental tissue, urine, feces, blood)

A nurse is caring for a client who is 2 weeks postpartum following a cesarean birth. Which of the following clinical findings should the nurse identify as an indication of postpartum infection? a. Unilateral breast pain - indicative of mastitis b. Persistent abdominal striae c. Lochia alba - malodorous or purulent d. WBC count 12,000/mm - this one's elevated too.

a. Unilateral breast pain - indicative of mastitis

Nurse is performing a Heel stick on a newborn. Which of the following actions should the nurse take? a. Use an automatic puncture device on the heel b. Puncture the heels of the inner aspect of the foot c. cleanse the newborns heel with an alcohol swab after the procedure d. place an ice pack on the newborn's heel 5 minutes before the procedure

a. Use an automatic puncture device on the heel

A nurse if caring for a client who is postpartum following repair of a vaginal laceration. The client has a firm fundus, moderate lochia rubra & reports moderate perineal discomfort & pressure. Which of the following actions should the nurse take? a. check the perineal area b. Perform deep fundal massage c. Administer methylergonovine 0.2 mg IM - for postpartum hemorrhage d. Obtain a vaginal culture

a. check the perineal area

A nurse is in a provider's office is caring for a 20 year old client with at 12 weeks of gestation and request and amniocentesis to determine the sex of the fetus. Which of the following responses should the nurse make? a. this procedure determines if your baby has genetic or congenital disorders b. your provider was schedule a chronic villus sampling to determine the sex of your baby c. you cannot have an amniocentesis until you're at least 35 years of age d. we can schedule the procedure for later today if you'd like

a. this procedure determines if your baby has genetic or congenital disorders

A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching? a. transmission can occur via the saliva and urine of the newborn b. this infection requires but airborne precautions be initiated for the newborn c. lesions are visible on the mother's genitalia d. mothers will receive prophylactic treatment with acyclovir year prior to delivery

a. transmission can occur via the saliva and urine of the newborn

A nurse is providing discharge instructions to a client who is 24 hr postpartum and has decided not to breastfeed. Which of the following instructions should the nurse include in the teaching? a. "Shower daily, allowing warm water to run directly over your breasts." - avoid warm water b. "Apply ice packs to your breasts using a 15-minute on, 45 minutes off schedule." c. "Wear a loose-fitting, nonbinding bra for 72 hours." - well fitting, supportive bra d. "Pump your breasts twice daily to relieve discomfort from engorgement."

b. "Apply ice packs to your breasts using a 15-minute on, 45 minutes off schedule."

A nurse is teaching a client who is at 8 weeks of gestation about self-care during pregnancy. Which of the following statements should the nurse make? a. "You can take 400 milligrams of ibuprofen for discomfort." b. "You should take 600 micrograms of folic acid per day." c. "You can take black cohosh once a day for insomnia."(induces labor, nerrrr) d. "You should limit your daily fluid intake to 1,000 milliliters per day."

b. "You should take 600 micrograms of folic acid per day."

A nurse is teaching a client about the basal body temperature method of contraception. Which of the following statements should the nurse include in the teaching? a. "Your risk of pregnancy is greatest on days 21 to 28 of your cycle." b. "You should take your temperature before getting up for the day." c. "You should abstain from intercourse when your temperature is above 100°F." d. "Your temperature may increase slightly immediately prior to ovulation." (Decrease)

b. "You should take your temperature before getting up for the day."

A nurse is teaching a prenatal class regarding false labor. Which of the following information should the nurse include? Are these all true labor or am I trippin ): - B says "temporarily" :) a. "You will have dilation and effacement of the cervix." b. "Your contractions will become temporarily regular." c. "You will have bloody show." d. "Your contractions will become more intense when walking."

b. "Your contractions will become temporarily regular.

A nurse is providing vehicle safety education to the parents of a premature newborn. Which of the following statements should the nurse include in the teaching? a. "You should secure your newborn's car seat at a 60-degree angle." - no more than 45 b. "Your newborn will need to have a car seat test prior to discharge." c. "Place your newborn in a front-facing car seat in the back seat of the vehicle."d. "Position the retainer clip at the level of your newborn's abdomen."

b. "Your newborn will need to have a car seat test prior to discharge."

A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend for an interdisciplinary care conference? a. A client who is at 37 weeks gestation and has an L/S ratio of 2:1 b. A client who is at 35 weeks of gestation and has a biophysical profile of 6 c. A client who is at 39 weeks of gestation and has a negative contraction stress test d. A client who is at 28 weeks of gestation and has a negative Coombs' titer

b. A client who is at 35 weeks of gestation and has a biophysical profile of 6

A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include? a. Offer the newborn 30mL (1 oz) of water between feedings b. Allow the baby to feed at least every 3 hrs - at least q3hrs day & q4hrs at night c. Feed the newborn 5-10 mins per breast - at least 15-20 minutes d. Expect 2 -4 wet diapers every 24 hrs

b. Allow the baby to feed at least every 3 hrs - at least q3hrs day & q4hrs at night

