ATI: Maternal/Newborn: 2 abcs
A nurse is caring for four newborns. Which of the following newborns is at the greatest risk for hypoglycemia? A. A newborn who is large for gestational age B. A newborn who has an Rh incompatibility C. A newborn who has pathological jaundice D. A newborn who has fetal alcohol syndrome
A newborn who is large for gestational age
A nurse is reinforcing teaching with a client who is postpartum and breastfeeding. Which of the following statements should the nurse include? A. "You will need to wait 3 months before resuming sexual intercourse." B. "You don't need to use contraception until you are 4 months postpartum." C. "As long as you breastfeed, you will experience an overproduction of vaginal lubrication." D. "A reduction in sexual interest could indicate postpartum depression."
"A reduction in sexual interest could indicate postpartum depression."
A nurse is reinforcing teaching about dietary changes with a client who is pregnant and has pregestational diabetes. Which of the following statements should the nurse include in the teaching? A. "Carbohydrates should make up 55% of your diet." B. "Protein should make up 70% of your diet." C. "Fats should make up 45% of your diet." D. "Fiber should make up 10% of your diet."
"Carbohydrates should make up 55% of your diet."
A nurse in a prenatal clinic is reinforcing teaching with a client who has a new diagnosis of heartburn. Which of the following statements should the nurse include? A. "Go for a walk after eating." B. "Limit your food consumption to 2 meals a day." C. "Drink plenty of water with your meals." D. "Wear tight clothing to enhance digestion."
"Go for a walk after eating."
A nurse is reinforcing teaching about breastfeeding with a client. Which of the following client statements indicates an understanding of the teaching? A. "I should consume about 700 extra calories a day while breastfeeding." B. "I will introduce bottle feeding of pumped breast milk when my baby is 2 weeks old." C. "I may notice increased cramping when I am feeding my baby." D. "I will place my baby on a strict feeding schedule to help establish a good feeding pattern."
"I may notice increased cramping when I am feeding my baby."
A nurse is reinforcing teaching with a parent about how to care for his newborn's circumcision site. Which of the following client statements indicates an understanding of the teaching? A. "I should clean the circumcision site with half-strength hydrogen peroxide twice a day." B. "I should apply the diaper loosely until the circumcision is healed." C. "I should notify the doctor if a yellow discharge forms on the head of the penis." D. "Newborns typically do not experience any pain from this procedure."
"I should apply the diaper loosely until the circumcision is healed."
A nurse is reinforcing teaching with a client who has an intrauterine device (IUD). Which of the following client statements indicates an understanding of the instructions? A. "I will tell my doctor when I have my regular menstrual period." B. "I should let my doctor know if I can feel the strings of the device." C. "I should call my doctor if I experience a headache." D. "I will notify my doctor if I have pain during vaginal intercourse."
"I will notify my doctor if I have pain during vaginal intercourse."
A nurse is reinforcing teaching about formula feeding with a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? A. "After boiling the water, I should allow it to cool for 45 min prior to mixing it with the formula." B. "I should add 2 scoops of powdered formula to an 8 oz bottle of water." C. "I can store prepared bottles in my refrigerator for 72 hr." D. "I will warm the bottle of formula by placing it in a pan of hot water."
"I will warm the bottle of formula by placing it in a pan of hot water."
A nurse is caring for a client who experienced a fetal loss. When initiating communication with this client, which of the following statements should the nurse make? A. "I understand how you feel." B. "I'm here for you if you would like to talk." C. "It is better that the loss happened now, before you got to know your baby." D. "You are young and can have other children."
"I'm here for you if you would like to talk."
A nurse is reinforcing teaching about nonstress testing with a client who is pregnant. Which of the following pieces of information should the nurse include? A. "This test is an invasive procedure that presents minimal risk to the fetus." B. "If the test is reactive, that means your baby's heart rate is healthy." C. "When your baby moves, the test should record the baby's heart rate by decreasing by about 15 beats per minute." D. "The results of the test will be recorded as positive if no fetal movement occurs during the 20 minute testing period."
"If the test is reactive, that means your baby's heart rate is healthy."
A nurse is reinforcing discharge instructions with a client who is breastfeeding her newborn. Which of the following statements should the nurse include? A. "Notify your provider if you notice cracking on your nipples." B. "Notify your provider if you have not had a bowel movement within 5 days." C. "Notify your provider if your breasts leak when you shower." D. "Notify your provider if your vaginal discharge is a brownish-red color."
"Notify your provider if you notice cracking on your nipples."
