HESI A2 Exit Exam Maternity Practice

A 30-year-old multiparous woman who has a 3-year-old boy and an newborn girl tells the nurse, "My son is so jealous of my daughter, I don't know how I'll ever manage both children when I get home." How should the nurse respond? a.Tell the older child that he is a big boy now and should love his new sister. b.Ask friends and relatives not to bring gifts to the older sibling because you do not want to spoil him. c.Let the older child stay with his grandparents for the first six weeks to allow him to adjust to the newborn. d.Regression in behaviors in the older child is a typical reaction so he needs attention at this time.

...

A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities? A.Wear support stockings. B. Reduce salt in her diet. C. Move about every hour. D. Avoid constrictive clothing.

...

During labor, the nurse determine that a full term client is demonstrating late decelerations. In which sequence should the nurse implement these nursing actions.

1. Reposition the client 2. Provide O2 via face mask 3. Increase IV fluid 4. Call the healthcare provider

According to Diane, her LMP is November 15, 2002, using the Naegle's rule what is her EDC? A. August 23, 2003 B. August 18, 2003 C. July 22, 2003 D. February 22, 2003

A

Family centered nursing care for women and newborn focuses on which of the following? A. Assisting individuals and families achieve their optimal health B. Diagnosing and treating problems promptly C. Preventing further complications from developing D. Conducting nursing research to evaluate clinical skills

A

Which of the following would cause a false-positive result on a pregnancy test? A. The test was performed less than 10 days after an abortion B. The test was performed too early or too late in the pregnancy C. The urine sample was stored too long at room temperature D. A spontaneous abortion or a missed abortion is impending

A - Explanation A false-positive reaction can occur if the pregnancy test is performed less than 10 days after an abortion. Performing the tests too early or too late in the pregnancy, storing the urine sample too long at room temperature, or having a spontaneous or missed abortion impending can all produce false- negative results.

A nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student responds correctly by stating that which of the following are functions of amniotic fluid? Select all that apply. A. Allows for fetal movement B. Is a measure of kidney function C. Surrounds, cushions, and protects the fetus D. Maintains the body temperature of the fetus E. Prevents large particles such as bacteria from passing to the fetus F. Provides an exchange of nutrients and waste products between the mother and the fetus

A, B, C, D

The nurse knows that there are psychological maternal changes that occurs during pregnancy in a primigravida patient. Select all the normal psychological maternal changes that happens throughout pregnancy. A. Ambivalence B. Breast tenderness C. Emotional lability D. Body image changes E. Bonding or relationship with the fetus F. Nausea and vomiting G. Syncope H. Urinary frequency

A, C, D, E

A 36 weeks gestation pregnant woman is complaining of urinary urgency and frequency. The nurse explained that the enlarging fetus is pressing the bladder which causes frequent urination. This is normally occuring during the first and third trimesters of pregnancy. The nurse advices the patient to do the following measures to prevent urinary frequency. Select all the necessary measures that the nurse can provide to the patient. A. Drink 2 quarts of fluid during the day B. Engaging in a regular exercise C. Performing Kegel exercises D. Soaking in a warm sitz bath E. Limiting fluid intake during the evening

A, C, E

A multigravida client arrives at the L&D unit and tells the nurse that her bag of water has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal HR is between 140 and 150 beats/min. What action should the nurse implement next? A. complete sterile vag exam B. take maternal temp every 2 hrs C. Prepare for an immediate cesarean bitrh D. Obtain sterile suction equipment

A. complete sterile vag exam

This is a dark streak down the midline of the abdomen that may appear as the uterus is enlarging. The LPN correctly describes this to the pregnant woman as?

LINEA NIGRA

A primigravida patient who is 12 weeks pregnant visits a helath promotion program in the community pertaining to the pregnancy care. A group of nursing student is educating the public about measures to prevent discomfort of pregnancy. The primigravida patient asks one of the student about measures on how to prevent heartburn she is experiencing throughout the day. Select all the necessary measures to prevent the primigravia patient's complaint. A. Eating small, frequent meals and avoiding fatty and spicy food B. Eating high fiber foods and increase drinking fluids C. Drinking milk between milk D. Arranging frequent rest periods throughout the day E. Sitting upright for 30 minutes after a meal F. Engaging in regular exercise

A, C, E

A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is best? A. home pregnancy test can be used right after your first missed period. B.These tests are most accurate after you have missed your second period. C. Home pregnancy tests often give false positives and should not be trusted. D . The test can provide accurate information when used right after ovulation.

A. A home pregnancy test can be used right after your first missed period.

The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception? A. Between the time the temperature falls and rises. B. Between 36 and 48 hours after the temperature rises. C. When the temperature falls and remains low for 36 hours. D. Within 72 hours before the temperature falls.

A. Between the time the temperature falls and rises.

Immediately after birth a newborn infant is suctioned, dried and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assesses an apical HR of 80 beats/minute and respirations of 20 breaths/min. What action should be performed next? A. Initiate positive pressure ventilation B . Intervene after one min Apgar is assessed. C. Initiate CPR on the infant D. Assess the infant's blood glucose level

A. Initiate positive pressure ventilation

Which nursing intervention is most helpful in relieving postpartum uterine contractions or "afterpains?" A. Lying prone with a pillow on the abdomen. B. Using a breast pump. C. Massaging the abdomen. D. Giving oxytocic medications.

A. Lying prone with a pillow on the abdomen.

client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first? A. Raise the foot of the bed. B.Assess for vaginal bleeding. C.Evaluate the fetal heart rate. D.Take the client's blood pressure.

A. Raise the foot of the bed.

Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client? A. The client's readiness to learn. B. The client's educational background. C. The order in which the information is presented. .DThe extent to which the pregnancy was planned.

A. The client's readiness to learn.

A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming to the unit suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate. A. dark,red vaginal bleeding B. lower back pain C. premature rupture of membranes D. increased uterine irritability E. bilateral pitting edema F. Rigid abdomen

A. dark,red vaginal bleeding D. increased uterine irritability F. Rigid abdomen

The healthcare provider prescribes terbutaline for a client in preterm labor. Before initating this prescription, it is most important for the nurse to assess the client for which of condition. A. gestational diabetes B. Elevated BP C. UTI D> Swelling in lower extremities

A. gestational diabetes

A 42 week gestational client is receiving an intravenous infusion of oxytocin(Pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for with pattern of contractions? A. transition labor with contractions every 2 mins, lasting 90 seconds each. B. early labor with contractions every 5 min, lasting 40 seconds each. C. Active labor with contractions every 31 mins, lasting 60 seconds each. D. Active labor with contraction every 2 to 3 mins, lasting 70 to 80 seconds each.

