CMS Practice Questions
A nurse is assessing a client during her first prenatal visit the client reports March 20th us her last menstrual.. Use Niagele's rule to calculate the estimated date of delivery. Use the mmdd format with four numerals and no spaces or punctuation
12/27/xx
A nurse is preparing to administer gentamycin 2 mg/kg Im to a client who has pelvic inflammatory disease and weighs 132 lb. Available is gentamycin injection 40 mg/ml. How many ml should the nurse administer?
3mL
A nurse is reviewing the laboratory report for a client who is in active labor. The client tested positive for group B strep. Which of the following medications should the nurse plan to administer to the client? A) Ampicillin B) Cefotetan C) Doxycycline D) Fluconazole
A) Ampicillin
A nurse is providing discharge teaching to a postpartum client about caring for her 5-day-old male newborn at home. Which of the following statements should the nurse make to the client? A) Notify your baby's pediatrician if he urinates less than six times a day B) Swaddle your baby tightly with his legs extended before laying him down to sleep C) Place triple antibiotic ointment on your baby's umbilical cord twice per day D) Retract the foreskin to clean your baby's penis during each bath
A) Notify your baby's pediatrician if he urinates less than six times a day
A nurse is performing a nonstress test on a client who is at 35 weeks of gestation and has diabetes. The test reveals no accelerations of the fetal heart rate for 20 minutes. Which of the following actions should the nurse take? A) Perform vibroacoustic stimulation B) Collect a specimen for an indirect Coomb's test C) Conduct a vaginal exam D) Place the client in the Trendelenburg position
A) Perform vibroacoustic stimulation
A nurse manager in a newborn nursery is reviewing infection control procedures with a group of newly hired nurses. Which of the following instructions should the nurse manager include in the teaching? A) Place newborn bassinets at least 3 feet apart B) Maintain airborne precautions C) Allow parents to enter the nursery if wearing a mask D) Place the newborns foot on a sterile field during a heel stick
A) Place newborn bassinets at least 3 feet apart
A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations. Which of the following actions should the nurse take? A) Place the client in a lateral position B) Decrease maintenance IV solution infusion rate C) Administer misoprostol 25 mcg vaginally D) Administer oxygen via face mask
A) Place the client in a lateral position
A nurse is admitting a client to the birthing unit who reports contractions started 1 hour ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions? A) Postpartum hemorrhage B) Incompetent cervix C) Ectopic pregnancy D) Hyperemesis gravidarum
A) Postpartum hemorrhage
A nurse is caring for a client who is in the second stage of labor. The nurse observes the fetal head retract against the clients perineum immediately following emergence . Which of the following actions should the nurse take? Assess fetal position using Leopold maneuvers Reposition the client in a left lateral position Apply pressure to the clients suprapubic area Empty the client's bladder using Crede's maneuver
Apply pressure to the clients suprapubic area
A nurse is providing prenatal teaching to a client who is vegan and is trying to increase intake of B12. Which foods should recommend? A) Fortified soy milk B) Brown rice C) Fresh citrus fruits D) Raw carrots
B) Brown rice
The nurse is assessing a newborn who is 4 hours old. Which of the following findings should the nurse identify as the priority to report to the provider? A) Overlapping of the cranial bones B) Small, distended white sebaceous glands on the face C) Forward and lateral positioning of the ears D) Bluish discoloration of the hands and feet
C) Forward and lateral positioning of the ears
A nurse is reviewing the medical record for a client who is receiving treatment for gestational diabetes. Which of the following medications should the nurse expect to administer? A) Nifedipine B) Chlorpromazine C) Glyburide D) Levothyroxine
C) Glyburide
Estimated delivery date of LMP August 10th A) May 20 B) May 13 C) May 17 D) May 3
C) May 17
A nurse is admitting a client who is at 38 weeks gestation following spontaneous rupture of membranes. The nurse performs a vaginal examination and palpates the umbilical cord. Which of the following actions should the nurse take first? A) Request that the provider insert an intrauterine pressure catheter B) Initiate oxytocin via continuous IV infusion C) Place the client in a left lateral position D) Exert continuous upward pressure on the presenting parts