A nurse is reinforcing teaching with a client who asks about using essential oils for her labor and delivery expected to occur next month. Which of the following responses should the nurse make? A. "Studies show that jasmine has an antidepressant effect during labor." B. "Studies show that the use of lavender is effective for strengthening contractions." C. "Studies do not promote diffusing essential oils during labor due to the possibility of respiratory compromise." D. "Studies show no evidence that essential oils improve labor outcomes."
"Studies show no evidence that essential oils improve labor outcomes."
A nurse is assisting with the preparation of a laboring client who is scheduled to receive an intrauterine pressure catheter. The client asks why this type of monitoring is needed. Which of the following responses should the nurse make? A. "This type of monitoring is necessary for timing of the frequency of your contractions." B. "This type of monitoring is noninvasive, so it is the best to monitor your labor contractions." C. "This type of monitor allows us to evaluate your baby's heart rate while you are in labor." D. "This type of monitoring will allow us to measure the intensity of your contractions."
"This type of monitoring will allow us to measure the intensity of your contractions."
A nurse is assisting with the care of a client who is in labor. The client asks the nurse, "Why is the other nurse pressing on my abdomen?" Which of the following responses should the nurse make? A. "To determine your baby's heart rate." B. "To determine if you have sufficient fluid around your baby." C. "To make sure your baby moves with stimulation." D. "To determine the position of your baby."
"To determine the position of your baby."
An antepartum client asks the nurse about safety tips for riding in a motor vehicle. Which of the following responses should the nurse make? A. "Wear the lap belt snugly across your pelvic bones." B. "Disable the airbags in your vehicle as per manufacturer instructions." C. "Place your seat as close as possible to the steering wheel." D. "Place the shoulder harness underneath your arm when driving."
"Wear the lap belt snugly across your pelvic bones."
A nurse is reinforcing teaching with a client who is at 10 weeks of gestation and reports frequent nausea and vomiting. Which of the following statements should the nurse make? A. "You should eat foods served at warm temperatures." B. "You should brush your teeth right after you eat." C. "You should try to eat sweet foods when you feel nauseated." D. "You should eat dry foods that are high in carbohydrates when you wake up."
"You should eat dry foods that are high in carbohydrates when you wake up."
A nurse is reinforcing teaching with a client who is pregnant and has type 1 diabetes mellitus. Which of the following statements should the nurse include in the teaching? A. "You should expect to increase your insulin dosage during the first trimester of pregnancy." B. "You should expect to decrease your insulin dosage during the second and third trimesters of pregnancy." C. "You should expect to decrease your insulin dosage immediately after you deliver your baby." D. "You will need to increase your insulin dosage if you are breastfeeding."
"You should expect to decrease your insulin dosage immediately after you deliver your baby."
A nurse is reinforcing teaching with a client who is pregnant. Which of the following instructions should the nurse include? A. "Take 600 milligrams of ibuprofen as needed for discomfort." B. "You should eat soft cheeses to increase your calcium intake." C. "You should roll your nipples daily to ensure they are everted." D. "You should use fluoride-based toothpaste to prevent dental caries."
"You should use fluoride-based toothpaste to prevent dental caries."
A nurse is reinforcing discharge teaching with the parent of a newborn. Which of the following statements should the nurse include in the teaching? A. "Your baby should be rear-facing in a car seat until 2 years of age." B. "Cover your baby with a light blanket during naps." C. "Set your hot water heater to no more than 140 degrees Farenheit." D. "Ensure your baby's crib has side rails that can be lowered."
"Your baby should be rear-facing in a car seat until 2 years of age."
A nurse is reinforcing teaching with a client who has come to the family-planning clinic requesting an intrauterine device (IUD). A. "If you lose weight, you will need a refitting for your IUD." B. "An IUD provides protection from certain sexually transmitted infections." C. "Your risk for ectopic pregnancy increases with an IUD." D. "You shouldn't use an IUD if you want to have children later."
"Your risk for ectopic pregnancy increases with an IUD."