A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take? a. Offer supplemental formula between the newborn's feedings b. Assess the newborn's latch while breastfeeding c. Instruct the client to wait 4 hrs between daytime feedings d. Have the client limit the length of breastfeeding to 5 min per breast

b. Assess the newborn's latch while breastfeeding

A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions Should the nurse include in the plan of care? a. Use a fetal scalp electrode during labor and delivery b. Bathe the newborn before initiating skin to skin contact c. instruct the client to stop taking the antiretroviral medication at 32 weeks of gestation d. administer pneumococcal immunization to the newborn within 4 hours following birth

b. Bathe the newborn before initiating skin to skin contact

A nurse is caring for a client who is 36 weeks gestation and has MRSA. Which of the following isolation precautions should the nurse initiate? a. Droplet b. Contact c. Airborne d. Protective environment

b. Contact

A nurse is caring for a client who has had a pudendal nerve block. The nurse should monitor for which of the following findings as an adverse effect a. Maternal hypertension b. Decreased ability to bear down c. Fetal bradycardia d. Uterine hyperstimulation

b. Decreased ability to bear down

14. A nurse is caring for a client who is at 20 weeks of gestation and reports constipation. Which of the following recommendations should the nurse make to help relieve this common discomfort of pregnancy? a. Include 18g of fiber in the diet each day (25 to 30g) b. Drink 2 to 3 L of water each day c. Add 30 mL of mineral oil to each meal d. Take 60 mL of magnesium hydroxide once daily

b. Drink 2 to 3 L of water each day

A nurse is assessing a client who is at 37 weeks of gestation. Which of the following statements by the client requires immediate intervention by the nurse a. My feet are really swollen today b. I have been seeing spots this morning c. I didn't have lunch today but I had breakfast this morning d. It burns when I urinate

b. I have been seeing spots this morning

A nurse is teaching a client who is breastfeeding and has mastitis. Which of the following statements by the client indicates an understanding of the teaching? a. I should use a nipple shield while breastfeeding b. I should apply lanolin to the infection site daily c. I should apply warm compresses after the feeding d. I should stop breastfeeding until the infection has healed

b. I should apply lanolin to the infection site daily

55. A nurse is providing teaching to a postpartum client who has a prescription for a rubella immunization. Which of the following client statements indicates an understanding of the teaching? a. I will receive a series of three immunizations and each one will be a month apart b. I should avoid becoming pregnant for at least one month following the immunization c. I should avoid breastfeeding for two weeks following the immunization d. I will report joint pain that develops after the immunization to my provider immediately

b. I should avoid becoming pregnant for at least one month following the immunization

67. A nurse is providing discharge teaching to the parent of a newborn about surgical site care following circumcision using a clamp technique. Which of the following statements by the parent indicates understanding? a. I will check the site hourly for bleeding b. I will apply petroleum jelly to area with each diaper change c. I will remove the crust with each diaper change - DO NOT wipe of yellow mucous d. I will wash the penis with soap and water daily

b. I will apply petroleum jelly to area with each diaper change

A nurse in a prenatal clinic is discussing quickening (16-20 weeks) with a client who is in the first trimester of her first pregnancy. Which of the following statements by the client indicates understanding of the teaching a. I will begin scheduling appointments every 2 wks b. I will feel movement at about 16-20 wks c. I will take 2 ibuprofen capsules for the discomfort d. I will plan to have a blood test when quickening occurs

b. I will feel movement at about 16-20 wks

A nurse is planning care for a client following a chorionic villus sampling. The nurse should recognize that the client is at risk for developing which of the following complications? a. Late decelerations b. Infection c. Anemia d. placental insufficiency

b. Infection

A nurse is assessing a client who is 27 weeks of gestation and has pre eclampsia. Which of the following findings should the nurse report to the provider? a. Hemoglobin 14.8 g/dL b. Platelet count 60,000/ mm c. Creatinine 0.8 mg/ dL d. Urine protein concentration 200 mg/24hr

b. Platelet count 60,000/ mm

A nurse is assessing a client immediately following the placement of an epidural. The nurse obtains a maternal blood pressure of 96/54 mmHg and a fetal heart rate of 102/min. which of the following actions should the nurse take? a. Administer naloxone to the client b. Position the client in a lateral position c. Place the client in knee chest position d. Prepare the client for an amnioinfusion

b. Position the client in a lateral position

A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions? a. Hyperemesis gravidarum b. Postpartum hemorrhage c. Incompetent cervix

b. Postpartum hemorrhage

A nurse is planning care for a newborn who has neonatal abstinence syndrome. Which of the following interventions should the nurse include in the plan of care? a. Increase the newborn's visual stimulation - (decrease stimulation) b. Swaddle the newborn in a flexed position c. Weigh the newborn every other day - (Q day) d. Discourage prenatal interaction until after a social service evaluation

b. Swaddle the newborn in a flexed position

A nurse is planning care for a client in the postpartum unit. Which of the following goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment? a. The client will identify individual family member roles - letting go phase b. The client will have adequate nutritional intake c. The client will verbalize appropriate car safety - taking hold phase d. The client will demonstrate proper bathing of the infant - taking hold phase

b. The client will have adequate nutritional intake

28. A nurse is monitoring a client who has preeclampsia and is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse report to the provider? a. Respiratory rate 14/min b. Urinary output 20 ml/hr (30/mL is normal) c. BP 148/94 mmHg d. 2+ deep tendon reflexes

b. Urinary output 20 ml/hr (30/mL is normal)

