Hesi Maternity 1
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
A multiparous client delivered a 7 lb 10 oz infant 5 hours ago. Upon fundal assessment, the nurse determines the uterus is boggy and is displaced above and to the right of the umbilicus. Which action should the nurse implement next? A- Document the color of the lochia. B- Observe maternal vital signs. C- Assist the client to the bathroom. D- Notify the healthcare provider.
C
A newborn infant is jaundiced due to Rh incompatibility. Which finding is most important for the nurse to report to the healthcare provider? A- Bruising. B- Oral intake. C- Hemoglobin. D- Bilirubin.
D
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
Which 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. D- She eagerly reaches for the infant and then holds the infant close to her own body.
B
While evaluating an external monitor tracing of a woman in active labor whose labor is being induced, the nurse notes that the fetal heart rate (FHR) begins to decelerate in a slow curve at the onset of several contractions and returns to baseline before each contraction ends. The nurse should: A) Insert an internal monitor B) Document the finding in the client's record. C) Discontinue the oxytocin infusion D) Change the woman's position
B
While inspecting a newborn's head, the nurse identifies a swelling of the scalp that does not cross the suture line. Which finding should the nurse document? A- Molding. B- Cephalohematoma. C- Caput succedaneum. D- Bulging fontanel.
B
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
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
A primigravida at 37-weeks gestation tells the nurse that her "bag-of-water" has broken. While inspecting the client's perineum, the nurse notes the umbilical cord protruding from the vagina. What action should the nurse implement first? A- Administer 10 L of oxygen via face mask. B- Give the healthcare provider a status report. C- Place the client in the knee-chest position. D- Wrap the cord with gauze soaked in saline.
C
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. D- The extent to which the pregnancy was planned.
A
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 heart rate of 80 beats/minute and respirations of 20 breaths/ minute. What action should the nurse perform next? A- Initiate positive pressure ventilation. B- Intervene after the one minute Apgar is assessed. C- Initiate CPR on the infant. D- Assess the infant's blood glucose level.
A
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
The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the nurse to assess the client for which condition? A- Gestational diabetes. B- Elevated blood pressure. C- Urinary tract infection. D- Swelling in lower extremities.
A
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. C- immediately before menstruation. D- three weeks before menstruation.
A
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
D
The nurse is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, "What if I start having red bleeding after it changes?" What should the nurse instruct the client to do? A- Reduce activity level and notify the healthcare provider. B- Go to bed and assume a knee-chest position. C- Massage the uterus and go to the emergency room. D- Do not worry as this is a normal occurrence.
A
The nurse notes a pattern of the fetal heart rate decreasing after each contraction. What action should the nurse implement? A- Give 10 liters of oxygen via face mask. B- Prepare for an emergency cesarean section. C- Continue to monitor the fetal heart rate pattern. D- Obtain an oral maternal temperature.
A
A client at 28-weeks gestation calls the ante-partal 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
A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion? A- 3+ deep tendon reflexes and hyper-clonus. B- Periorbital edema, flashing lights, and aura. C- Epigastric pain in the third trimester. D- Recent decreased urinary output.
A
A client at 35-weeks gestation visits the clinic for a prenatal check-up. Which complaint by the client warrants further assessment by the nurse? A- Periodic abdominal pain. B- Ankle edema in the afternoon. C- Backache with prolonged standing. D- Shortness of breath when climbing stairs.
A
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
A multiparous client is experiencing bleeding 2 hours after a vaginal delivery. What action should the nurse implement next? A- Determine the firmness of the fundus. B- Give oxytocin (Pitocin) intravenously. C- Inform the healthcare provider of the bleeding. D- Assess the vital signs for indicators of shock.
A
Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The nurse knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as A- a cephalhematoma, caused by forceps trauma and may last up to 8 weeks. B- a subarachnoid hematoma, which requires immediate drainage to prevent further complications. C- molding, caused by pressure during labor and will disappear within 2 to 3 days. D- a subdural hematoma which can result in lifelong damage.
A
What position would be least effective when gravity is desired to assist in fetal descent? A) Lithotomy B) Walking C) Kneeling D) Sitting
A
Which action should the nurse implement when preparing to measure the fundal height of a pregnant client? A- Have the client empty her bladder. B- Request the client lie on her left side. C- Perform Leopold's maneuvers first. D- Give the client some cold juice to drink.
A
The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform? A- Elicit a positive scarf sign on the affected side. B- Observe for an asymmetrical Moro (startle) reflex. C- Watch for swelling of fingers on the affected side. D- Note paralysis of affected extremity and muscles.
B
The nurse should explain to a 30-year-old gravida 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
During labor a fetus with an average heart rate of 175 beats/min over a 15-minute period would be considered to have: A) A normal baseline heart rate. B) Bradycardia. C) Hypoxia. D) Tachycardia.