D) Exert continuous upward pressure on the presenting parts
A nurse is assessing a full-term newborn. Which of the following findings should the nurse report to the provider? A) Temperature 36.5 degrees C (97.7 degrees F) B) Blood pressure 80/50 mm Hg C) Respiratory rate 55/min D) Heart rate 72/min
D) Heart rate 72/min
A nurse is caring for a client who is in active labor. The nurse administers butorphanol IV bolus for pain. Which of the following findings should the nurse report to the provider following this medication? A) Moderate fetal heart rate variability B) Blood pressure 136/88 C) Urinary output 120 mL in 2 hours D) Respiratory rate 10/min
D) Respiratory rate 10/min
A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following actions should the nurse take? A) Maintain eye contact during feedings B) Plan care to minimize handling the newborn C) Schedule larger volume feedings at less frequent intervals D) Swaddle the newborn with his legs extended
D) Swaddle the newborn with his legs extended
A nurse is assessing a full-term newborn upon admission to the nursery Which of the following clinical findings should the nurse report to the provider. A) Subconjunctival hemorrhage B) Rust stained urine C) Single palmar creases D) Transient circumoral cyanosis
D) Transient circumoral cyanosis
A nurse is monitoring a newborn whose mother reports recent opiate use for neonatal abstinence syndrome. Which of the following findings indicates narcotic withdrawal? Respiratory rate 50/min Unequal pupils Hypotonia Excessive crying
Excessive crying
A nurse is caring for a client who is receiving prenatal care and is at her 24-week appointment. Which of the following laboratory tests should the nurse plan to conduct? a. 1 hour glucose tolerance test b. rubella titer c. Group B strep culture d. blood type and Rh
a. 1 hour glucose tolerance test
A nurse is planning care immediately following birth for a newborn who has Myelomeningocele that is cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care? a. Administer broad-spectrum antibiotics b. cleanse the site with Povidone iodine c. monitor the rectal temperature every 4 hours d. prepare for surgical closure after 72 hours
a. Administer broad-spectrum antibiotics
A nurse in a prenatal Clinic is reviewing the laboratory results for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take? (Click on the exhibit button for additional information about the client. There are three tabs that contain separate categories of data.) a. Administer ceftriaxone IM b. administer rubella vaccine c. obtain a maternal serum alpha-fetoprotein specimen d. obtain a blood culture
a. Administer ceftriaxone IM
A nurse is providing dietary teaching to a client who is 32 weeks of gestation and has cholelithiasis. Which of the following foods should the nurse recommend for the client to include in her diet? a. Baked chicken b. whole milk c. french fries d. bacon cheeseburger
a. Baked chicken
A nurse is assessing a newborn was exposed to cocaine in utero. Which of the following findings should the nurse expect? a. High-pitched cry b. Hypotonicity c. increased head circumference d. decreased startle response
a. High-pitched cry
A nurse is caring for a client who received epidural analgesia during labor and is 4 hours for postpartum. Which of the following client reports should the nurse address first? a. Itching b. inability to void c. abdominal cramps d. tingling in the legs
a. Itching
A nurse is caring for a client who is at 32 weeks of gestation and has gestational diabetes mellitus. Which of the following findings should the nurse report to the provider? a. The client has a fundal height of 38 cm b. the client reports 12 fetal movements in 1 hour c. The client has a fasting blood glucose of 90 mg / DL d. the client has non pitting pedal edema
a. The client has a fundal height of 38 cm
A nurse is caring for a newborn. Which of the following assessment findings should indicate to the nurse that suctioning of the nasopharynx is needed? a. The newborn's pulse oximeter is 91% b. the newborns respiratory rate is 32 / minutes c. the newborn is beginning to cough d. the newborns respiratory rate is the regular
a. The newborn's pulse oximeter is 91%
