Maternity 2

The nurse is monitoring a client who is in the active stage of labor. The client has been experiencing contractions that are short, irregular, and weak. The nurse documents that the client is experiencing which type of labor dystocia? 1. Hypotonic 2. Precipitous 3. Hypertonic 4. Preterm labor

1

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? 1. Changes in vital signs 2. Signs of heavy bleeding 3. Complaints of intense pain 4. Complaints of a tearing sensation

1

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. the client had a midline episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? 1. Client pain level 2. Inadequate urinary output 3. Client perception of body changes 4. Potential for imbalanced body fluid volume

1

The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include? 1. The diet should include additional fluids 2. Prenatal vitamins should be discontinued 3. Soap should be used to cleanse the breasts 4. Birth control measures are unnecessary while breast feeding

1

The nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed? 1. I will flush the eye after instilling the ointment 2. I will clean the newborn's eyes before instilling the ointment 3. I need to administer the eye ointment within 1 hour after delivery 4. I will instill the eye ointment into each of the newborns conjunctival sacs

1

The postpartum nurse is providing instructions to a client after delivery of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? 1. 3 days postpartum 2. 7 days postpartum 3. On the day of delivery 4. Within 2 weeks postpartum

1

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? SATA 1. Wear a supportive bra 2. Rest during the acute phase 3. Maintain fluid intake of at least 3000 mL 4. Continue to breast-feed i the breasts are not too sore 5. Take the prescribed antibiotics until the soreness subsides 6. Avoid decompression of the breasts by breast-feeding or breast pumps

1,2,3,4

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statement(s)? SATA 1. I should wear a bra that provides support 2. Drinking alcohol can affect my milk supply 3. The use of caffeine can decrease my milk supply 4. I will start my estrogen birth control pills again as soon as I get home 5. I know if my breasts get engorged I will limit my breast-feeding and supplement the baby 6. I plan on having bottled water available in the refrigerator so I can get additional fluids easily

1,2,3,6

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? 1. Flushing 2. HTN 3. Increased urinary output 4. Depressed respirations 5. Extreme muscle weakness 6. Hyperactive deep tendon reflexes

1,4,5

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta prevue. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? 1. Infection 2. Hemorrhage 3. Chronic HTN 4. DIC

2

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abrupt placentae. Which assessment finding should the nurse expect to note if this condition is present? 1. Soft abdomen 2. Uterine tenderness 3. Absence of abdominal pain 4. Painless, bright red vaginal bleeding

2

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? 1. A temperature of 100.4 f 2. An increase in pulse rate from 88 to 102 3. A blood pressure change from 130/88 4. An increase in the respiratory rate from 18-22 breaths/minute

2

The nurse is performing an initial assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? 1. The client is a 35-year-old primigravida 2. The client has a history of cardiac disease 3. The clients hgb is 13.5 4. The client is a 20-year-old primigravida of average weight and height

2

The nurse is planning care for a newborn of a mother with DM. What is the priority nursing consideration for this newborn? 1. Developmental delays because of excessive size 2. Maintaining safety because of low blood glucose levels 3. Choking because of impaired suck and swallow reflexes 4 Elevated body temperature because of excess fat and glycogen

2

The nurse is preparing to administer beractant (Servanta) to a premature infant who has respiratory distress syndrome. The nurse plans to administer the medication by which route? 1. Intradermal 2. Intratracheal 3. Subcut 4. IM

2

The nurse notes hypotonia,, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects FAS and is aware that which additional sign would be consistent with this syndrome? 1. Length of 19 inches 2. Abnormal palmar creases 3. Brith weights of 6 lb, 14 oz 4. Head circumference appropriate for gestational age

2

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which most appropriate instruction to the mother? 1. Feed the newborn less frequently 2. Continue to breast-feed every 2-4 hours 3. Switch to bottle feeding the infant for 2 weeks 4. Stop breast-feeding and switch to bottle feeding permanently

2

The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 1 hour. How should the nurse document this finding? 1. Scant 2. Light 3.Heavy 4. Excessive

3

The nurse is reviewing the health care provider's prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? 1. Monitor FHR continuously 2. Monitor maternal vital signs frequently 3. Perform a vaginal exam q shift 4. Administer ampicillin 1 g as an ivpb q 6 hours

3

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign would the nurse note if superficial venous thrombosis were present? 1. Paleness of the calf area 2. Coolness of the calf area 3. Enlarged, hardened veins 4. Palpable dorsalis pedis pulses

