FINAL!!!!!!!!!! labor and deliver
A primigravida in her first trimester visits the prenatal clinic for the first time. Which statement illustrates a psychologic reaction to pregnancy that usually occurs in the first trimester? a. "I know I'm going to be a terrible mother - I'll forget the baby when I go out." b. "I'm excited about the baby, but I'm not sure that I'm ready to be a mother." c. "I know I'm going to have a girl. I dreamed that she would be a doctor or a lawyer and be very successful." d. "I'm so excited about this baby, but I'm so afraid of losing control during labor. I know I'll be a terrible patient."
B
A woman asks the nurse about the safety of sexual intercourse during her pregnancy. Which response by the nurse is the most correct? a. "Sexual activity should be avoided after the first trimester." b. "Sexual activity should be ceased in the case of vaginal bleeding." c. "Sexual activity should be avoided in the second trimester." d. "Sexual activity should be limited to activity that does not include intercourse."
B
After performing Leopold's maneuvers on a client in labor, the nurse should prepare the client for a vaginal delivery after determining whether the fetus is in which of the following positions? a. Transverse lie b. Vertex presentation c. Oblique lie d. Face presentations
B
Early in the first trimester, a woman complains of morning sickness. What does the nurse suggest to aid with the discomfort? a. Eating something with a high-fat content b. Eating dry crackers before getting up c. Eating three well-balanced meals d. Getting rest and taking antiemetics
B
Laboratory studies reveal that a pregnant client's blood type is O and she is Rh-positive. Problems related to incompatibility may develop in her infant if the infant is what? a. Rh-negative b. Type A or B c. Born preterm d. Type O and Rh-positive
B
Methylergonovine has been ordered for a postpartum client. The nurse should withhold this drug when which of the following situations is present? a. Pulse rate of 89 beats/min and respiratory rate of 20 breaths/min b. Blood pressure of 170/95 mm Hg c. Tender breasts and a temperature of 100.1° F (37.8° C) d. Increased uterine blood flow
B
The first-time mother has been told by the nurse that the first stage of labor is the longest. What would be an appropriate nursing intervention for comfort during this time? a. Cool fluids to drink b. A backrub in the sacral area c. Assisting to lie in a supine position d. Decreasing illumination in the room
B
The nurse is alarmed as she assesses a protruding umbilical cord from the vagina. What immediate action should the nurse take? a. Monitor intensity of contractions. b. Place the patient in the knee-chest position. c. Notify the charge nurse. d. Ask the patient to perform a Valsalva's maneuver.
B
The nurse is collecting data from a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks, and she tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse should document which as the GTPAL for this client? a. G = 3, T = 2, P = 0, A = 0, L = 1 b. G = 2, T = 1, P = 0, A = 0, L = 1 c. G = 1, T = 1, P = 1, A = 0, L = 1 d. G = 2, T = 0, P = 0, A = 0, L = 1
B
A woman is admitted in active labor, and the nurse assesses the fetal heart rate (FHR) at 124 beats/min. What action should the nurse take based on the assessment? a. Position patient on her left side. b. Start oxygen per nasal cannula. c. Reassure the mother the rate is normal. d. Notify the health care provider at once.
C
A client planning to become pregnant is receiving education from the nurse. Which client statement suggests an understanding of fetal alcohol syndrome? a. "I can have a glass of wine with meals, because food absorbs the alcohol." b. "Beer is okay, because it is low in alcohol." c. "I have to drink a lot of alcohol to cause significant harm to my child." d. "If I consume alcohol, the baby can be harmed before I even know I am pregnant."
D
A nurse prepares to administer vitamin K to a newborn. What rationale explains why newborns are deficient in this vitamin? a. Alterations in blood coagulation interfere with vitamin K production. b. A newborn's liver does not produce it immediately after birth. c. Increased bilirubin levels interfere with vitamin K synthesis during the neonatal period. d. A newborn's intestinal tract does not synthesize it for several days after birth.
D
A patient has been diagnosed with a tubal pregnancy. What is the typical outcome of a tubal pregnancy? a. The patient will carry the pregnancy to term and have a cesarean delivery. b. The patient will have to remain in bed for the remainder of the pregnancy. c. The patient will spontaneously abort this ectopic pregnancy. d. The patient will require surgery to remove the zygote.