A. transition labor with contractions every 2 mins, lasting 90 seconds each.

The nurse is assessing a 3 day old infant with a cephalohematoma in the newborn nursery. Which assessment finding should the nurse report to the healthcare provider? A. yellowish tinge to the skin B. babinski reflex present bilaterally C. pink papular rash on the face D. moro reflex noted after a loud noise

A. yellowish tinge to the skin

The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40-weeks. What findings should the nurse identify to determine if the neonate is small for gestational age (SGA)? (Select all that apply.) A.Admission weight of 4 pounds, 15 ounces (2244 grams) B.Head to heel length of 17 inches (42.5 cm). C.Frontal occipital circumference of 12.5 inches (31.25 cm). D.Skin smooth with visible veins and abundant vernix. E.Anterior plantar crease and smooth heel surfaces. F. Full flexion of all extremities in resting supine position.

A.Admission weight of 4 pounds, 15 ounces (2244 grams) B.Head to heel length of 17 inches (42.5 cm). C.Frontal occipital circumference of 12.5 inches (31.25 cm).

A vaginally delivered infant of an HIV positive mother is admitted to the newborn nursery. What intervention should the nurse perform first?

A.Bathe the infant with an antimicrobial soap. B.Measure the head and chest circumference. C. Obtain the infant's footprints. D. Administer vitamin K (AquaMEPHYTON).

A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? A.Come to the clinic today for an ultrasound. B.Go immediately to the emergency room. C.Lie on your left side for about one hour and see if the bleeding stops. D.Bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection.

A.Come to the clinic today for an ultrasound.

A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide this client? A.Complete bedrest decreases oxygen needs and demands on the heart muscle tissue. B.We want your baby to be healthy, and this is the only way we can make sure that will happen. C.I know you're upset. Would you like to talk about some things you could do while in bed? D.Labor is difficult and you need to use this time to rest before you have to assume all child-caring duties.

A.Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.

The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern? A.Edema, basilar rales, and an irregular pulse. B. Increased urinary output and tachycardia. C.Shortness of breath, bradycardia, and hypertension. D.Regular heart rate and hypertension.

A.Edema, basilar rales, and an irregular pulse.

The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at 8-weeks gestation. What type of emotional response should the nurse anticipate? A.Grief related to her perceptions about the loss of this child. B.Relief of ambivalent feelings experienced with this pregnancy. C.Shock because she may not have realized that she was pregnant. D. Guilt because she had not followed her healthcare provider's instructions.

A.Grief related to her perceptions about the loss of this child.

Which nursing intervention is helpful in relieving "afterpains" (postpartum uterine contractions)? A.Using relaxation breathing techniques. B.Using a breast pump. C.Massaging the abdomen. D.Giving oxytocic medications.

A.Using relaxation breathing techniques.

The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs A.two weeks before menstruation. B.immediately after menstruation. immediately before menstruation. C. immediately before menstruation. D. three weeks before menstruation.

A.two weeks before menstruation.

28 year old client in active labor complains of cramps in her leg.What intervention should the nurse implement. A. massage the calf and foot B. extend the leg and dorsiflex the foot C. lower the leg off the side of the bed D. elevate the leg above the heart.

B. Extend the leg and dorsiflex the foot.

Q.12) A nurse is collecting data during the admission asessment of a client who is pregnant with twins. The client also has 5 year old child. The nurse would document which gravida and para status on this client? A. G1P1 B. G2P1 C. G2P2 D. G3P2

B

Which of the following prenatal laboratory test values would the nurse consider as significant? A. Hematocrit 33.5% B. Rubella titer less than 1:8 C. White blood cells 8,000/mm3 D. One hour glucose challenge test 110 g/dL

B Explanation A rubella titer should be 1:8 or greater. Thurs, a finding of a titer less than 1:8 is significant, indicating that the client may not possess immunity to rubella. A hematocrit of 33.5% a white blood cell count of 8,000/mm3, and a 1 hour glucose challenge test of 110 g/dl are with normal parameters.

A pregnant patient asks the nurse Kate if she can take castor oil for her constipation. How should the nurse respond? A. "Yes, it produces no adverse effect." B. "No, it can initiate premature uterine contractions." C. "No, it can promote sodium retention." D. "No, it can lead to increased absorption of fat-soluble vitamins."

B Explanation Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects, but it does not promote sodium retention. Castor oils is not known to increase absorption of fat-soluble vitamins, although laxatives in general may decrease absorption if intestinal motility is increased.

During which of the following would the focus of classes be mainly on physiologic changes, fetal development, sexuality, during pregnancy, and nutrition? A. post partum phase B. first trimester C. second trimester D. third trimester

B Explanation First-trimester classes commonly focus on such issues as early physiologic changes, fetal development, sexuality during pregnancy, and nutrition. Some early classes may include pregnant couples. Second and third trimester classes may focus on preparation for birth, parenting, and newborn care.

The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The LPN should tell the patient that she can expect to feel the fetus move at which time? A. Between 10 and 12 weeks' gestation B. Between 16 and 20 weeks' gestation C. Between 21 and 23 weeks' gestation D. Between 24 and 26 weeks' gestation

B Explanation A pregnant woman usually can detect fetal movement (quickening) between 16 and 20 weeks' gestation. Before 16 weeks, the fetus is not developed enough for the woman to detect movement. After 20 weeks, the fetus continues to gain weight steadily, the lungs start to produce surfactant, the brain is grossly formed, and myelination of the spinal cord begins.

Which of the following would the nurse identify as a presumptive sign of pregnancy? A. Hegar sign B. Nausea and vomiting C. skin pigmentation changes D. positive serum pregnancy test

B Explanation resumptive signs of pregnancy are subjective signs. Of the signs listed, only nausea and vomiting are presumptive signs. Hegar sign, skin pigmentation changes, and a positive serum pregnancy test are considered probably signs, which are strongly suggestive of pregnancy.