D
What action should the nurse implement when caring for a newborn receiving phototherapy? A- Reposition every 6 hours. B- Place an eyeshield over the eyes. C- Limit the intake of formula. D- Apply an oil-based lotion to the skin.
B
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
The LPN/LVN providing care for the laboring woman should understand that amnioinfusion is used to treat: A) Fetal tachycardia. B) Fetal bradycardia. C) Variable decelerations D) Late decelerations.
C
The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement? A- Insert an internal fetal monitor. B. Assess for cervical changes q1h. C- Monitor bleeding from IV sites. D- Perform Leopold's maneuvers.
C
The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (Select all that apply.) A- Litmus paper. B- Fetal scalp electrode. C- A sterile glove. D- An amniotic hook. E- Sterile vaginal speculum. F- A Doppler.
C, D, F
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
One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM Å~ 1. What action should the nurse take immediately? A- Give the medication as prescribed and monitor for efficacy. B- Encourage the client to breastfeed rather than bottle feed. C- Have the client empty her bladder and massage the fundus. D- Call the healthcare provider to question the prescription.
D
The apnea monitor alarm sounds for the third time during one shift for a neonate who was delivered at 37-weeks gestation. What nursing action should be implemented first? A- Provide tactile stimulation. B- Administer flow by 100% oxygen. C- Asses the functionality of the monitoring device. D- Evaluate the newborn's color and respirations.
D
The nurse is assessing a client who is having a non-stress test (NST) at 41- weeks gestation. The nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occurring. What action should the nurse take? A- Check the client for urinary bladder distention. B- Notify the healthcare provider of the non-reactive results. C- Have the mother stimulate the fetus to move. D- Ask the client if she has felt any fetal movement.
D
The nurse is caring for a client whose labor is being augmented with oxytocin (Pitocin). Which finding indicates that the nurse should discontinue the oxytocin infusion? A- The client needs to void. B- Amniotic membranes rupture. C- Uterine contractions occur every 8 to 10 minutes. D- The fetal heart rate is 180 bpm without variability
D
The nurse is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure? A- A gravida 6, para 5 who is 38 years of age and in early labor. B- A 37-week primigravida who presents at 100% effacement, 3 cm cervical dilatation, and a -1 station. C- A gravida 2, para 1 who is at 1 cm cervical dilatation and a 0 station admitted for induction of labor due to post dates. D- A 40-week primigravida who is at 6 cm cervical dilation and the presenting part is not engaged.
D
The nurse is providing discharge teaching for a gravid client who is being released from the hospital after placement of cerclage. Which instruction is the most important for the client to understand? A- Plan for a possible cesarean birth. B- Arrange for home uterine monitoring. C- Make arrangements for care at home. D- Report uterine cramping or low backache.
D
To assess uterine contractions the nurse would A- Asses duration from the beginning of the contraction to the peak of the same contraction, frequency by measuring the time between the beginning of one contraction to the beginning of the next contraction. B- Assess frequency as the time between the end of one contraction and the beginning of the next contraction, duration as the length of time from the beginning to the end of contractions, and palpate the uterus for strength C- Assess duration from beginning to end of each contraction. Assess the strength of the contraction by the external fetal monitor reading. Measure frequency by measuring the beginning of one contraction to another. D- Assess duration from beginning to end of each contraction., frequency by measuring the time between the beginnings of contractions, and palpate the fundus of the uterus for strength.
D
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
Which client should the nurse report to the healthcare provider as needing a prescription for Rh Immune Globulin (RhoGAM)? A- Woman whose blood group is AB Rh-positive. B- Newborn with rising serum bilirubin level. C- Newborn whose Coombs test is negative. D- Primigravida mother who is Rh-negative.
D
Which finding for a client in labor at 41-weeks gestation requires additional assessment by the nurse? A- Cervix dilated 2 cm and 50% effaced. B- Score of 8 on the biophysical profile. C- Fetal heart rate of 116 beats per minute. D- One fetal movement noted in an hour.
D
While assessing a newborn the nurse observes diffuse edema of the soft tissues of the scalp that cross the suture lines. How should the nurse document this finding? A- Molding. B- Hemangioma. C- Cephalohematoma. D- Caput succedaneum.
D
The factors that affect the process of labor and birth, known commonly as the five Ps, include all EXCEPT: A) Passageway. B) Powers. C) Passenger. D) Pressure.
D :: The 5 P's are: 1. Powers (contractions)2. Passengers (fetus & placenta) 3. Passageway (birth canal)4. Position (of the mother)5. Psychological Response
A client at 28-weeks gestation is concerned about her weight gain of 17 pounds. What information should the nurse provide this client? A- It is not necessary to keep such a close watch on weight gain. B- Try to exercise more because too much weight has been gained. C- Increase the calories in your diet to gain more weight per week. D- The weight gain is acceptable for the number of weeks pregnant.
