Mother Baby NCLEX week 4
A 32-week-gestation client was last seen in the prenatal client at 28 weeks gestation. Which of the following changes should the nurse bring to the attention of the certified nurse midwife? A. Weight change from 128 pounds to 138 pounds. B. Pulse rate change from 88 bpm to 92 bpm. C. Blood pressure change from 120/80 to 118/78. D. Respiratory rate change from 16 rpm to 20 rpm.
A
A 40-week-gestation woman has received Cytotec (misoprostol) for cervical ripening. For which of the following signs/symptoms should the nurse carefully monitor the client? A. Diarrhea and back pain. B. Hypothermia and rectal pressure. C. Urinary retention and rash. D. Tinnitus and respiratory distress.
A
A client has been diagnosed with water intoxication after having received IV Oxytocin (pitocin) for over 24 hours. Which of the following signs/symptoms would the nurse expect to see? A. Confusion, drowsiness, and vomiting. B. Hypernatremia and hyperkalemia. C. Thrombocytopenia and neutropenia. D. Paresthesias, myalgias, and anemia.
A
A client just spontaneously ruptured membranes. Which of the following factors makes her especially at high risk for having a prolapsed cord? Select all that apply. A. Breech presentation. B. Station -3. C. Oligohydramnios. D. Dilation 2 cm. E. Transverse lie.
A, B, D
A client, 32 weeks' gestation with placenta previa, is on total bedrest. The physician expects her to be hospitalized on bedrest until her cesarean section, which is scheduled for 38 weeks' gestation. To prevent complications while in the hospital, the nurse should do which of the following? Select all that apply. A. Perform passive range-of-motion exercises. B. Restrict the fluid intake of the client. C. Decorate the room with pictures of family. D. Encourage the client to eat a high-fiber diet. E. Teach the client deep-breathing exercises.
A, C, D, E
During a vaginal delivery, the obstetrician declares that a shoulder dystocia has occurred. Which of the following actions by the nurse is appropriate at this time? A. Administer oxytocin intravenously per doctor's orders. B. Flex the woman's thighs sharply toward her abdomen. C. Apply oxygen using a tight-fitting face mask. D. Apply downward pressure on the woman's fundus.
B
In which of the following clinical situations would it be appropriate for an obstetrician to order a labor nurse to perform amnioinfusion? A. Placental abruption. B. Meconium-stained fluid. C. Polyhydramnios. D. Late decelerations.
B
A 24-week-gravid client is being seen in the prenatal clinic. She states, "I have had a terrible headache for the past 2 days." Which of the following is the most appropriate action for the nurse to perform next? A. Inquire whether or not the client has allergies B. Take the woman's blood pressure. C. Assess the woman's fundal height. D. Ask the woman about stressors at work.
B
A 29-week-gestation woman diagnosed with severe pre-eclampsia is noted to have blood pressure of 170/112, 4+ proteinuria, and a weight gain of 10 pounds over the past 2 days. Which of the following signs/symptoms would the nurse also expect to see? A. Fundal height of 32 cm. B. Papilledema. C. Patellar reflexes of +2. D. Nystagmus.
B
A client is admitted in labor with spontaneous rupture of membranes 24 hours earlier. The fluid is clear and the fetal heart rate is 124 with moderate variability. Which assessment is most important for the nurse to make at this time? A. Contraction frequency and duration B. Maternal temperature. C. Cervical dilation and effacement. D. Maternal pulse rate.
B
The fetal monitor tracing of a laboring woman who is 9 cm dilated shows recurring late decelerations to 100 bpm. The nurse notes a moderate amount of greenish-colored amniotic fluid gush from the vagina after a practitioner performs an amniotomy. Which of the following nursing diagnoses is appropriate at this time? A. Risk for infection related to rupture of membranes. B. Risk for fetal injury related to possible intrauterine hypoxia. C. Risk for impaired tissue integrity related to vaginal irritation. D. Risk for maternal injury related to possible uterine rupture.
B
The nurse is caring for an eclamptic client. Which of the following is an important action for the nurse to perform? A. Check each urine for presence of ketones. B. Pad the client's bed rails and headboard. C. Provide visual and auditory stimulation. D. Place the bed in the high Fowler position.
B
The nurse is grading a woman's reflexes. Which of the following grades would indicate reflexes that are slightly brisker than normal? A. +1. B. +2. C. +3. D. +4.