A client at 36 weeks' gestation is schedule for a routine ultrasound prior to an amniocentesis. After teaching the client about the purpose for the ultrasound, which of the following client statements would indicate to the nurse in charge that the client needs further instruction? A. The ultrasound will help to locate the placenta B. The ultrasound identifies blood flow through the umbilical cord C. The test will determine where to insert the needle D. The ultrasound locates a pool of amniotic fluid

B. Explanation Before amniocentesis, a routine ultrasound is valuable in locating the placenta, locating a pool of amniotic fluid, and showing the physician where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this.

A 25-year-old client with diabetes type I visits the clinic to discuss her and her husband's desire to start a family. This diabetic client A. should be discouraged from becoming pregnant B. has a greater risk of complications during pregnancy C. should be informed about treatment for infertility D. will be able to carry out a completely normal pregnancy

B. Explanation Clients with DM are at greater risk for developing maternal and fetal complications during pregnancy.

The nurse caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention? A. Emptying the bladder during delivery is difficult because of the position of the presenting fetal part. B. An over-distended bladder could be traumatized during labor as well as prolong the progress of labor. C.Urine specimens for glucose and protein must be obtained at certain intervals throughout labor. D. Frequent voiding minimizes the need for catheterization which increases the chance of bladder infection.

B. An over-distended bladder could be traumatized during labor as well as prolong the progress of labor.

During a lecture on reproduction, a student nurse asks the instructor what determines the sex of a fetus. Accurate information in response to this question would be: A. "The sex of the fetus is not determined until the eighth week of gestation." B. "The fertilization of the zygote is the point at which sex is determined." C. "Males have one less pair of chromosomes than females." D. "Sex is determined by the chromosomes contributed by the ovum."

B. Explanation The sex of the fetus is determined at the point that the sperm fertilizes the ovum to form the zygote. Sex is ultimately determined by the chromosome contributed by the sperm.

A 28-year-old client in active labor complains of cramps in her leg. What intervention should the nurse implement? A. Massage the calf and foot. B. Extend the leg and dorsiflex the foot C. Lower the leg off the side of the bed. D. Elevate the leg above the heart.

B. Extend the leg and dorsiflex the foot

A full term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn? a. Length of labor and method of delivery b. Infant's condition at birth and treatment received. C. Feeding method chosen by the parents. D. History of drugs given to the mother during labor.

B. Infant's condition at birth and treatment received.

client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge? A. Supplementary iron is more efficiently utilized during pregnancy. B. It is difficult to consume 18 mg of additional iron by diet alone. C. Iron absorption is decreased in the GI tract during pregnancy. D. Iron is needed to prevent megaloblastic anemia in the last trimester.

B. It is difficult to consume 18 mg of additional iron by diet alone.

A client with gestational htn is an active labor and receiving an infusion of magnesium sulfate. Which drug should the nurse available for signs of potential toxicity? A. oxytocin B. calcium gluconate C. terbutaline D. naloxone 9

B. calcium gluconate

30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks' gestation in preterm labor. She is given a dose of terbutaline sulfate (Brethine) 0.25 mg subcutaneous. Which assessment is the highest priority for the nurse to monitor during the administration of this drug? A. Maternal blood pressure and respirations. B.Maternal and fetal heart rates. C.Hourly urinary output. D.Deep tendon reflexes.

B.Maternal and fetal heart rates.

A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation should the nurse provide? A.Weigh the baby daily, and if she is gaining weight, she is eating enough. B.Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day. C.Offer the baby extra bottle milk after her feeding, and see if she is still hungry. D.If you're concerned, you might consider bottle feeding so that you can monitor her intake.

B.Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day.

The nurse should explain to a 30 year old gravid client that alpha fetoprotein testing is recommended for which purpose? A.detect cardiovascular disorders B.screen for neural tube defects c .monitor the placental functioning d. assess for maternal pre-eclampsia

B.screen for neural tube defects

The LPN is preparing to administer Solu-medrol 40 mg mixed in 150 mL of sodium chloride via intravenous piggyback. The medication is to be administered over 30 minutes. Using the tubing with a drop factor of 15 ggts/mL, what would the LPN calculate the rate to be in drops per minute? A. 40 B. 50 C. 75 D. 150

C

The hormone responsible for the development of the ovum during the menstrual cycle is? A. estrogen B. progesterone C. follicle stimulating hormone (Correct Answer) D. leutenizing hormone (Your Answer)

C

A client LMP began July 5. Her EDD should be which of the following? A. January 2 B. March 28 C. April 12 D. October 12

C Explanation To determine the EDD when the date of the client's LMP is known use Nagele rule. To the first day of the LMP, add 7 days, subtract 3 months, and add 1 year (if applicable) to arrive at the EDD as follows: 5 + 7 = 12 (July) minus 3 = 4 (April). Therefore, the client's EDD is April 12.

Heartburn and flatulence, common in the second trimester, are most likely the result of which of the following? A. increased plasma HCG levels B. decreased intestinal motility C. decrease gastric acidity D. elevated estrogen levels

C Explanation During the second trimester, the reduction in gastric acidity in conjunction with pressure from the growing uterus and smooth muscle relaxation, can cause heartburn and flatulence. HCG levels increase in the first, not the second, trimester. Decrease intestinal motility would most likely be the cause of constipation and bloating. Estrogen levels decrease in the second trimester.

Which of the following represents the average amount of weight gained during pregnancy? A. 12 to 2 lbs B. 15 to 25 lbs C. 25 to 35 lbs D. 25 to 40 lbs

C Explanation The average amount of weight gained during pregnancy is 25 to 35 lb. This weight gain consists of the following: fetus - 7.5 lb; placenta and membrane - 1.5 lb; amniotic fluid - 2 lb; uterus - 2.5 lb; breasts - 3 lb; and increased blood volume - 2 to 4 lb; extravascular fluid and fat - 4 to 9 lb. A gain of 12 to 22 lb is insufficient, whereas a weight gain of 15 to 25 lb is marginal. A weight gain of 25 to 40 lb is considered excessive.

When talking with a pregnant client who is experiencing aching swollen, leg veins, the nurse would explain that this is most probably the result of which of the following? A. thrombophlebitis B. pregnancy induced hypertension C. pressure on blood vessels from the enlarging uterus D. the force of gravity pulling down on the uterus

C - Explanation Pressure of the growing uterus on blood vessels results in an increased risk for venous stasis in the lower extremities. Subsequently, edema and varicose vein formation may occur. Thrombophlebitis is an inflammation of the veins due to thrombus formation. Pregnancy-induced hypertension is not associated with these symptoms. Gravity plays only a minor role with these symptoms.