A nurse is instructing a client about how to use a diaphragm. In what order should the client complete the insertion process? A. Hold the diaphragm between the thumb and fingers B. Place 2 tsp of contraceptive jelly on the side of the diaphragm C. Assume a squatting position D. Insert the diaphragm into the vagina E. Inspect the diaphragm
1. Inspect the diaphragm 2. Place 2 tsp of contraceptive jelly on the side of the diaphragm 3. Assume a squatting position 4. Hold the diaphragm between the thumb and fingers 5. Insert the diaphragm into the vagina
A nurse is collecting data from a full-term newborn who is demonstrating the Moro reflex. Which of the following movements are expected responses to this reflex? (select all that apply) A. Thumb and forefinger forming a "C" B. Legs extending before pulling upward C. Arms and legs adducting D. Arms falling backward after startling E. Head turning to the right
1. Thumb and forefinger forming a "C" 2. Legs extending before pulling upward
A nurse is assisting with the plan of care for a client who is pregnant and is Rh-negative. In which of the following situations should the nurse administer Rh(D) immune globulin? A. While the client is in labor B. Following an episode of influenza during pregnancy C. Prior to a blood transfusion D. At 28 weeks of gestation
at 28 week of gestations
The nurse is collecting data from a newborn. Which of the following techniques should the nurse use? A. Count the newborn's respirations for 30 seconds B. Auscultate the heart rate when the newborn is crying and active C. Use a sphygmomanometer on the newborn's arm D. Measure the newborn's head at the widest part
measure the newborn's head at the widest part
A nurse is reinforcing teaching about oxytocin with a client who is in the third trimester of pregnancy and has pre-eclampsia. Which of the following is a contraindication for use of this medication? A. Prolonged rupture of membranes at 38 weeks of gestation B. Intrauterine growth restriction C. Active genital herpes D. Post-term pregnancy
Active genital herpes
A nurse is caring for a client who is 1 day postpartum following a cesarean birth. Which of the following laboratory findings should the nurse report to the provider? A. Hematocrit 34% B. White blood cell count 12,000/mm3 C. Blood glucose 50 mg/dL D. Erythrocyte sedimentation rate 33 mm/hr
Blood glucose 50 mg/dL
A nurse is discussing contraceptive choices with a client who has a history of thrombophlebitis. Which of the following methods of contraception should the nurse recommend? A. Copper intrauterine device B. Combination pill C. Vaginal ring D. Medroxyprogesterone injection
Copper intrauterine device
A nurse is collecting data from a newborn who has hypogylcemia. Which of the following findings should the nurse expect? A. Abdominal distention B. Decreased temperature C. Increased muscle tone D. Transient nystagmus
Decreased temperature
A nurse is collecting data from a client who has placenta previa and is at 27 weeks of gestation. Which of the following manifestations should the nurse expect? A. Severe abdominal pain B. Increased blood pressure C. Decreased urinary output D. Cool, clammy skin
Decreased urinary output
A nurse is reinforcing teaching with new parents about formula feeding. Which of the following instructions should the nurse include? A. The bedtime bottle can be placed in the crib after the infant is 6 months of age B. Discard opened cans of forumla after 48 hr of refrigeration C. Powdered and concentrated formula can be reconstituted with tap water from the faucet D. Bottles and nipples can be hand-washed in hot, soapy water
Discard opened cans of formula after 48 hr of refrigeration
A nurse is caring for a client who has preeclampsia with severe features and is receiving a continuous infusion of magnesium sulfate. The nurse notes that the client is difficult to arouse and has absent deep tendon reflexes. Which of the following action should the nurse take? A. Discontinue the magnesium sulfate B. Reposition the client to a left lateral recumbent position C. Administer hydralazine intravenously D. Darken the room and avoid making loud noises
Discontinue the magnesium sulfate
A charge nurse is teaching newly licensed nurses about teratogens that affect fetal development. Which of the following is an example of a teratogen? A. Consuming caffeine during pregnancy B. Family history of a genetic disorder C. Gum disease in a pregnant client D. Drinking alcohol during pregnancy
Drinking alcohol during pregnancy
A nurse is assisting with the care of a client who is labor and is receiving an infusion of oxytocin. The nurse should monitor the client for which of the following potential adverse effects? A. Diarrhea B. Thromboembolism C. Fetal asphyxia D. Oliguria
Fetal asphyxia
A nurse is collecting data from a client who is postpartum. The nurse should identify which of the following findings as a manifestation of endometritis? A. Foul-smelling lochia B. Fundus 2 cm above the umbilicus C. Decreased heart rate D. Dysuria
Foul-smelling lochia
A nurse in an antepartum clinic is collecting data from a client who is at 38 weeks of gestation. Which of the following findings should the nurse report to the provider? A. Leg cramps B. Insomnia C. Glycosuria D. Leukorrhea
