NUR 221 - Final (l)
A nurse is caring for a client who was admitted with the diagnosis of severe preeclampsia and is now receiving an intravenous infusion of magnesium sulfate. What is the classification of this medication? Diuretic Oxytocic Antihypertensive agent Central nervous system depressant
Central nervous system depressant
A nursing student is learning about expected postpartum anatomic and physiologic changes. Which statement made by the nursing student indicates a need for further learning? "The capacity of the bladder increases postpartum." "The uterus involutes to approximately 350 g by two weeks after birth." "The cervical dilation decreases to 2 to 3 cm by the second or third postpartum day." "After birth, the vagina gradually decreases in size and returns to its pre-pregnancy state."
"After birth, the vagina gradually decreases in size and returns to its pre-pregnancy state." During the postpartum period, normal anatomic and physiological changes occur. After a birth, the vagina gradually decreases in size; however, does not return to its pre-pregnancy state.
The nurse is teaching participants in a prenatal class regarding breastfeeding versus formula feeding. A client asks, "What is the primary advantage of breastfeeding?" Which response is most appropriate? "Breastfed infants have fewer infections." "Breastfeeding inhibits ovulation in the mother." "Breastfed infants adhere more easily to a feeding schedule." "Breastfeeding provides more protein than cow's milk formula does."
"Breastfed infants have fewer infections."
The husband of a client who is in the transition phase of the first stage of labor becomes very tense and anxious and asks a nurse, "Would it be best for me to leave, since I don't seem to be doing my wife much good?" What is the appropriate response by the nurse? "This is the time when your wife needs you. Don't run out on her now." "I know that this is hard for you. Let me try to help you coach her during this difficult phase." "I know that this is hard for you. Why don't you go have a cup of coffee to help you relax and then come back in a little while?" "If you feel that way, you'd best go out and sit in the fathers' waiting room for a while. You'll just end up transmitting your anxiety to your wife."
"I know that this is hard for you. Let me try to help you coach her during this difficult phase."
A woman who has just delivered an infant asks to take the placenta home with her upon discharge. What is the most appropriate response by the nurse? "I'll wrap that right up for you." "I'm sorry, but you can't do that." "I'll give it to you for your husband to take home now." "I need to check the hospital protocol for our policy on that practice."
"I need to check the hospital protocol for our policy on that practice."
A nurse at a women's health clinic confirms that client teaching regarding the use of an oral contraceptive is understood when the client makes which statement? "I can stop the pill and try to get pregnant right away." "I may miss two periods and not worry about being pregnant." "I will take my pill at the same time every day." "I am so glad we won't have to use condoms even if I miss just one pill during the month."
"I will take my pill at the same time every day."
During a routine second-trimester visit to the prenatal clinic a client expresses concern regarding gaining weight and losing her figure. She says to the nurse, "I'm going on a diet." What is the nurse's best response? "That's fine as long as you include a variety of foods daily." "It's a good idea for you to keep your weight down during your pregnancy." "If you add 340 calories a day to your regular diet, you won't become overweight." "Gain no more than 25 lb (11 kg) so that it'll be easier to lose the weight after the baby is born."
"If you add 340 calories a day to your regular diet, you won't become overweight."
At 12 weeks' gestation a client with a history of several spontaneous abortions says to the nurse, "Every day I wonder whether I'll be able to have this baby." How should the nurse respond? "I can understand why you're worried; however, you'll have other chances in the future to get pregnant." "You're getting the best of care. Please tell me about the problems with your previous pregnancies." "It's understandable for you to be worried that you won't be able to carry this pregnancy to term. You've had a difficult time." "Your pregnancy has lasted past the time when most early spontaneous abortions occur. I think you'll be able to continue the pregnancy."
"It's understandable for you to be worried that you won't be able to carry this pregnancy to term. You've had a difficult time."
A 28-year-old woman seeks advice about oral contraceptives from the nurse in her company health office. What should the nurse tell her if she is a smoker? "Oral contraceptives can cause thrombophlebitis." "Oral contraceptives must be used with other methods." "Some oral contraceptives can be used without concern." "Some oral contraceptives are safe, but others are not safe."
"Oral contraceptives can cause thrombophlebitis."
A pregnant client tells the nurse, "I'm sticking to my diet, and I don't eat anything containing salt." How should the nurse respond? "You're doing fine. Just keep up the good work." "A low-salt diet will protect you from getting swollen feet." "We now encourage pregnant women to increase their salt intake because of changes in the circulation." "Salt is necessary in your diet. Use a little when you're cooking, but avoid processed meats and canned foods with salt."
"Salt is necessary in your diet. Use a little when you're cooking, but avoid processed meats and canned foods with salt."
A new mother asks the nurse administering erythromycin ophthalmic ointment to her newborn why her baby must be subjected to this procedure. What is the best response by the nurse? "It will keep your baby from going blind." "This ointment will protect your baby from bright lights." "There is a law that newborns must be given this medicine." "This antibiotic helps keep babies from contracting eye infections."
"This antibiotic helps keep babies from contracting eye infections."
A pregnant client has a positive group B Streptococcus (GBS) test at 36 weeks' gestation. What is the priority instruction that the nurse will include in the client's teaching plan? "Go straight to the outpatient area of the maternity unit for a nonstress test." "You'll need to schedule visits twice a week with your healthcare provider until you deliver." "Your baby will have to spend at least 3 days in the neonatal intensive care unit because of this infection." "This information will be in your prenatal record; however, please remind your labor and delivery nurse of this finding."
"This information will be in your prenatal record; however, please remind your labor and delivery nurse of this finding."
The nurse is teaching a group of adolescents about the calendar method of contraception. Which statement made by an adolescent indicates effective learning? "This type of contraception requires a regular menstrual cycle." "This contraceptive method is 100% effective to prevent pregnancy." "This contraception may decrease sensation and reduce spontaneity." "This type of contraception is simple, must fit correctly, and is reusable."
"This type of contraception requires a regular menstrual cycle."
A 16-year-old adolescent visits the prenatal clinic because she has missed three menstrual periods. Before her physical examination she says, "I don't know what the problem is, but I just can't be pregnant." What is the nurse's most therapeutic response? "Many young women are irregular at your age." "You probably are pregnant if you had intercourse." "Why did you decide to come to the prenatal clinic?" "Should I ask the primary healthcare provider to talk to you?"
