Maternity HESI Questions

A 16-year-old male is admitted after a motor vehicle collision with 50% burns over his body one leader of muscle arm lean as prescribed to infuse over 4 hours the drop factor is 60 drops per ML the nurse should regulate the infusion to administer how many drops per minute

250

1. A34-week primigravida woman with preeclampsia is receiving lactated ringer's 500ML with magnesium sulfate 20 grams at the rate of 3 gramps/hour. How many ML/Hour should the nurse program the infusion pump?

50.75

. A 34-week Primigravida woman with preeclampsia is receiving lactate ringers 500 mL with magnesium sulfate 20 grams at the rate of 3 grams/hour. How many ml/hour should the nurse program the infusion pump?

75ml/hour

1. The nurse is caring for a client in the emergency department after an assault by the spouse. The client has a history of similar emergency visits. Which action best assist the client? A. Provide guidance to identify triggering behaviors B. Complete a patient health questionnaire-9 (PHQ9) C. Develop a plan for initiating a rapid exit D. Advice couple counseling as the next step

A. Advice couple counseling as the next step

1. the mother of a child who is hospitalized with croup and is in a mist tent brings the child's favorite stuffed animal to the hospital. what action should the nurse take? A. Allow the child to have the stuffed toy in the tent B. limit play with the stuffed toy went out of tent C. spray toy with disinfect it before placing intent D. ask the mother to wash the toy daily at home

A. Allow the child to have the stuffed toy in the tent

1. An older man with a history of multiple falls at home tells the clinic nurse that his son who was incarcerated last year for assault and battery has become increasingly abusive since his release from prison six weeks ago. which intervention is most important for the nurse to implement? A. refer the client to a program for victims of domestic violence B. verify the client's report by determining if there is physical evidence of abuse C. Assist the client in developing an emergency safety plan D. tell the client to call adult Protective Services if his son's abuse continues

A. Assist the client in developing an emergency safety plan

1. the nurse is counseling a client who is at six weeks gestation and is experiencing morning sickness but does not want to take any drug for the discomfort which herbal supplement is likely to help the client with nausea she is experiencing? A. Ginger B. Peppermint C. Chamomile D. Ginko

A. Ginger

1. The nurse is planning a class for pregnant women in their first trimester of pregnancy. Which information is most important for the nurse to include in this class? A. since eating often relieves nausea, carry low-fat snacks to eat whenever nausea occurs. B. If morning dizziness occurs, rise slowly, and sit on the side of the bed for one minute. C. Plan rest periods and increase sleep time to 8 hours per day when fatigued. D. If any vaginal bleeding occurs, notify the healthcare provider immediately.

A. If any vaginal bleeding occurs, notify the healthcare provider immediately.

1. An adolescent who has lost 20 pounds in the last three months is admitted to the hospital with hypertension and tachycardia. The client reports irregular menses and hair loss. which intervention for the nurse is most important for the nurse to include in the client's Plan of care? A. Initiate caloric and nutritional therapy B. evaluate the client for low self-esteem C. record daily weights and graph trend D. implement behavioral modification therapy

A. Initiate caloric and nutritional therapy

1. A breastfeeding woman who delivered her infant 2 weeks ago develops mastitis in her left breast. A cephalosporin antibiotic is prescribed after consultation with the infant's pediatrician. Which instruction regarding breastfeeding should the nurse provide? A. Limit breastfeeding to unaffected breasts B. Initiate feeding on the unaffected breasts first C. Put ice packs on the affected breast for comfort D. Alternate breastfeeding and bottle feeding

A. Initiate feeding on the unaffected breasts first

1. A female client present in the emergency department and states, "I was raped tonight." Which interventions is most important for the nurse to implement? A. Ask the client if she can identify the attacker B. Instruct the client to remove all clothing carefully C. Assess client's sexual activity for the past 30 days D. Obtain a history of sexually transmitted diseases

A. Instruct the client to remove all clothing carefully

1. The nurse is assessing a newborn who was precipitously delivered at 38-weeks gestation. the newborn is tremulous, tachycardic, and hypertensive. which assessment action is most important for the nurse to implement? A. determine reactivity of neonatal reflexes B. weigh measure the newborn C. Perform gestational age assessment D. Obtain a drug screen for cocaine.