The nurse identifies substance abuse behaviors exhibited by a pregnant client during an initial prenatal screening. While promoting a therapeutic and accepting environment, the care managment by the nurse would be MOST appropriate if focused on which of the following? A. Discouraging substance use during pregnancy B. Termination of the pregnancy at an early stage C. Eliminating substance use during pregnancy D. Setting boundaries with the client in regards to substance use

C. Explanation Use of substances during pregnancy can lead to severe fetal or neonatal abnormalities, complications, and death. The primary goal of nursing care should be prevention or elimination of substance use during pregnancy.

Cervical softening and uterine souffle are classified as which of the following? A. diagnostic signs B. presumptive signs C. probable signs D. positive signs

C. Explanation Cervical softening (Goodell sign) and uterine soufflé are two probable signs of pregnancy.Probable signs are objective findings that strongly suggest pregnancy. Other probable signs include Hegar sign, which is softening of the lower uterine segment; Piskacek sign, which is enlargement and softening of the uterus; serum laboratory tests; changes in skin pigmentation; and ultrasonic evidence of a gestational sac. Presumptive signs are subjective signs and include amenorrhea; nausea and vomiting; urinary frequency; breast tenderness and changes; excessive fatigue; uterine enlargement; and quickening.

A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The nurse plans to monitor for which primary side effect of terbutaline sulfate? A. Drowsiness and bradycardia. B. Depressed reflexes and increased respirations. C. Tachycardia and a feeling of nervousness. D. A flushed, warm feeling and a dry mouth

C. Tachycardia and a feeling of nervousness.

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny looking head." Which response by the nurse is best? A.This is not an unusual shaped head, especially for a first baby. B.It may look funny to you, but newborn babies are often born with heads like your baby's. C. That is normal; the head will return to a round shape within 7 to 10 days. D.Your pelvis was too small, so the baby's head had to adjust to the birth canal.

C. That is normal; the head will return to a round shape within 7 to 10 days.

A 4 week old premature infant has been receiving epoetin alfa for the last 3 weeks. WHich assessment finding indicates to the nurse that the drug is effective. A.slowly increasing urinary output over the last week B.rr changes from 40s to the 60s C. changes in apical HR from the 180 to the 140 D.Change in indirect bilirubin from 12mg/dl to 8mg/dl.

C. changes in apica HR from the 180 to the 140

A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pads are completely saturated a nd the client is lying in a 6inch diameter pool of blood. A. Cleanse the perineum B. obtain a BP C. palpate the firmness of the fundus D; inspect the perineum for lacerations

C. palpate the firmness of the fundus

A client at 32-weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates the therapeutic drug level has been achieved? A. 4+ reflexes. B.Urinary output of 50 ml per hour. C.A decrease in respiratory rate from 24 to 16. D. A decreased body temperature.

C.A decrease in respiratory rate from 24 to 16.

A newborn infant is brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. What action should the nurse take first? A.Notify the pediatrician immediately. B.Suction the infant's nares, then the oral cavity. C.Check the infant's oxygen saturation rate. D.Position the infant on the right side.

C.Check the infant's oxygen saturation rate.

A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness? A. Wear a cotton bra. B. Increase nursing time gradually. C.Correctly place the infant on the breast. D.Manually express a small amount of milk before nursing.

C.Correctly place the infant on the breast.

The total bilirubin level of a 36-hour, breastfeeding newborn is 14 mg/dl. Based on this finding, which intervention should the nurse implement? A.Provide phototherapy for 30 minutes q8h. B. Feed the newborn sterile water hourly. C.Encourage the mother to breastfeed frequently. D.Assess the newborn's blood glucose level.

C.Encourage the mother to breastfeed frequently.

The nurse is teaching breastfeeding to prospective parents in a childbirth education class. Which instruction should the nurse include as content in the class? A.Begin as soon as your baby is born to establish a four-hour feeding schedule. B.Resting helps with milk production. Ask that your baby be fed at night in the nursery. C.Feed your baby every 2 to 3 hours or on demand, whichever comes first. D. Do not allow your baby to nurse any longer than the prescribed number of minutes.

C.Feed your baby every 2 to 3 hours or on demand, whichever comes first.

At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse implement next?A. Check the hematocrit results. B. Administer pain medication. C.Increase the rate of IV fluids. D.Monitor client for contractions.

C.Increase the rate of IV fluids.

A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first? A.Provide oral hydration. B.Have a complete blood count (CBC) drawn. C.Obtain a specimen for urine analysis. D.Place the client on strict bedrest.

C.Obtain a specimen for urine analysis.

Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action should the nurse take? A. Notify the healthcare provider or anesthesiologist immediately. B.Continue to assess the blood pressure q5 minutes. C.Place the woman in a lateral position. D.Turn off the continuous epidural.

C.Place the woman in a lateral position.

A couple, concerned because the woman has not been able to conceive, is referred to a healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which postprocedure complaint indicates that the fallopian tubes are patent? A.Back pain B.Abdominal pain. C.Shoulder pain. D. Leg cramps.

C.Shoulder pain.

The nurse is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding? A.Two vessels: one artery and one vein. B.Two vessels: two arteries and no veins. C.Three vessels: two arteries and one vein. D.Three vessels: two veins and one artery

C.Three vessels: two arteries and one vein.

When preparing a class on newborn care for expectant parents, what content should the nurse teach concerning the newborn infant born at term gestation? A.Milia are red marks made by forceps and will disappear within 7 to 10 days. B.Meconium is the first stool and is usually yellow gold in color. C.Vernix is a white, cheesy substance, predominantly located in the skin folds. D.Pseudostrabismus found in newborns is treated by minor surgery.

C.Vernix is a white, cheesy substance, predominantly located in the skin folds.

The nurse should encourage the laboring client to begin pushing when A.there is only an anterior or posterior lip of cervix left. B.the client describes the need to have a bowel movement. C.the cervix is completely dilated. D.the cervix is completely effaced.

C.the cervix is completely dilated.