"Why did you decide to come to the prenatal clinic?"
During a discussion regarding nutrition, the nurse explains to a pregnant client that she will need additional calcium during pregnancy and that the ideal source is milk. The client states, "I never drink milk or eat milk products. They turn my stomach." What is the nurse's best reply? "Your practitioner can prescribe calcium supplements." "Just make sure that the rest of your diet is nutritionally sound." "Eliminating milk from your diet may cause your teeth to loosen." "Drinking milk is so important for your baby to develop strong bones."
"Your practitioner can prescribe calcium supplements."
A nurse is caring for a postpartum client. Where does the nurse expect the fundus to be located if involution is progressing as expected 12 hours after birth? 2 cm below the umbilicus 3 cm above the umbilicus 1 cm above the umbilicus 3 cm below the umbilicus
1 cm above the umbilicus Twelve hours after birth, the uterus is 1 cm above the umbilicus, and each succeeding day it descends one fingerbreadth. Therefore the uterus should be 2 cm below the umbilicus on the second postpartum day. A uterus 3 cm above the umbilicus indicates that the bladder is full. The uterus is 3 cm below the umbilicus on the fourth postpartum day because the uterus descends one fingerbreadth per day.
The nurse is reviewing the documented results of a lecithin/sphingomyelin (L/S) ratio. Which finding is indicative of fetal lung maturity? 1:1 1.4:1 1.8:1 2:1
2:1
A neonate weighing 5 lb 6 oz (2438 g) is born in a cesarean birth and admitted to the newborn nursery. What range of resting respiratory rate should the nurse anticipate? 20 to 40 breaths/min 30 to 60 breaths/min 60 to 80 breaths/min 70 to 90 breaths/min
30 to 60 breaths/min
The nurse instructs a pregnant client in the sources of protein that can be used to meet the increased daily requirement during pregnancy. How many grams of protein should the client eat each day? 65 g 60 g 55 g 50 g
60 g The Food and Nutrition Board of the National Academy of Sciences recommends that a pregnant woman consume 60 g of protein daily to meet the needs of pregnancy. The recommended daily intake of protein for a breastfeeding (lactating) woman is 65 g.
The nurse gently performs Leopold maneuvers on a client with a suspected placenta previa. What does the nurse expect to find during this assessment? Firm engagement of the fetal head Difficulty palpating small fetal parts A high, floating fetal presenting part A hard and tetanically contracted uterus
A high, floating fetal presenting part
A woman is admitted to the high-risk unit in preterm labor at 30 weeks' gestation. Which factor does the nurse suspect precipitated this preterm labor? Android pelvis Incompetent cervix First-time pregnancy Antiseizure medication
Incompetent cervix
The nurse is caring for a client who is in the taking-in phase of the postpartum period. What area of health teaching will the client be most responsive to? Perineal care Infant feeding Infant hygiene Family planning
Perineal care
A client at 32 weeks' gestation is admitted to the birthing unit because she is having regular labor contractions. A prescription for 6 mg of intramuscular dexamethasone, twice a day for 2 days, is issued. The client asks why she needs this medicine. The nurse explains that this corticosteroid is prescribed because it does what? Promotes sleep May stop contractions Relaxes uterine muscles Accelerates fetal lung maturity
Accelerates fetal lung maturity
A pregnant woman in her second trimester arrives at the local health department, requesting a flu shot. The client states that she gets the flu vaccine every year and has never had an adverse reaction. What action should the nurse perform? Do not administer the vaccine until checking with the healthcare provider. Do not administer the vaccine due to pregnancy contraindication. Administer the usual dose of the vaccine. Administer half the usual dose of the vaccine.
Administer the usual dose of the vaccine.
When assessing a neonate and mother after a vaginal delivery, the nurse finds that the neonate's blood group is B positive and mother's is AB negative. The nurse also finds that the mother has a negative Coombs test. What is the appropriate intervention in this situation? Administering Rho(D) immune globulin intravenously to the mother within 1 week of delivery Administering Rho(D) immune globulin intramuscularly to the mother within 72 hours of delivery Administering Rho(D) immune globulin intramuscularly to the neonate within 1 week of delivery Administering Rho(D) immune globulin intravenously to the neonate within 72 hours of delivery
Administering Rho(D) immune globulin intramuscularly to the mother within 72 hours of delivery
A client required an extensive episiotomy because her newborn was large. What is a priority nursing intervention that minimizes edema and lessens discomfort at the episiotomy site? Applying ice packs to the perineum Positioning the client off the incisional area Administering an oral analgesic to the client Spraying the perineum with a local anesthetic
Applying ice packs to the perineum
A client comes to the clinic for a 6-week postpartum check-up. She confides that she is experiencing exhaustion that is not relieved by sleep and feelings of failure as a mother because the infant "cries all of the time." When asked whether she has a support system, she replies that she lives alone. Which response would provide the most accurate information? Providing information about a local support group Explaining that it is normal to feel depressed after childbirth Asking the client questions, using a postpartum depression scale Suggesting that the client find someone who can take care of the baby for 24 hours
Asking the client questions, using a postpartum depression scale
On the second postpartum day a client mentions that her nipples are becoming sore from breastfeeding. What is the nurse's initial action in response to this information? Assess her breastfeeding techniques to identify possible causes. Provide a nipple shield to keep the infant's mouth off the nipples. Instruct her to apply warm compresses 10 minutes before she begins to breastfeed. Explain that she should limit breastfeeding to 5 minutes per side until the soreness subsides.
Assess her breastfeeding techniques to identify possible causes.
A client who has had a cesarean birth appears upset. She has been having difficulty breastfeeding for two days and now asks the nurse to bring her a bottle of formula. What is the nurse's initial action? Obtaining the requested formula Administering the prescribed pain medication Assessing the client's breastfeeding technique Notifying the practitioner of the client's request to switch feeding methods
Assessing the client's breastfeeding technique
The nurse is providing preoperative teaching to a client who has scheduled a vasectomy. What information is essential for the nurse to explain to the client? Recanalization of the vas deferens is impossible. Unprotected coitus is safe within 1 week to 10 days. Some impotency is to be expected for several weeks after the procedure. At least 15 ejaculations to clear the tract of sperm must occur before the semen is checked.