A. Obtain a drug screen for cocaine.

1. A newborn infant is receiving immunization prior to discharge. Which action should the nurse implement? A. Ask the mother if she wants the infant immunize for Haemophilus influenza. B. Give The first dose of vaccine for rotavirus if any sibling has diarrhea now. C. Prepare the first dose of Diphtheria, tetanus toxoid and acellular (DTaP) D. Obtain signed consent from the mother for add ministration of Hepatitis B vaccine

A. Obtain signed consent from the mother for add ministration of Hepatitis B vaccine

1. The nurse is teaching the parents of a child with cystic fibrosis about home care. Which intervention should the nurse ensure the parents understand about managing the child respiratory secretions? A. Prophylactic antibiotics. B. Percussion and postural drainage C. vitamin supplementation D. Inhaled hypotonic saline

A. Percussion and postural drainage

1. A multiparous Client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take? A. Prepare for a caesarean section B. obtain blood culture C. cover the lesion with a dressing D. administer penicillin

A. Prepare for a caesarean section

1. which type of anesthesia, use with a client in labor, produces a loss of sensation only to the vagina and perineum? A. Epidural block B. Pudendal block C. Paracervical block D. Saddle block

A. Pudendal block

1. a child diagnosed with strep throat three days ago enters the clinic crying hysterically. the parent tells the nurse that the child screams in pain even with a light touch. the child is short of breath and anxious. which assessment finding warrants immediate intervention by the nurse? A. Red, hot, and swollen joints B. Pulse Ox of 88% ???? C. heart rate of 110 beats per minute D. slightly raised rash with ragged edges

A. Pulse Ox of 88% ????

1. A Couple who is trying to have a baby ask the nurse when they are most likely to conceive a child. The woman has a regular 36 day menstrual cycle, and the first day of her last menstrual. Was on January 16. Which information should the nurse provide? A. The woman should ovulate mid cycle, as this is when ovulation should occur? B. Plan to have intercourse on February 7, as this is when ovulation should occur. C. have intercourse every three days to ensure that ovulation and intercourse coincide D. Have Intercourse every other morning because this is when the sperm count is higher

A. The woman should ovulate mid cycle, as this is when ovulation should occur?

1. a 38-week primigravida Is admitted to the labor and delivery after a non-reactive result on a non-stress test (NST). the nurse begins a contraction stress test (CST) with an oxytocin infusion. which finding is most important to the nurse to report to the health care provider? A. absence of uterine contraction within 20 minutes B. spontaneous rupture of membranes C. fetal heart rate acceleration with fetal movement D. a pattern of fetal late deceleration

A. a pattern of fetal late deceleration

1. A client who is 3- weeks postpartum continues to have moderate lochia. the nurse determines her uterus to be 1 centimeter below the umbilicus. which pathophysiological causes most likely contributing to these findings? A. Retained Placental fragments B. Early postpartum hemorrhage C. a vaginal hematoma ???? D. the resumption of menstruation

A. a vaginal hematoma ????

1. the nurse notes on the fetal monitor that a laboring client has a variable deceleration. which action should the nurse implement first? A. assess cervical dilation B. turn off the oxytocin infusion C. Change the client's position D. administer oxygen via face mask

A. administer oxygen via face mask

1. Which action is most important for the nurse to implement to prevent bleeding in the neonate during the first hour of birth? A. provide the first oral fluid using formula B. replace them umbilical cord clamp close to the infant's body C. administer vitamin K IM D. use the axillary method to obtain core body temperature

A. administer vitamin K IM

1. the nurse notes that a client with a history of self-mutilation has increased body tension and his piecing in the hallway. which nursing intervention is most important at this time? A. complete a three room search to ensure client does not have access to objects that can be used for self-harm B. give client firm consistent expectations that self-mutilating Behaviors are unacceptable and will not be allowed C. provide the client time alone in the client's room to reduce external stimulation an promote relaxation D. alert the assigned staff to closely monitor client and intervene as needed to reduce risk of self—mutilating.

