Exam 2 P1
A multigravida client admitted in active labor has progressed well and the client and fetus have remained in good condition. Which action should the nurse prioritize if the client suddenly shouts out, 'The baby is coming!'?
Inspect the perineum. ✓
30. The nurse is preparing a nursing care plan for an immediate postpartum client. Which nursing diagnosis should the nurse prioritize?
Risk for injury: postpartum hemorrhage related to uterine atony ✓
The nurse is assisting a 79-year-old patient with information about diet and weight loss. The patient has a body mass index (BMI) of 31. How should the nurse instruct this patient?
"You are considered obese and will need to consult with your doctor about a plan that includes exercises, not diet, to decrease weight."
The nurse has been monitoring a multipara client for several hours. She cries out that her contractions are getting harder and that she cannot do this. The nurse notes the client is very irritable, nauseated, annoyed, and doesn't want to be left alone. Based on the assessment the nurse predicts the cervix to be dilated how many centimeters?
8 to 10 ✓
The nurse is conducting an annual examination on a young female who reports her last menses was 2 months ago. Although the client insists she is not pregnant due to a negative home pregnancy test, which assessment should the nurse prioritize to assess for a possible pregnancy?
A fetal heartbeat ✓
The nurse is analyzing the readout on the EFM and determines the FHR pattern is reassuring based on which recording?
Acceleration of at least 15 bpm for 15 seconds ✓
The nurse is assessing a laboring client and notes: 5 cm dilated, 80% effaced, zero station, contractions every 2 to 3 minutes, lasting 50 seconds, becoming increasingly uncomfortable, and apprehensive but appropriate and focused on breathing and relaxation. The nurse determines which nursing diagnosis is most appropriate for this client?
Acute pain related to uterine contractions ✓
A primigravida client in the second stage of labor has been moaning, screaming, and generally vocal throughout her labor. Her husband is distraught seeing his wife this way and asks the nurse for more pain medication for her. What is the nurse's best response?
Ask the client to describe the intensity of her pain on a scale of 0 to 10. ✓
A nurse is preparing a nursing care plan for a client who is admitted at 22 weeks' gestation with advanced cervical dilatation to 5 cm, cervical insufficiency, and a visible amniotic sac at the cervical opening. Which primary goal should the nurse prioritize at this point?
Bed rest to maintain pregnancy as long as possible ✓
The nurse is assisting a new mother who just transferred from the PACU. The nurse determines the client has already been adapting to her role as a mother by performing which actions of the first stage of adaptation?
Beginning attachment and preparation for family ✓
A client at 42 weeks' gestation presents for induction of labor. Which assessment should the nurse prioritize as the best indicator for the induction to proceed?
Bishop score of 7 ✓
The nurse is assessing a client in active labor and notes a small, rounded mass above the symphysis pubis that is distended but nontender. What action should the nurse prioritize?
Check the chart for the last void. ✓
The 29-year-old client presents at 5:30 a.m. with labor pains. Her history reveals G4, three previous vaginal births, and gynecoid pelvis. At 9 a.m. her assessment reveals 80% effaced and dilated at 3 cm. What nourishment can the nurse provide if the client mentions she hasn't eaten since 5 p.m. yesterday and is hungry?
Clear liquids but no solid food ✓
The nurse is assessing a pregnant client at her 20-week visit. Which breast assessment should the nurse anticipate documenting?
Darkened breast areolae ✓
The nurse is preparing information for a client who has just been diagnosed with gestational diabetes. Which instruction should the nurse prioritize in this information?
Maintain a daily blood glucose log ✓
A pregnant client reports difficulty sleeping well. Which suggestion for sleeping should the nurse prioritize to assist this client?
On her side with the weight of the uterus on the bed ✓
The nursing instructor is leading a group discussion on the various types of delivery. The instructor determines the session is successful when the students correctly categorize forceps or vacuum-assisted delivery as what type?
Operative vaginal delivery ✓
A 31-year-old client at 28 weeks' gestation reports frequent low back pain and ankle edema by the end of the day. Which suggestion should the nurse prioritize for this client?
Rest when possible with feet elevated at or above the heart. ✓
The nurse is assessing a client at her first prenatal visit and reports her LMP started December 1. Which date will the nurse predict for the EDD?