During which of the following phase of the menstrual cycle is it ideal for implantation of a fertilized egg to occur? A. ischemic phase B. mentrual phase C. proliferative phase D. secretory phase

D

A client is pregnant with her third child. Medical history of the client indicates a previous precipitate labor and birth. Which of the following interventions would NOT be expected during labor of the present pregnancy? A. Use of magnesium sulfate B. Close monitoring of the fetus for hypoxia C. The nurse stays at the bedside constantly or as much as possible D. amnioinfusion will be performed

D Explanation Amnioinfusion is instillation of fluid into the amniotic sac within the uterus to treat oligohydraminios. This is not done to prevent precipitate labor and birth.

The LPN has initiated the administration of vancomycin via IV piggyback . In which of the following situations should the nurse recognize that the client may be experiencing a fatal reaction to this medication? A. The client start coughing B. The client complains of pain at the intravenous catheter insertion site C. The nurse hears the client snoring from the hall D. The nurse notices the client's neck and chest is bright red

D Explanation While administering vancomycin the LPN should know to monitor the client carefully for the development of Red Man Syndrome or anaphylactic shock. The common side effects of this medicine are pruritus, flushing and erythema to the head, neck, and upper body.

31) During the prenatal visit, the client states that she has been experiencing heartburn frequently. The LPN provides instruction on the cause and prevention of heartburn. When she ask to verbalize understanding of the information, which of the following statements by the client indicates further instruction may be necessary? A. "The sphincter that normally prevents stomach contents from going back up into the esophagus is relaxed." B. "I should try to avoid drinking fluids while I'm eating." C. "Eating six or seven small meals a day may help my symptoms." D. "I'll eat enough to ensure that I am full at every meal."

D Explanation It suggests that the instruction might need to be reinforced on preventing stomach distention.

A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing hx, the client indicates that she has delivered premature twins, one full term baby and has had no abortions. Which GTPAL should the nurse document in this client's record? A. 3-1-2-0-3 B. 4-1-2-0-3 C. 2-1-2-1-2 D. 3-1-1-0-3

D. 3-1-1-0-3

When assessing a client who is at 12 week gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? A. at 16 weeks gestation B.at 20 weeks gestation C. at 24 weeks gestation D. at 30 weeks gestation

D. At 30 weeks gestation.

What action should the nurse implement to decrease the client's risk for hemorrhage after c-section. A. Monitor urinary output via an indwelling catheter. B. assess the abdominal dressings for drainage. C. Give the Ringer's lactated infusion at 125ml D. Check the firmness of the uterus every 15mins.

D. Check the firmness of the uterus every 15mins.

Pediazole is a suspension medication that contains 200 mg erythromycin and 600 mg sulfisoxazole per 5 mL. The physician orders Pediazole 4 mL PO every 12 hours. How many mg of sulfisoxazole is this client receiving in a 24-hour period? A. 160 mg B. 320 mg C. 480 mg D. 960 mg

D. Explanation 600 mg/ 5 mL = x mg/ 4 mL 2400 = 5x x= 2400/5 x= 480 mg per dose x 2 = 960 mg in 24 hours.

In developing a teaching plan for expectant parents the nurse plans to include formation about when the parents can expect the infants fontanels to close. The nurse bases the explanation on knowledge that for the normal newborn, the A. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week. B. anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week. C. anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month. D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month

D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month

After each feeding, a 3-day-old newborn is spitting up large amounts of Enfamil® Newborn Formula, a nonfat cow's milk formula. The pediatric healthcare provider changes the neonate's formula to Similac® Soy Isomil® Formula, a soy protein isolate based infant formula. What information should the nurse provide to the mother about the newly prescribed formula? A.The new formula is a coconut milk formula used with babies with impaired fat absorption. B.Enfamil® Formula is a demineralized whey formula that is needed with diarrhea. C. The new formula is a casein protein source that is low in phenylalanine. D. Similac® Soy Isomil® Formula is a soy-based formula that contains sucrose.

D. Similac® Soy Isomil® Formula is a soy-based formula that contains sucrose.

A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important for the nurse to provide this client? A.Elevate lower legs while resting. b.Increase caloric intake by 200 to 300 calories per day. c.Increase water intake to 8 full glasses per day. d.Take prescribed multivitamin and mineral supplements.

D. Take prescribed multivitamin and mineral supplements.

In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The nurse bases the explanation on knowledge that for the normal newborn, the A. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week. B.anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week. C.anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month. D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.

D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.

A 40 week gestation primigravida client is being induced with an ocytocin secondary infusion and complains of pain in her lower back. Which intervention should the nurse implement? A. Discontinue the oxytocin infusion B. place the client in a semi-fowler's position C. inform the healthcare provider D. apply firm pressure to sacral area

D. apply firm pressure to sacral area

Which assessment finding should the nursery nurse report to the pediatric healthcare provider? A. blood glucose level of 45mg/dl B. blood pressure of 82/45 mmHG C. Non bulging anterior fontanel D. central cyanosis when crying

D. central cyanosis when crying

When assessing a client who is at 12-weeks gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? A.At 16-weeks gestation. B.At 20-weeks gestation. C.At 24-weeks gestation. D.At 30-weeks gestation.

D.At 30-weeks gestation.

An expectant father tells the nurse he fears that his wife "is losing her mind." He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father? A. Reassure him that these are normal reactions to pregnancy and suggest that he discuss his concerns with the childbirth education nurse. B.Help him to understand that his wife is experiencing normal symptoms of ambivalence about the pregnancy and no action is needed. C. Ask him to observe his wife's behavior carefully for the next few weeks and report any similar behavior to the nurse at the next prenatal visit. D.Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement.

D.Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement.

A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant? A. Encourage the mother to provide total care for her infant. B. Provide privacy so the mother can develop a relationship with the infant. C. Encourage the father to provide most of the infant's care during hospitalization. D.Meet the mother's physical needs and demonstrate warmth toward the infant.

D.Meet the mother's physical needs and demonstrate warmth toward the infant.

Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention is best for the nurse to implement first? A.Assess the husband's feelings about his wife's decision to breastfeed their baby. B.Ask the client to describe why she was unsuccessful with breastfeeding her last child. C.Encourage the client to develop a positive attitude about breastfeeding to help ensure success. D.Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.

D.Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.

An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? A.Use a thread to tie off the umbilical cord. B.Provide as much privacy as possible for the woman. C.Reassure the husband and try to keep him calm. D.Put the newborn to breast

D.Put the newborn to breast

A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot." Which explanation should the nurse give to this anxious client? A.Some care is required when touching the large soft area on top of your baby's head until the bones fuse together. B.That's just an 'old wives' tale' so don't worry, you can't harm your baby's head by touching the soft spot. C.The soft spot will disappear within 6 weeks and is very unlikely to cause any problems for your baby. D.There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair.