A. alert the assigned staff to closely monitor client and intervene as needed to reduce risk of self—mutilating.

1. The nurse is teaching the parents of an adolescent with depression about the warning signs of suicide. which statement by the parents indicates an understanding of the teaching provided? A. most young people contemplating suicide do not talk about their intentions B. talking openly about suicide can increase my child's risk for suicide behavior C. an improvement in mood after a suicide attempt indicates that a suicidal crisis is over D. indirect statements about feeling hopelessness are just as serious as direct statements about suicide

A. an improvement in mood after a suicide attempt indicates that a suicidal crisis is over

1. The school nurse is preparing a teaching about nutrition for school-aged children, 9-11 years old. Which activity is best for the nurse to included in the teaching plan? A. Ask the older children to Teach the younger children about proper diet. B. ask the children to classify pictures of snacks as good or bad foods C. encourage the children to select a nutritionists menu for their family D. allow the children to prepare a nutritious meal for their classmates

A. ask the children to classify pictures of snacks as good or bad foods

1. A young adult client is admitted to a psychiatric facility with a diagnosis of bulimia nervosa. Which nursing intervention has the highest priority? A. schedule the client for group therapy with other bulimic clients B. assess and report the client's electrolyte status to a health care provider C. assign the clients care toy nurse of approximately the same age D. monitor the client carefully for bingeing activities

A. assess and report the client's electrolyte status to a health care provider

1. The night shift nurse reports to the oncoming day shift nurse that in order client who is characteristically argumentative, and demanding was compliant during the night shift and slept through vital signs and other physical assessments. Which intervention should the dayshift nurse implement? A. allow the client to rest and sleep as much as desired. B. reward the client by offering more choices for daily care. C. assess the client immediately and hourly during shift D. document the client's compliance with routine care no

A. assess the client immediately and hourly during shift

What is the priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (the) fistula ? A. body temperature B. level of pain C. time of first void D. number of vessels in the cord

A. body temperature

1. Developing a teaching plan for a client at 8-week gestation which instruction has the highest priority? A. Try eating crackers when you first feel nauseated B. call the clinic if you have any vaginal bleeding or cramping??? C. eat a well-balanced diet using this printed diet instruction sheet D. you should enroll in this month's childbirth preparation class

A. call the clinic if you have any vaginal bleeding or cramping???

1. A client who has type one diabetes and is 10 weeks gestation comes to the prenatal clinic complaining of a headache nausea sweating feeling shaky and being tired all the time. what action should the nurse take first? A. assess urine for ketone levels B. provide the client with a protein snack C. Draw blood for a hemoglobin A1C D. check the blood glucose level

A. check the blood glucose level

1. A pregnant woman who is at 10 weeks gestation an is 35 years of age tells the nurse that she is concerned about the possibility of having a baby with Down syndrome. which information should the nurse provide to the client? A. weekly fundal height measurement is a noninvasive method news to check for Down syndrome B. maternal serum HCG can identify Down syndrome at six weeks gestation C. Anne amniocentesis conducted at 24 weeks gestation confirms or denies Down syndrome in the fetus D. chronic villus sampling at 12 weeks to station is the earliest screening testing used to identify Down syndrome

A. chronic villus sampling at 12 weeks to station is the earliest screening testing used to identify Down syndrome

1. A primigravida Is at 33 weeks gestation presents to the labor and delivery unit with complaints of a headache the initial assessment finding include: blood pressure 144 / 96, facial edema, and 3+ pitting edema in lower extremities. which assessment should the nurse perform next? A. Temperature, pulse, and respirations B. deep tendon reflexes on clonus C. intensity of pain with contraction D. fetal heart rate

A. deep tendon reflexes on clonus

1. A couple who are both carriers of Phenylketonuria (PKU) I have a 2-year-old daughter with PKU. the couple tells the nurse that they believe their next baby is sure not to be affected. what information should the nurse provide to the couple? A. a genetic counseling referral should be made by the health care provider B. if the next baby is a boy and not a girl the chance is reduced by 50% C. each consumption has a 25% chance for the child to be affected D. future children have a less chance of inheriting the defective gene