At least 15 ejaculations to clear the tract of sperm must occur before the semen is checked.
After performing Leopold maneuvers on a laboring client, the nurse determines that the fetus is in the right occiput posterior (ROP) position. Where should the Doppler ultrasound transducer be placed to best auscultate fetal heart tones? Above the umbilicus in the midline Above the umbilicus on the left side Below the umbilicus on the right side Below the umbilicus near the left groin
Below the umbilicus on the right side
The nurse is caring for a postpartum client who has experienced an abruptio placentae. Which assessment indicates that disseminated intravascular coagulation (DIC) is occurring? Boggy uterus Hypovolemic shock Multiple vaginal clots Bleeding at the venipuncture site
Bleeding at the venipuncture site
A 16-year-old adolescent at 24 weeks' gestation visits the prenatal clinic for the first time. After the physical examination she tells the nurse, "I can't believe how big I am. Will I get much bigger?" What information about adolescent growth and development does the nurse need to understand before responding? Adolescents generally regain their figures 2 weeks after the birth, so size is of moderate concern. Adolescents are in a high-risk category, so weight gain should be limited to prevent complications. Body image is very important to adolescents; therefore pregnant teenagers are overly concerned about body size. Physiological growth in adolescents is more rapid than in adults, so the gravid size is larger than that of an adult woman.
Body image is very important to adolescents; therefore pregnant teenagers are overly concerned about body size.
A nurse is caring for a preterm neonate with physiologic jaundice who requires phototherapy. What is the physiologic mechanism of this therapy? Stimulates the liver to dispose of the bilirubin Breaks down the bilirubin into a conjugated form Facilitates the excretion of bilirubin by activating vitamin K Dissolves the bilirubin, allowing it to be excreted by the skin
Breaks down the bilirubin into a conjugated form
A pregnant client is diagnosed with gestational hypertension. The client tells the nurse that she has been following the recommended pregnancy diet. What should the nurse teach her about her diet at this time? Limit proteins Change nothing Restrict sodium Increase carbohydrates
Change nothing The recommended diet for a client with gestational hypertension is the same as that recommended for a normotensive pregnant client. Protein intake should be increased during pregnancy. Pregnant clients with gestational hypertension should not restrict their sodium intake or increase their carbohydrate intake over the recommended amount.
A client's membranes rupture while her labor is being augmented with an oxytocin infusion. The nurse observes variable decelerations in the fetal heart rate on the fetal monitor strip. Which action should the nurse initiate next? Changing the client's position Taking the client's blood pressure Stopping the client's oxytocin infusion Preparing the client for an immediate birth
Changing the client's position
A client who is in labor is admitted 30 hours after her membranes ruptured. Which condition is this client at increased risk for? Cord prolapse Placenta previa Chorioamnionitis Abruptio placentae
Chorioamnionitis
After the removal of a hydatidiform mole, the nurse assesses the client's laboratory data during a follow-up visit. The nurse notes that a prolonged increase of the serum human chorionic gonadotropin (hCG) level is a danger sign. Which condition is this client at increased risk of developing? Uterine rupture Choriocarcinoma Hyperemesis gravidarum Disseminated intravascular coagulation (DIC)
Choriocarcinoma hCG increases shortly after the onset of pregnancy, peaks at the end of the second month, then decreases and is sustained at a lower level until the end of pregnancy; a continued increase indicates retained trophoblastic tissue and possible choriocarcinoma.
What should the nurse include in the teaching plan for parents of an infant with phenylketonuria (PKU)? Testing for PKU is done immediately after birth. Cognitive impairment occurs if PKU is untreated. Treatment for PKU includes lifelong medications. PKU is transmitted by an autosomal dominant gene.
Cognitive impairment occurs if PKU is untreated.
Which are barrier methods of contraception? Select all that apply. Condom Lea's shield Diaphragm Spermicidal foam Coitus interruptus
Condom Lea's shield Diaphragm
A pregnant adolescent reports genital warts. What interventions would reduce the discomfort? Select all that apply. Take imiquimod Consider cryotherapy Bathe with an oatmeal solution Wear loose-fitting cotton clothes Use less water to clean the genitals
Consider cryotherapy Bathe with an oatmeal solution Wear loose-fitting cotton clothes
A client has been taking methadone 40 mg/day for treatment of an opioid addiction. During a methadone clinic visit she tells the counselor that she is 3 months pregnant and receiving prenatal care. The counselor notifies the nurse in the prenatal clinic about the client's addiction history. What should the nurse in the prenatal clinic recommend that the client do? Withdraw the methadone slowly over the next several weeks. Continue the prescribed methadone to prevent withdrawal symptoms. Temporarily discontinue the methadone to improve maternal and neonatal outcome. Leave the methadone maintenance program during the pregnancy and reenter it after the birth.
Continue the prescribed methadone to prevent withdrawal symptoms.
A client at 43 weeks' gestation has just given birth to an infant with typical postmaturity characteristics. Which signs of postmaturity does the nurse identify? Select all that apply. Cracked and peeling skin Long scalp hair and fingernails Red, puffy appearance of face and neck Vernix caseosa covering the back and buttocks Creases covering the neonate's full soles and palms
Cracked and peeling skin Long scalp hair and fingernails Creases covering the neonate's full soles and palms
Twelve hours after a spontaneous birth a client's temperature is 100.4° F (38° C). What should the nurse suspect as the cause of this increase in temperature? Mastitis Dehydration Puerperal infection Urinary tract infection
Dehydration
A pregnant client at 30 weeks' gestation begins to experience contractions every 5 to 7 minutes. She is admitted with a diagnosis of preterm labor. Although the client is being given tocolytic therapy, her cervix continues to dilate, and it is determined that a preterm birth is inevitable. Which medication does the nurse expect the primary healthcare provider to prescribe? Norgestrel Aminophylline Dexamethasone Magnesium sulfate
Dexamethasone
A nurse assesses a client in the labor room and finds that the client's Bishop score for her cervical status is 6. Which medication may be administered to this client? Oxytocin Dinoprostone Mifepristone Methylergonovine
Dinoprostone Rationale Dinoprostone is a synthetic derivative of naturally occurring prostaglandin E 2. This drug is used for cervical ripening when there is an obstetric need for labor induction. Mifepristone is given to induce an abortion. Methylergonovine is used to reduce postpartum hemorrhage. Oxytocin is given to enhance labor during the gestation period.