D
A patient is a gravida 1, Rh-negative woman at a 28 weeks' gestation. The father of her child is Rh positive. The mother is asking the nurse about the effect on her unborn child of RhoGAM that has been ordered. What is the nurse's best reply? a. "Your child will do well after birth once transfusions are administered." b. "If the baby is Rh negative at birth, he or she will need RhoGAM also." c. "RhoGAM kills antibodies you make, so your child will be protected." d. "Your baby may be Rh positive and cause you to make antibodies. These won't affect this baby but could affect future children if RhoGAM isn't given."
D
A patient with hyperemesis gravidarum asks the nurse what would have happened if she had not come to the hospital. What result is the best response by the nurse? a. A large for gestational age infant b. Anorexia nervosa c. Preterm delivery d. Maternal or fetal death
D
A pregnant woman comes to the hospital 3 weeks before her estimated date of birth (EDB) complaining of severe pain and a rigid abdomen. What should the nurse immediately suspect as the cause of the pain? a. Placenta previa b. Appendicitis c. Ectopic pregnancy d. Abruptio placentae
D
During the immediate postpartum period, the mother has a temperature of 100.2°F (37.8°C), pulse 52, respirations 18, BP 138/84. What should the nurse do? a. Report the temperature as abnormal. b. Continue to monitor every 5 minutes. c. Report the pulse as abnormal. d. Nothing as the vital signs are normal.
D
The nurse in the labor room is caring for a client in the first stage of labor. When monitoring the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Which is the appropriate nursing action? a. Notify the registered nurse. b. Administer oxygen via face mask. c. Place the mother in Trendelenburg's position. d. Document the findings and continue to monitor the fetal patterns.
D
The nurse receives a report on the following laboring clients. Which client should the nurse see first? a. G2 P0 with SROM at 7 cm of dilation b. G2 P1 with SROM in the active phase c. G1 P0 with intact membranes in the latent phase d. G6 P5 with intact membranes at 5 cm of dilation
D
A patient is admitted to the hospital with signs of an ectopic pregnancy. What should the plan of care include for the patient? a. Long-term bed rest b. Episodes of extreme hypertension c. Surgery to remove the embryo/fetus d. Treatment for dehydration
C
The nurse should monitor for which signs associated with respiratory distress syndrome (RDS) in a preterm newborn? a. Tachypnea and intercostal retractions b. Acrocyanosis and grunting c. Hypotension and bradycardia d. The presence of a barrel chest with acrocyanosis
A
What does the nurse document when a healthcare provider places a direct fetal scalp electrode? a. Time of placement, the healthcare provider's name, and fetal heart rate b. Fetal movements, the time of placement, and the healthcare provider's name c. Time of placement, fetal heart rate, and fetal movements d. Time of placement and fetal movements
A
What is the optimal method for the nurse to use to assess blood loss in a client with placenta previa? a. Count or weigh perineal pads b. Monitor pulse and blood pressure c. Check hemoglobin and hematocrit values d. Measure or estimate the height of the fundus
A
When observing the fetal heart monitor, the nurse recognizes the fetal heart rate (FHR) decreases to 120 beats/min at the beginning of a contraction and returns to a baseline of 155 beats/min at the end of the contraction. What should this indicate to the nurse? a. Early deceleration due to head compression b. That the fetus is in acute distress c. Variable decelerations due to cord compression d. That these are late decelerations
A
A patient at 33 weeks' gestation is admitted to the obstetric unit in active labor with symptoms associated with pregnancy-induced hypertension (PIH). Which action(s) will the nurse implement? (Select all that apply.) a. Vital signs hourly ! b. Administration of IV pitocin c. Administration of magnesium sulfate IV d. Fetal stress test e. Assessment of deep tendon reflexes
ACDE
During the second stage of labor, how often should the nurse should monitor the fetal heart rate? a. Every 5 minutes b. Every 15 minutes c. Every 30 minutes d. Every hour
A
Shortly after birth the nurse instills erythromycin ophthalmic ointment in the newborn's eyes. The father asks why an antibiotic is needed. The nurse explains that it is routinely administered to prevent what type of infection? a. Gonorrhea b. Toxoplasmosis c. Rubella d. Cytomegalovirus
A
A postpartum nurse is reinforcing instructions to a mother regarding how to provide a bath to the newborn. Which statement by the mother indicates the need for further teaching? a. "I need to bathe my newborn after a feeding." b. "I will never leave the newborn in the tub of water alone." c. "I will gather all my supplies before I start bathing my newborn." d. "I need to fill a clean basin or sink with 2 to 3 inches of water and then check the temperature using the wrist."