D
A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this client? A- Which symptom did you experience first? B- Are you eating large amounts of salty foods? C- Have you visited a foreign country recently? D- Do you have a history of rheumatic fever?
D
A client in her second trimester of pregnancy asks if it is safe for her to have a drink with dinner. How should the nurse respond to the client? A- During second trimester beer can be consumed without harm to the fetus. B- Wine can be consumed several times a week after the first trimester. C- Only one drink with the evening meal is not harmful to the fetus. D- Abstinence is strongly recommended throughout the pregnancy.
D
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- 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
At 10-weeks gestation, a high-risk multiparous client with a family history of Down syndrome is admitted for observation following a chorionic villus sampling (CVS) procedure. What assessment finding requires immediate intervention? A- Uterine cramping. B- Abdominal tenderness. C- Systolic blood pressure < 100 mmHg. D- Intermittent nausea.
A
What three measures should the nurse implement to provide intrauterine resuscitation? Select the response that best indicates the priority of actions that should be taken. A) Reposition the mother, increase intravenous (IV) fluid, and provide oxygen via face mask. B) Perform a vaginal examination, reposition the mother, and provide oxygen via face mask. C) Administer oxygen to the mother, increase IV fluid, and notify the care provider. D) Call the provider, reposition the mother, and perform a vaginal examination
A
Which basic type of pelvis includes the correct description and percentage of occurrence in women? A- Platypelloid: flattened, wide, shallow; 3% B- Anthropoid: resembling the ape; narrower; 10% C- Android: resembling the male; wider oval; 15% D- Gynecoid: classic female; heart shaped; 75%
A
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
While monitoring a client in active labor, the nurse observes a pattern of a 15-beat increases in the fetal heart rate that lasts 15 to 20 seconds and returns to baseline. Which information should the nurse report during shift change? A- Fetal well being with labor progression. B- Signs of uteroplacental insufficiency. C- Episodes of fetal head compression. D- Occurrences of cord compression.
A
A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the nurse that the drug is effective? A- Slowly increasing urinary output over the last week. B- Respiratory rate changes from the 40s to the 60s. C- Changes in apical heart rate from the 180s to the 140s. D- Change in indirect bilirubin from 12 mg/dl to 8 mg/dl.
C
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
Perinatal nurses are legally responsible for: A) Applying the external fetal monitor and notifying the care provider. B) Correctly interpreting fetal heart rate (FHR) patterns, initiating appropriate nursing interventions, and documenting the outcomes. C) Greeting the client on arrival, assessing her, and starting an intravenous line. D) Making sure that the woman is comfortable.
B
The most common cause of decreased variability in the fetal heart rate (FHR) that lasts 30 minutes or less is: A) Fetal hypoxemia B) Fetal sleep cycles C) Altered cerebral blood flow. D) Umbilical cord compression.
B
A client at 28-weeks gestation arrives at the labor and delivery unit with a complaint of bright red, painless vaginal bleeding. For which diagnostic procedure should the nurse prepare the client? A- Contraction stress test. B- Internal fetal monitoring. C- Abdominal ultrasound. D- Lecithin-sphingomyelin ratio.
C
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
When using intermittent auscultation (IA) to assess uterine activity, the nurse should be aware that: A) The resting tone between contractions is described as either placid or turbulent B) The examiner's hand should be placed over the fundus before, during, and after contractions. C) The frequency and duration of contractions is measured in seconds for consistency D) Contraction intensity is given a judgment number of 1 to 7 by the nurse and client together.
B
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
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
A client at 39-weeks gestation is admitted to the labor and delivery unit. Her obstetrical history includes 3 live births at 39-weeks, 34-weeks, and 35-weeks gestation. Using the GTPAL system, which designation is the most accurate summary of this client's obstetrical history? A- 3-1-1-1-3. B- 4-1-2-0-3. C- 3-0-3-0-3. D- 4-3-1-0-2.
B
A client is admitted to the labor and delivery unit with contractions that are 3-5 minutes apart, lasting 60-70 seconds. She reports that she is leaking fluid. A vaginal exam reveals that her cervix is 80 percent effaced and 4 cm dilated and a -1 station. The nurse knows that the client is in which phase and stage of labor? A- Latent phase, First Stage B- Active Phase of First Stage C- Latent phase of Second Stage D- Transition
B
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
A multiparous client has been in labor for 8 hours when her membranes rupture. What action should the nurse implement first? A- Prepare the client for imminent birth. B- Assess the fetal heart rate and pattern. C- Document the characteristics of the fluid. D- Notify the client's primary HCP
B
A multiparous client is admitted to the postpartum unit after a rapid labor and birth of an infant weighing 4,000 grams. The client's fundus is boggy, lochia is heavy, and vital signs are unchanged. After having the client void and massaging the uterus, the client's fundus remains difficult to locate, and the rubra lochia remains heavy. What action should the nurse implement next? A- Recheck the client's vital signs. B- Notify the healthcare provider. C- Insert an indwelling urinary catheter. D- Massage the fundus in 30 minutes.