Glycosuria
A nurse is caring for a client who is postpartum. The nurse should identify which of the following findings as a manifestation of a urinary tract infection? A. Hematuria B. Temperature 39C (102.2 F) C. Diuresis D. 2 saturated perineal pads per hour
Hematuria
A nurse is reviewing the laboratory findings of a newborn who is 24 hours old. Which of the following findings should the nurse report to the provider? A. Hemoglobin 12 g/dL B. Platelet count 200,000/mm3 C. Total bilirubin 4 mg/dL D. Glucose 50 mg/dL
Hemoglobin 12 g/dL
A nurse is discussing potential complications of newborn hypothermia with a newly licensed nurse. Which of the following complications should the nurse include? A. Tachycardia B. Hypoglycemia C. Flushed skin D. Generalized petechiae
Hypoglycemia
An adolescent reports abdominal cramping due to dysmenorrhea. Which of the following analgesics should the nurse expect the provider to prescribe? A. Fentanyl B. Acetaminophen and oxycodone C. Acetaminophen and hydrocodone D. Ibuprofen
Ibuprofen
A nurse in an antepartum clinic answers a phone call from a client who at 37 weeks of gestation. The client reports, "I became very dizzy while lying in bed this morning, but the feeling went away when I turned onto my side." Which of the following actions should the nurse take? A. Instruct the client about vena cava syndrome and measures to prevent it B. Arrange for the client to come to the clinic for an assessment C. Check the client's chart for gestational diabetes mellitus D. Schedule a nonstress test for the client
Instruct the client about vena cava syndrome and measures to prevent it
A nurse is assisitng with the plan of care for a client who is postpartum and has a history of a pulmonary embolus. The provider has prescribed heparin therapy prophylactically. Which if the following interventions should the nurse recommend to include in the plan? A. Monitor aPTT and platelet count B. Perform fundal massage every 1 to 2 hours C. Assist the client with using a breast pump until therapy is discontinued D. Maintain strict bedrest
Monitor aPTT and platelet count
A nurse is assisting with the care of a client in active labor who is experiencing hypotension following epidural placement. Which of the following actions should the nurse take? A. Decrease IV fluids B. Give oxygen at 2 L/min via nasal cannula C. Place the client in a lateral position D. Administer indomethacin
Place the client in a lateral position
A nurse is reinforcing teaching with a client who is at 32 weeks of gestation and reports regular alcohol use during her pregnancy. The nurse should inform the client that her child is at risk for which of the following characteristics? A. Large head size B. Increased weight C. Poor coordination D. Hypoactive reflexes
Poor coordination
A nurse on an antepartum unit is assisting the charge nurse with an in-service session for new licensed nurses. Which of the following description should the nurse identify as referring to a pudendal block? A. Using low-voltage electric currents to decrease pain B. Eliminating sensation from the umbilicus to the thighs C. Providing local anesthesia to the perineum during delivery D. Removing sensation from the breasts to the feet
Providing local anesthesia to the perineum during delivery
A nurse is collecting data from a client who is postpartum. Which of the following findings should the nurse report to the provider? A. Blood pressure 139/89 mmHg B. Deep tendon reflexes 2+ C. Report of blurred vision D. Bilateral, dull headache
Report of blurred vision
A nurse is preparing to perform a heel stick on a newborn. Which of the following actions should the nurse take? A. Wrap a cold compress around the newborn's foot B. Restrain the newborn's foot C. Make the puncture at the inner aspect of the heel D. Apply pressure to the big toe
Restrain the newborn's foot
A nurse is reinforcing teaching with new parents about newborn reflexes. Which of the following reflexes facilitates infant feeding? A. Stepping B. Moro C. Rooting D. Babinski
Rooting
A nurse is collecting data from a pregnant client who is at 16 weeks of gestation. Which of the following manifestations should the nurse reports to the provider? A. Urinary urgency B. Constipation C. Periodic tingling in fingers D. Pyrosis
Urinary urgency
A nurse is caring for a client who has preeclampsia and is postpartum. Which of the following actions should the nurse implement when measuring the client's blood pressure? A. Encourage the client to take a walk in the halls prior to measuring blood pressure B. Hold the client's arm above heart level during the measurement C. Choose a cuff that covers 50% of the client's upper arm D. Use the Korotkoff phase V to record the diastolic value
Use the Korotkoff phase V to record the diastolic value
A nurse is evaluating a client who has just received instructions about breastfeeding. Which of the following statements should the nurse identify as an indication that the client understands how to prevent mastitis? A. "I will wear an underwire bra to provide support when my milk comes in." B. "I will apply petroleum jelly if my nipples become cracked." C. "I will apply warm compresses to my breasts twice a day." D. "I should avoid waiting too long between feedings."