A. each consumption has a 25% chance for the child to be affected

1. The nurse is preparing a young couple and their 24 old infant for discharge from the hospital in conducting discharge teaching which intervention is most important for the nurse to implement? A. evaluate infant feeding techniques prior to discharge B. provide the results of the infants hearing test to the parents C. ensure that they have the pediatric clinics phone number D. request a return demonstration of a diaper change

A. evaluate infant feeding techniques prior to discharge

1. A female client comes into the emergency department complaining of frequent panic attacks the last few days and states that her life is out of control. she is currently taking Alprazolam 1mg twice daily and Sertraline 200mg daily for anxiety. which assessment is most important for the nurse to obtain? A. is there a family member available who can provide additional information B. if she is having any other symptoms such as tremors C. how long the client has been taking the anti-anxiety drugs D. if the client has any thoughts about ending her life ????

A. if the client has any thoughts about ending her life ????

1. A female client who is 5 feet 5 inches tall (164 cm) and weighs 72 pounds (36kg) presents to the emergency department after a syncopal episode at home. she has poor skin turgor with tenting, and blood pressure is 80/50 mmHg. what action should the nurse implement first? A. obtain date of last menstrual cycle. B. calculate body mass index (BMI) C. assess routine daily dietary intake D. insert peripheral Ivy for fluid resuscitation.

A. insert peripheral Ivy for fluid resuscitation.

1. during a high school class on substance abuse a student tells the group, " if I tried cocaine I know I can handle it I know when to stop." what response is best for the nurse to provide? A. addiction affects all aspects of one's life an ones family B. denial of an addiction problem is often the first response to the behavior C. an overdose of cocaine can be lethal D. mind altering drugs take away one's ability to make good decisions

A. mind altering drugs take away one's ability to make good decisions

1. A diabetic client delivers a full term large for gestational age (LGA) infant who is jittery. which action should the nurse take first? A. feed the infant glucose water (10%) B. administer oxygen C. obtain a blood glucose level D. decrease environmental stimuli

A. obtain a blood glucose level

1. At 39 weeks of gestation a multigravida is having a non-stress test (NST). the fetal heart rate has remained non-reactive during 30 minutes of evaluation. Based on the finding which action should the nurse implement A. initiate an intravenous infusion B. observe the FHR pattern for 30 minutes C. place an acoustic stimulator on the abdomen D. schedule a biophysical profile

A. place an acoustic stimulator on the abdomen

1. Following a vaginal delivery, the nurse places the neonate under the radiant warmer provide naso-oropharyngeal Suction and rise the neonate skin to elicit spontaneous respirations. The newborn heart rate is 100 beats per minute and remains apneic when the nurse flicks the soles of the feet. Which action should the nurse implement first? A. Assist neonatologist with intubation B. Start IV infusion in a scalp vein C. Give blow-by oxygen via cannula D. provide positive pressure ventilation

A. provide positive pressure ventilation

1. The nurse is administering a treatment to a child experiencing an asthma attack. The child is anxious, fearful, and hyperventilation. The nurse anticipates the child developing which acid base in balance? A. respiratory alkalosis B. metabolic alkalosis C. respiratory acidosis D. Metabolic acidosis

A. respiratory alkalosis

1. an older client is observed to be experiencing an increase in daytime drowsiness loss of appetite and listlessness. which action is most important for the nurse to implement? A. encourage the client to engage in social activities B. observe carefully for extrapyramidal symptoms (EPS) C. appraise light sensitivity tiredness and dizzy spells D. review medication for drug and food interactions

A. review medication for drug and food interactions

1. A 7-year-old male is referred to the school clinic because he fainted on the playground. his height is 3 feet 7 inches (107.5 cm) keyways 55 pounds(25 kg) and his body mass index(BMI) is 20.9. which assessment finding is most important for the nurse to address? A. the child's father has a history of fainting when exercising B. reports drinking 324 high calorie carbonated beverage daily C. since age 3 he has experienced exercise induced asthma D. he consumed 2 bottles of water 30 minutes prior to fainting