A nurse is caring for a client who is in labor and is prescribed an amnioinfusion. Which of the following findings is an indication for this procedure? a. Fetal macrosomia b. Variable decelerations c. Early decelerations d. Increased uterine tone

b. Variable decelerations

A nurse in a newborn Nursery is receiving change-of-shift report for for newborns. Which of the following newborn should the nurse assess first? a. Newborn who is 24 hours old and has not had meconium stool b. a newborn who is 10 hours old and has a new onset tachypnea c. newborn who has a short frenulum and is having difficulty breastfeeding d. a newborn was 30 hours old and has blood-tinged discharge in her diaper

b. a newborn who is 10 hours old and has a new onset tachypnea

a nurse is assessing a client who is at 32 weeks of gestation and is receiving magnesium sulfate via continuous IV solution. Which of the following findings should the nurse report to the provider? a. decrease in frequency of contractions b. absent deep tendon reflexes c. urinary output 35 ml/hr d. BP 150 / 100 mmhg

b. absent deep tendon reflexes

A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include? a. Expect 2 to 4 wet diapers every 24 hours b. allow the baby to feed at least every 3 hours c. offer the newborn 30 ml (1 oz.) a water between feedings d. feed the newborn 5 to 10 minutes per breast

b. allow the baby to feed at least every 3 hours

65. A nurse is caring for a client who is postpartum and experiencing hypovolemic shock. Which of the following findings should the nurse expect? a. Bounding pulses b. cool clammy skin c. respiratory rate 18 / minutes d. urinary output 30ml / hour

b. cool clammy skin

A nurse is observing an adolescent client who is offering her newborn a bottle while he is laying in the bassinet. When the nurse offers to pick the newborn up and place them in the client's arms, the mother States " No, the baby is too tired to be held". Which of the following actions should the nurse take? a. Insist that the mother pick up the newborn to feed him b. demonstrate how to hold a newborn and allow the client to practice c. persuade the client to breastfeed the newborn to promote bonding d. offer to take the newborn to the nursery to finish his feeding

b. demonstrate how to hold a newborn and allow the client to practice

A nurse is assessing a newborn whose mother had a primary cytomegalovirus (CMV) infection during pregnancy. The newborn acquired CMV trans placenta Lee. Which of the following findings should the nurse expect the newborn to exhibit? a. urinary tract infection b. hearing loss c. Macrosomia d. Cataracts

b. hearing loss

A nurse is providing teaching to the parents of a newborn about the plastibell circumcision technique. Which of the following? a. the plastibell will be removed 4 hours after the procedure b. notify the provider is the end of your penis appears dark red c. make sure the newborn's diaper is snug d. yellow exudate will form at the surgical site in 24 hours

b. notify the provider is the end of your penis appears dark red

A nurse is caring for a client who has pacenta previa. Which of the following findings should the nurse expect? a. Firm rigid abdomen b. painless, vaginal bleeding c. uterine hypertonicity d. persistent headache

b. painless, vaginal bleeding

A nurse is admitting a client with a birthing unit reports for contractions started 1 hour ago. the nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions? a. Ectopic pregnancy b. postpartum hemorrhage c. hyperemesis gravidarum d. incompetent cervix

b. postpartum hemorrhage

a nurse is assessing a full-term newborn arm admission to the nursery. Which of the following clinical findings should the nurse report to the provider? a. Transient circumoral cyanosis b. single Palmar creases c. subconjunctival hemorrhage d. rust stain urine

b. single Palmar creases

A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository? a. vaginal candidiasis b. third-degree perineal laceration c. abdominal distension d. Afterpains

b. third-degree perineal laceration

A nurse is assisting the provider to administer a dinoprostone to induce labor for a client. Which of the following actions should the nurse take? a. Allow the medication to reach room temperature prior to Administration b. verify that informed consent is obtained prior to Administration c. instruct the client to avoid urinary elimination until after Administration d. please to clean and I send my followers position for 1 hour after Administration

b. verify that informed consent is obtained prior to Administration

I'm not just caring for a client following a vaginal delivery of a term fetal demise. which of the following statements should the nurse make? a. You should name the baby so she can have an identity b. you can bathe and dress your baby if you'd like to c. if you don't hold the baby it will make Letting Go much harder d. I'm sure you'll be able to have another baby when you're ready

b. you can bathe and dress your baby if you'd like to

A nurse is caring for a client who is 2 days postpartum and states, "I want to continue breastfeeding, but my nipples are so sore." Which of the following responses should the nurse make? a. "Removing breast shields from your bra will decrease discomfort." b. "You should switch your infant to formula until the soreness goes away." 13 c. "Allow expressed milk to air dry on the nipples after feeding your infant." d. "Apply an antibiotic ointment to the nipples prior to each feeding." (should be after feeding)

c. "Allow expressed milk to air dry on the nipples after feeding your infant."

A nurse is planning to teach a group of clients who are pregnant about breastfeeding after returning to work. Which of the following information should the nurse include in the teaching? a. "Thawed breast milk that is unused can be refrozen." b. "Breast milk can be stored at room temperature for up to 12 hours." 8 hours c. "Breast milk can be stored in a deep freezer for 12 months." d. "Thawed breast milk can be refrigerated for up to 72 hours." 24 hr

c. "Breast milk can be stored in a deep freezer for 12 months."