D.There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair.

A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate toxicity? A.Deep tendon reflexes 2+. B.Blood pressure 140/90. C.Respiratory rate 18/minute. D.Urine output 90 ml/4 hours.

D.Urine output 90 ml/4 hours.

During a prenatal visit, the nurse discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have A. lower Apgar scores. B. lower birth weights. C. respiratory distress. D. a higher rate of congenital anomalies.

Move about every hour.

A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the healthcare provider immediately. A.heart rate of 100 beats min B. variable fetal HR C. Onset of uterine contractions D. Burning on urination

Onset of uterine contractions.

Ativan 0.5 mg IM every 1 hour as needed is prescribed for a client experiencing delirium tremens. The medication vial reads 2mg/mL of solution. How many mL should the LPN draw into the syringe for single dose administration?

Possible correct answers: 0.25 mL0.25mL0.25ml0.25 ml Explanation 2mg/mL= 0.5mg/xmL 2x=0.5 x=0.5/2 x=0.25 mL

The nurse is performing a AGA on a full-term newborn during the first hour of transition using the Dubowitz scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40 weeks. Which findings should the nurse identify to determine if the neonate is SGA? (Select all that apply.) a. admission weight of 4 lbs 15 oz b. head to heel length of 17 in c. frontal occipital circumference of 12.5 in d. skin smooth with visible veins and abundant vernix e. anterior plantar crease and smooth heel surfaces f. full flexion of all extremities in resting supine position

a, b, c

When explaining postpartum blues to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (select all that apply) a. panic attacks b. tearfulness c. decreased need for sleep d. mood swings e. disinterest in the infant

b, d

A full-term infant is admitted to the newborn nursery and, after careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms is this newborn likely to have exhibited? a. Choking, coughing, and cyanosis. b. Projectile vomiting and cyanosis. c. Apneic spells and grunting. d. organomegaly.

a. Choking, coughing, and cyanosis.

A woman with Type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement? a. Describe diet changes that can improve the management of her diabetes. b.Inform the client that oral hypoglycemic agents are teratogenic during pregnancy. c. Demonstrate self-administration of insulin. d. Evaluate the client's ability to do glucose monitoring.

a. Describe diet changes that can improve the management of her diabetes.

On admission to the prenatal clinic, a 23 year old woman tells the nurse that her last menstrual period began on February 15 that previously her periods were regular. Her pregnancy test is positive. This client's expected date of delivery a. November 22 b. November 8 c. December 22 d. October 22

a. November 22

A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask wen she could use a home pregnancy test to diagnose pregnancy. Which response is best? a. a home pregnancy test can be used right after your first missed period b. these tests are most accurate after you have missed your second period c. home pregnancy tests often give false positives and should not be trusted d. the test can provide accurate information when used right after ovulation

a. a home pregnancy test can be used right after your first missed period

A mutigravida client at 41 weeks gestation present in the labor and delivery unit after a non-stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status? a. biophysical profile b. ultrasound for fetal abnormalities c. maternal serum alpha-fetoprotein screening d. percutaneous umbilical blood sampling

a. biophysical profile

A client at 28 weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? a. come to the clinic today for an ultrasound b. go immediately to the emergency room c. lie on your left side for about one hour and see if the bleeding stops d. bring a urine specimen to the lab tomorrow to determine if you have a UTI

a. come to the clinic today for an ultrasound

Immediately after birth a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assess an apical heart rate of 80 bpm and respirations 20. What action should the nurse perform next? a. initiate positive pressure ventilation b. intervene after one minute APGAR is assessed c. initiate CPR on the infant d. assess the infant's blood glucose level

a. initiate positive pressure ventilation

A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care? a. patellar reflex 4+ b. blood pressure 158/80 c. four hour urine output 240 ml d. respiration 12/minute

a. patellar reflex 4+

A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first? a. raise the foot of the bed b. assess for vaginal bleeding c. evaluate the fetal heart rate d. take the client's blood pressure

a. raise the foot of the bed

A couple concerned because the woman has not been able to conceive is referred to a HCP for a fertility workup and a hysterosalpingography is scheduled. Which postprocedure complaint indicates that the fallopian tubes are patent? a. shoulder pain b. leg cramps c. back pain d. abdominal pain

a. shoulder pain

The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurses should know that ovulation usually occurs a. two weeks before menstruation b. immediately after menstruation c. immediately before menstruation d. three weeks before menstruation

a. two weeks before menstruation

Which nursing intervention is helpful in relieving "afterpains"? a. using relaxation breathing techniques b. using a breast pump c. massaging the abdomen d. giving oxytocic medications

a. using relaxation breathing techniques

The nurse is assessing a 3 day old infant with a cephalohematoma in the newborn nursery. Which assessment finding should the nurse report to the healthcare provider? a. yellowish tinge to the skin b. Babinski reflex present bilaterally c. pink papular rash on the face d. Moro reflex noted after a loud noise

a. yellowish tinge to the skin

A multigravida client at 41-weeks gestation presents in the labor and delivery unit after a non-stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status? a.Biophysical profile (BPP). t b.Ultrasound for fetal anomalies. c.Maternal serum alpha-fetoprotein (AF) screening d.Percutaneous umbilical blood sampling (PUBS).

a.Biophysical profile (BPP).

When explaining "postpartum blues" to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (Select all that apply.) a.Mood swings. b.Panic attacks. c.Tearfulness d.Decreased need for sleep. e. Disinterest in the infant

a.Mood swings. c.Tearfulness

On admission to the prenatal clinic, a 23-year-old woman tells the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. This client's expected date of delivery (EDD) is a.November 22. b.November 8. c.December 22. d.October 22.

a.November 22.