While reviewing laboratory results of clients seen at the maternity clinic, the nurse notes that one client's maternal serum alpha-fetoprotein level is lower than expected. What does the nurse recognizes that this may be associated with? Fetal demise Down syndrome Neural tube defects Esophageal obstruction
Down syndrome Chromosomal trisomies such as Down syndrome may be marked by a lower-than-typical level of alpha-fetoprotein. Fetal demise, neural tube defects, and esophageal obstruction typically result in increased levels of alpha-fetoprotein.
A client at 35 weeks' gestation calls the prenatal clinic, concerned that she has "not felt the baby move as much as usual." The most appropriate recommendation by the nurse is to have the client call the clinic with the results after she has done what? Drunk a glass of orange juice and timed 10 fetal movements Sat in a tub filled with warm water and then timed 30 fetal movements Taken a nap and counted the number of fetal movements for 20 minutes Walked for 15 minutes and checked to see whether the fetus has moved more frequently
Drunk a glass of orange juice and timed 10 fetal movements
A 28-year-old woman is recovering from her third consecutive spontaneous abortion in 2 years. What is the most therapeutic nursing intervention for this client at her follow-up appointment? Focusing on the client's physical needs Encouraging the client to verbalize her feelings about the loss Reminding the client that she will be able to become pregnant again Encouraging the client to think of herself, her husband, and their future
Encouraging the client to verbalize her feelings about the loss
The cervix of a client in labor is fully dilated and 100% effaced. The fetal head is at +3 station, the fetal heart rate ranges from 140 to 150 beats per minute, and the contractions, lasting 60 seconds, are 2 minutes apart. What does the nurse expect to see when inspecting the perineum? Small tears Greenish-yellow amniotic fluid Enlarging area of caput with each contraction An increasing amount of amniotic fluid with each contraction
Enlarging area of caput with each contraction
A client asks the nurse about the use of an intrauterine device (IUD) for contraception. Which information should the nurse include in the response? Select all that apply. Expulsion of the device Occasional dyspareunia Delay of return to fertility Risk for perforation of the uterus Increased number of vaginal infections
Expulsion of the device Occasional dyspareunia Risk for perforation of the uterus
A nurse teaching a prenatal class is asked why infants of diabetic mothers are larger than those born to women who do not have diabetes. On what information about pregnant women with diabetes should the nurse base the response? Taking exogenous insulin stimulates fetal growth. Consuming more calories covers the insulin secreted by the fetus. Extra circulating glucose causes the fetus to acquire fatty deposits. Fetal weight gain increases as a result of the common response of maternal overeating.
Extra circulating glucose causes the fetus to acquire fatty deposits.
Which of the following variables are scored on a biophysical profile? Select all that apply. Fetal tone Fetal position Fetal movement Amniotic fluid index Fetal breathing movements Contraction stress test results
Fetal tone Fetal movement Amniotic fluid index Fetal breathing movements
During the assessment of a client in labor, the cervix is determined to be dilated 4 cm. What stage of labor does the nurse record? First Second Prodromal Transitional
First
The nurse is assessing a newborn of 33 weeks' gestation. Which sign alerts the nurse to notify the health care provider? Flaring nares Acrocyanosis Heartbeat of 140 beats/min Respirations of 40 breaths/min
Flaring nares
Neonates have difficulty maintaining their body temperature; however, their bodies have several mechanisms to help them do so. Which ones should a nurse remember when caring for the newborn? Select all that apply. Flexed fetal position Hepatic insulin stores Brown fat metabolism Peripheral vasoconstriction Parasympathetic nervous system
Flexed fetal position Brown fat metabolism Peripheral vasoconstriction
A pregnant client arrives at the prenatal clinic, and the nurse obtains her obstetrical history. The client has two children at home, one born at 38 weeks' gestation and the second born at 34 weeks' gestation. She has also had one miscarriage, at 18 weeks, and an elective abortion. Using the GTPAL system, what is the client's obstetrical record? G5 T1 P1 A2 L2 G4 T2 P2 A1 L4 G2 T3 P3 A2 L1 G3 T2 P1 A3 L3
G5 T1 P1 A2 L2
The nurse is reviewing the obstetric history of a client who has had an abruptio placentae. Which prenatal condition does the nurse expect to find in this client's history? Cardiac disease Hyperthyroidism Gestational hypertension Cephalopelvic disproportion
Gestational hypertension
A multigravida client has a spontaneous vaginal birth. Five minutes later the placenta is expelled. Where does a nurse expect to locate the uterine fundus at this time? In the pelvic cavity Just below the xiphoid process At the umbilicus and in the right quadrant Halfway between the symphysis pubis and the umbilicus
Halfway between the symphysis pubis and the umbilicus
What should be included in the nursing care for a client at 41 weeks' gestation who is scheduled for a contraction stress test? Having the client empty her bladder Placing the client in a supine position Informing the client about the need for cesarean birth Preparing the client for insertion of an internal monitor
Having the client empty her bladder
A client with preeclampsia is admitted to the labor and birthing suite. Her blood pressure is 130/90 mm Hg, and she has 2+ protein in her urine along with edema of the hands and face. Which signs or symptoms would the client display if she were developing hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome)? Select all that apply. Headache Constipation Abdominal pain Vaginal bleeding Flulike symptoms
Headache Abdominal pain Flulike symptoms
How should a nurse direct care for a client in the transition phase of the first stage of labor? Decreasing intravenous fluid intake Helping the client maintain control Reducing the client's discomfort with medications Having the client use simple breathing patterns during contractions
Helping the client maintain control Assisting the client in maintaining control is the most difficult part of labor. The client needs encouragement and support to cope. Intravenous fluids may need to be increased because of the increase in metabolism. Medication at this time will depress the newborn and is contraindicated. Breathing patterns at this time should be complex and require a high level of concentration to distract the client.
