OB final

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply.

- The cervix is dilated completely. - The spontaneous urge to push is initiated from perineal pressure.

The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? Select all that apply.

- The client has a history of intravenous drug use. - The client has a history of sexually transmitted infections.

The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply.

- age 54 - body mass index of 28 - previous difficulty with fertility

The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply

- ballottement - Chadwick's sign - uterine enlargement - positive pregnancy test

Jennie's sister is concerned about the edema in her sister's face and hands. She asks the RN if the (HCP) will prescribe some of "those water pills" (diuretics) to help get rid of the excess fluid. Which response by the RN is correct?

"Let me explain to you about the effect of diuretics on pregnancy."

The nurse prepares to administer a phytonadione (vitamin K) injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide?

"Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."

A pregnant client in the prenatal clinic is scheduled for a biophysical profile (BPP). The client asks the nurse what this test involves. The nurse should make which appropriate response?

"This test measures amniotic fluid volume and fetal activity."

The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process?

"We want to attend a support group."

After the perinatologist and CNM leave, Amanda appears confused and asks the RN, "Does this mean I will always have diabetes?" Which response should the nurse give to the client?

"You will need to be periodically evaluated for Type 2 diabetes for the rest of your life"

Jennie's partner asks if some friends can come and watch television with him now that the baby has been born. Which response by the RN is most appropriate?

"Your partner is still at risk for complications, so visitors are limited to family members, and only for a short period of time."

The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5 year old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart?

21001

The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function?

3 days postpartum

How should the nurse record Amanda's obstetrical history using the G-T-P-A-L designation?

4-1-1-1-3

What is the primary action of magnesium sulfate when given in preeclampsia?

A CNS depressant

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss?

An increase in the pulse rate from 88 to 102 beats/minute

The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action?

Assess the baseline fetal heart rate.

A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate and contractions have stopped. If the client's labor can be inhibited for the next 28 hours, the nurse anticipates a prescription for which medication?

Bethamethasone

The charge nurse refuses, telling the nurse that "there just isn't anyone else." What should the nurse do next?

Contact the nursing supervisor

For which complication is Jennie most at risk following the epidural with a local anesthestic, such as bupivacaine or ropivacaine?

Hypotension

A nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instructions?

I need to lay flat on my back to perform the procedure

When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate?

Notify the health care provider (HCP).

The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery?

Prepare an ice pack for application to the area.

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?

Variable decelerations

The nurse recognizes that what information in the client's history supports a diagnosis of gestational diabetes?

Youngest child weighed 4300 grams at 39 weeks' gestation

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching?

"I should avoid exercise because of the negative effects on insulin production."

The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse?

"I should drink adequate fluids and increase my intake of high-fiber foods."

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction?

"I should wash my nipples daily with soap and water."

Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction?

"I will ask the nurse to attend to my infant if I am napping and my husband is not here."

The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction?

"I will begin abdominal exercises immediately."

The nurse asks a nursing student describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed about administration of the eye medication?

"I will flush the eyes after instilling the ointment"

A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction?

"I will maintain strict bed rest throughout the remainder of the pregnancy."

The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement?

"I will need to increase my insulin dosage during the first 3 months of pregnancy."

Jennie's sister offers to sign the consent forms for her because Jennie is so young and just isn't feeling well right now. Which response by the RN is correct?

"Jennie should sign the consent forms herself since she is the one receiving the care."

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement?

"My contractions will increase in duration and intensity."

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply.

- "I should wear a bra that provides support." - "Drinking alcohol can affect my milk supply." - "The use of caffeine can decrease my milk supply." - "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply.

- A gravida II who has just been diagnosed with dead fetus syndrome - A primigravida at 29 weeks of gestation who was recently diagnosed with severe preeclampsia

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply.

- Bright red vaginal bleeding - Soft, relaxed, contender uterus - Fundal height may be greater than expected for gestation

A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are still intact and she is at a -2 station. The health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply.

- Increased efficiency of contractions - The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord

The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply.

- Proteinuria - Hypertension

The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? Select all that apply.

- Routine administration of subcutaneous heparin may be prescribed. - An overbed lift may be necessary if the client requires a cesarean section. - Thromboembolism stockings or sequential compression devices may be prescribed.

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply.

- cyanosis - tachypnea - retractions - audible grunts

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? select all that apply

- flushing - depressed respirations - extreme muscle weakness

The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of this newborn? Select all that apply.

- irritability - constant crying - difficult to comfort

Which purposes of placental functioning should the nurse include in a prenatal class? Select all that apply

- it is the way the baby gets food and oxygen - it provides an exchange of nutrients and waste products between the mother and the developing fetus

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply.