A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for which pattern of contractions? a.Transition labor with contractions every 2 minutes, lasting 90 seconds each. b.Early labor with contractions every 5 minutes, lasting 40 seconds each. c.Active labor with contractions every 31 minutes, lasting 60 seconds each. d.Active labor with contractions every 2 to 3 minutes, lasting 70 to 80 seconds each.

a.Transition labor with contractions every 2 minutes, lasting 90 seconds each.

the nurse is assessing a 3-day old infant with a cephalohematoma in the newborn nursery. Which assessment finding should the nurse report to the healthcare provider? a.Yellowish tinge to the skin. b. Babinski reflex present bilaterally. c.Pink papular rash on the face. d.Moro reflex noted after a loud noise.

a.Yellowish tinge to the skin.

hich maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time? a. She eagerly reaches for the infant, undresses the infant, and examines the infant completely. b. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. c. Her arms and hands receive the infant and she then cuddles the infant to her own body. She eagerly reaches for the infant and then holds the infant close to her own body.

b. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips.

A pregnant client tells the nurse that the first day of her last menstrual period was August 2, 2006. Based on Nagele's rule, what is the estimated date of delivery? a. April 25, 2007 b. May 9, 2007 c. May 29, 2007 d. June 2, 2007

b. May 9, 2007

A client who has an autosomal dominant inherited disorder is exploring family planning options and the risk of transmission of the disorder to an infant. The nurses's response should be based on what information? a. males inherit the disorder with a greater frequency than females b. each pregnancy carries a 50% chance of inheriting the disorder c. the disorder occurs in 25% of pregnancies d. all children will be carriers of the disorder

b. each pregnancy carries 50% chance of inheriting the disorder

A 28 year old client in active labor complains of cramps in her leg. What intervention should the nurse implement? a. massage the calf and foot b. extend the leg and dorsiflex the foot c. lower the leg off the side of the bed d. elevate the leg above the heart

b. extend the leg and dorsiflex the foot

A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge? a. iron absorption is decreased in the GI tract during pregnancy b. it is difficult to consume 18 mg of additional iron by diet alone c. iron is needed to prevent megaloblastic anemia in the last trimester d. supplementary iron is more efficiently utilized during pregnancy

b. it is difficult to consume 18 mg of additional iron by diet alone

A 38 week primigravida who works as a secretary and sits at a computer 8 hrs each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling blood in the lower extremities? a. avoid constrictive clothing b. move every hour c. wear support stockings d. reduce salt in her diet

b. move every hour

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny looking head." Which response by the nurse is best? a. this is not an unusual shaped head especially for a first baby b. that is normal the head will return to a round shape within 7 to 10 days c. it may look funny to you but newborn babies are often born with heads like your baby's d. your pelvis was too small so the baby's head had to adjust to the birth canal

b. that is normal the head will return to a round shape within 7 to 10 days

A new mother asks the nurse "How do I know that my daughter is getting enough breast milk?" Which explanation should the nurse provide? a. weigh the baby daily and if she is gaining weight she is eating enough b. your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day c. offer the baby extra bottle milk after her feeding and see if she is still hungry d. if you're concerned you might consider bottle feeding so that you can monitor her intake

b. your milk is sufficient if the bay is voiding pale straw-colored urine 6 to 10 times a day

A client who has an autosomal dominant inherited disorder is exploring family planning options and the risk of transmission of the disorder to an infant. The nurse's response should be based on what information? a.Males inherit the disorder with a greater frequency than females. b.Each pregnancy carries a 50% chance of inheriting the disorder. c.The disorder occurs in 25% of pregnancies. d.All children will be carriers of the disorder.

b.Each pregnancy carries a 50% chance of inheriting the disorder.

A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which adverse effect should the nurse monitor for during the infusion of Pitocin? a.Dehydration. b.Hyperstimulation. c. Galactorrhea. d.Fetal tachycardia.

b.Hyperstimulation.

tells the nurse that she want to have an uncomplicated pregnancy and a healthy baby. What information should the nurse share with the client? a.Your current dose of Insulin should be maintained throughout your pregnancy. b.Maintain blood sugar levels in a constant range within normal limits during pregnancy. c.The course and outcome of your pregnancy is not an achievable goal with diabetes. d.Expect an increase in insulin dosages by 5 units/week during the first trimester.

b.Maintain blood sugar levels in a constant range within normal limits during pregnancy.

The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take? a.Ask the mother why she won't look at the infant. b.Observe the mother for other attachment behaviors. c.Examine the newborn's eyes for the ability to focus. d.Recognize this as a common reaction in new mothers.

b.Observe the mother for other attachment behaviors.

The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse correctly calculates that the woman's next fertile period is a.January 14-15. b.January 22-23. c.January 30-31. d.February 6-7.

c. January 30-31.

A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most likely presenting symptom for a pediatric client with AIDS is: a. shortness of breath b. joint pain c. a persistent cold d. organmegaly

c. a persistent cold

A 4 week old premature infant has been receiving epoetin alfa for the last three weeks. Which assessment finding indicates to the nurse that the drug is effective? a. slowly increasing urine output over the last week b. respiratory rate changes from the 40s to the 60s c. changes in apical heart rate from the 180 to the 140s d. change in indirect bilirubin from 12 mg/dl to 8 mg/dl

c. changes in apical rate from the 180s to the 140s

A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!" The nurse performs a vaginal examination that reveals the cervix is 3 cm dilated and 75% effaced. What additional information is most important for the nurse to obtain? a. gravidity and parity b. time and amount of last oral intake c. date of last normal menstrual period d. frequency and intensity of contractions

c. date of last normal menstrual period

The total bilirubin level of a 36 hour breastfeeding newborn is 14 mg/dl. Based on this finding which intervention should the nurse implement? a. feed the newborn sterile water hourly b. assess the newborn's blood glucose level c. provide phototherapy for 30 mins q8h d. encourage the mother to breastfeed frequently

c. encourage the mother to breastfeed frequently

The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling finger and dizziness. What action should the nurse take? a. administer o2 by face mask b. notify the HCP for the client's syndrome c. have the client breathe into her cupped hands d. check the client's BP and fetal HR/

c. have the client breathe into her cupped hands.