September 8 ✓
The nurse is assessing a 37-year-old woman who has presented in active labor and notes the client has an increased risk for abruptio placentae. Which assessment finding should the nurse prioritize?
Sharp fundal pain and discomfort between contractions ✓
The nurse is admitting an obstetric client in early labor. As the nurse assists the client into the bed, which assessment should the nurse prioritize?
Signs that birth is imminent ✓
The nurse is assisting a pregnant client who has just underwent a nonstress test that was ruled reactive. Which factor will the nurse point out when questioned by the client about the results?
The fetal heart rate increases with activity and indicates fetal well-being. ✓
The home care nurse is assessing an older patient diagnosed with mild cognitive impairment (MCI) in the home setting. Which information is of concern?
The patient has lost 10 pounds (4.5 kg) during the last month. ✓
A pregnant client in her third trimester, lying supine on the examination table, suddenly grows very short of breath and dizzy. Concerned, she asks the nurse what is happening. Which response should the nurse prioritize?
The uterus requires more blood in a supine position. ✓
The client in labor at 3 cm dilation and 25% effaced is asking the nurse for analgesia. Which explanation should the nurse provide when explaining why it is too early to administer an analgesic?
This may prolong labor and increase complications. ✓
The nurse is caring for a client who has remained in stable condition at 37 weeks' gestation. The client's condition suddenly changes. Which assessment change should the nurse prioritize?
Vaginal bleeding and no pain ✓
The nurse is preparing discharge for a client who plans to bottle-feed her infant. Which instruction should the nurse prioritize for this client in the discharge teaching?
Wear a tight, supportive bra. ✓
The nurse is preparing discharge instructions for several clients after their admission for emergent care of a pregnancy complication. To the client with which condition will the nurse stress the importance of frequent office visits to monitor her progress?
a molar pregnancy ✓
A woman at 31 weeks' gestation presents to the emergency department with bright red vaginal bleeding, reporting that the onset of the bleeding was sudden and without pain. Which diagnostic test should the nurse prioritize?
a transvaginal ultrasound ✓
The nurse is conducting the initial postpartum assessment on a client. The nurse will assist the client into which position to properly assess the postpartum uterus?
supine ✓
The nurse is assessing a client at her first prenatal visit and notes the fundal height is palpable at the level of the umbilicus. The nurse predicts the client is at which gestational age?
20 weeks ✓
The nurse is assessing a client at her first prenatal visit and notes that she is exposed to various chemicals at her place of employment. Which statement by the client would indicate she needs additional health education to protect her and her fetus?
"The gloves they provide irritate my hands, so I don't use them." ✓
A client in her first trimester is concerned about how weight gain will affect her appearance and questions the nurse concerning dietary restrictions. How much weight gain should the nurse point out will be safe for this client with a low BMI?
28 to 40 pounds (13 to 18 kilograms) ✓
The nursing instructor is conducting a class exploring the various changes which occur in the early postpartum period. The instructor determines the session is successful when the students correctly point out which definition of bonding?
A process of developing an attachment and becoming acquainted with each other ✓
A 28-year-old client and her current partner present for the first antenatal OB appointment. The client has no children but does question a possible miscarriage 2 years ago; however, she never sought medical attention because she felt fine. Labs reveal both client and partner are Rh negative. Which action should the nurse prioritize?
Assess client for anti-D antibodies ✓
The nurse is preparing a woman for discharge after a birth and notes the mother's record indicates Rh negative and rubella titer is positive. Which nursing intervention will the nurse prioritize?
Assess the Rh of the baby. ✓
The nurse is preparing a client for discharge and notes an order for rubella vaccine. Which teaching should the nurse prioritize?
Do not to attempt another pregnancy for at least 3 months. ✓
A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture?
Clear to straw-colored fluid ✓
A nulliparous client at 37 weeks' gestation calls the labor and delivery unit to report she thinks she is in labor. The nurse predicts she is in true labor based on which answer to her assessment questions?
Contraction, regular and lasting longer and stronger ✓
The client is experiencing back labor and reporting intense pain in the lower back. The nurse should point out which intervention will be the most effective at this point?