C
A 26-week-gestation woman is diagnosed with severe pre-eclampsia with HELLP syndrome. The nurse will assess for which of the following signs/symptoms? A. Low serum creatinine. B. High serum protein. C. Bloody stools. D. Epigastric pain.
D
A 40-week-gestation client has an admitting platelet count of 90,000 cells/mm and a hematocrit of 29%. Her laboratory values I week earlier were platelet count 200,000 cells/mm and hematocrit 37%. Which additional abnormal laboratory value would the nurse expect to see? A. Decreased serum creatinine level. B. Elevated red blood count (RBC). C. Decreased alkaline phosphatase D. Elevated alanine transaminase (ALT).
D
A client has severe pre-eclampsia. The nurse would expect the primary healthcare practitioner to order tests to assess the fetus for which of the following A. Severe anemia. B. Hypoprothrombinemia. C. Craniosynostosis. D. Intrauterine growth restriction.
D
A gravid woman is carrying monochorionic twins. For which of the following complications should this pregnancy be monitored? A. Oligohydramnios. B. Placenta previa. C. Cephalopelvic disproportion. D. Twin-to-twin transfusion.
D
A gravid client with 4+ proteinuria and 4+ reflexes is admitted to the hospital. The nurse must closely monitor the woman for which of the following A. Grand Mal Seizure B. High Platelet Count C. Explosive Diarrhea D. Fractured Pelvis
A
A client, G4 P1021, has been admitted to the labor and delivery suite for induction of labor. The following assessments have been made: Bishop score of 2, fetal heart rate of 156 with good variability and no decelerations, TPR 98.6°F, P 88, R 20, BP 120/80, negative obstetric history. Cervidil (dinoprostone) has been inserted. Which of the following findings would warrant the removal of the prostaglandin? A. Bishop score of 4 B. Fetal heart rate of 152. C. Respiratory rate of 24. D. Contraction frequency of 1 minute.
D
A nurse administers magnesium sulfate via infusion pump to an eclamptic woman in labor. Which of the following outcomes indicates that the medication is effective? A. Client has no patellar reflex response. B. Urinary output is 30 mL/hr. C. Respiratory rate is 16 rpm. D. Client has no grand mal seizures.
D
A nurse is caring for four clients on the labor and delivery unit. Which of the following actions should the nurse take first? A. Check the blood sugar of a gestational diabetic. B. Assess the emotional status of a client who is post-spontaneous abortion. C. Assess the patellar reflexes of a client with mild pre-eclampsia. D. Check the fetal heart rate of a client who just ruptured membranes.
D
A nurse remarks to a 38-week-gravid client, "It looks like your face and hands are swollen." The client responds. "Yes, you're right. Why do you ask?" The nurse's response is based on the fact that the changes may be caused by which of the following? A. Altered glomerular filtration. B. Cardiac failure. C. Hepatic insufficiency. D. Altered splenic circulation.
A
A patient, 32 weeks pregnant with severe headache, is admitted to the hospital with pre-eclampsia. In addition to obtaining baseline vital signs and placing the client on bedrest, the physician ordered the following four items. Which of the orders should the nurse perform first? A. Assess deep tendon reflexes. B. Obtain complete blood count. C. Assess baseline weight. D. Obtain routine urinalysis.
A
Immediately after a woman spontaneously ruptures her membranes, the nurse notes a loop of the umbilical cord protruding from the woman's vagina. Which of the following actions should the nurse perform first? A. Put the client in the knee-chest position. B. Assess the fetal heart rate. C. Administer oxygen by tight face mask. D. Telephone the obstetrician with the findings.
A
A client, G8 P3406, 14 weeks' gestation, is being seen in the prenatal clinic. During the nurse's prenatal teaching session, the nurse will emphasize that the woman should notify the obstetric office immediately if she notes which of the following? A. Change in fetal movement. B. Signs and symptoms of labor. C. Swelling of feet and ankles. D. Appearance of spider veins.
B
A full-term client, contracting every 15 min x 30 sec, has had ruptured membranes for 20 hours. Which of the following nursing interventions is contraindicated at this time? A. Intermittent fetal heart auscultation. B. Vaginal examination. C. Intravenous fluid administration. D. Nipple stimulation.