At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse implement next? a. Check the hematocrit results. b. Administer pain medication. c. Increase the rate of IV fluids. d. Monitor client for contractions.

c. increase the rate of IV fluids

During a prenatal visit, the nurse discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have a. a higher rate of congenital abnormalities b. respiratory distres c. lower birth weights d. lower APGAR scores

c. lower birth weights

The nurse assess a client admitted to the labor and delivery unit and obtains the following data: BP 110/68, FHR 110 bpm, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement? a. insert a fetal monitor b. assess for cervical changes q1H c. monitor bleeding from IV sites d. perform Leopold's maneuvers

c. monitor for bleeding from IV sites

The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take? a. recognize this is a common reaction in new mothers b. ask the mother why she won't look at the infant c. observe the mother for other attachment behaviors d. examine the newborn's eyes for the ability to focus

c. observe the mother for other attachment behaviors

Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action should the nurse take? a. notify the healthcare provider or anesthesiologist b. continue to assess the blood pressure q5min c. place the woman in a lateral position d. turn off continuous epidural

c. place the woman in a lateral position

An off-duty finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? a. provide as much privacy as possible for the woman b. use a thread to tie off the umbilical cord c. put the newborn to breast d. reassure the husband and try to keep him calm

c. put the newborn to breast

A 24-hour-old newborn has a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action should the nurse implement? a.Notify the healthcare provider. b.Move the newborn to an isolation nursery. c.Document the finding in the infant's record. d.Obtain a culture of the vesicles.

c.Document the finding in the infant's record.

The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn. Which infectious organism will this treatment prevent from harming the infant? a.Herpes. b.Staphylococcus c.Gonorrhea. d. Syphilis.

c.Gonorrhea.

A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the healthcare provider immediately? a.Heart rate of 100 beats/minute. b.Variable fetal heart rate. c.Onset of uterine contractions. d.Burning on urination.

c.Onset of uterine contractions.

A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pads are completely saturated and the client is lying in a 6-inch diameter pool of blood. Which action should the nurse implement next? a.Cleanse the perineum. b.Obtain a blood pressure. c.Palpate the firmness of the fundus d. Inspect the perineum for lacerations.

c.Palpate the firmness of the fundus

The nurse observes a new mother is rooming-in and caring for her newborn infant. Which observation indicates the need for further teaching? a.Cuddles the baby close to her. b.Rocks and soothes the infant in her arms. c.Places the infant prone in the bassinet. d. Wraps the baby in a warm blanket after bathing.

c.Places the infant prone in the bassinet.

A 23-year-old client who is receiving Medicaid benefits is pregnant with her first child. Based on knowledge of the statistics related to infant mortality, which plan should the nurse implement with this client? a.Refer the client to a social worker to arrange for home care. b.Recommend perinatal care from an obstetrician, not a nurse-midwife. c.Teach the client why keeping prenatal care appointments is important. d.Advise the client that neonatal intensive care may be needed.

c.Teach the client why keeping prenatal care appointments is important.

Which assessment finding should the nursery nurse report to the pediatric healthcare provider? a.Blood glucose level of 45 mg/dl. b. Blood pressure of 82/45 mmHg. c.Non-bulging anterior fontanel. d.Central cyanosis when crying.

d.Central cyanosis when crying.

In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The nurse bases the explanation on knowledge that for the normal newborn, the a. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week b. anterior fontanel closes at 5 to 7 months and the posterior by the end of the week c. anterior fontanel closes at 8 to 11 months and the posterior by the end of the second week d. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month

d. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month

Which assessment finding should the nursery nurse report to the pediatric healthcare provider? a. blood glucose level of 45 b. blood pressure of 82/45 c. non-bulging anterior fontanel d. central cyanosis when crying

d. central cyanosis when crying

A newborn infant is brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. What action should the nurse take first? a. notify the pediatrician immediately b. position the infant on the right side c. suction the infant's nares then the oral cavity d. check the infant's oxygen saturation rate

d. check the infant's oxygen saturation rate

A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pads are completely saturated and the cline is lying in a 6 in diameter pool of blood. Which action should the nurse implement next? a. obtain a blood pressure b. inspect the perineum for lacerations c. cleanse the perineum d. palpate the firmness of the fundus

d. palpate the firmness of the fundus

After each feeding, a 3 day old newborn is spitting up large amounts of newborn formula, a nonfat cow's milk formula. The pediatric healthcare provider changes the neonates's formula to Similac. What information should the nurse provide to the mother about the newly prescribed formula? a. Enfamil formula is demineralized whey formula that is needed with diarrhea b. The new formula is a coconut milk formula used with babies with impaired fat absorption c. the new formula is a casein protein source that is low in phenylalanine d. similac is a soy based formula that contains sucrose

d. similac is a soy based formula that contains sucrose

A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important for the nurse to provide this client? a. elevate lower legs while resting b. increase caloric intake by 200 to 300 calories per day c. increase water intake to 8 full glasses per day d. take prescribed multivitamin and mineral supplements

d. take prescribed multivitamin and mineral supplements

A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider? a.Cervical dilation of 5 cm with 90% effacement. b.White blood cell count of 12,000/mm3. c.Hemoglobin of 12 mg/dl and hematocrit of 38%. d.A platelet count of 67,000/mm3.

d.A platelet count of 67,000/mm3.

What action should the nurse implement to decrease the client's risk for hemorrhage after a cesarean section? a.Monitor urinary output via an indwelling catheter. b.Assess the abdominal dressings for drainage. c.Give the Ringer's Lactated infusion at 125 ml/hr. d.Check the firmness of the uterus every 15 minutes.

d.Check the firmness of the uterus every 15 minutes.

the nurse is planning preconception care for a new female client. Which information should the nurse provide the client? a.Discuss various contraceptive methods to use until pregnancy is desired. b.Provide written or verbal information about prenatal care. c.Ask the client about risk factors associated with complications of pregnancy. d.Encourage healthy lifestyles for families desiring pregnancy.

d.Encourage healthy lifestyles for families desiring pregnancy.

A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide? a.Herbs are a cornerstone of good health to include in your treatment. b.Touch is also therapeutic in relieving discomfort and anxiety. c.Your healthcare provider should direct treatment options for herbal therapy. d.It is important that you want to take part in your care.

d.It is important that you want to take part in your care.

The nurse is calculating the estimated date of confinement (EDC) using Nägele's rule for a client whose last menstrual period started on December 1. Which date is most accurate? a.August 1. b.August 10. c.September 3. d.September 8.

d.September 8.

While breastfeeding, a new mother strokes the top of her baby's head and asks the nurse about the baby's swollen scalp. The nurse responds that the swelling is caput succedaneum. Which additional information should the nurse provide this new mother? a.The infant should be positioned to reduce the swelling. b.The swelling is a subperiosteal collection of blood. c.The pediatrician will aspirate the blood if it gets larger. d.The scalp edema will subside in a few days after birth.

d.The scalp edema will subside in a few days after birth.