A. since age 3 he has experienced exercise induced asthma

1. The nurses receiving report for a laboring client who arrived in the emergency center with ruptured membranes that the client did not recognize. which is the priority nursing action to implement when the client is admitted to the labor and delivery suite? A. prepare to start an IV B. monitor amniotic fluid for meconium C. begin a pad count D. take the clients temperature

A. take the clients temperature

1. a middle-aged male who drinks 1/5 of liquor every night is confronted at a prearranged family intervention with the family health care provider and nurse. when the health care provider leaves the room to make arrangements for the hospitalization admission the client shouts at the nurse that he sees no reason for hospitalization. how should the nurse respond? A. explain to the client that his family cares about him and wants him to be hospitalised during detoxification. B. listen attentively to the clients expression of anger then support the families wishes that the client be hospitalized C. use a matter-of-fact manner to inform the client that hospitalization is necessary during detoxification D. tell a client that monitoring and medication management during detoxification as best provided in the hospital

A. tell a client that monitoring and medication management during detoxification as best provided in the hospital

1. A recently widowed older male client is hospitalized because his family reported that he has suddenly become confused, has lost weight, and his motor activity has become impaired. the nurse's response to the family should be based on which factual information? A. delirium is often a sign of underlying mental illness and institutionalization is often necessary B. the client's delirium may be due to depression and his possibly reversible C. the client is exhibiting symptoms of dementia and because of his age, it is probably permanent D. if the dementia is a result of Alzheimer's disease it is often reversible even in the late stages

A. the client's delirium may be due to depression and his possibly reversible

1. A young adult male client is admitted for substance abuse treatment. He reportedly violates the unit rules and when confronted about his behavior, smiles and says, "I should know better." what response is best for the nurse to provide? A. the unit rules are not flexible you must comply with these guidelines B. do you think you can function in the community by breaking rules C. you are going to lose your privilege if you keep breaking these rules D. have you considered how breaking the rules affects others on the units

A. the unit rules are not flexible you must comply with these guidelines

1. An older client with Alzheimer's disease is experiencing hallucinations and delusions. Which non-pharmacological approach should the nurse implement? A. awaken the client for reality checks q4 hours at night B. reduce the client's interaction with others during day C. use distraction and therapeutic communication skills D. clarify reality with the client about delusional thoughts

A. use distraction and therapeutic communication skills

1. during a well-baby clinic visit the mother a 6-month-old infant ask the nurse if she can have a prescription for Poly Vi Sol with fluoride. does the infant is still breastfeeding the mother provides the child with supplemental formula feedings. which assessment is most important for the nurse to obtain? A. the infant's current hemoglobin and hematocrit B. water source used with supplement feedings C. weight gain and type of formula taken daily D. the newborns gestational age assessment

A. water source used with supplement feedings

A primipara has delivered a stillborn fetus at 30 weeks gestation. To asses the parents in the grieving process which intervention is most for the nurse to implement ? A. explain the possible cause of the fetal demise B. Provide a time for the parents to hold their infant in privacy C. Encourage the parents to seek counseling within the next few weeks D. Assist the couple to request autopsy

B. provide a time for the parents to hold their infant in privacy

1. An older female client with a history of alcoholism tells the nurse that she was at a shopping mall all day yesterday however her son reports that she slept until early afternoon then watched television until bedtime based on these findings the nurse can conclude that the client is exhibiting which type of behavior? A. Sublimation B. Projection C. Denial D. Confabulation

Confabulation

A primigravida arrives at the observation unit of the maternity unit because thinks is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats/minute and the contractions are occurring irregularly every 10 to 15 minutes. What assessment finding confirms to the nurse that the client is not labor at this time?

Contractions decrease with walking.