A
During the assessment of a client in labor, the cervix is determined to be dilated 4 cm. What stage of labor does the nurse record? a. First b. Second c. Prodromal d. Transitional
A
The nurse is assisting in preparing to care for a client undergoing an induction of labor with an infusion of oxytocin. The nurse should include which in the plan of care? a. Administer antibiotics. b. Maintain complete bed rest. c. Notify the neonatal resuscitation team. d. Maintain continuous electronic fetal monitoring.
D
The nurse is caring for a client scheduled for a cesarean delivery. The nurse reviews the client's health record, knowing that which finding needs to be further investigated before delivery? a. Hemoglobin of 11.5 g/dL b. Fetal heart rate of 154 beats per minute c. Maternal pulse rate of 90 beats per minute d. White blood cell count of 35,000 mm3
D
Which type of monitor will assesses the intensity of contractions? a. External monitor b. Fetal monitor c. Maternal monitor d. Internal monitor
D
What is the cause of frequent urination in early pregnancy? a. Increased fluid intake b. The fetus's kidneys functioning c. Retention of fluid d. Increased circulating volume
D
A client who is pregnant for the first time and is carrying twins is scheduled for a cesarean birth. What should the nurse tell the client to expect? a. "We'll give you an enema before the surgery." b. "We'll be encouraging you to walk early after surgery." c. "You'll be discharged from the hospital in a week." d. "You should take sponge baths until the incision is healed."
B
A pregnant teenager presents with the following complaints. Which complaint could be an indicator of a serious complication? a. Painful hemorrhoids b. Linea nigra c. Visual disturbances d. Low back pain
C
A newly married client is experiencing amenorrhea, nausea, and vomiting. Upon consulting a healthcare provider, the client finds out she is pregnant. The client is very excited while also feeling afraid of the impending situation of her pregnancy. Which psychological state of pregnancy has the client achieved? a. Preparing for the end of the pregnancy b. Accepting the pregnancy c. Accepting the baby d. Preparing for parenthood
B
When assessing a mother 12 hours following the delivery of a baby, where should the nurse expect to palpate the fundus? a. 2 cm below the umbilicus b. At the umbilicus c. 1 cm below the umbilicus d. Halfway between the umbilicus and the symphysis pubis
B
A pregnant woman tells a nurse, "I think I can feel the baby move now. It feels like butterflies in my stomach. My friend calls it feeling life." What term should the nurse include when discussing fetal movement with the woman? a. Lightening b. Quickening c. Engagement d. Ballottement
B
A pregnant college student is waiting patiently to be discharged after being treated for premature uterine contractions. The nurse assesses the client before discharge and notices a pool of blood under the client's pelvis. The client reports no pain, discomfort, or nausea. What should the nurse do before discharging the client? a. Explain to the client that a small amount of blood is normal. b. Stop the discharge and notify the healthcare provider. c. Tell the client to report any amount of bleeding while at home .d. Ask the client to "teach back" the discharge instructions to help confirm the client's knowledge.
B
A pregnant human immunodeficiency virus (HIV)-positive woman delivers a baby. The nurse provides guidance to help the client make decisions regarding newborn care. Which statement by the woman indicates that additional guidance is needed? a. "I will be sure to wash my hands before feeding the newborn." b. "I will breastfeed, especially for the first 6 weeks postpartum c. "I will be sure to wash my hands before and after bathroom use." d. "I will administer the prescribed antiviral medication to the newborn for the first 6 weeks after delivery."
B
The patient's membranes have just ruptured. What is the first priority of the nurse? a. Turn the patient on the left side. b. Perform a Nitrazine test. c. Check the fetal heart rate (FHR) d. Perform a vaginal examination.