Counterpressure against the sacrum ✓
The nursing instructor has completed a session on the induction of labor and how it is occurring more frequently. The instructor determines the session is successful when the students correctly choose which factor to be contributing to the increased induction rates?
Elective inductions by choice of both physician and client ✓
A 24-year-old woman presents with vague abdominal pains, nausea, and vomiting. An urine hCG is positive after the client mentioned that her last menstrual period was 2 months ago. The nurse should prepare the client for which intervention if the transvaginal ultrasound indicates a gestation sac is found in the right lower quadrant?
Immediate surgery ✓
The nurse is teaching a discharge session to a group of postpartum clients. When asked how long to expect the bleeding, which time frame should the nurse point out?
In approximately 10 days ✓
The nurse is preparing to assist with a pudendal block. The nurse predicts the client is at which point in the labor process?
Just before birth ✓
A woman with class II heart disease is experiencing an uneventful pregnancy and is now prescribed bed rest at 36 weeks' gestation by her health care provider. The nurse should point out that this is best accomplished with which position?
Lie in a semi-recumbent position. ✓
The nurse is appraising the post birth laboratory results of a client and discovers the WBC is 22,000 cells/mcL. The nurse predicts which action should be prioritized in response?
None, a normal variation due to labor ✓
The nurse is monitoring a client who is 3 hours postpartum. On assessment the nurse notes a temperature of 102.4°F. Which action should the nurse prioritize?
Notify the RN; she will notify the provider. ✓
A 17-year-old primigravida at 37 weeks' gestation has been unable to maintain adequate control of her blood glucose throughout her pregnancy. The nurse should prioritize which action after the health care provider suspects the infant has macrosomia based on the recent ultrasound?
Prepare for assessment of fetal lung maturity. ✓
The nursing instructor is teaching a group of nursing students about the various responsibilities of the labor and delivery medical team. The instructor determines the session is successful when the students correctly choose which function as the primary role of the LPN/LVN members of the team?
Provide care under the supervision of an RN ✓
A multigravida woman arrives in the emergency department panting and screaming, 'The baby's coming!' Which action should the nurse prioritize?
Quickly evaluate the perineum. ✓
A multigravida woman arrives in the emergency department panting and screaming, 'The baby's coming!' Which action should the nurse prioritize?
Quickly evaluate the perineum. ✓
A 33-year-old client has been progressing slowly through an unusually long labor. The nurse assesses the fetal scalp pH and determines it is 7.26. How should the nurse explain this result to the client when asked what it means?
Reassuring; it is associated with normal acid-base balance. ✓
The client has been progressing well through the labor process and the health care provider prepares to deliver the infant and performs an episiotomy. The nurse predicts which situation is the reason for this procedure?
Shoulder dystocia ✓
The nurse is monitoring a client who is recovering from a cesarean delivery with spinal anesthesia. Which sign or symptom should the nurse prioritize if noted on assessment after the administration of morphine sulfate, simethicone, and diphenhydramine?
Slow respiration, less than 12 breaths per minute ✓
The nurse is assessing a 35-year-old Hispanic woman at 22 weeks' gestation who has had recent laboratory work. The nurse notes fasting blood glucose 146 mg/dL, hemoglobin 13 g/dL, and hematorcrit 37%. Based on these results which instruction should the nurse prioritize?
Take daily iron supplements. ✓
The nurse has completed assessing the vital signs of several clients who are from 36 to 48 hours postpartum. For which set of vital signs should the nurse prioritize for interaction?
Temp: 98.6° F (37° C), HR 74, RR 16, BP 150/85 ✓
The nurse is teaching a pregnant teenager the importance of proper nutrition and adequate weight gain throughout the pregnancy. What is the best response when the client refuses to eat due to fear of possible weight gain?
The infant will be small and could have problems. ✓
The nurse is admitting a client who is to have labor induced at 37 weeks' gestation. When asked by the client what the fibronectin test is for, what is the nurse's best response?