1. The nurse is caring for a client whose fetus died and utero at 32 weeks gestation after the fetus is delivered vaginally the nurse implements routine fetal demise protocol an identification procedure which action is most important for the nurse to take? A. Determine if the mother desires a visit from her clergy B. Encourage the mother to hold and spend time with her baby C. Explain reasons consent for an infant autopsy is needed D. Create a memory box of baby's footprints and photographs

Encourage the mother to hold and spend time with her baby

The nurse is consoling a client who is at 6-weeks, gestation and is experiencing morning sickness, but doos not want to take any drugs for this discomfort which herbal supplement Is likely to help this client with the nausea She is experiencing? a. Ginger. b. Ginko. c. Chamomile. d. Peppermint.

Ginger

10. The nurse is planning a class for pregnant women in their first trimester of pregnancy. Which information is most important foe the nurse to include in this class? a. If morning dizziness occurs, rise slowly and sit on the side of the bed for one minute. b. Since eating often relieves nausea, carry low-fat snacks to eat whenever nausea occurs c. If any vaginal bleeding occurs, notify the healthcare provider immediately. d. Plan rest periods and increase sleep time to 8 hours per day when fatigued.

If any vaginal bleeding occurs, notify the healthcare provider immediately.

A neonate whose mother is addicted to heroin received morphine for signs of neonatal abstinence syndrome (NAS). After the course of opioid therapy, the healthcare provider prescribes clonidine. Which intervention is most important for the nurse to include in the plan of care? a. Feed the prescribed supplemental formula q2 hours. b. Drape crib with a blanket and place a white noise machine in the crib. c. Monitor neonate's vital signs, slop, feeding, and weight gain patterns. d. Provide close contact using a baby wrap carrier PRN.

Monitor neonate's vital signs, slop, feeding, and weight gain patterns.

A diabetic client delivers a full-term largo-for-gestational-age (LGA) infant who is jittery. Which action should the nurse take first? a. Decrease environmental stimuli b. Obtain a blood glucose level. c. Administer oxygen. d. Feed the infant glucose water (10%).

Obtain a blood glucose level.

1. The nurse is providing teaching to a client and family about schizophrenia before discharge from an inpatient facility the nurse should instruct the family to notify the health care provider when which behavior is observed? A. Decrease attention to detail B. Social withdrawal C. Fear of large dogs D. Change an appetite

Social withdrawal

The nurse notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the nurse implement first? a. Change the client's position. b. Administer oxygen via facemask. c. Turn off the oxytocin infusion. d. Assess cervical dilatation

a. Change the client's position.

A Client who has Typo diabetes and is at 10-weeks gestation comes to the prenatal clinic complaining of a headache, nausea, sweating, feeling shaky and being tired all the time What actions should the nurse take first? a. Provide the client with a protein snack. b. Check the blood glucose level. c. Assess urine for ketone levels: d. Draw blood for a Hemoglobin A1C.

a. Check the blood glucose level.

A newborn infant is receiving immunizations prior to discharge. Which action should the nurse implement? a. Obtain signed consent from the mother for administration of Hepatitis B vaccine. b. Ask the mother if she wants the infant immunized for Homophilus influenzae. c. Prepare the first dose for Diphtheria, tetanus toxoid and acellular pertussis (DTaP). d. Give the first dose of the vaccine for Rotavirus if any sibling have diarrhea now.

a. Obtain signed consent from the mother for administration of Hepatitis B vaccine.

A client who is 4-hours post-spontaneous vaginal birth has excessive blood loss. She has a history of asthma, controlled with inhaler as needed. Her current vital signs are:temperature 99.1°F. (37.3° C), heart rate 104 beats/minute, respirations 20 breaths/minute, and blood pressure 148/92 mmHa. Which medication should the nurse expect to administer to this client? a. Ergonovine. b. Carboprost tromethamine. c. Methylergonovine. d. Oxytocin.

a. Oxytocin.

Which type of anesthesia, used with a client in labor, produces a loss of sensation only to the vagina and perineum? a. Saddle block. b. Paracervical block. c. Epidural block. d. Pudendal block.

a. Pudendal block.