"I should avoid waiting too long between feedings."
A nurse is reinforcing teaching with a client about a nonstress test. Which of the following statements by the client indicates an understanding of the teaching? A. "I know not to eat anything after midnight." B. "I will have medication given to me to cause contractions." C. "I should press the button on the handheld marker when my baby moves." D. "I will have to stimulate my breast to cause contractions."
"I should press the button on the handheld marker when my baby moves."
A nurse is reinforcing teaching about lactation suppression with a client whose newborn will be bottle-fed. Which of the following client statements indicates understanding of the teaching? A. "I should lightly massage my breasts when I feel discomfort." B. "I should express a small amount of milk if my breasts feel tight." C. "I should take a warm shower twice a day." D. "I should wear a support bra for a few days."
"I should wear a support bra for a few days."
A nurse is reinforcing teaching about the use of nitrous oxide analgesia for pain control with a client who is in labor. Which of the following statements by the client indicates an understanding of the teaching? A. "Nitrous oxide could make my baby sleepy when he is born." B. "I should inhale the nitrous oxide between contractions." C. "I will feel the effects of the nitrous oxide almost immediately." D. "Nitrous oxide can make me feel disoriented."
"I will feel the effects of the nitrous oxide almost immediately."
A nurse is reinforcing teaching with a client who is at 28 weeks of gestation. The client asks, "Is it safe for me to take a 12 hour drive to visit my family?" Which of the following responses should the nurse make? A. "Yes, but avoid using rest-stop bathrooms to reduce your exposure to infection." B. "Yes, but stop and lie down in the back seat if you feel dizzy. Sitting for long periods can put pressure on a major blood vessels and make you faint." C. "Yes, but be sure to get out of the car and walk around regularly so you don't develop clots in your legs." D. "Yes, but monitor your blood pressure. Remaining in a sitting position during a long car trip can lower your blood pressure."
"Yes, but be sure to get out of the car and walk around regularly so you don't develop clots in your legs."
A nurse is reinforcing nutritional teaching with a pregnant client who has a BMI of 32. Which of the following statements should the nurse make? A. "You should have considered losing weight before getting pregnant." B. "You baby has a higher chance of low birth weight duse to your BMI." C. "You might want to consider a weight-reduction diet." D. "You might be at risk for a longer stay than planned."
"You might be at risk for a longer stay than planned."
A nurse is caring for a client who had a vaginal delivery 24 hours ago. Which of the following findings should the nurse report to the provider? A. 2,000 mL urine since delivery B. 3+ deep tendon reflexes C. Fundus at umbilicus D. Soft breasts
3+ deep tendon reflexes
A nurse is contributing to the plan of care who is at 34 weeks of festation and has preeclampsia with severe features. Which of the following interventions should the nurse inclide as the priority action following a seizure. A. Provide a peaceful, relaxing environment for the client B. Administer oxygen to the client at 10 L/min via face mask C. Place blankets on the raised side rails of the client's bed D. Insert an indwelling urinary catheter for the client
Administer oxygen to the client at 10 L/min via face mask
A nurse is collecting data from a client 24 hr after delivery and notes the fundus is 2 cm above the umbilicus. Which of the following actions should the nurse take? A. Administer a tocolytic medication B. Apply a heating pad to the mid abdominal area C. Reassess the fundus in 2 hr D. Ambulate the client to the bathroom
Ambulate the client to the bathroom
A nurse is reinforcing teaching about circumcision care with a parent of a newborn. Which of the following instructions should the nurse include? A. Wash the site with soap and warm water once daily B. Gently remove the yellow exudate that forms around the site C. Avoid using diaper wipes on the site during diaper changes D. Apply the diaper tightly to apply pressure to the site
Avoid using diaper wipes on the site during diaper changes
A nurse is assessing a newborn immediately after birth. The newborn is pink and crying and has a heart rate of 108/min. Which of the following actions should the nurse take? A. Initiate chest compressions B. Dry the newborn on the mother's chest C. Administer epinephrine to the newborn D. Apply an oxygen saturation monitor
Dry the newborn on the mother's chest
A nurse is assisting with the plan of care for a newborn who requires phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan of care? A. Swaddle the newborn in a receiving blanket during the treatment B. Maintain NPO status until the newborn's bilirubin is within the expected reference range C. Ensure the newborn's eyes are closed before applying the eye shield D. Apply lotion to the newborn's skin twice per day
Emsure the newborn's eyes are closed before applying the eye shield