C
During which gestational week can a primigravida expect to first feel fetal movement? a. 8 b. 10 c. 16 d. 20
C
The nurse who is caring for a postpartum mother being tested for endometritis notes that the client has little interest in caring for her infant. Which intervention should best facilitate the client's participation in infant care? a. Limiting fluid intake to keep the bladder empty b. Promoting family members to care for the infant c. Encouraging the client to take pain medication as prescribed d. Maintaining the client in a supine position whenever possible
C
A 36-week primigravida patient has been admitted to the unit with a blood pressure of 200/120 mm Hg, severe headache, and edema. Which medication does the nurse anticipate that the healthcare provider will order? a. Nifedipine (Procardia) b. Furosemide (Lasix) c. Magnesium sulfate d. Terbutaline (Brethine)
C
When caring for the neonate immediately following delivery, the priority nursing diagnosis will be a. risk for bleeding. b. altered body temperature. c. ineffective airway clearance. d. risk for infection.
C
A 37-year-old woman agrees to have a prenatal test done in order to diagnose fetal defects. There is a history of Down syndrome in her family. Which invasive prenatal test provides the earliest diagnosis and rapid test results? a. Nonstress test b. Amniocentesis c. Chorionic villus sampling d. Percutaneous umbilical blood sampling
C
A client at 34 weeks' gestation calls the hospital with concerns of leaking vaginal fluid. What should the nurse do? a. Advise the client to have a prenatal checkup the following day. b. Tell the client not to panic, as this is normal, and advise her to report to the hospital once her uterine contractions are 5 minutes apart. c. Tell the client to report immediately to the hospital. d. Tell the client that she needs to be placed on home bed rest.
C
A nurse is reviewing her assignments, which patient should she assess first? a. 12-hour old infant who is small for gestational age b. Nine hour old infant who has not voided c. Four hour old infant with a cardiac defect d. Three day old infant waiting for discharge
C
A patient arrives at the hospital having contractions. How should the nurse determine that the patient is in true labor? a. There is no dilation. b. The contractions are in the fundus. c. The cervix has softened and effaced. d. The contractions are irregular.
C
A patient in her second trimester of pregnancy arrives at the hospital complaining of bright red, painless vaginal bleeding. What condition should the nurse immediately suspect? a. Abruptio placentae b. Hemorrhage c. Placenta previa d. Placentitis
C
A patient with mastitis asks the nurse if her infant will be infected if she continues to breastfeed. Which of the following is the appropriate response by the nurse? a. The infant will need to be started on antibiotic therapy b. The infant received immunity through the breast milk and will not be infected c. Continue breastfeeding because the bacteria is localized in the breast tissue and will not enter the breast milk d. Yes, your infant will be infected and you have to stop breastfeeding
C
The nurse plans to weigh a newborn. What is the most appropriate way to obtain the newborn's weight most accurately? a. Placing the naked infant on the scale b. Removing the infant's clothes except for the diaper before weighing c. Weighing the infant's clothes and then subtracting that weight from the clothed infant's weight d. Having the mother hold the infant while on an adult scale and subtracting the mother's weight from the combined weight
A
A client in labor at 39 weeks gestation is told by the primary healthcare provider that she will require a cesarean delivery. The nurse reviews the client's prenatal history. What preexisting condition is the most likely reason for the cesarean birth? a. Gonorrhea b. Chlamydia c. Chronic hepatitis d. Active genital herpes
D
A client is scheduled for a sonogram at 36 weeks gestation. Shortly before the test she tells the nurse that she is experiencing severe abdominal pain. Assessment reveals heavy vaginal bleeding, a drop in blood pressure, and an increased pulse rate. Which complication does the nurse suspect? a. Hydatidiform mole b. Vena cava syndrome c. Marginal placenta previa d. Complete abruptio placentae
D
A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation? a. 6 and 8 weeks' gestation b. 8 and 10 weeks' gestation c. 10 and 12 weeks' gestation d. 16 and 20 weeks' gestation
D
Using Leopold maneuvers to assess fetal position, the nurse finds a soft rounded prominence at the level of the fundus, a hard round prominence just above the symphysis pubis, and nodulations on the left side of the uterus. How should the nurse document the fetal position? a. Right occiput anterior (ROA), vertex b. Left occiput anterior (LOA), vertex c. Right occiput transverse (ROT), breech d. Left occiput anterior (LOA), breech
A
A pregnant client is asking the nurse when she will gain the greatest amount of weight during the pregnancy. At which time during prenatal development should the nurse tell the client to expect the greatest fetal and maternal weight gain? a. Implantation period b. First 8 weeks c. Second trimester d. Third trimester
D
A young adult client in the third trimester of pregnancy is rushed to the hospital for abrupt, painless bright red vaginal bleeding. After an ultrasound, the healthcare provider diagnoses placenta previa. What is the nurse's immediate care measure? a. Do an internal examination to check whether or not the cervix is dilated. b. Inspect the perineum for bleeding and estimate the present rate of blood loss. c. Place the client on bed rest in a side-lying position. d. Assess the duration of pregnancy and the time bleeding began.