Nurse is performing a Heel stick on a newborn. Which of the following actions should the nurse take? a. Use an automatic puncture device on the heel b. Puncture the heels of the inner aspect of the foot c. cleanse the newborns heel with an alcohol swab after the procedure d. place an ice pack on the newborn's heel 5 minutes before the procedure
a. Use an automatic puncture device on the heel
I'm not just caring for a client following vaginal delivery of a term fetal demise. Which of the following statements should the nurse make? a. You should name the baby so she can have an identity b. you can bathe and dress your baby if you'd like to c. if you don't hold the baby it will make letting go much harder d. I'm sure you'll be able to have another baby when you're ready
a. You should name the baby so she can have an identity
A nurse is providing prenatal teaching to a client who practices of vegan diet and is trying to increase intake on vitamin 12. Which of the following foods should the nurse recommend? a. fortified soy milk b. brown rice c. fresh citrus fruits d. raw carrots
a. fortified soy milk
A nurse is caring for a client who is in the latent phase of the first stage of Labor and is in pain. Which of the following nursing interventions is appropriate to reduce pain? Select all that apply d. administer 70% nitrous oxide mixed with oxygen a. have a client sit in a tub of warm water b. ambulate the client in the hallway c. apply counter pressure to the sacral area d. administer 70% nitrous oxide mixed with oxygen e. perform Leopold's maneuver
a. have a client sit in a tub of warm water b. ambulate the client in the hallway c. apply counter pressure to the sacral area
A nurse is in a provider's office is caring for a 20 year old client with at 12 weeks of gestation and request and amniocentesis to determine the sex of the fetus. Which of the following responses should the nurse make? a. this procedure determines if your baby has genetic or congenital disorders b. your provider was schedule a chronic villus sampling to determine the sex of your baby c. you cannot have an amniocentesis until you're at least 35 years of age d. we can schedule the procedure for later today if you'd like
a. this procedure determines if your baby has genetic or congenital disorders
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching? a. transmission can occur via the saliva and urine of the newborn b. this infection requires but airborne precautions be initiated for the newborn c. lesions are visible on the mother's genitalia d. mothers will receive prophylactic treatment with acyclovir year prior to delivery
a. transmission can occur via the saliva and urine of the newborn
Nurse is caring for a client who has hyperemesis gravidarum. Which of the following laboratory results should the nurse anticipate? a. urine ketones b. rapid plasma reagin c. Prothrombin time d. urine culture
a. urine ketones
A nurse is caring for a client who is 36 weeks gestation and has MRSA. Which of the following isolation precautions should the nurse initiate? a. Droplet b. Contact c. Airborne d. Protective environment
b. Contact
A nurse is providing teaching to a postpartum client who has a prescription for a rubella immunization. Which of the following client statements indicates an understanding of the teaching? a. I will receive a series of three immunizations and each one will be a month apart b. I should avoid becoming pregnant for at least one month following the immunization c. I should avoid breastfeeding for two weeks following the immunization d. I will report joint pain that develops after the immunization to my provider immediately
b. I should avoid becoming pregnant for at least one month following the immunization
A nurse is planning care for a client following a chorionic villus sampling. The nurse should recognize that the client is at risk for developing which of the following complications? a. Late decelerations b. Infection c. Anemia d. placental insufficiency
b. Infection
A nurse is caring for a client who reports spontaneous rupture. The nurse observed fetal bradycardia in the FHR tracing and notices the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following should the nurse take next? a. Initiate an infusion of IV fluids for the client b. Perform vaginal examination by applying upward pressure on the presenting part d. Administer oxygen via non rebreather mask at 8L/ min. D. Cover the umbilical cord with sterile saline saturated towel.