A nurse is assisting with the care of client who is pospartum and reports abdominal cramping. Which of the following actions should the nurse take? A. Advise the client to lie on her side B. Request a prescription for an opioid analgesic C. Offer a sitz bath to the client D. Encourage the client to interact with the newborn
Encourage the client to interact with the newborn
A nurse is caring for a client who is 24 years old and at 13 weeks of gestation. The client's history includes a BMI of 31 prior to pregnancy, a prior post-term delivery, and a newborn birth weight of 4,167.38 g (9 lb 3 oz). Which of the following laboratory values should the nurse expect to collect? A. Maternal serum alpha-fetoprotein B. Pregnancy-associated plasma protein A C. Chorionic villus sampling D. HbA1c
HbA1c
A nurse is collecting data from a newborn. Which of the following findings should the nurse report to the provider? A. Respiratory rate 52/min B. Weight 2500 grams (5.5 lb) C. Head circumference 28 cm (11 in) D. Blood glucose 48 mg/dL
Head circumference 28 cm (11 in)
A nurse is collecting data from a client who is postpartum. Which of the following findings should the nurse report to the provider? A. Tinnitus B. Numbness in the hand C. Headache D. Nasal stuffiness interfering with sleep
Headache
A nurse is reinforcing teaching with a group of clients who are pregnant about vitamin K for newborns. Vitamin K helps prevent which of the following conditions in a newborn? A. altered carbohydrate metabolism B. Hyperbilirubinemia C. Intracranial hemorrhage D. Hypoglycemia
Intracranial hemorrhage
A nurse is calculating is calculating a client's estimated date of delivery using Naegele's rule. The client's last menstrual period started on January 20. Which of the following is the client's expected date of delivery? A. October 13 B. November 13 C. October 27 D. November 27
October 27
A nurse is assisting with the care of a postpartum client who has preeclampsia and excessive bleeding. The nurse should plan to administer which of the following medications? A. Terbutaline B. Magnesium sulfate C. Oxytocin D. Methylergonovine
Oxytocin
A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which of the following findings is a risk factor for an ectopic pregnancy? A. Anemia B. Frequent urinary tract infections C. Previous cesarean birth D. Pelvic inflammatory disease
Pelvic inflammatory disease
A nurse is assisting with the care of a client who is in labor and has received epidural analgesia. The nurse observes that the fetal heart tracing shows late decelerations. Which of the following actions should the nurse take? A. Assist the client to the bathroom to empty her bladder B. Position the client on her side C. Assist with an examination for cord prolapse D. Provide glucose via oral hydration or IV
Position the client on her side
A nurse is assisting with care for a preterm infant in the NICU. Which of the following actions by the nurse will promote the infant's optimal development? A. Avoid swaddling B. Place the infant in the supine position C. Provide physical care at short, frequent intervals D. Reduce ambient noise and lighting
Reduce ambient noise and lighting
A nurse is reinforcing teaching with a client about physiological changes that can occur with menopause. Which of the following changes should the nurse include? A. Urinary hesitancy B. Hematuria C. Stress incontinence D. Increased vaginal moisture
Stress incontinence
A nurse is assisting with the care of a client who is at 34 weeks of gestation and presents with vaginal bleeding. Which of the following data should the nurse collect to determine if the bleeding is caused by placenta previa versus abruptio placenta? A. Uterine tone B. Fetal heart rate C. Blood pressure D. Amount of bleeding
Uterine tone
A nurse is teaching the guardian of a newborn about caring for the newborn's umbilical cord. For which of the following reasons should the nurse instruct the guardian to avoid using antimicrobial agents on the cord? A. They can cause increased pain from the cord B. They can cause delayed cord separation C. They can cause swelling of the surrounding tissue D. They can cause skin discoloration
They can cause delayed cord separation
A nurse is assisting with the care of a client in labor. Her cervix is dilated to 9 cm, and she has strong contractions every 2 minutes that last 75 seconds. The nurse should recognize that this client is in which of the following phases or stages of labor? A. Latent phase of first stage B. Active phase of first stage C. Second stage D. Transition phase of first stage
Transition phase of first stage
A nurse is assisting with the care of a pregnant client at 37 weeks of gestation who has a biophysical profile score of 4. Which of the following actions should the nurse anticipate taking? A. Discharge the client to home B. Administer betamethasone C. Perform an amnioinfusion D. Prepare the client for delivery
prepare the client for delivery
A nurse is reinforcing discharge teaching with the parents of a newborn about how to care for their child's uncircumcised penis. Which of the following statements should the nurse make? A. "Retract the foreskin until you feel resistance." B. "Clean the penis once per day with soap and water." C. "Use a cotton swab to clean under the foreskin." D. "Apply petroleum jelly to the foreskin every other day."