A client and her partner ask the nurse for information about permanent contraception. Which of the following statements should the nurse include in the counseling? a. "A man is usually sterile immediately after a vasectomy" use birth control for 20 ejaculations/1 week to several months = allow all of the sperm to clear the vas deferens b. "The menstrual cycle is shorter after a tubal ligation" - cut/burns/block fallopian tubes to prevent ovum from being fertilized c. "Most sterilization procedures are considered irreversible" d. A woman should use contraception for 1-2 months after a tubal ligation"

c. "Most sterilization procedures are considered irreversible"

63. A nurse is teaching a client about using a diaphragm. Which of the following instructions should the nurse include in the teaching? a. "Insert the diaphragm up to 12 hours before intercourse." - up to 6 hrs b. "Remove the diaphragm 2 hours after intercourse." c. "Replace the diaphragm every 2 years." d. "Use 2 teaspoons of baby oil to lubricate the diaphragm before insertion." -

c. "Replace the diaphragm every 2 years."

A nurse in a provider's office is caring for a 20-year old client who is at 12 weeks of gestation and requests an amniocentesis to determine the gender of the fetus. Which of the following responses should the nurse make. a. "We can schedule the procedure for later today if you'd like." b. "You cannot have an amniocentesis until you are at least 35 years of age." c. "This procedure determines if your baby has genetic or congenital disorders." d. "Your provider will schedule a chorionic villus sampling to determine the sex of your baby."

c. "This procedure determines if your baby has genetic or congenital disorders."

A nurse is providing education to a client who is to receive misoprostol for induction of labor. Which of the following instructions should the nurse include in the teaching? ● Uterine STIMULANT, controls postpartum bleeding a. " I will insert a urinary catheter before I administer the medication" b. "I will begin an oxytocin infusion w/in 2 hrs of your last dose of medication" - (w/in 6-12hs) c. "You will lie on your side for 40 minutes after I administer the medication i think it's this one d. "You will receive an antacid containing magnesium before the medication" - concurrent use = diarrhea

c. "You will lie on your side for 40 minutes after I administer the medication i think it's this one

A nurse at an antepartum clinic is caring for four clients. Which of the following clients should the nurse assess first? a. A client who is at 8 weeks of gestation and reports severe vomiting b. A client who is at 36 weeks of gestation and reports back pain following intercourse c. A client who is at 24 weeks of gestation and reports periodic tingling of the fingers d. A client who is at 10 weeks gestation and reports frequent urination

c. A client who is at 24 weeks of gestation and reports periodic tingling of the fingers

A nurse is caring for four newborns. Which of the following findings should the nurse report to the provider? a. A newborn who has molding with overlapping suture lines - normal from head compression during labor b. A female newborn who has blood-tinged vaginal discharge - normal for newborns (crystals in urine) c. A newborn who has a high-pitched cry with exaggerated Moro (startle) reflex

c. A newborn who has a high-pitched cry with exaggerated Moro (startle) reflex

A nurse is caring for four newborns. Which of the following findings should the nurse report to the provider? a. A newborn who has molding with overlapping suture lines - normal from head compression during labor b. A female newborn who has blood-tinged vaginal discharge - normal for newborns (crystals in urine) c. A newborn who has a high-pitched cry with exaggerated Moro (startle) reflex - hypoglycemia d. A male newborn who has scrotal edema

c. A newborn who has a high-pitched cry with exaggerated Moro (startle) reflex - hypoglycemia

A nurse is caring for a client who has preeclampsia and is receiving mag sulfate by continuous IV infusion. The nurse should monitor for which of the following adverse effects? a. Elevated BP b. Hypertonia c. Absence of deep tendon reflexes d. Polyuria

c. Absence of deep tendon reflexes

A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take? a. Apply an ice pack to the incision site. b. Replace the surgical dressing c. Administer 500 mL lactated ringer's IV bolus (initiate IV fluids to replace fluid volume loss w/ isotonic solution) d. Evaluate urinary output

c. Administer 500 mL lactated ringer's IV bolus (initiate IV fluids to replace fluid volume loss w/ isotonic solution)

A nurse is reviewing the laboratory report of a client who is 24 hr postpartum vaginal delivery. The client has a hemoglobin level of 9.0 g/dL (11-13) and hematocrit of 25% (33-39). Which of the following actions should the nurse take? a. Initiate IV access for isotonic solution with an 18-gauge catheter b. Prepare the client for a blood transfusion c. Administer an iron supplement to the client - i think (ATI p.69) b/c of low H&H d. Instruct the client that the provider will check for placental fragments

c. Administer an iron supplement to the client - i think (ATI p.69) b/c of low H&H

A nurse is caring for a client who is in labor. The nurse observes late decelerations of the fetal heart rate on the external fetal monitor. After placing the client in a side-lying position, which of the following actions should the nurse take? (ATI pg.98) a. Decrease the rate of IV fluids - increase b. Elevate the client's head - side lying c. Administer oxygen via a face mask d. Perform fetal scalp stimulation

c. Administer oxygen via a face mask

A nurse is caring for a client who is in the latent phase of the first stage of labor and is in pain. Which of the following nursing interventions are appropriate to reduce pain. (Select all that apply) a. Perform Leopold maneuvers b. Have the client sit in a tub of warm water c. Ambulate the client in the hallway d. Administer 70% nitrous oxide mixed with o2 e. Apply counterpressure to the sacral area

c. Ambulate the client in the hallway e. Apply counterpressure to the sacral area

A nurse is providing discharge instructions to a client is 24 hours post partum and has decided not to breastfeed. Which of the following instruction should the nurse include in the teaching? a. Wear loose-fitting non-binding bra for 72 hours b. shower daily allow warm water to run directly over your dress c. Apply ice packs to your breast using a 15 minutes on, 45 minutes off schedule d. Pump your breast twice-daily to relieve discomfort from engorgement

c. Apply ice packs to your breast using a 15 minutes on, 45 minutes off schedule

A nurse is caring for a client who is in the second stage of labor. The nurse observes the fetal head retract against the clients' perineum immediately following emergence. Which of the following actions should the nurse take? a. Assess fetal position using Leopold maneuvers - isn't this done before patient goes into labor b. Reposition the client in a left lateral position - what would this do? c. Apply pressure to the clients suprapubic area - for LGA newborns.. d. Empty the client's bladder using Crede's maneuver -

c. Apply pressure to the clients suprapubic area - for LGA newborns..