C
An infant born at 40 weeks' gestation weighs 6 lb 13 oz (3090 g). What category describes this neonate? a. SGA and term b. SGA and preterm c. AGA and term d. AGA and preterm
C
A client has meconium-stained amniotic fluid. Fetal scalp sampling indicates a blood pH of 7.12 and fetal bradycardia is present. Based on these findings, the nurse should take which action? a. Reposition the patient. b. Prepare for a cesarean section. c. Start an IV infusion as prescribed d. Administer amnioinfusion.
B
A client is admitted to the labor and delivery suite with an intrauterine fetal demise. The nurse determines that the discussion with the parents was effective in preparing them for the delivery when the parents make which response? a. State they have no questions b. Request to hold the infant following delivery c. Refuse a footprint and picture of the infant to take home d. Are surprised by the appearance of the infant following delivery
B
A mother delivered her baby at midnight and it is now 9 a.m. She wants to sleep and asks the nurse to take care of the baby. What is this considered? a. Fatigue from labor b. Normal "taking in" response c. Abnormal "taking in" response d. Risk for altered maternal-infant bonding
B
A pregnant client in the first trimester comes to the clinic concerned because of urinary frequency and white vaginal discharge. How does the nurse appropriately respond to the client? a. "This is abnormal and could be associated with cervical cancer." b. "You do not have to worry-Both are normal discomforts of pregnancy." c. "Are you practicing a polygamous relationship?" d. "You might have a urinary tract infection and must see a healthcare provider for antibiotic treatment."
B
A pregnant client is completely dilated and at +2 station. Her contractions are strong and last 50 to 70 seconds. Based on this information, the nurse should know that the client is in which stage of labor? a. First stage of labor b. Second stage of labor c. Third stage of labor d. Fourth stage of labor
B
Which medication is used to treat a patient with atonic uterus? a. Estradiol b. Ergonovine c. Ergotamine d. Egophony
B
Which of the following measures could help prevent infant abduction? (Select all that apply.) a. Only transport infants by carrying them. b. Require staff members to wear appropriate identification badges. c. Respond immediately when an alarm sounds. d. Never leave infants unattended at any time. e. Take all the infants to their mothers at the same time.
BCD
A pregnant patient with tuberculosis asks the nurse how the disease will affect her pregnancy and her newborn. What statements by the nurse are most appropriate? (Select all that apply.) a. "You have nothing to worry about. You will be disease free before you deliver." b. "The tuberculosis can be transmitted to the fetus in rare occurrences." ! c. "Your newborn will be tested for tuberculosis after delivery." ! d. "There is no approved treatment for the infant if she tests positive for the disease." e. "You will not be able to hold your newborn until you have been cleared according to the health department guidelines."