A primipara delivered 12 hours ago. Although an ice bag has been applied to her perineal area, the client continues to complain of rectal pressure resulting in excruciating pain in the area of the episiotomy. This has also not been relieved by the administration of analgesics. What does the nurse conclude is the cause of the client's pain? A normal response after delivery Low tolerance of pain Hematoma in the perineal area Infection at the episiotomy site
Hematoma in the perineal area
The nurse is performing a physical assessment of a pregnant woman. Which factor in the client's history increases the risk for abruptio placentae? Hydramnios Hypertension Cardiac disease Diabetes mellitus
Hypertension
A primary healthcare provider suspects ectopic pregnancy in an adolescent and conducts further evaluation. Which signs and symptoms have led the provider to suspect ectopic pregnancy? Select all that apply. Hypotension Abdominal pain Vaginal bleeding Cervical abnormalities Maternal systemic illness
Hypotension Abdominal pain Vaginal bleeding
A nurse suspects that a newborn has toxoplasmosis, one of the TORCH infections. How and when may it have been transmitted to the newborn? In utero through the placenta In the postpartum period through breast milk During birth through contact with the maternal vagina After the birth through a blood transfusion given to the mother
In utero through the placenta
The nurse is caring for a preterm neonate who is receiving gastric feedings. Which neonatal clinical finding unique to necrotizing enterocolitis (NEC) leads the nurse to suspect that the neonate is experiencing this complication? Persistent diarrhea Decreased abdominal circumference Increased amount of residual gastric aspirates Small amount of vomitus after each gastric feeding
Increased amount of residual gastric aspirates
The nurse is caring for a client during active labor. The recording on the electronic fetal monitor indicates fetal tachycardia. What should the nurse consider as a potential cause of this pattern? Fetal head compression Umbilical cord compression Increased maternal metabolism Pudendal anesthesia administration
Increased maternal metabolism A rapid fetal heart rate occurs when the maternal metabolism is accelerated; this can be a result of maternal fever. Fetal head compression causes early decelerations of the fetal heart rate, not fetal tachycardia. Umbilical cord compression is most commonly associated with variable decelerations. Pudendal anesthesia does not affect the fetal heart rate.
The nurse is caring for a pregnant client with type 1 diabetes. Which complication is the result of type 1 diabetes? Increased risk of hypertensive states Abnormal placental implantation Excessive weight gain because of increased appetite Decreased amount of amniotic fluid as the pregnancy progresses
Increased risk of hypertensive states
A nurse caring for a pregnant woman determines that she is engaging in the practice of pica. Why should the nurse prepare a teaching plan for this client? Inedible items are being ingested. The client has a need for a particular food. Many foods can cause nausea and vomiting. The client has a dislike for an essential group of foods.
Inedible items are being ingested.
A nurse is educating a group of adolescent girls about the risk of pregnancy. Which statements does the nurse include to help ensure adequate teaching? Select all that apply. Infants born to adolescent mothers have low birth weights. Pregnant adolescents are more likely to seek out prenatal care. Infants born to adolescent mothers are more likely to be premature. Pregnant adolescent girls should avoid participating in prenatal classes. Infants born to adolescent girls have an increased risk of alcohol and drug exposure.
Infants born to adolescent mothers have low birth weights. Infants born to adolescent mothers are more likely to be premature. Infants born to adolescent girls have an increased risk of alcohol and drug exposure.
The nurse is caring for a client in her third trimester who is scheduled for an amniocentesis. What should the nurse do to prepare the client for this test? Instruct her to void immediately before the test. Tell her to assume the high Fowler position before the test. Encourage her to drink three glasses of water before the test. Advise her to take nothing by mouth for several hours before the test.
Instruct her to void immediately before the test.
On her first visit to the prenatal clinic, a client with rheumatic heart disease asks the nurse whether she has any special nutritional needs. What supplements in addition to the regular pregnancy diet and prenatal vitamin and minerals will she need? Select all that apply. Iron Calcium Folic acid Vitamin C Vitamin B 12
Iron Folic acid
During a home visit the nurse obtains information regarding a postpartum client's behavior and suspects that she is experiencing postpartum depression. Which assessments support this conclusion? Select all that apply. Lethargy Ambivalence Emotional lability Increased appetite Long periods of sleep
Lethargy Ambivalence Emotional lability
The nurse is teaching a prenatal class regarding the risks of smoking during pregnancy. What neonatal consequence of maternal smoking should the nurse include in the teaching? Low birthweight Facial abnormalities Chronic lung problems Hyperglycemic reactions
Low birthweight
The primary healthcare provider diagnoses placenta previa in a primiparous client. What does this indicate to the nurse regarding the condition of the placenta? Infarcted Low-lying Immaturely developed Separating prematurely
Low-lying
The nurse is caring for preterm infants with respiratory distress in the neonatal intensive care unit. What is the priority nursing action? Limiting caloric intake to decrease metabolic rate Maintaining the prone position to prevent aspiration Limiting oxygen concentration to prevent eye damage Maintaining a high-humidity environment to promote gas exchange
Maintaining a high-humidity environment to promote gas exchange
The nurse who is caring for a 32-week appropriate-for-gestational-age (AGA) neonate develops a plan of care for the neonate. What is the priority intervention at this time? Promoting bonding Preventing infection Supporting temperature Maintaining respirations
Maintaining respirations
A client who is at 38 weeks' gestation is admitted to the birthing unit because her membranes ruptured 24 hours ago and contractions have started. The fetus is in a breech presentation. The nurse observes that the amniotic fluid is green. What does the nurse conclude from these findings? The fetus has a neural tube defect Fetal well-being is compromised Intrauterine infection has developed Meconium is being expelled with contractions
Meconium is being expelled with contractions
A vaginal examination reveals that a client's cervix is 90% effaced and dilated to 6 cm. The fetus's head is at station 0, and the fetus is in a right occiput anterior (ROA) position. The contractions are occurring every 3 to 4 minutes, are lasting 60 seconds, and are of moderate intensity. What should the nurse record about the client's stage of labor? Early first stage of labor Transition stage of labor Beginning second stage of labor Midway through first stage of labor
Midway through first stage of labor
The nurse is assessing a new mother at a healthcare facility. Which symptom does the nurse identify as a risk factor for postpartum blues? Frantic energy Mild irritability Hallucinations Unwillingness to sleep
Mild irritability
What is the most widely used off-label drug for cervical ripening and the enhancement of uterine muscle tone? Misoprostol Mifepristone Dinopristone Methylergonovine
Misoprostol Misoprostol is the most widely used off-label drug for cervical ripening and the enhancement of uterine muscle tone because it is relatively affordable. Mifepristone is used to induce labor. Dinoprostone is used for cervical ripening but is not an off-label drug for cervical ripening. Methylergonovine is used to enhance myometrial tone but is not used to augment labor.