To determine if a specific protein is present that is associated with readiness ✓
A primigravida 28-year-old client is noted to have Rh negative blood and her husband is noted to be Rh positive. The nurse should prepare to administer RhoGAM after which diagnostic procedure?
amniocentesis ✓
The client and her partner have prepared for a natural birth and bring a picture of a sunset over the ocean with them. The nurse predicts they will be using which technique during labor?
attention focusing ✓
The nurse is performing an assessment on a 2-day postpartum client and discovers a boggy fundus at the umbilicus and slightly to the right. The nurse determines that this is most likely related to which situation?
bladder distension ✓
The nurse is assessing a woman at 37 weeks' gestation who has presented with possible signs of labor. The nurse determines the membranes have ruptured based on which color of the Nitrazine paper?
blue ✓
For the past 18 hours, the client has been progressing slowly in labor in spite of various attempts to encourage the labor. The health care provider decides a cesarean delivery is necessary to ensure the well-being of both the mother and fetus. The nurse should point out to the client that this is due to which situation?
dystocia ✓
A 28-year-old client with a history of endometriosis presents to the emergency department with severe abdominal pain and nausea and vomiting. The client also reports her periods are irregular with the last one being 2 months ago. The nurse prepares to assess for which possible cause for this client's complaints?
ectopic pregnancy ✓
An African American is at an increased risk for which of the following? (Select all that apply.)
hypertension ✓ type 2 diabetes ✓ metabolic syndrome ✓ vitamin D deficiency ✓
The nursing instructor is teaching a session on the birth process. During which stage does the woman's cardiac output increase 80% above the pre-labor level?
immediately after birth ✓
A 37-year-old primigravida client at 40 weeks' gestation is seen in the clinic for a scheduled prenatal visit. The nurse predicts the woman is close to labor based on which assessment finding?
nesting ✓
The nurse is preparing to teach a pregnant client with iron deficiency anemia about the various iron-rich foods to include in her diet. Which food should the nurse point out will help increase the absorption of her iron supplement?
orange juice ✓
A group of nursing students are preparing a presentation which will illustrate various components of the birthing process. When presenting the pelvis, the students should point out that it is often referred to as which term?
passageway ✓
The nurse is preparing a client for administration of prostaglandin E to prepare for induction of labor. The nurse should explain this is administered via which route to the client?
vaginal ✓
The nurse is teaching a client who is diagnosed with preeclampsia how to monitor her condition. The nurse determines the client needs more instruction after making which statement?
"If I have changes in my vision, I will lie down and rest." ✓
A client at 40 weeks' gestation informs the nurse that she is tired of being pregnant. What is the best response from the nurse?
"That is a very normal feeling, especially at this point in pregnancy." ✓
The nursing instructor is teaching a group of nursing students about the uniqueness of pain involved with the birthing process. The instructor determines the session is successful when the students correctly choose which pain factor to be related to psychosocial influences?
Fear of pain during labor ✓
An OB/GYN care provider has just finished evaluating the 100th client. If the nurse could review all the documentation from each client thus far, which types of pelvis would the nurse predict the care provider has seen the most and the least?
gynecoid and platypelloid, respectively ✓
The nurse is admitting a client who is in early labor. After determining that the birth is not imminent, which assessment should the nurse perform next?
fetal staus ✓
The nurse is discussing the various positions for delivery with a client and her partner. The client mentions she would like a position which speeds up the process, decreases stress to her baby, and reduces the possibility of needing an episiotomy. Which positions should the nurse point out will best meet the client's desires?
hands and knees ✓
The nurse is preparing the client so that the health care provider can ripen the client's cervix for induction of labor. The nurse predicts the health care provider will probably use which most commonly used mechanical method?
membrane stripping ✓
The nurse is assessing a client who believes she is pregnant. The nurse points out a more definitive assessment is necessary due to which sign being considered a probable sign of pregnancy?
positive home pregnancy test ✓
The following hourly assessments are obtained by the nurse on a client with preeclampsia receiving magnesium sulfate: 97.3 F (36.2 C), HR 88, RR 1, BP 148/110 mm Hg. What other priority physical assessments by the nurse should be implemented to assess for potential toxicity?
reflexes ✓
The nurse is monitoring a client who is in active labor. The nurse will carefully monitor which phase of the involuntary uterine contraction to ensure the fetus is progressing adequately?
relaxation ✓