BCE
A 22-year-old primigravida is admitted to the hospital in labor. After performing a vaginal examination, the nurse determines that the client's cervix is dilated 2 cm and 80% effaced and that the presenting part is at 0 station. What is the location of the presenting part? a. Entering the vagina b. Floating within the bony pelvis c. At the level of the ischial spines d. Above the level of the ischial spines
C
A 30-year-old primipara is administered an epidural anesthesia. During the first hour of post-epidural anesthesia administration, which of the following signs and symptoms should be referred immediately to the anesthesiologist? a. Chills and cold, clammy skin b. Urinary frequency c. Respiratory distress d. Nausea and vomiting
C
A pregnant client is attending a check up at the healthcare provider's office. The client learns that the child has chromosomal abnormalities and will be mentally and physically handicapped. When the client begins to cry, how should the nurse respond? a. Suggest an elective termination of the pregnancy. b. Recommend a second opinion. c. Contact the social worker to provide the client with resources. d. Sit with the client and allow her to cry and express her feelings
D
A pregnant couple is attending childbirth preparation classes. Which exercise should the nurse teach the mother to increase the tone of the muscles of the pelvic floor? a. Pelvic tilt b. Half sit-ups c. Pelvic rocking d. Kegel exercises
D
A woman tells the nurse that this is her third pregnancy. She has had twin girls at full term and one miscarriage. How does the nurse record the information? a. G2, T2, L3 b. G4, T3, A1, L1 c. G3, T3, A2, L1 d. G3, T1, A1, L2
D
A woman who has just discovered she is pregnant states that the first day of her last menstrual period was January 10. What will be her expected date of birth (EDB)? a. April 10 b. April 17 c. May 10 d. October 17
D
In planning postpartum nursing care for a client with cardiac disease, the nurse would question which of the following physician orders? a. High fiber diet b. Monitor vital signs every 2 hours c. Strict monitoring of input and output d. High fluid intake
D
The client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client's systolic blood pressure (BP) dropped 20 points, the diastolic BP dropped 10 points, and her pulse is 120 beats per minute. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. Based on this diagnosis, the nurse should plan which action? a. Reassure the client. b. Apply perineal pressure. c. Monitor fundal height d. Prepare the client for surgery.
D
The new mother has decided not to breastfeed the baby. How should the nurse correctly instruct the mother to suppress her milk supply? a. Pump the breasts to remove milk b. Apply warm, moist compresses c. Restrict oral fluids d. Apply a firm bra and ice pack
D
The nurse assures an anxious primigravida that during fetal development from week 34 and beyond, maternal antibodies are transferred to the baby. How long will these antibodies provide the baby with immunity? a. 1 month b. 3 months c. 4 months d. 6 months
D
The nurse is caring for a woman who has delivered a baby after a pregnancy complicated with placenta previa. Which complication is the client most at risk for developing? a. Coagulopathy b. Postpartum infection c. Chronic hypertension d. Postpartum hemorrhage
D
A young adult primigravida goes to the clinic for a prenatal visit. Which prenatal assessment is not routinely included for this client? a. Personal and family history b. HIV testing c. Nutritional needs d. Pelvimetry e. Complete blood count
D\
The nurse caring for a client who is receiving oxytocin for the induction of labor notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, which is the nurse's priority action? a. Stop the oxytocin infusion. b. Check the client's blood pressure. c. Check the client for bladder distention. d. Place the client in a knee-chest position.
A
The nurse is assessing a "kick count" for a patient with gestational hypertension. What result should be a cause for concern? a. Less than three kicks per hour b. Less than five kicks per hour c. Less than seven kicks per hour d. Less than nine kicks per hour
A
The nurse is talking to a pregnant client with human immunodeficiency virus (HIV) infection regarding care for the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? a. "You will need to bottle-feed your newborn. b. "You will need to feed your newborn by nasogastric tube feeding." c. "You will be able to breastfeed for 6 months and then will need to switch to bottle-feeding." d. "You will be able to breastfeed for 9 months and then will need to switch to bottle-feeding.
A
Which findings indicate to the nurse that placental separation has occurred? Select all that apply. a. Sudden trickle or spurt of blood b. Fetal membranes are seen at the introitus c. Change from globular to discoid shape d. Lengthening of umbilical cord e. Fundus is boggy following separation
ABD
A woman diagnosed with type 1 diabetes mellitus is in labor. Based on the knowledge of insulin and diabetes and pregnancy, the nurse will be prepared to care for a newborn infant who is likely to have which complication? a. Anemia b. Macrosomia c. Hyperglycemia d. Postmaturity syndrome
B
During her first visit to the prenatal clinic a client is found to be obese. During the ensuing 5 months, the client has been unsuccessful in adhering to her nutritional plan. Which finding indicates to the nurse that the client has been successful during the sixth month? a. Weight loss of 1 lb (0.45 kg) b. Weight gain of 2 lb (0.91 kg) c. No change in weight from last month d. The client's statement that she lost weight last week
B
During their initial visit to the prenatal clinic a couple asks the nurse whether the woman should have an amniocentesis for genetic studies. Which factor indicates that an amniocentesis should be performed? a. Recent history of drug abuse b. Family history of genetic abnormalities c. A client history of more than three prior spontaneous abortions d. Maternal age older than 30 years at the time of the first pregnancy
B
The nurse is assessing a client after delivery and finds the uterine fundus boggy and 1 centimeter above the umbilicus. Which of the following is the priority nursing intervention? a. Assess the vital signs. b. Massage the uterus c. Notify the physician. d. Assess the perineal area.