B
During a prenatal interview, a client tells the nurse, "My mother told me she had toxemia during her pregnancy and almost died!" Which of the following questions should the nurse ask in response to this statement? A. "Does your mother have a family history of cancer?" B. "Did your mother tell you what she was toxic from? C. "Does your mother have diabetes now?" D. "Did your mother say whether she had a seizure or not?"
D
The nurse is to intervene when caring for a laboring client whose baby is exhibiting signs of fetal distress. Which of the following actions should the nurse take? A. Administer oxygen via nasal cannula. B. Place the client in high Fowler position. C. Remove the internal fetal monitor electrode. D. Increase the intravenous infusion rate.
D
Which of the following situations should the nurse conclude is a vaginal delivery emergency? A. Third stage of labor lasting 20 minutes. B. Fetal heart dropping during contractions: C. Three-vessel cord. D. Shoulder dystocia.
D
Which of the following pregnant clients is most high risk for preterm premature rupture of the membranes (PPROM)? Select all that apply. A. 31 weeks' gestation with prolapsed mitral valve (PMV). B. 32 weeks' gestation with urinary tract infection (UTI). C. 33 weeks' gestation with twins post-in vitro fertilization (IVF). D. 34 weeks' gestation with gestational diabetes (GDM). E. 35 weeks' gestation with deep vein thrombosis (DVT).
B, C
A client is admitted to the hospital with severe pre-eclampsia. The nurse is assessing for clonus. Which of the following actions should the nurse perform? A. Strike the woman's patellar tendon. B. Palpate the woman's ankle. C. Dorsiflex the woman's foot. D. Position the woman's feet flat on the floor.
C
A client with mild pre-eclampsia who has been advised to be on bedrest at home asks why doing so is necessary. Which of the following is the best response for the nurse to give the client? A. "Bed Rest will help you to conserve energy for your labor." B. "Bed Rest will help to relieve your nausea and anorexia." C. "Reclining will increase the amount of oxygen that your baby gets." D. "The position change will prevent the placenta from separating."
C
A client, 39 weeks' gestation, fetal heart baseline at 144 bpm, tells the admitting labor and delivery room nurse that she has had to wear a pad for the past 4 days because I keep leaking urine." Which of the following is an appropriate action for the nurse to perform at this time? A. Palpate the woman's bladder to check for urinary retention. B. Obtain a urine culture to check for a urinary tract infection. C. Assess the fluid with nitrazine and see if the paper turns blue. D. Percuss the woman's uterus and monitor for ballottement.
C
A delirious patient is admitted to the hospital in labor. She has had no prenatal care and vials of crack cocaine are found in her pockets. The nurse monitors this client carefully for which of the following intrapartum complications? A. Prolonged labor. B. Prolapsed cord. C. Abruptio placentae. D. Retained placenta.
C
The nurse is evaluating the effectiveness of bedrest for a client with mild pre-eclampsia. Which of the following signs/symptoms would the nurse determine is a positive finding? A. Weight Loss B. 2+ proteinuria. C. Decrease in plasma protein. D. 3+ patellar reflexes.
A
The nurse is monitoring a woman, G2P1001, 41 weeks' gestation, in labor. A 12 p.m. assessment revealed: cervix, 4 cm; 80% effaced; -3 station; and FH 124 with moderate variability. A 5 p.m. assessment: cervix, 6 cm; 90% effaced: -3 station; and FH 120 with moderate variability. A 10 p.m. assessment: cervix, 8 cm; 100% effaced; -3 station and FH 124 with moderate variability. Based on the assessments, which of the following should the nurse conclude: A. Labor is progressing well. B. The woman is likely carrying a macrosomic fetus. C. The baby is in fetal distress. D. The woman will be in second stage in about five hours.
C
A client, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin) for hypertension and oligohydramnios. She is contracting q 3 min x 60 to 90 seconds. She suddenly complains of abdominal pain accompanied by significant fetal heart bradycardia. Which of the following interventions should the nurse perform first? A. Turn off the oxytocin infusion. B. Administer oxygen via face mask. C. Reposition the patient. D. Call the obstetrician.
A
The physician has ordered oxytocin (Pitocin) for induction for 4 gravidas. In which of the following situations should the nurse refuse to comply with the order A. Primigravida with a transverse lie. B. Multigravida with cerebral palsy. C. Primigravida who is 14 years old. D. Multigravida who has type 1 diabetes.