- monitor skin temperature closely - reposition the newborn every 2 hours - cover the newborn's eye with eye shields or patches

A rubella titer result of a 1-day postpartum client is less than 1:8, & a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information t the client about the vaccine? Select all that apply

- pregnancy needs to be avoided for 1 to 3 months - the vaccine is administered by the subcutaneous route - exposure the immunosuppressed individuals needs to be avoided - a hypersensivity reaction can occur if the client has an allergy to eggs

A pregnant client is receiving magnesium sulfate for management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted on assessment? select all that apply

- respirations of 10 breaths/minute -urine output of 20 ml in an hour

The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan? Select all that apply

- the ductus arteriousus allows blood to bypass the fetal lungs - one vein carries oxygenated blood from the placenta to the fetus - two arteries carry deoxygenated blood and waste products away from the fetus to the placenta

The nurse reviews the assessment history for a client with a suspected ectopic pregnancy. Which assessment findings predispose the client to an ectopic pregnancy? Select all that apply.

- use of fertility medications - history of chlamydia - use of an intrauterine device - history of PID

The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment finding should cause the nurse to immediately discontinue the oxytocin infusion? select all that apply

- uterine hyperstimulation - late decelerations of the fetal heart rate

The nurse is assessing a client with a diagnosis of gestational trophoblastic disease (hydatidiform mole). The nurse understands that which findings are associated with this condition? Select all that apply.

- vaginal bleeding - excessive nausea and vomiting - larger than normal uterus for gestational age - elevated levels of hCG

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply.

- wear a supportive bra - rest during the acute phase - maintain a fluid intake of at least 3000 mL/day - continue to breast feed if the breast are not too sore

While the RN is awaiting the lab results to determin if Jennie has elevatioin in liver function, diminished kidney function, or altered coagulopathies, which question should the RN ask Jennie? (Select all)

-"Do you have a headache?" -"Do you have blurry vision?" -"Do you have epigastric pain?" -"Do you have shortness of breath or chest discomfort?"

She asks the nurse to clarify what the RD told her about the content and timing of her meals. Which response (s) should the nurse give to the client? (Select all)

-Choose complex carbohydrates that are high in fiber content -Drink between 8-10 cups of fluids daily.

In reviewing Jennie's history, the RN is correct in concluding that Jennie is in jeopardy of developing a hypertensive disorder because of her age (15). Which other factor(s) add to Jennie's risk of developing preeclampsia? (Select all)

-Familial history -Preexisting medical or genetic condition, such as Factor V Leiden -Nulliparity

Which information is most important for the nurse to discuss concerning the use of contraception while breastfeeding? (Select all)

-If a dose is taken more than 3 hours late, a backup method of birth control must be used for the next 48 hours. -It is important to use another method of contraception prior to starting the Mini Pill

The nursing instructor asks a nursing student to explain the characteristics of the amnionic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? Select all that apply

-allows for fetal movement -surrounds, cushions, and protects the fetus -maintains the body temperature of the fetus - can be used to measure fetal kidney functions

At what rate should the nurse initially set the intravenous pump?

10 mL/hr

After the RN establishes IV placement, she collects a bag of D5LR for the oxytocin, which is available as 20 units in 1000mL D5LR. The order from the HCP is oxytocin 2mU/min to augment labor. Calculate the drip rate for the oxytocin. (Whole number)

6

The day shift charge nurse is preparing to make client care assignments. Which client should be assigned to the most experienced RN?

A 35-year-old gravida 3, para 2, with HELLP syndrome

Which client should the charge nurse assign the LPN?

A multigravida who had an uncomplicated term delivery and is breastfeeding

The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage?

A multiparous client who delivered a large baby after oxytocin induction

A non stress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented negative. How should the nurse document this finding?

A normal test result

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome?

Abnormal palmar creases

When performing a nonstress test, the RN will be assessing for which parameters?

Acceleration of the fetal heart rate in response to fetal movement

Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action?

Administer oxygen 8 to 10 L/minute, via face mask

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action?

Administer oxygen via face mask.

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that they client is tachycardia and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. What should be the initial nursing action?

Administer oxygen, 4 to 10 L/minute, by face mask

The nurse's response should be based on what information?

An elevated glucose in labor increases the risk of neonatal hypoglycemia

The RN asks Jennie if the HCP has discussed the labor and delivery process, potential complications, and the management of those complications with her and if she understands them. Jennie replies "I think so," and then asks for a pen. Which action should the RN take?

Ask Jennie to explain what she understands about the procedures

Prior to the amniocentesis, which action should the nurse take first?

Assist the client to the bathroom and ask her to empty her bladder

Rho(D) immune globulin is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the women understands the purpose if the woman states that it will protect her next baby from which condition?

Being affected by Rh incompatibility

Methylergonovine is prescribed for a women to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority assessment?

Blood pressure

The nurse is reviewing the record of a pregnant woman and notes that the health care provider has documented the presence of Chadwick's sign. Which assessment finding supports the presence of Chadwick's sign?