A client who is 3 weeks postpartum continues to have moderate lochia rubra. The nurse determines her uterus to be 1 cm below the umbilicus Which pathophysiological cause is most likely contributing to these findings? a. Early postpartum hemorrhage. b. A vaginal hematoma. c. Retained placental fragments. d. The resumption of menstruation.

a. Retained placental fragments.

Breastfeeding woman who delivered her infant two weeks ago develops masses in her left breast. A cephalosporin antibiotic is prescribed after consultation with the infants pediatrician. Which instructions regarding breastfeeding should the nurse provide? a. Limit breastfeeding to unaffected breast. b. Initiate feeding on the unaffected breast first. c. Put Ice packs on the affected breast for comfort. d. Alternate breastfeeding and bottle feeding

b. Initiate feeding on the unaffected breast first.

The nurse is assessing a newborn who was precipitously delivered at 38-weeks gestation. The newborn is tremulous tachycardic, and hypertensive. Which assessment action is most important for the nurse to implement? a. Perform gestational age assessment. b. Obtain a drug screen for cocaine. c. Weigh and measure the newborn. d. Determine reactivity of neonatal reflexes.

b. Obtain a drug screen for cocaine.

The nurse is receiving report for a laboring client who arrived in the emergency center with ruptured membranes that the client did not recognize. Which is the priority nursing action to implement when the client is admitted to the labor and delivery suite? a. Monitor amniotic fluid for meconium. b. Take the client's temperature. c. Prepare to start an IV. d. Begin a pad count.

b. Take the client's temperature.

A 38-week primigravida is admitted to labor and delivery after a non-reactive result on a non stress test (NST). The nurse begins a contraction stress test (CST) win an oryta infusion. Which finding is most important for the nurse to report to the healthcare provider? a. Fetal heart rate accelerations with fetal movement b. Absences of uterine contractions within 20 minutes. c. A pattern of fetal late decelerations. d. Spontaneous rupture of membranes.

c. A pattern of fetal late decelerations.

When developing a teaching plan for a client at 8-weeks gestation, what instruction has the highest priority? a. Eat a well-balanced diet using this printed diet instruction sheet. b. Try eating crackers when you first feel nauseated. c. Call the clinic if you have any vaginal bleeding or cramping. d. You should enroll in this month's childbirth preparation classes.

c. Call the clinic if you have any vaginal bleeding or cramping.

A pregnant woman who is at 10-weeks gestation and is 35-years of age tells the nurse that she is concerned about the possibility of having a baby with Down Syndrome. Which information should the nurse provide this client? a. Maternal serum Human Chorionic Gonadotropic (HG) can identify Down Syndrome at 6 weeks gestation. b. An amniocentesis conducted at 24 weeks gestation confirms or denies Down Syndrome in the fetus. c. Chorionic villus sampling at 12 weeks gestation is the earliest screening test used to identity Down Syndrome. d. Weekly fundal height measurements is a noninvasive method used to check for Down Syndrome.

c. Chorionic villus sampling at 12 weeks gestation is the earliest screening test used to identity Down Syndrome.

The nurse is caring for a client whose fetus died in utero at 32-weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures. Which action is most important for the nurse to take? a. Determine if the mother desires a visit from her clergy. b. Create a memory box of baby's footprints and photographs. c. Encourage the mother to hold and spend time with her baby. d. Explain reasons consent for an infant autopsy is needed.

c. Encourage the mother to hold and spend time with her baby.

The nurse is preparing a young couple and their 24-hour-old infant for discharge from the hospital. In conducting discharge teaching which intervention is most important for the nurse to implement? a. Provide the results of the infant's hearing test to the parents. b. Request a return demonstration of a diaper change. c. Evaluate infant feeding techniques prior to discharge. d. Ensure that they have the pediatric clinic's phone number.

c. Evaluate infant feeding techniques prior to discharge.

A mother calls the clinic nurse and reports that after each breastfeeding, her 5-day-old infant has a bowel movement that is yellow, sticky, and smells like sour milk. Which information should the nurse provide? a. Tell the mother to bring the infant to the clinic to be assessed for an infection. b. Encourage the mother to bottle feed until the stool changes color and odor. c. Instruct the mother to continue breastfeeding because the stool is normal. d. Inquire about the number and duration of feedings during the last 24 hours.

c. Instruct the mother to continue breastfeeding because the stool is normal.