A
On ultrasound, it is noted that the pregnancy of a hospitalized woman who is carrying monochorionic twins is complicated by twin-to-twin transfusion. The nurse should carefully monitor this client for which of the following? A. Rapid fundal growth. B. Vaginal bleeding. C. Projectile vomiting, D. Congestive heart failure.
A
The nurse is caring for a laboring gravida who is +3 weeks pregnant. For which of the following should the nurse carefully monitor this client and fetus? A. Late decelerations. B. Hyperthermia. C. Hypotension. D. Early decelerations.
A
A known drug addict is in active labor. She requests pain medication. Which of the following actions by the nurse is appropriate? A. Encourage the woman to refrain from taking medication to protect the fetus. B. Notify the physician of her request. C. Advise the woman that she can receive only an epidural because of her history. D. Assist the woman to do labor breathing.
B
A woman, G4 P0210 and 12 weeks' gestation, has been admitted to the labor and delivery suite for a cerclage procedure. Which of the following line outcomes appropriate for this client? A. The client will gain less than 25 pounds during the pregnancy. B. The client will deliver after 38 weeks' gestation. C. The client will have a normal blood glucose throughout the pregnancy. D. The client will deliver a baby who is appropriate for gestational age.
B
An induction of a 42-week gravida with IV oxytocin (Pitocin) is begun at 0900 at a rate of 0.5 milliunits per minute. The woman's primary physician orders: Increase the oxytocin drip by 0.5 milliunits per minute every 10 minutes until contractions are every 3 minutes x 60 seconds. The nurse refuses to comply with the order. Which of the following is the rationale for the nurse's action? A. Fetal distress has been noted in labors when oxytocin dosages greater than 2 milliunits per minute are administered. B. The relatively long half-life of oxytocin can result in unsafe intravascular concentrations of the drug. C. It is unsafe practice to administer oxytocin intravenously to a woman who is carrying a postdates fetus. D. A contraction duration of 60 seconds can lead to fetal compromise in a baby who is postmature.
B
A nurse is counseling a pre-eclamptic client about her diet. Which should the nurse encourage the woman to do? A. Restrict sodium intake. B. Increase intake of fluids. C. Eat a well-balanced diet. D. Avoid simple sugars.
C
A nurse is performing an assessment on four 22-week-pregnant clients. The nurse reports to the obstetrician that which of the clients may be carrying twins? A. The client whose progesterone levels are elevated. B. The client with a weight gain of 13 pounds. C. The client whose fundal height measurement is 26 cm. D. The client whose alpha-fetoprotein level is one-half normal.
C
After a multiparous woman has been in active labor for 15 hours, an ultrasound is done. The results state that the obstetric conjugate is 10 cm and the suboccipitobregmatic diameter is 10.5 cm. Which of the following labor findings is related to these results? A. Full dilation of the cervix. B. Full effacement of the cervix. C. Station of -3. D. Frequency every 5 minutes.
C
There are four clients in the labor suite. Each client's labor is being augmented with oxytocin (Pitocin). Which of the women should the nurse monitor carefully for the potential of uterine rupture: A. Age 15. G3 PO020, in active labor. B. Age 22, GI P0000, eclampsia. C. Age 25, G4P3003, last delivery by cesarean section. D. Age 32, G2 P0100, first baby died during labor.
C
Four women request to labor in the hospital bathtub. In which of the following situations is the procedure contraindicated? Select all that apply. A. Woman during transition B. Woman during second stage of labor. C. Woman receiving oxytocin for induction. D. Woman with meconium-stained fluid. E. Woman with fetus in the occiput posterior position.
C, D
A nurse is monitoring a client who is receiving an amnioinfusion. Which of the following assessments is critical for the nurse to make to prevent a serious complication related to the procedure? A. Color of the amniotic fluid. B. Maternal blood pressure. C. Cervical effacement. D. Uterine resting tone.
D
A woman, G3 P2002, is 6 cm dilated. The fetal monitor tracing shows recurring deep late decelerations. The woman's doctor informs her that the baby must be delivered by cesarean section. The woman refuses to sign the informed consent. Which of the following actions by the nurse is appropriate? A. Strongly encourage the woman to sign the informed consent. B. Prepare the woman for the cesarean section. C. Inform the woman that the baby will likely die without the surgery D. Provide the woman with ongoing labor support.
D