Bluish discoloration of cervix and vagina

What should the nurse recommend to Amanda in regard to infant feeding?

Breastfeeding should be initiated immediately and done on demand

The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother?

Bring the infant to the clinic.

What medication should the RN have readily available as an antidote for magnesium sulfate?

Calcium gluconate

The RN is aware that which medication is safest for Jennie if a second drug is needed to treat postpartum hemorrhage?

Carboprost tromethamine

What is the pathophysiology responsible for Jennie's complaint of a pounding headache and the elevated DTRs?

Cerebral edema

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma?

Changes in vital signs

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client?

Client pain level

The nurse is monitoring the amount of loch drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding initially?

Contact the health care provider and inform the HCP of this finding

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which instruction to the mother?

Continue to breast-feed every 2 to 4 hours.

If Jennie had HELLP syndrome, which lab results would the RN expect to see?

Decreased hemoglobin and hematocrit with burr cells, elevated liver enzymes, platelet count 3

An ultrasound is performed on a client at term gestation that is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that an abruptio placenta is present. Based on these findings, the nurse would prepare the client for:

Delivery of the fetus

The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action?

Discontinue the infusion of oxytocin.

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be most appropriate?

Do you plan to have any other children

The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate?

Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate?

Document the findings.

The nurse in the prenatal clinic is providing nutritional counseling to a pregnant client. The nurse instructs the client to increase the intake of folic acid and tells the client that which food item is highest in folic acid?

Dried peas

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation?

Drying the infant with a warm blanket

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client?

Encouraging fluid intake

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present?

Enlarged, hardened veins

The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis?

Evidence of bleeding, such as in the gums, petechiae, and purpura

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)?

Fetal heart rate of 180 beats/minute

Which assessment following an amniotomy should be conducted first?

Fetal heart rate pattern

Amanda asks if there are any special instructions for the test in addition to fasting for 8 hours immediately prior to the test. Which instruction should the nurse give the client?

Follow an unrestricted diet and exercise pattern for at least 3 days before the test.

Which technique should the RN use when evaluating Jennie's blood pressure while Jennie is on bedrest?

Have Jennie lie in a lateral position and take the blood pressure on the dependent arm

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa?

Hemorrhage

The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data, if noted on the client's record, should alert the nurse that the client is at risk for a spontaneous abortion?

History of syphilis

The nurse's response should be based on the understanding of which normal physiologic change of pregnancy?

Hormonal changes in the second and third trimesters result in increased maternal insulin resistance

The NICU RN anticipates and prepares for which complications in the newborn related to treatment of the mother with magnesium sulfate?

Hyporeflexia and decreased respirations

What should the RN do next to ensure intrauterine resuscitation?

Implement a prescribed fluid bolus to improve maternal blood volume

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2°F (37.8°C). What is the priority nursing action?

Increase hydration by encouraging oral fluids.

A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate?

Instruct the client that these contractions are common and may occur throughout pregnancy

The nurse is assessing a client who is 6 hours post party after delivering a full term healthy new born. The client complains to the nurse of faintness and dizziness. Which nursing action is most appropriate?

Instruct the client to request help when getting out of bed

The nurse is preparing to administer exogenous surfactant to a premature infant who has respiratory distress syndrome. The nurse prepares to administer the medication by which route?

Intratrachial

A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan?

Isoniazid plus rifampin will be required for 9 months.

A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last normal menstrual period was October 19, 2018. Using Nagele's Rule, which is date of delivery should the nurse document in the client's chart?

July 26, 2019

The RN recognizes what type of periodic fetal heart rate change that is occurring?

Late decelerations

The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn?

Maintaining safety because of low blood glucose levels

The nurse creates a plan of care for a woman with human immunodeficiency virus (HIV) infection and her newborn. The nurse should include which intervention in the plan of care?

Maintaining standard precautions at all times while caring for the newborn

On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action?

Massage the fundus until it is firm.

The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate?

Massage the fundus until it is firm.

Where will the nurse expect to palpate the uterine fundus?

Midline at the umbilicus

The nurse is creating a plan of care for a newborn diagnosed with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care?

Monitor the newborn's response to feedings and weight gain pattern.

The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action?

Monitoring the fetal heart rate

Amanda asks the nurse why the insulin was discontinued after the baby was born and asks if she will have to take the medication as a "shot" or a "pill" now. The nurse's response should be based on which information?

Most women with gestational diabetes return to normal glucose levels after birth

Jennie remains on magnesium sulfate. No further seizures have occurred, and she is stable at the present time. The anesthesia provider has released Jennie from the postanesthesia care unit. Which room and nursing staff assignments should be made for Jennie?

Move Jennie to a quiet room close to the nursing station in Labor and Delivery, and assign one RN to care for her

An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily available if respiratory depression occurs?