3

When performing a postpartum assessment on a client, a nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? 1. Document the findings 2. Reassess the client in 2 hours 3. Notify the health care provider 4. Encourage increased oral intake of fluids

3

The nurse is preparing to care for four assigned clients. Which client is at highest risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago 2. A multiparous client who delivered 6 hours ago 3. A primiparous client who delivered 6 hours ago and had epidural anesthesia 4. A multiparous client who delivered a large baby after Pitocin induction

4

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction? 1. I should breast feed every 2-3 hours 2. I should change the breast pads frequently 3. I should wash my hands well before breastfeeding 4. I should wash my nipples daily with soap and water

4

The nurse prepares to administer a vitamin K injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide? 1. Your newborn needs vitamin k to develop immunity 2. the vitamin K will protect your newborn from being jaundiced 3. Newborns have sterile bowels, and vitamin K promotes the growth of the bacteria in the bowel 4. Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding

4

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2. What is the priority nursing action? 1. Document the findings 2. Retake the temperature in 15 minutes 3. Notify the health care provider 4. Increase hydration by encouraging oral fluids

4

Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction? 1. I will place my baby's crib close to the door 2. Some health care personnel won't have name badges 3. It's OK to allow the unlicensed assistive personnel to carry my newborn to the nursery 4. I will ask the nurse to attend to my infant if I am napping and my husband is not here

4

The nurse is performing an assessment on a client diagnosed with placenta prevue. Which of these assessment findings would the nurse expect to note? SATA 1. Uterine rigidity 2. Uterine tenderness 3. Severe abdominal pain 4. Bright red vaginal bleeding 5. Soft, relaxed, contender uterus 6. Fundal height may be greater than expected for gestational age

4,5,6

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? SATA 1. Avoid stimulation 2. Decrease fluid intake 3. Expose all of the newborn's skin 4. Monitor skin temp closely 5. Reposition the newborn q 2 hours 6. Cover the newborns eyes with eye shields or patches

4,5,6

An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily available if respiratory depression occurs? 1. Naloxone 2. Morphine sulfate 3. Betamethasone 4. Meperidine hydrochloride

1

An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription? 1. Delivery of the fetus 2. Strict monitoring of intake and output 3. Complete bed rest for the remainder of the pregnancy 4. The need for weekly monitoring of coagulation studies until the time of delivery

1

The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother? 1. Bring the infant to the clinic 2. This is a normal occurrence 3. Increase the number of times the the cord is cleaned per day 4. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues

1

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration and intensity. what is the priority nursing action? 1. Provide pain relief measures 2. Prepare the client for an amniotomy 3. Promote ambulation q 30 minutes 4. Monitor the Pitocin infusion closely

1

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings would alert the nurse to the possibility of this syndrome? 1. Tachypnea and retractions 2. Acrocyanosis and grunting 3. Hypotension and bradycardia 4. Presence of a barrel chest and acrocyanosis

1

A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate and contractions have stopped. If the client' labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication? 1. Nalbuphine (Nubain) 2. Betamethasone (Celestone) 3. RhoGAM 4. Dinoprostone (Cervidil vaginal insert)

2

A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention would be most appropriate? 1. Elevate the client's legs 2. Massage the funds until it is firm 3. Ask the client to turn on her left side 4. Push on the uterus to assist in expressing clots

2

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority nursing action in the care of the client? 1. Providing sitz baths 2. Encouraging fluid intake 3. Placing ice on the perineum 4. Monitoring H & H levels

2

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication fi which finding is noted on assessment? 1. Proteinuria of 3 + 2. Respirations of 10 breaths/min 3. Presence of deep tendon reflexes 4. Serum magnesium level of 6 mEq/L

2

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. What should the nurse do to help the woman process the delivery? 1. Encourage the mother to breast feed soon after birth 2. Support the mother in her reaction to the newborn 3. Tell the mother that it is important to hold the newborn infant 4. Document a complete account of the mother's reaction on the birth record

2

Methylergonovine (Methergine) is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority nursing assessment? 1. Uterine tone 2. Blood pressure 3. Amount of lochia 4. Deep tendon reflexes

2

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta prevue. The nurse reviews the health care provider's prescriptions and should question which prescription? 1. Prepare the client for an ultrasound 2. Obtain equipment for a manual pelvic examination 3. Prepare to draw a hemoglobin and hematocrit blood sample 4. Obtain equipment for external electronic fetal heart rate monitoring