A pregnant client with type 1 diabetes is visiting the prenatal clinic for the first time. The client is at risk for serious complications. What is the most important goal during pregnancy to decrease risk of complications? Monitor and control blood glucose levels. Limit pregnancy weight gain to an average of 25 pounds. Preplan for a cesarean section. Show up for all perinatal office visits.
Monitor and control blood glucose levels.
What is the optimal area for the nurse to assess adequate tissue oxygenation in a neonate born of African-American parents? Heels and buttocks Upper tips of the ears Nailbeds on the hands and feet Mucous membranes of the mouth
Mucous membranes of the mouth
The nurse is assessing several postpartum clients at the very beginning of her shift. Which problem does the nurse identify that might predispose a client to postpartum hemorrhage? Preeclampsia Multifetal pregnancy Prolonged first-stage labor Cephalopelvic disproportion
Multifetal pregnancy
The nurse is measuring the body temperature of four neonates born at term in a pediatric health setting. Which neonate has normal body temperature? Neonate 1: 35.5 Neonate 2: 36.0 Neonate 3: 37.1 Neonate 4: 38.5
Neonate 3 36.5° C to 37.5° C.
The nurse is assessing newborns 24 hours after birth in a pediatric healthcare setting. Which neonate requires priority action from the nurse? Neonate 1: 3kg 66 mL/24 hours Neonate 2: 2.4kg 60 mL/24 hours Neonate 3: 3.8kg 46mL/24 hours Neonate 4: 2.5 kg 40ml/24hours
Neonate 3 Neonates produce and excrete approximately 15 to 60 mL of urine per kilogram every 24 hours. Therefore a neonate who weighs 3.8 kg should produce and excrete 57 to 228 mL of urine every 24 hours.
A pregnant client's blood test reveals an increased alpha-fetoprotein (AFP) level. Which condition does the nurse suspect that this result indicates? Cystic fibrosis Phenylketonuria Down syndrome Neural tube defect
Neural tube defect Increased levels of alpha-fetoprotein in pregnant women have been found to reflect open neural tube defects such as spina bifida and anencephaly. Down syndrome is a chromosomal defect that is associated with a low AFP level.
A client at 38 weeks' gestation is admitted to the prenatal unit with preeclampsia. A loading dose of magnesium sulfate is administered, and the dosage is subsequently lowered to a maintenance dosage. What is the most important parameter for the nurse to assess while monitoring the client for magnesium sulfate toxicity? Pulse rate Daily weight Patellar reflex Blood pressure
Patellar reflex
A client with preeclampsia has a prescription for a magnesium sulfate infusion to be initiated. The nurse assesses the client's status to obtain baseline information. Which assessments are necessary? Select all that apply. Patellar reflex Output of urine Respiratory rate Body temperature Urine specific gravity
Patellar reflex Output of urine Respiratory rate
An epidural anesthetic is planned for the adolescent who is in labor. What nursing interventions are essential before epidural anesthesia is administered? Select all that apply. Performing a baseline vaginal examination Telling the adolescent what to expect with each procedure Identifying risk factors that contraindicate epidural anesthesia Having the parents sign a consent form for the epidural anesthesia Explaining the need to stay in one position while the epidural catheter is in place
Performing a baseline vaginal examination Telling the adolescent what to expect with each procedure Identifying risk factors that contraindicate epidural anesthesia
A client who is having a difficult labor is found to have cephalopelvic disproportion. Which prescription should the nurse question? Maintain nothing by mouth (NPO) status. Start a peripheral intravenous (IV) drip of 25% normal saline. Record fetal heart tones every 15 minutes. Piggyback another 10-unit bag of oxytocin.
Piggyback another 10-unit bag of oxytocin.
The nurse in the postpartum unit is teaching self-care to a group of new mothers. What color does the nurse teach them that the lochial discharge will be on the fourth postpartum day? Dark red Deep brown Pinkish brown Yellowish white
Pinkish brown
A client at 42 weeks' gestation is admitted for a nonstress test. The nurse concludes that this test is being done because of what possible complication related to a prolonged pregnancy? Polyhydramnios Placental insufficiency Postpartum infection Subclinical gestational diabetes
Placental insufficiency
A postpartum client is being prepared for discharge. The laboratory report indicates that she has a white blood cell (WBC) count of 16,000/mm 3. (16 X 10 9/L) What is the next nursing action? Checking with the nurse manager to see whether the client may go home Reassessing the client for signs of infection by taking her vital signs Delaying the client's discharge until the practitioner has conducted a complete examination Placing the report in the client's record because this is an expected postpartum finding
Placing the report in the client's record because this is an expected postpartum finding
A strict vegetarian (vegan) becomes pregnant and asks the nurse whether there is anything special she should do in regard to her diet during pregnancy. What is the most important measure for the nurse to instruct the client to take? Eat at least 40 g/day of protein. Drink at least 1 quart/day of milk. Take a vitamin supplemented with iron every day. Plan to eat from specific groups of vegetable proteins each day.
Plan to eat from specific groups of vegetable proteins each day.
A woman is exposed to indomethacin during the third trimester of pregnancy. Which teratogenic effect of the medication is expected in the newborn? Neural tube defects Neonatal hypoglycemia Cleft lip with cleft palate Premature closure of the ductus arteriosus
Premature closure of the ductus arteriosus
A client asks the nurse at the prenatal clinic whether she may continue to have sexual relations while pregnant. What is one indication that the client should refrain from intercourse during pregnancy? Fetal tachycardia Presence of leukorrhea Premature rupture of membranes Imminence of the estimated date of birth
Premature rupture of membranes
The primary healthcare provider prescribes a contraction stress test (CST) for a client whose nonstress test (NST) was nonreactive. Which maternal complications should prompt the nurse to question the prescription? Select all that apply. Hypertension Preterm labor Drug addiction Incompetent cervix Premature rupture of membranes
Preterm labor Drug addiction Incompetent cervix Premature rupture of membranes
A nurse explains preterm labor to a group of nursing students. Which description of preterm labor indicates effective teaching? Preterm labor is defined as contractions during the delivery. Preterm labor is defined as contractions induced by prostaglandins. Preterm labor is defined as contractions between 20 and 36 weeks of gestation. Preterm labor is defined as contractions occurring before 20 weeks of gestation.