A nurse is caring for a client who is postpartum. The client reports no relief in perineal pain following the administration of oxycodone/acetaminophen. Which of the following actions should the nurse take first? a. Reposition the client b. Apply an ice pack to the client's perineum c. Assess the client's perineal area for swelling d. Administer ibuprofen to the client

c. Assess the client's perineal area for swelling

A nurse is assessing a newborn upon admission to the nursery. Which of the following findings should the nurse expect? a. Length from head to heel of 40 cm (15.7 in) - 45-55 cm (18-22 in) b. Bulging fontanels - indicate inc ICP, infection, hemorrhage c. Chest circumference 2 cm (0.8 in) smaller than the head circumference d. Nasal flaring - respiratory distress

c. Chest circumference 2 cm (0.8 in) smaller than the head circumference

A nurse is caring for a client who is in the first stage of labor & the fetal head is in a posterior position. The client reports pressure and pain in her lower back. Which of the following non-pharmacological comfort measure should nurse suggest first? a. Effleurage b. Patterned breathing c. Counterpressure d. Guided imagery

c. Counterpressure

A nurse is caring for a newborn who has exstrophy of the bladder. Which of the following actions should the nurse take prior to the beginning of surgical correction? a. Keep the newborn in a side-lying position b. Restrict the newborn's fluid intake c. Cover the newborn's bladder with a sterile, non-adherent dressing d. Exert gentle pressure on the newborn's bladder with sterile gauze

c. Cover the newborn's bladder with a sterile, non-adherent dressing

A nurse is caring for a client who is at 30 weeks of gestation. The nurse should plan to immunize the client which of the following vaccinations? Select all the apply a. Varicella b. human papillomavirus c. Diphtheria - acellular pertussis d. inactivated influenza e. measles, mumps, and rubella

c. Diphtheria - acellular pertussis d. inactivated influenza

A nurse is reviewing a client's rubella titer of 1:8 at her second prenatal visit. Which of the following statements by the nurse is appropriate? a. Because rubella is a live vaccine you will not be able to breastfeed your newborn- (it is not communicable in breast milk. However the virus is shed in urine and other body fluids so it should not be given to other members who are immunocompromised.) b. Your titer indicates you are susceptible to rubella- if <1:8 c. During your third trimester you will need to repeat blood test for the titer d. You will need a rubella immunization at your next prenatal visit

c. During your third trimester you will need to repeat blood test for the titer

A nurse is reviewing laboratory findings for a client who is at 20 weeks of gestation. Which of the following findings should the nurse report to the provider? a. Creatinine 0.9 mg/dL - normal 0.5-1.1 b. WBC count 11,000/mm - normal 4.5-11k c. Fasting blood glucose 180 mg/dL - possible gestational diabetes! (Norm: Less than 100) d. Hematocrit 35%

c. Fasting blood glucose 180 mg/dL - possible gestational diabetes! (Norm: Less than 100)

A nurse is assessing the fetal heart rate for a client who is at 38 weeks of gestation. When using an ultrasound device, the nurse hears blood rushing through the umbilical vessels in synchronization with the fetal heartbeat. Which of the following terms should the nurse use to document this finding? a. Goodell's sign - probable sign - softening of cervical tip b. Quickening - presumptive sign - slight fluttering movements of the fetus felt by the woman (between 16-20 weeks of gestation) c. Funic souffle d. Hegar's sign - probable sign - softening and compressibility of the lower uterus

c. Funic souffle

A charge nurse is discussing STIs with a newly licensed nurse. Which of the following infections should the nurse include in the teaching as an indication for a cesarean birth a. Gonorrhea- spread genital to genital b. Chlamydia c. HIV d. Syphilis

c. HIV

43. A nurse is providing teaching to a client who is postpartum about car seat safety. Which of the following statements by the client indicates an understanding of the teaching a. I will fasten the harness clip 1 in about my baby underarms b. I will swaddle my baby in a blanket before putting her in the car seat c. I will ensure that my baby is position 45 degree angle in the car seat

c. I will ensure that my baby is position 45 degree angle in the car seat

A nurse is teaching a client who is postpartum about car seat safety. Which of the following statements indicates an understanding of the instructions? a. I will adjust the angle of the car seat so that my baby is at a 90 degree angle (45) b. I will position the car seat in the front passenger seat facing the front of the car - back passenger, rear facing c. I will place the shoulder harness slightly below my baby's shoulders (Nipple line ) d. I will make sure the retainer clip is at the level of my baby's abdomen (armpit)

c. I will place the shoulder harness slightly below my baby's shoulders (Nipple line )