2

The nurse develops a plan of care for a woman with HIV and her newborn. the nurse should include which intervention in the plan of care? 1. Monitoring the newborn's vital signs routinely 2. Maintaining standard precautions at all times while caring for the newborn 3. Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems 4. Instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment

2

The nurse has developed a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? 1. Providing comfort measures 2. Monitoring FHR 3. Changing the client's position frequently 4. Keeping the significant other informed of the progress of labor

2

The nurse in a NICU receive a telephone call to prepare for the admission of a 43- week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority? 1. Turn on the apnea and cardiorespiratory monitors 2. Connect the resuscitation bag to the O2 outlet 3. Set up the intravenous line with 5% dextrose in water 4. Set the radiant warmer control temperature at 36.5 c (97.6 f)

2

The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding? 1. Gently push the cord into the vagina 2. Place the client in Trendelenburgs position 3. Find the closest telephone and page the health care provider stat 4. Call the delivery room to notify the staff that the client will be transported immediately

2

On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. the nurse should take which initial action? 1. Elevate the client's legs 2. Document the findings 3. Massage the fundus until it is firm 4. Push on the uterus to assist in expressing clots

3

The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1. Warming the crib pad 2. Closing the doors to the room 3. Drying the infant with a warm blanket 4. Turning on the overhead radiant warmer

3

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? 1. Record the findings 2. Massage the fundus 3. Notify the health care provider 4. Place the client in Trendelenburg's position

3

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action would be most appropriate? 1. Raise the head of the bed 2. Obtain hgb and hct levels 3. Instruct the client to request help when getting out of bed 4. Inform the nursery room nurse to avoid bringing the newborn to the client until the mother's symptoms have subsided

3

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? 1. Apply gentle pressure 2. Reinforce the dressing 3. Document the findings 4. Contact the health care professional

3

The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which assessment finding would the nurse expect to note during the assessment of this newborn? 1. Lethargy 2. Sleepiness 3. Constant crying 4. Cuddles when being held

3

The nurse is developing a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? 1. Assess vital signs q 4 hours 2. Measure fundal height q 4 hours 3. Prepare an in ice pack for application to the area 4. Inform the health care provider of assessment findings

3

The nurse is monitoring a client who is receiving Pitocin to induce labor. Which assessment finding would cause the nurse to immediately discontinue the oxytocin infusion? 1. Fatigue 2. Drowsiness 3. Uterine hyperstimulation 4. Early decels of the FHR

3

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardia and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1. Initiate an intravenous line 2. Assess the client's bp 3. Prepare to administer morphine sulfate 4. Administer O2, 8 to 10 L/min by face mask

4

Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth., what is the most important nursing action? 1. Slow the iv flow rate 2. Place the client in high fowler's 3. Continue the Pitocin 4. Administer O2, 8 to 10 L/min, via face mask

4

Methylergonovine (Methergine) is prescribed for a client with postpartum hemorrhage. Before administer the medication, the nurse contacts the health care provider who prescribed the medication if which condition is documented in the client's medical history? 1. Hypotension 2. Hypothyroidism 3. DM 4. Peripheral vascular disease

4

RhoGAM is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition? 1. Having Rh-pos blood 2. Developing a rubella infection 3. Developing physiological jaundice 4. Being affected by Rh incompatibility

4

The nurse administers erythromycin ointment to the eyes of the newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? 1. Protects the newborn's eyes from possible infections acquired while hospitalized 2. Prevents cataracts in the newborn born to a woman who is susceptible to rubella 3. Minimizes the spread of microorganisms to the newborn from invasive procedures during labor 4. Prevents an infection called ophthalmia neonatorum from occurring after delivery in a newborn born to a woman with an untreated gonococcal infection

4

The nurse in a labor room is monitoring a client with dysfunctional labor for sings of fetal or maternal compromise. Which assessment finding would alert the nurse to a compromise? 1. Maternal fatigue 2. Coordinated uterine contractions 3. Progressive changes in the cervix 4. Persistent non reassuring fetal heart rate

4

The nurse is caring for four 1-day postpartum clients. Which client would require further nursing action? 1. The client with mild afterpains 2. The client with a pulse rate of 60 bpm 3. The client with colostrum discharge from both breasts 4. The client with lochia that is red and has a foul smelling odor

4

The nurse is preparing a plan of car for a newborn with FAS. The nurse should include which priority intervention in the plan of care? 1. Allow the newborn to establish own sleep-rest pattern 2. Maintain the newborn in a brightly lighted area of the nursery 3. Encourage frequent handling the newborn by staff and parents 4. Monitor the newborn's response to feedings and weight gain pattern

4