"Clean the penis once per day with soap and water."
A client at 12 weeks of gestation reports practicing Hinduism. The provider states that the client needs more protein in her diet and suggests eating more meat. After the provider leaves the examination room, the client tells the nurse that eating animal products will cause her to miscarry. Which of the following responses should the nurse make? A. "Let's discuss other foods that are high in protein that you could substitute for meat." B. "Eating meat during pregnancy provides necessary protein and does not cause miscarriage." C. "Why do you think that eating animal products will cause you to have a miscarriage?" D. "Your doctor is recommending what is best for you and your baby."
"Let's discuss other foods that are high in protein that you could substitute for meat."
A nurse is caring for a client who is 48 hours postpartum. The client expresses distress about her older children's acceptance of the new baby. Which of the following statements should the nurse make? A. "It would be best if your children met the new baby at home in a familiar setting." B. "Present the older children with a small gift and say it is from the baby." C. "Make sure you are holding the baby when the older children come to visit." D. "Try not to split up the children so no one will feel left out."
"Present the older children with a small gift and say it is from the baby."
A nurse is caring for a newborn who has a prescription for phototherapy. The mother asks why the newborn needs to lay under a special light. Which of the following responses should the nurse make? A. "The light helps your baby maintain his body temperature." B. "The light helps your baby establish a regular sleeping pattern." C. "The light will help lower your baby's bilirubin level." D. "The light will help regulate your baby's blood sugar."
"The light will help lower your baby's bilirubin level."
A nurse is reinforcing teaching with a client about squatting exercises during pregnancy. Which of the following statements should the nurse include? A. "These exercises should be done for 15 minutes each day to strengthen the perineal muscles." B. "Squatting exercises can tone your abdomen, helping you lose weight faster following delivery." C. "Practicing squatting exercises during pregnancy will reduce lower back pain during labor." D. "Doing squatting exercises 3 times per week will improve your overall fitness."
"These exercises should be done for 15 minutes each day to strengthen the perineal muscles."
A nurse is speaking with an expectant father who reports feeling resentful of the attention others are giving to his wife since the pregnancy was announced several weeks ago. Which of the following responses should the nurse provide? A. "Has your wife sensed your anger toward her and the baby?" B. "These feelings are common for expectant fathers in early pregnancy." C. "I'm sure that accepting this situation is hard when the baby's yours, too." D. "You should speak to a therapist about these feelings."
"These feelings are common for expectant fathers in early pregnancy."
A nurse is collecting date for a newborn who is 12 hours old and notes mild jaundice of the face and trunk. Which of the following actions should the nurse take? A. Administer phytonadione IM B. Obtain a stat prescription for a bilirubin level C. Obtain a bagged urine specimen D. Perform a gestational age assessment
Obtain a stat prescription for a bilirubin level
A nurse is a provider's office is caring for a client who is in the first trimester of pregnancy. Which of the following psychological tasks should the nurse expect the client to accomplish during this trimester? A. Accepting the pregnancy B. Preparing for the end of pregnancy C. Preparing for parenthood D. Accepting the baby
Accepting the pregnancy
A nurse is caring for a client who is postpartum. After bringing the newborn back to the parent following an assessment, the parent immediately gives the infant to the grandparent. Which of the following actions should the nurse take? A. Make a referral to child protective services B. Ask the client about the family's cultural beliefs C. Take the newborn back to the nursey until the mother is ready to offer care D. Explain to the client the importance of caring for the newborn personally
Ask the client about the family's cultural beliefs
A nurse is contributing to the plan of care for a client who is in the active stage of labor and expresses a desire to use nonpharmacological methods of pain relief. Which of the following interventions should the nurse take? A. Encourage the client to listen to music B. Instruct the client how to use informational feedback C. Ask the client to reconsider using a regional anesthetic D. Assist the client into a warm shower
Assist the client into a warm shower
A nurse is collecting data from a client who delivered vaginally 8 hours ago. The nurse notes that the client's fundus is 2 fingerbreadths above the umbilicus and has shifted to the left, and there is a large amount of lochia rubra on the perineal pad. Which of the following actions should the nurse take first? A. Administer analgesia B. Administer carboprost IM C. Assist the client to the toilet D. Obtain a blood speciment to test Hct and Hgb levels