A nurse is teaching a client who is pregnant about a new prescription for iron supplements. Which of the following instructions should the nurse include in the teaching. a. Take an extra pill if you miss a dose b. Drink 8oz of milk with each pill c. Increase intake of food rich in vitamin C d. Report black stools to the provider

c. Increase intake of food rich in vitamin C

A nurse is caring for a client who is 8 hr postpartum following vaginal delivery and is unable to void. Which of the following interventions should the nurse use to promote voiding? a. Apply suprapubic pressure b. Administer a diuretic to the client c. Insert an indwelling urinary catheter d. Encourage the client to void in the shower

c. Insert an indwelling urinary catheter

A nurse is caring for a client who is at 35 weeks of gestation and on bed rest due to severe preeclampsia. Which of the following is an appropriate action for the nurse to take? a. Maintain NPO status b. Obtain BP every 8 hr c. Keep the lights dimmed in the room - to prevent stimulation of seizures d. Auscultate fetal heart tones twice per day

c. Keep the lights dimmed in the room - to prevent stimulation of seizures

A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings place the client at ri sk for postpartum hemorrhage? (Select all that apply) a. History of human papillomavirus b. Vacuum-assisted delivery c. Labor induction with oxytocin d. Newborn weight 2.948 kg (6 lb 8 oz) - nahh this a skinny babbbby e. History of uterine atony

c. Labor induction with oxytocin e. History of uterine atony

A nurse is calculating the estimated date of birth using Nagele's rule for a client who is pregnant and whose last menstrual cycle started June 21. Which of the following is the estimated date of delivery in the next year? a. March 14 b. March 21 c. March 28 d. April 4

c. March 28

A nurse is using Niagele's rule to calculate the expected delivery date of a client who reports the first day of the last menstrual cycle was July 28th. Which of the following dates should the nurse document as a client expected delivery date? a. April 21st b. April 4th c. May 5th d. May 21st

c. May 5th

A nurse is planning care for a newborn who is to undergo a circumcision using a plastic bell device. Which of the following interventions should the nurse include in the plan of care? a. Wash the circumcision site with mild soap and water 24 hr following the procedure -sponge bath around area NOT on it! b. Take off the plastic bell 2 hr after the procedure - if falls off in 5-7 days c. Monitor for bleeding every 15 min for the first hour d. Remove the yellow drainage on the 2nd postoperative day

c. Monitor for bleeding every 15 min for the first hour

A nurse is discussing family planning with a client who has a history of DVT. The nurse should inform the client that this condition is a contraindication for which of the following birth control methods? a. Intrauterine device b. Cervical cap c. Oral contraceptive d. Diaphragm

c. Oral contraceptive

A nurse is caring for a client who is in active labor. The nurse administers butorphanol (STADOL)IV bolus for pain. Which of the following findings should the nurse report to the provider following this medication a. BP 136/88 mmHg b. Urinary output 120 ml in 2 hrs. c. Respiratory rate 10 min d. Moderate fetal heart rate variability

c. Respiratory rate 10 min

A nurse is a caring for a client who is at 24 weeks of gestation and has a glucose screening test result of 150 mg/dL. Which of the following actions should the nurse take? a. Perform a urine screen for ketones b. Repeat the glucose screening test in 15mins to verify results c. Schedule the client for a 3 hour oral glucose tolerance test d. Determine if the client has fasted

c. Schedule the client for a 3 hour oral glucose tolerance test

A nurse in a prenatal clinic is caring for a client who has hyperemesis gravidarum. Which of the following is the initial laboratory test used to evaluate this condition? a. Liver enzymes b. Complete blood count c. Urine ketones - and acetone - due to breakdown of protein and fat - most important initial lab test d. Thyroid levels

c. Urine ketones - and acetone - due to breakdown of protein and fat - most important initial lab test

A nurse is planning care for a newborn who is scheduled to start phototherapy using a lap. Which of the following actions should the nurse include? a. Apply a thin layer lotion to the newborn skin every 8 hours b. trust in you born in a thin layer clothing during the therapy c. ensure the newborn's eyes are closed beneath the shield d. give the newborn 1 oz of glucose water every 4 hours

c. ensure the newborn's eyes are closed beneath the shield

A nurse is reviewing the laboratory results of a newborn. Which of the following findings should the nurse report to the provider? a. Blood glucose 58 mg / DL b. hematocrit 48% c. platelets 100,000/ mm 3 d. hemoglobin 16 G / DL

c. platelets 100,000/ mm 3

A nurse is caring for a newborn Boys 6 hours old and has a bedside glucose meter reading of 65 mg / DL. The New Orleans mother has Type 2 diabetes mellitus. Which of the following actions should the nurse take? a. Administer 50 mL of dextrose solution IV b. obtain a blood sample of serum glucose level c. reassess the blood glucose level prior to the next feeding d. Feed the newborn immediately

c. reassess the blood glucose level prior to the next feeding

A nurse is caring for a client who reports spontaneous rupture. The nurse observed fetal bradycardia in the FHR tracing and notices the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following should the nurse take next? a. Initiate an infusion of IV fluids for the client b. Perform vaginal examination by applying c. upward pressure on the presenting part d. Administer oxygen via non rebreather mask at 8L/ minCover the umbilical cord with sterile saline saturated towel.