Preterm labor is defined as contractions between 20 and 36 weeks of gestation.
A pregnant client who has asthma is expected on the unit for induction of labor. What medication should the nurse question when evaluating newly written prescriptions from the primary healthcare provider? Albuterol inhaler Epidural anesthesia Intravenous D 5W with piggyback oxytocin Prostaglandin E 2 vaginal suppository
Prostaglandin E 2 vaginal suppository One side effect of prostaglandin E2 is bronchoconstriction, which may cause a bronchospasm in a client with asthma. An albuterol inhaler may be used as needed. Epidural anesthesia is not contraindicated for pregnant clients with asthma. Intravenous D 5W with piggyback oxytocin is not contraindicated for a pregnant client with asthma.
A woman at 40 weeks' gestation is having contractions. Wondering whether she is in true labor, she asks, "How will you know if I'm really in labor?" Which information should the nurse provide to the patient at this time? The cervix dilates and becomes effaced in true labor. Bloody show is the first sign of true labor. The membranes rupture at the beginning of true labor. Fetal movements lessen and become weaker in true labor.
The cervix dilates and becomes effaced in true labor.
An infant born at 36 weeks' gestation weighs 4 lbs 3 oz (1,899 g) and has Apgar scores of 7 and 9. Which nursing actions will be performed upon the infant's admission to the nursery? Select all that apply. Recording the neonate's vital signs Administration nasal cannula oxygen Offering a bottle of dextrose in water Evaluation of the neonate's health status Keeping the neonate's body warm
Recording the neonate's vital signs Evaluation of the neonate's health status Keeping the neonate's body warm
A newborn is diagnosed as having neonatal abstinence syndrome (NAS) after exhibiting jitteriness, irritability, and a shrill cry. What is the priority nursing care? Administering an opioid antagonist Limiting fluid intake to inhibit vomiting Assessing for age-appropriate developmental level Reducing environmental stimuli to promote relaxation
Reducing environmental stimuli to promote relaxation
A client with a history of phenylketonuria (PKU) who was maintained on a low-phenylalanine diet until 9 years of age is pregnant. What is most important for the nurse to discuss with this client? The infant may be developmentally disabled because of her history of PKU. Reinstitution of the low-phenylalanine diet will protect her baby from the disorder. The fetus is not at risk prenatally but will require immediate care at birth to prevent PKU. The client should avoid phenylalanine even when she is not pregnant so her body is able to support a pregnancy.
Reinstitution of the low-phenylalanine diet will protect her baby from the disorder.
A fetal monitor is applied to a client in labor. The nurse should take immediate action in response to which fetal heart rate? Remains at 140 beats/min during contractions Uniformly drops to 120 beats/min with each contraction Fluctuates from 130 to 140 beats/min unrelated to contractions Repeatedly drops abruptly to 90 beats/min unrelated to contractions
Repeatedly drops abruptly to 90 beats/min unrelated to contractions
Which point in the figure is the site for salpingitis in a client with gonorrhea?
Salpingitis (inflammation of the fallopian tubes) appears at point A in the diagram of a client with gonorrhea.
A client appears at the clinic after getting a positive result on a home pregnancy test. She states that her last menstrual period began 10 weeks ago. The client expresses fear because she has been recently diagnosed with syphilis. What prescriptions will the nurse expect to receive from the primary healthcare provider because of this information? Select all that apply. A wait-and-see approach Recommendation for elective abortion Screening and testing of sexual partners None, because the syphilis will most likely not affect the fetus in utero Intramuscular benzathine penicillin G, 2.4 million units, one dose
Screening and testing of sexual partners Intramuscular benzathine penicillin G, 2.4 million units, one dose The Centers for Disease Control and Prevention (CDC) recommend the intramuscular administration of 2.4 million units of benzathine penicillin G in one dose for those, pregnant or nonpregnant, in whom syphilis has been diagnosed within the preceding year. Syphilis is a bacterial infection, usually spread by sexual contact. This treatment has been found effective for pregnant women and newborns. Diagnosis of syphilis and no allergy to penicillin should be verified before medication is administered. Sexual partners should be screened and tested to prevent the spread of syphilis. Untreated syphilis can result in stillbirth, preterm birth, and birth defects.
Which finding indicates the development of a complication resulting from bilateral cephalohematomas? Urine output Skin color Glucose level Rooting/sucking reflex
Skin color Cephalohematomas are gradually absorbed. As the hematoma resolves, hemolysis of red blood cells occurs, and jaundice may result. Urine output, glucose level, and the rooting/sucking reflex are not affected by a cephalohematoma.
The nurse is assessing the newborn of a known opioid user for signs of withdrawal. What clinical manifestations does the nurse expect to identify? Select all that apply. Sneezing Hyperactivity High-pitched cry Exaggerated Moro reflex Reduced deep tendon reflexes
Sneezing Hyperactivity High-pitched cry Exaggerated Moro reflex
A woman comes into the clinic and states that she is thinking about becoming pregnant. What can the woman do to improve the health of her baby before she becomes pregnant? Go buy maternity clothes. Start running 3 miles (4.8 km) a day. Start taking prenatal vitamins. Buy a crib for the baby to sleep in.
Start taking prenatal vitamins.
A pregnant woman continues consuming alcohol during pregnancy. Which teratogenic effects might be seen in the fetus or neonate? Select all that apply. Stillbirth Ebstein anomaly Neural tube defects Spontaneous abortion Intellectual disabilities
Stillbirth Spontaneous abortion Intellectual disabilities
The nurse is caring for a preterm infant who is receiving oxygen therapy. What should the nurse do to prevent retinopathy of prematurity (ROP)? Cover the neonate's eyes with a shield Place the neonate in an elevated side-lying position Assess the neonate every hour with a pulse oximeter Support the neonate's oxygen saturation while providing minimal FiO 2
Support the neonate's oxygen saturation while providing minimal FiO 2
A client arrives at the clinic with swollen, tender breasts and flulike symptoms. A diagnosis of mastitis is made. What does the nurse plan to do? Help her wean the infant gradually. Teach her to empty her breasts frequently. Review breastfeeding techniques with her. Send a sample of her milk to the laboratory for testing.