Assist the client to the toilet
A nurse is reinforcing safety teaching with the parents of a newborn. Which of the following instructions should the nurse include? A. Position the newborn on the stomach when sleeping B. Cleanse the newborn's ears with a cotton-tipped swab C. Burp the newborn frequently during feedings D. Allow the newborn to air dry after bathing
Burp the newborn frequently during feedings
A nurse is reinforcing discharge instructions with a client who has had a cesarean birth 4 days ago. The client's hemoglobin level is 9.2 g/dL, and the provider has prescribed an iron supplement. Which of the following foods should the nurse recommend to help increase the client's iron intake? A. Spinach B Citrus fruit C. Milk D. Whole-grain bread
Citrus fruit
A charge nurse is providing teaching for a newly hired nurse about the potential side effects of an epidural anesthetic for a laboring client. Which of the following effects should the charge nurse include in the teaching? A. Newborn respiratory depression at birth B. Impaired ability of the neonate to maintain body temperature C. Impaired placental perfusion D. Decreased fetal heart rate (FHR) variabilityt
Impaired placental perfusion
A nurse is a clinic is collecting data from a client who is at 13 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse identify as the priority? A. Blood pressure 90/52 mmHg B. Ketones 2+ C. Specific gravity 1.035 D. Sodium 130 mEq/L
Ketones 2+
A nurse is caring for a client who requests an intrauterine device (IUD) for contraception. Which of the following findings is a contraindication for the use of this device? A. Hypertension B. Menorrhagia C. History of multiple gestations D. History of thromboembolic disease
Menorrhagia
A nurse is reinforcing teaching about formula feeding with the guardian of a newborn. Which of the following pieces of information should the nurse include? A. Boil bottles and nipples for 20 minutes after each use B. Mix 1 scoop of powdered formula with 2 oz of water C. Store prepared bottles in the refrigerator for up to 4 days. D. Warm formula by heating bottles in the microwave on the lowest setting
Mix 1 scoop of powdered formula with 2 oz of water
A nurse is collecting data from a newborn. Which of the following findings suggests the newborn is post-mature? A. Pale, translucent skin B. Nails extending over the fingers C. Weak gag reflex D. Thin covering of fine hair on the shoulders and back
Nails extending over the fingers
A nurse is collecting data from a newborn. Which of the following findings should the nurse immediately report to the provider? A. Milia B. Epstein pearls C. Nasal flaring D. Meconium stools
Nasal flaring
A nurse is collecting data from postpartum client and observes a steady trickle of bright red blood from the client's vagina. The uterus is palpated as firm, midline, and located 1 cm below the umbilicus. Which of the following actions should the nurse take? A. Massage the fundus B. Instruct the client to empty her bladder C. Notify the provider D. Teach the client how to perform a sitz bath
Notify the provider
A nurse in a provider's office is reviewing the medical record of a client who is at 28 weeks of gestation. The nurse should identify that prophylactic administration of Rh immune globulin is contraindicated for which of the following findings? A. The client is a Jehovah's Witness B. The client has Rh-positive blood C. The client had an external cephalic version D. The client is currently pregnant with fraternal twins
The client has Rh-positive blood
A nurse enters a postpartum client's room and notices many visitors in the room, conversing loudly and taking turns holding the newborn. The newborn intermittently cries and attempts to suck on her hand. After a few minutes, the newborn quiets, stares, and turns her head away when someone talks to her. What teaching should the nurse provide for this family? A. The newborn would benefit from skin-to-skin contact in a quiet environment B. The newborn's blanket should be removed so her movements will not be restricted C. The newborn's hat should be removed to avoid overheating D. The newborn should be discouraged from sucking on her hand since this habit can interfere with feeding
The newborn would benefit from skin-to-skin contact in a quiet environment
A nurse is measuring the head circumference of a newborn. Which of the following actions should the nurse take? A. Use a tape measure to obtain the greatest breadth and width of the head B. Expect the measurement to be approximately 27 cm (11 in) in diameter. C. Collect neurological data if the head circumference has a diameter of 33 to 35 cm (13 to 14 in) D. Expect the head circumference to be a smaller value than the chest circumference
Use a tape measure to obtain the greatest breadth and width of the head
A nurse is reinforcing teaching with a client in the third trimester of pregnancy who reports difficulty sleeping. Which of the following instructions should the nurse provide? A. Eat a high-fat smack before bed B. Exercise in the evening before bed C. Sleep in the supine position D. Use additional pillows to support extremities and abdomen
Use additional pillows to support extremities and abdomen