c. upward pressure on the presenting part

A nurse is caring for a client who is at 30 weeks of gestation and receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication? a. Respiratory rate a 16 / minutes b. Hypertension c. urine output 20 ml / hour d. hyperglycemia

c. urine output 20 ml / hour

A client who is 16 weeks of gestation asks the nurse how to prepare her father to a younger sibling. Statements should the nurse make? a. You should hold your newborn in your arms when you introduce him to your toddler b. you should move your toddler out of her crib 2 weeks prior to your due date c. you should give your toddler a gift from the baby when she visit you in the facility d. You should place your toddler in timeout if she exhibits regressive Behavior after the baby is born

c. you should give your toddler a gift from the baby when she visit you in the facility

62. A nurse is receiving report on four postpartum clients. Which of the following clients should the nurse plan to attend to first? a. A client who reports abdominal pain during breastfeeding b. A client who reports changing her perineal pad every 2 hr c. A client who has a urine output of 250 mL in 6 hr d. A client who has hyporeflexia while receiving IV magnesium sulfate

d. A client who has hyporeflexia while receiving IV magnesium sulfate

A nurse is assessing the results of a nonstress test for an antepartal client at 35 wks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing? a. Three fetal movements perceived by the client in a 20 min testing period b. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration w/in a 10 min testing period c. Irregular contractions of 10-20 secs in duration that are not felt by the client d. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40 min testing period-

d. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40 min testing period-

A nurse is assessing a client who is in her second trimester for common physiological changes during pregnancy. The nurse notes a blotchy discoloration on the client's forehead, nose & cheeks. Which of the following changes should the nurse document a. Linea nigra -(dark line pigmentation from umbilicus to the pubic area.) b. Epulis - (not found on ati book, but it is a tumor on the mouth caused by gingervitis.) c. Striae gravidarum - (stretch marks found on abdomen and thigh) d. Chloasma -( increase pigmentation on the face)

d. Chloasma -( increase pigmentation on the face)

A nurse is monitoring a newborn whose mother reports recent opiate use for neonatal abstinence syndrome. Which of the following findings indicates narcotic withdrawal? a. Respiratory rate 50/min b. Unequal pupils c. Hypotonia ( No rigid muscle) d. Excessive crying (inconsolable)

d. Excessive crying (inconsolable)

A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect? a. Telangiectatic nevi b. Periauricular papillomas c. Erythema toxic - newborn rash d. Facial petechiae

d. Facial petechiae

A nurse is assessing a full-term newborn. Which of the following findings should the nurse report to the provider? a. Temperature 36.5°C (97.7°F) b. Blood pressure 80/50 mm Hg c. Respiratory rate 55/min d. Heart rate 72/min

d. Heart rate 72/min

A nurse is caring for a client following an amniocentesis. The nurse should observe the client for which of the following complications? a. Proteinuria b. Hyperemesis c. Hypoxia d. Hemorrhage

d. Hemorrhage

A nurse is teaching a prenatal client about listeriosis and dietary medications during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? a. I can still have a hotdog at the ballpark b. I can purchase a seafood salad from the grocery store- should not be eaten c. I can have a midday snack with soft cheese d. I can eat grilled chicken on a bun at lunch time

d. I can eat grilled chicken on a bun at lunch time

34. A nurse is providing teaching to a client who is primigravid and is scheduled to have an abdominal ultrasound. Which of the following statements by the client indicates an understanding of the teaching? a. I need to take a stool softener the night before the test b. I can't have anything to eat after midnight c. I won't apply perfumed lotion to my abdomen before the test d. I will drink water before the test until my bladder feels full

d. I will drink water before the test until my bladder feels full

A nurse is assessing current medication use with a client who is at 6 weeks of gestation. The nurse should recognize that pregnancy is a contraindication to the administration of which of the following medications? a. Azithromycin b. Metformin c. Diphenhydramine d. Istotretinoin

d. Istotretinoin

A nurse is admitting a client who is in preterm labor to the labor and delivery unit. The nurse should anticipate which of the following tests to assess for fetal lung maturity? a. Direct Coombs' test b. Biophysical profile c. Chorionic villus sampling (CVS) d. Lecithin/sphingomyelin ratio

d. Lecithin/sphingomyelin ratio

20. A nurse is assessing a client who is 1 hr postpartum. The nurse notes a large amount of vaginal bleeding with several large blood clots on the client's peripad. The clients bp is 70/42 mmHg and her heart rate is 150/min. Which of the following actions should the nurse take first a. Apply O2 at 10-12 L/min b. Elevate the legs c. Administer an IV bolus of oxytocin d. Massage the fundus

d. Massage the fundus

A nurse in a prenatal clinic is reviewing the lab results for a client who is 12 wks gestation. Which of the following actions should the nurse take a. Administer rubella b. Obtain a maternal serum alfa fetoprotein specimen c. Administer ceftriaxone IM d. Obtain a blood culture

d. Obtain a blood culture

A nurse in a prenatal clinic is reviewing the lab results for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take (EXHIBIT QUESTION) a. Administer ceftriaxone IM - isn't this cross sensitive to PCN allergy though? ; cephalosporin; can't give w/ PCN allergy; check PHARM pg 358 b. Administer rubella vaccine - given for titer <1:8 - contraindicated for pregnant women c. Obtain a maternal alpha-fetoprotein specimen - done between 16-18 weeks of gestation d. Obtain a blood culture

d. Obtain a blood culture

A nurse is providing prenatal teaching to a group of clients who are in their trimester of pregnancy. Which of the following statements by a client indicates an understanding of the teaching? a. I should lie on my back as much as possible during the labor process b. I will be allowed to start to push once my cervix is dilated to 5 cm c. Once my water has broken, I will not be able to have epidural anesthesia d. Panting will help me control the urge to push when my cervix is not completely dilated

d. Panting will help me control the urge to push when my cervix is not completely dilated

A nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider? a. Hemoglobin 14.8 g/dL b. Urine protein concentration 200 mg/24 hr (normal: <80 mg/24 hr) c. Creatinine 0.8 mg/dL d. Platelet count 60,000/mm (Norm 150-400,000)

d. Platelet count 60,000/mm (Norm 150-400,000)

9. A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take? a. Inform the client that the law requires her to name the fetus b. Limit the amount of time the fetus is in the client's room c. Instruct the client that an autopsy should be performed within 24 hr. d. Prepare the client for what to expect the fetus to look like.

d. Prepare the client for what to expect the fetus to look like.

A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client. a. Intense contractions lasting 45-60 seconds - active phase - normal b. An urge to have a bowel movement during contractions - transition phase - baby about to come out!! c. A sense of excitement and warm, flushed skin - latent phase? d. Progressive sacral discomfort during contractions

d. Progressive sacral discomfort during contractions

57. A nurse is reviewing the Immunization status of a client who is pregnant. The nurse should inform the client that it is safe for her to receive which of the following immunizations during pregnancy? a. Varicella b. Rubella - live vaccine c. Tetanus d. Rubeola

d. Rubeola

A nurse is caring for a client who has preacher labor and receiving magnesium sulfate by continuous IV infusion. Which of the following laboratory values should the nurse review during tocolytic therapy? a. indirect Coombs test b. liver enzymes c. uric acid level d. Serum medication level

d. Serum medication level

A nurse is assessing a newborn who is 2 hrs. old. Which of the following findings should the nurse report to the provider? a. Lanugo on the pinna of the ears b. Overlapping the sutures with molding c. Transient nystagmus d. Single transverse palmar crease bilaterally

d. Single transverse palmar crease bilaterally

38. A nurse is assisting with precipitous delivery of a term newborn. After the head emerges, the nurse palpates the cord around the newborn's neck. Which of the following actions should the nurse take? a. Apply fundal pressure b. Place the client in the knee-chest position c. Apply a water-based lubricant to the cord d. Slip the cord over the newborn's head

d. Slip the cord over the newborn's head

A nurse is caring for a newborn. Which of the following assessment findings should indicate to the nurse that suctioning of the nasopharynx is needed? a. The newborn's respiratory rate is 32/minà normal RR 30-60 b. The newborn's pulse ox is c. The newborn is beginning to cough d. The newborn's respiratory rate is irregular

d. The newborn's respiratory rate is irregular

A nurse is assessing a full term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider a. Single palmar creases - "simian crease" indication of down syndrome b. Rust stained urine c. Subconjunctival hemorrhage d. Transient circumoral cyanosis

d. Transient circumoral cyanosis

A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statements should the nurse make? a. If you don't hold the baby it will make letting go much harder b. I'm sure you will be able to have another baby when you are ready c. You should name the baby so she can have an identity d. You can bathe and dress your baby if you'd like so

d. You can bathe and dress your baby if you'd like so

A nurse is caring for a newborn who has exstrophy of bladder. Which of the following actions should the nurse take prior to the beginning of the surgical correction? a. keep the newborn in a side-lying position b. restricted newborns fluid intake c. Exert gentle pressure on the newborn splattered with sterile gauze d. cover the newborns bladder with a sterile non-adherent dressing

d. cover the newborns bladder with a sterile non-adherent dressing

A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which of the following clinical findings should the nurse instruct the client to report? a. Increased urinary output b. increased respiratory rate c. increased fetal movement d. increased muscle weakness

d. increased muscle weakness

A nurse is providing discharge teaching to a postpartum client about caring for her five-year 5-day old male newborn at home. Which of the following statements should the nurse make to the client? a. Retract the foreskin to clean your baby's penis during each bath b. is triple antibiotic ointment on your baby's umbilical cord twice per day c. swaddle your baby tightly with legs extended before laying him down to sleep d. notify your baby's pediatrician if he urinates less than 6 times per day

d. notify your baby's pediatrician if he urinates less than 6 times per day

A nurse is conducting a class for a group A client's about birth control. Which of the following information should the nurse include in the teaching? a. Your fertility will return six months after your provider removes your IUD b. you should use spermicide 3 hours prior to sexual intercourse c. you will not need to use birth control for one month after receiving emergency contraception d. you should have an annual examination to assess your diaphragm

d. you should have an annual examination to assess your diaphragm

A nurse is providing teaching to a client who is 2 days postpartum And wants to continue using her diaphragm for contraception. Which of the following instruction should the nurse include? a. You should use an oil based vaginal lubricant when inserting your diaphragm b. you should store your diaphragm in sterile water after each use c. you should keep the diaphragm in place for at least 4 hours after intercourse d. you should have your provider refit you for a new diaphragm

d. you should have your provider refit you for a new diaphragm

I'm nurse is teaching a client and her partner about the technique of counter pressure during labor. Which of the following statements by the nurse is appropriate? a. your partner will apply upward pressure on your lower abdomen between contractions b. your partner will apply continuous from pressure between your thumb and index finger c. your partner will apply pressure to the top of your uterus during contractions d. your partner will apply steady pressure with a tennis ball to your lower back

d. your partner will apply steady pressure with a tennis ball to your lower back