Teach her to empty her breasts frequently.
A nurse is assessing a pregnant 16-year-old client. Which factors should the nurse consider when developing a plan of care for this client that may impact the outcome of the pregnancy? Select all that apply. Tendency to abuse drugs Inappropriate dietary choices Immature reproductive system Underdeveloped musculoskeletal system Undeveloped secondary sex characteristics
Tendency to abuse drugs Inappropriate dietary choices Immature reproductive system Underdeveloped musculoskeletal system
A client is admitted to the birthing unit because fluid is leaking from her vagina. She is unsure whether her "bag of water" has broken. What should the nurse do to help determine whether the fluid is amniotic fluid? Test the fluid with Nitrazine paper. Inspect the fluid for its characteristics. Assess the fluid for the presence of protein. Send the fluid to the laboratory for analysis.
Test the fluid with Nitrazine paper.
The nurse is assessing clients on the postpartum unit for pain. The nurse knows which client will most likely complain of and/or experience more severe afterbirth pains? The client who is a grand multipara The client who is a breastfeeding primipara The client who had a vaginal birth for a first pregnancy The client who had a cesarean birth at 43 weeks' gestation
The client who is a grand multipara
A drug is administered to a client in her third trimester of pregnancy. Which statement regarding the drug administration is correct? All drugs should not be given to the pregnant client. The dose of a drug should not be altered for a pregnant client. The dose of a drug should be increased for pregnant clients. The dose of a drug should be decreased for pregnant clients.
The dose of a drug should be increased for pregnant clients. During pregnancy, a client's hepatic metabolism and glomerular filtration are increased. As a result, the excretion rate is faster. Therefore the dose of a drug should be increased for the drug action to be optimal.
A pregnant client is concerned that she may have been infected with human immunodeficiency virus (HIV). Which information should a nurse include when counseling this client regarding HIV testing? Select all that apply. The risks of passing the virus to the fetus What positive or negative test results indicate The risk factors for contracting HIV The need for pregnant women to be tested for HIV The emotional, legal, and medical implications of test results
The risks of passing the virus to the fetus What positive or negative test results indicate The emotional, legal, and medical implications of test results
Which information should the nurse include in the discharge teaching of a postpartum client? The prenatal Kegel tightening exercises should be continued. The episiotomy sutures will be removed at the first postpartum visit. She may not have a bowel movement for up to a week after the birth. She should schedule a postpartum checkup as soon as her menses returns.
The prenatal Kegel tightening exercises should be continued.
A 37-year-old client with hypertension, type 1 diabetes and good glycemic control is pregnant for the third time. Her first child is 4 years old, and her second pregnancy resulted in a stillbirth. She is seen in the antepartum testing unit for a nonstress test (NST) at 33 weeks' gestation. What are the primary risk factors in the client's history that indicate the need for a nonstress test? Select all that apply. Age older than 35 years The risk for placenta previa The risk for placental insufficiency A history of stillbirth from her last pregnancy Maternal history of hypertension
The risk for placental insufficiency A history of stillbirth from her last pregnancy Maternal history of hypertension
Which statements relate to preterm labor? Select all that apply. A premature baby has good cognitive development. The treatment for preterm labor includes bed rest and hydration. Preterm labor before the 20th week is indicative of a nonviable fetus. It is not desirable to stop the delivery in the case of preterm labor. Preterm labor refers to uterine contractions progressing to delivery before the 27th week of pregnancy.
The treatment for preterm labor includes bed rest and hydration. Preterm labor before the 20th week is indicative of a nonviable fetus.
A pregnant woman was exposed to a teratogenic drug during her first trimester. Which nursing interventions would be beneficial to the client? Select all that apply. Ultrasound scanning should be avoided. The woman should be referred for evaluation. The woman's pregnancy should be terminated even if minor malformations are found. The woman should be educated about the risks of drug-induced malformations. The woman should be assured that the risk is minimal if the malformation is minor.
The woman should be referred for evaluation. The woman should be educated about the risks of drug-induced malformations. The woman should be assured that the risk is minimal if the malformation is minor.
Within minutes of giving birth to a healthy infant, the client displays symptoms of respiratory distress. An amniotic fluid embolism is suspected. In addition to respiratory distress, for what other complication should the nurse assess the client? Hypertension Uterine atony Thrombophlebitis Uncontrolled bleeding
Uncontrolled bleeding
What is the nurse's most critical assessment for a client with preeclampsia during the immediate postpartum period? Vital signs Emotional status Signs of hemorrhage Signs of hypovolemic shock
Vital signs
Two days after being discharged a new mother calls the clinic stating that she is not sure that her baby is receiving enough breast milk. What information does the nurse need to determine whether the infant is being fed adequately? Voids four times before 2 pm Sleeps 3.5 to 4 hours between feedings Has two or more bowel movements each day Nurses 5 minutes on the first breast and 10 on the other
Voids four times before 2 pm Typically six to eight wet diapers a day indicates adequate fluid intake.
What is the most appropriate time for the nurse to administer an intravenous opioid analgesic to a client in active labor? Between contractions When a contraction starts At the peak of a contraction Just before the end of a contraction
When a contraction starts
A woman who is admitted to the labor suite has herpes simplex virus type 2 (HSV-2) with active lesions in the perineal area. What should the nurse's plan of care include? Withholding oral fluid intake Discussing the need for formula feeding Obtaining permission for a paracervical block Applying moist compresses to the perineal area
Withholding oral fluid intake
A client is scheduled for a laparoscopic bilateral tubal ligation. What important information should the nurse include in preoperative teaching? "Menstruation will stop after the surgery." "You'll need to use birth control until your follow-up visit." "You will be admitted as an outpatient for same-day surgery." "You can have the operation reversed if you decide to have more children."
You will be admitted as an outpatient for same-day surgery."
A client is admitted to the birthing room in active labor. The nurse determines that the fetus is in the left occiput posterior (LOP) position. At which point can the fetal heart be heard? https://eolscontent.elsevier.com/10D35D8019H/image/1251_preguncomplicated1_q63_image.png a b c d
d