A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take? a. Administer penicillin. b. Obtain blood cultures. c. Prepare for a cesarean section. d. Cover the lesion with a dressing.

c. Prepare for a cesarean section.

Which action is most important for the nurse to implement to prevent bleeding in the neonate during the first hour after birth? a. Provide the first oral fluids using formula. b. Replace the umbilical cord clamp close to the infant's body. c. Use the axillary method to obtain core body temperature. d. Administer phytonadione (Vitamin K) IM.

d. Administer phytonadione (Vitamin K) IM.

A primigravida client who is at 33 weeks gestation presents to the labor and delivery unit with complaints of a headache. The initial assessment findings include: blood pressure 144/96 mm Hg, facial edema, and 3+ pitting edema in lower extremities. Which assessment should the nurse perform next? a. Temperature, pulse, and respirations. b. Intensity of pain with contraction. c. Fetal heart rate. d. Deep tendon reflexes and clonus.

d. Deep tendon reflexes and clonus.

43. A couple who is trying to have a baby asks the nurse when they are most likely to conceive a child. The woman has a regular 35-day menstrual cycle, and the first day of her last menstrual period was on January 16. Which information should the nurse provide? a. Have intercourse every three days to ensure that ovulation and intercourse coincide. b. The woman should ovulate mid-cycle, so plan to have intercourse on February 3. c. Have intercourse every other morning because this is when the sperm count is higher. d. Plan to have intercourse on February 7, as this is when ovulation should occur.

d. Plan to have intercourse on February 7, as this is when ovulation should occur.

A primigravida client asks the nurse about exercising during pregnancy to help her prepare for labor. Which recommendation should the nurse provide? a. Avoid weight-bearing exercises until the postpartum period. b. Limit exercise to brisk walking during pregnancy. c. Leg lifts will help to strengthen abdominal muscles. d. Stretching exercises are good preparation for labor.

d. Stretching exercises are good preparation for labor.

1. A mother tells the clinic nurse and reports that after each breastfeeding her five-day old infant has a bowel movement that is yellow sticky and smells like sour milk. which information should the nurse provide? A. instruct the mother to continue breastfeeding because the stool is normal B. encourage the mother to bottle feed until the stool changes color an odor C. inquire about the number and duration of feedings during the last 24 hours D. tell the mother to bring the infant to the clinic to be assess for an infection

instruct the mother to continue breastfeeding because the stool is normal

1. A primigravida client asked the nurse about exercising during pregnancy to help her prepare for labor. Which recommendation should the nurse provide? A. limit exercise to brisk walking during pregnancy B. avoid weight bearing exercises until postpartum period C. stretching exercise are good preparation for labor D. leg lifts will help to strengthen abdominal muscles

limit exercise to brisk walking during pregnancy

1. A female client with obsessive compulsive disorder Complains that she feels driven to check the locks on her front door at least six times every night which response is best for the nurse to provide. A. Have you had a bad experience related to unlock doors B. what are your thoughts when you are checking the locks C. repeating the same behavior helps you to diminish your anxiety D. feelings of being driven to do something are related to anxiety

repeating the same behavior helps you to diminish your anxiety

1. A client diagnosed with dementia is disorientated wandering has a decreased appetite and is having trouble sleeping. which is the priority nursing problem for the client? A. disturbed thought process B. imbalance nutrition less than C. risk for injury D. alter sleep pattern

risk for injury

1. a young adult with eroded tooth enamel presents to the clinic with multiple complaints including severe pain in the chest and upper abdomen that occurred when the client induced vomiting after eating a large breakfast. the client also reports severe heartburn in the last week and describe the history of taking laxatives and eating prunes whenever overeating. which client problem should the nurse address first? A. erosion of tooth enamel B. upper abdominal pain C. severe heartburn D. laxative use after bingeing

upper abdominal pain