Naloxone

Since Jennie is receiving magnesium sulfate and oxytocin, the RN should make what adjustments to the oxytocin?

No adjustment to the oxytocin induction

The nurse is assessing a client in the fourth stage of labor and notes that the funds is firm, but that bleeding is excessive. Which should be the initial nursing action?

Notify the health care provider

The nurse is performing an assessment on a client who is at 38 weeks gestation and notes that the FHR is 174 beats/minute. On the basis of this finding, what is the priority nursing action?

Notify the health care provider

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate?

Notify the health care provider (HCP).

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription?

Obtain equipment for a manual pelvic examination.

What assessment information is most important for the nurse to validate with the laboring client before giving the medication?

Past or present history of opioid dependence

The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question?

Perform a vaginal examination every shift.

Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse should contact the health care provider who prescribed the medication if which condition is documented in the cline's medical history?

Peripheral vascular disease

The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise?

Persistent nonreassuring fetal heart rate

The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding?

Place the client in Trendelenburg position

To accurately assess this client's condition, what information from the prenatal record is most important for the RN to obtain?

Prenatal blood pressure readings

The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis?

Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection.

Which fingerstick blood glucose (FSBG) testing protocol should the diabetes educator recommend for Amanda?

Prior to breakfast (fasting) and 2 hours after each meal

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action?

Provide pain relief measures.

While the antepartum nurse is in the room, Amanda's membranes rupture spontaneously. Which action by the nurse takes priority?

Reapply the external fetal monitor to evaluate the fetal heart rate

The nurse and perinatologist recognize these signs as an indication of shoulder dystocia. What should the nurse do immediately?

Reposition the client using McRobert's maneuver

Amanda tells the nurse that she would like to receive one-half of the prescribed dose of butorphanol tartrate (Stadol) because the last time she was given that medication she felt like she was floating and then experienced some confusion. What should the nurse do?

Request that the provider change the prescription

Which assessment finding would indicate to the RN that a client is experiencing magnesium sulfate toxicity?

Respiratory rate of <12 breaths/min, and absent DTRs

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time?

Rest between contractions

As the charge nurse is going down the hall to tell the nurses about the new admissions, she hears one nurse giving misinformation about the Rubella vaccine to a client and her husband. What action should the charge nurse take?

Speak to the nurse in the hall so the nurse can correct the information for the client

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position?

Supine position with a wedge under the right hip

After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery?

Support the mother in her reaction to the newborn infant.

a pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 12 weeks gestation because of what factor?

The appearance of external genitalia

The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the health care provider (HCP)?

The client complains of a headache and blurred vision.

The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor?

The client has a history of cardiac disease.

The nurse is performing an assessment of a pregnant client who is at 28 weeks gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How should the nurse interpret this finding?

The client is measuring for normal for gestational age

The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up?

The client with lochia that is red and has a foul-smelling odor

The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include?

The diet should include additional fluids.

When the RN evaluates the fetal monitor strip, she notes a decrease in the fetal heart rate with minimal variability. What is the best explanation for this change?

The fetus has a magnesium level equal to the mother's, causing the fetus to be somewhat sedated

Jennie asks why the magnesium sulfate was increased. What explanation should the RN provide?

The magnesium is being excreted through the kidneys

The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn?

The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to he?

The vaginal discharge may be bothersome, but is a normal occurrence

At 0930 Jennie's sister rings the call bell and yells, "Come quickly, Jennie is shaking all over." The RN determines that Jennie is experiencing an eclamptic seizure. Which nursing intervention takes priority?

Turn Jennie onto her side and place a pillow behind her to stabilize the position

The nurse recognizes which fetal heart rate (FHR) changes indicate a reactive nonstress test?

Two episodes of acceleration (>15 beats/minute, lasting >15 seconds) related to fetal movement in a 20-minute period

The nurse should recognize that which newborn behavior indicates that the infant has suffered a complication from the shoulder dystocia?

Unilateral absence of the Moro reflex

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present?

Uterine tenderness

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief?

What can I do for you?

At 1130 Jennie complains of rectal pressure and an urge to push. The RN reviews the proper pushing technique with Jennie and her partner. What should the RN tell Jennie?

When the urge to push is felt, take a deep breath and bear down while exhaling over 5 to 7 seconds. Then take another deep breath and repeat the pushing pattern until the urge to push subsides.

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?

You will need to bottle feed your newborn

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instructions should the nurse provide?

an informed consent needs to be signed before the procedure

The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venous?

it connects the umbilical vein to the inferior vena cava

The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurses best response?

it promotes the fertilized ovum's normal implantation in the top portion of the uterus

A 55 year old male client confides in the nurse that he is concerned about his sexual function. What is the nurse's best response?

please share with me more about your concerns

The nurse should make which statement to a pregnant client found to have gynecoid pelvis?

your type of pelvis is the most favorable for labor and birth