B
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.
C
While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate late in the contraction, with the nadir of the decelerations occurring after the peak of the contraction. The nurse first priority is to: A) Notify the care provider. B) Assist with amnioinfusion C) Change the woman's position D) Insert a scalp electrode.
C
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
A couple has been trying to conceive for nine months without success. Which information obtained from the clients is most likely to have an impact on the couple's ability to conceive a child? A- Exercise regimen of both partners includes running four miles each morning. B- History of having sexual intercourse 2 to 3 times per week. C- The woman's menstrual period occurs every 35 days. D- They use lubricants with each sexual encounter to decrease friction.
D
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
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
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
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
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
A
A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the nurse take? A- Apply cold compresses to both breasts for comfort. B- Instruct the client run warm water on her breasts. C- Wear a loose-fitting bra to prevent nipple irritation. D- Express small amounts of milk to relieve pressure.
A
A multiparous client delivered a 7 lb 10 oz infant 5 hours ago. Upon fundal assessment, the nurse determines the uterus is boggy and is displaced above and to the right of the umbilicus. Which action should the nurse implement next? A- Document the color of the lochia. B- Observe maternal vital signs. C- Assist the client to the bathroom. D- Notify the healthcare provider.
C
As a perinatal nurse you realize that a fetal heart rate that is tachycardic, is bradycardic, or has late decelerations with loss of variability is nonreassuring and is associated with A) Cord compression B) Hypotension C) Hypoxemia/acidemia D) Maternal drug use.
C
The nurse assesses a male newborn and determines that he has the following vital signs: axillary temperature 95.1 F, heart rate 136 beats/minute and a respiratory rate 48 breaths/minute. Based on these findings, which action should the nurse take first? A- Check the infant's arterial blood gases. B- Notify the pediatrician of the infant's vital signs. C- Assess the infant's blood glucose level. D- Encourage the infant to take the breast or sugar water.
C
The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take? A- Administer oxygen by face mask. B- Notify the healthcare provider of the client's symptoms. C- Have the client breathe into her cupped hands. D- Check the client's blood pressure and fetal heart rate.
C
The nurse is caring for a client in active labor and observes V shape decelerations in the fetal heart rate occurring with the peak of each contraction. What action should the nurse implement? A- Notify the healthcare provider of fetal status. B- Give oxygen at 10 L per nasal cannula. C- Place the client in a side-lying position. D- Increase the flow rate of intravenous fluids.
C
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 ly 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
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
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
When assessing a newborn infant's heart rate, which technique is most important for the nurse to use? A- Quiet the infant before counting the heart rate. B- Listen at the apex of the heart. C- Count the heart rate for at least one full minute. D- Palpate the umbilical cord.
C
A pregnant client tells the nurse that the first day of her last menstrual period was August 2, 2006. Based on Nägele'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
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.
B
A client at 28-weeks gestation experiences blunt abdominal trauma. Which parameter should the nurse assess first for signs of internal hemorrhage? A- Vaginal bleeding. B- Complaints of abdominal pain. C- Changes in fetal heart rate patterns. D- Alteration in maternal blood pressure.
C
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 client in active labor at 39-weeks gestation tells the nurse she feels a wet sensation on the perineum. The nurse notices pale, straw-colored fluid with small white particles. After reviewing the fetal monitor strip for fetal distress, what action should the nurse implement? A- Escort the client to the bathroom. B- Offer the client a bedpan. C- Perform a nitrazine test. D- Clean the perineal area.
C
A client in labor receives an epidural block. What intervention should the nurse implement first? A- Encourage oral fluids. B- Assess contractions. C- Monitor blood pressure. D- Obtain a radial pulse.
C
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 centimeters 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
A macrosomic infant is in stable condition after a difficult forceps-assisted delivery. After obtaining the infant's weight at 4550 grams (9 pounds, 6 ounces), what is the priority nursing action? A- Assess newborn reflexes for signs of neurological impairment. B- Leave the infant in the room with the mother to foster attachment. C- Obtain serum glucose levels frequently while observing closely for signs of hypoglycemia. D- Perform a gestational age assessment to determine if the infant is large- for-gestational-age
C
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
A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, 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
A preterm infant with an apnea monitor experiences an apneic episode. Which action should the nurse implement first? A- Ventilate with an Ambu bag. B- Perform nasal and airway suctioning. C- Administer supplemental oxygen. D- Gently rub the infant's feet or back.
D