B
The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse should tell the client that fetal circulation consists of which components? a. Two umbilical veins and one umbilical artery b. Two umbilical arteries and one umbilical vein c. Arteries that carry oxygenated blood to the fetus d. Veins that carry deoxygenated blood to the fetus
B
The nurse is helping a mother breast-feed her newborn. What is the best indication that the newborn has achieved an effective attachment to the breast? a. The tongue is securely on top of the nipple. b. The mouth covers most of the areolar surface. c. Loud sucking sounds are heard during the 15 minutes spent at each breast. d. Vigorous suckling occurs for the 5 minutes the infant spends at each breast before falling asleep.
B
Why is the nurse concerned about a patient in her first trimester of pregnancy being exposed to German measles? a. The disease is capable of causing a spontaneous abortion. b. The disease is capable of causing birth defects. c. The disease is capable of causing high fever and convulsions. d. The disease is capable of interfering with placental implantation.
B
The nurse should perform which of the following nursing actions when a client with preeclampsia has a seizure during the postpartum period? a. Give phenytoin, IV push, stat. b. Insert a tongue blade in the patient's mouth. c. Restrain the patient. d. Stay with the client, administer oxygen, position to prevent aspiration, and maintain a safe environment
D
What complication of delivery should the nurse expect with the birth of multiple fetuses? a. An ectopic tendency b. Difficulty with breast-feeding c. A vaginal delivery d. Loss of uterine tone
D
A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Based on this finding, which nursing action is appropriate? a. Contact the health care provider. b. Instruct the client to maintain bed rest for the remainder of the pregnancy. c. Tell the client that these are common and they may occur throughout the pregnancy. d. Call the maternity unit and inform them that the client will be admitted in a prelabor condition.
C
A primigravida patient is admitted to the labor and delivery unit. During initial assessment, the baby is found to be engaged. Which statement is true? a. The narrowest diameter of the presenting part has reached the pelvic outlet. b. The descending part is being initiated through the midpelvis. c. The widest diameter of the presenting part crosses the pelvic inlet. d. The narrowest diameter of the presenting part is at the ischial spines.
C
An infant presents 5 minutes after delivery with a heart rate of 105, is crying, has some flexion in the arms, sneezes, and has a pink body and blue limbs. What Apgar score should be assigned to this infant? a. 5 b. 7 c. 8 d. 10
C
During a prenatal visit, the nurse checks the fetal heart rate (FHR) of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which heart rate is noted? a. 80 beats per minute b. 100 beats per minute c. 150 beats per minute d. 180 beats per minute
C
For which reason will betamethasone IM be administered to the mother in premature labor? a. To stop uterine contractions b. To prevent precipitous labor c. To stimulate lung maturity in the fetus d. To stimulate prolactin to enhance breastfeeding
C
The nurse has reinforced instructions to a new mother about how to perform postpartum exercises. The nurse determines that the client understands the instructions when she makes which statement? a. "Strenuous exercises should be started while in the hospital." b. "Exercise should be delayed for 4 weeks to allow healing time c. "I should alternately contract and relax the muscles of the perineal area." d. "The use of postpartum exercises can result in stress urinary incontinence."
C
The postpartum mother with a third degree laceration tells the nurse she is afraid to have a bowel movement because of her painful episiotomy. What should the nurse do? a. Offer a suppository or enema. b. Encourage ambulation. c. Offer stool softeners as prescribed. d. Offer pain medication before defecating.
C
A 34-year-old pregnant client is in the clinic for the first trimester checkup. While assessing the client's health history, what is the nurse most concerned about? a. The child's father has type 1 diabetes. b. The client's father had Guillain-Barré syndrome. c. The client takes folic acid daily. d. The client takes over-the-counter medication.
D