b. Perform vaginal examination by applying upward pressure on the presenting part
A nurse is assessing a client who is 27 weeks of gestation and has pre eclampsia. Which of the following findings should the nurse report to the provider? a. Hemoglobin 14.8 g/dL b. Platelet count 60,000/ mm c. Creatine 0.8 mg/ dL d. Urine protein concentration 200 mg/24hr
b. Platelet count 60,000/ mm
A nurse is caring for four antepartum clients. Which of the following clients should the nurse assess first? a. A client who is at 7 weeks of gestation and reports urinary frequency b. a client who is at 32 weeks of gestation and reports seeing floating spots c. a client who is 38 weeks of gestation and reports leg cramps d. a client who is at 20 weeks of gestation and reports periodic numbness in her fingers
b. a client who is at 32 weeks of gestation and reports seeing floating spots
A nurse in a newborn Nursery is receiving change-of-shift report for for newborns. Which of the following newborn should the nurse assess first? a. Newborn who is 24 hours old and has not had meconium stool b. a newborn who is 10 hours old and has a new onset tachypnea c. newborn who has a short frenulum and is having difficulty breastfeeding d. a newborn was 30 hours old and has blood-tinged discharge in her diaper
b. a newborn who is 10 hours old and has a new onset tachypnea
a nurse is assessing a client who is at 32 weeks of gestation and is receiving magnesium sulfate via continuous IV solution. Which of the following findings should the nurse report to the provider? a. decrease in frequency of contractions b. absent deep tendon reflexes c. urinary output 35 ml/hr d. BP 150 / 100 mmhg
b. absent deep tendon reflexes
A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include? a. Expect 2 to 4 wet diapers every 24 hours b. allow the baby to feed at least every 3 hours c. offer the newborn 30 ml (1 oz.) a water between feedings d. feed the newborn 5 to 10 minutes per breast
b. allow the baby to feed at least every 3 hours
A nurse is caring for a newborn following delivery. Which of the following actions should the nurse take first? a. Apply prophylactic eye ointment b. apply identification bands to the newborn c. administer IM vitamin K d. obtain the newborn's weight
b. apply identification bands to the newborn
A nurse is assessing a client who is in preterm labor and has a new prescription or terbutaline 0.25 mg subcutaneous. For which of the following findings should the nurse Withhold the medication and Report to the provider? a. fasting blood glucose 75 mg / DL b. blood pressure 88/58 mmhg c. urinary output 40 ml /hr d. FHR 120/min
b. blood pressure 88/58 mmhg
A nurse is caring for a client who is postpartum and experiencing hypovolemic shock. Which of the following findings should the nurse expect? a. Bounding pulses b. cool clammy skin c. respiratory rate 18 / minutes d. urinary output 30ml / hour
b. cool clammy skin
A nurse is observing an adolescent client who is offering her newborn a bottle while he is laying in the bassinet. When the nurse offers to pick the newborn up and place them in the client's arms, the mother States " No, the baby is too tired to be held". Which of the following actions should the nurse take? a. Insist that the mother pick up the newborn to feed him b. demonstrate how to hold a newborn and allow the client to practice c. persuade the client to breastfeed the newborn to promote bonding d. offer to take the newborn to the nursery to finish his feeding
b. demonstrate how to hold a newborn and allow the client to practice
A nurse is assessing a newborn whose mother had a primary cytomegalovirus (CMV) infection during pregnancy. The newborn acquired CMV trans placenta Lee. Which of the following findings should the nurse expect the newborn to exhibit? a. urinary tract infection b. hearing loss c. Macrosomia d. Cataracts
b. hearing loss
A nurse is caring for a client who has gestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse the client has hyperglycemia? a. double vision b. increased urination c. Sweating d. dizziness
b. increased urination
A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following information places the client at risk for infection? a. Placenta previa b. midline episiotomy c. gestational hypertension d. meconium stained fluid
b. midline episiotomy
A nurse is caring for a client who has placenta previa. Which of the following findings should the nurse expect? a. Firm rigid abdomen b. painless, vaginal bleeding c. uterine hypertonicity d. persistent headache
b. painless, vaginal bleeding
A nurse is admitting a client with a birthing unit reports for contractions started 1 hour ago. the nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions? a. Ectopic pregnancy b. postpartum hemorrhage c. hyperemesis gravidarum d. incompetent cervix
b. postpartum hemorrhage
A nurse is assessing a full-term newborn arm admission to the nursery. Which of the following clinical findings should the nurse report to the provider? a. Transient circumoral cyanosis b. single Palmar creases c. subconjunctival hemorrhage d. rust stain urine
b. single Palmar creases (indicates down syndrome)
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository? a. vaginal candidiasis b. third-degree perineal laceration c. abdominal distension d. Afterpains
b. third-degree perineal laceration
A nurse is assessing a client who is 6 hours postpartum and has endometritis. Which of the following findings should the nurse expect? a. Scant lotia b. urine tenderness c. temperature 37.4 C ( 99.3 F) d. WBC 9,000/mm
b. urine tenderness
A nurse is assisting the provider to administer a dinoprostone to induce labor for a client. Which of the following actions should the nurse take? a. Allow the medication to reach room temperature prior to Administration b. verify that informed consent is obtained prior to Administration c. instruct the client to avoid urinary elimination until after Administration d. please to clean and I send my followers position for 1 hour after Administration
b. verify that informed consent is obtained prior to Administration
A nurse is caring for a client who is receiving oxytocin to induce labor. The nurse should discontinue the oxytocin if which of the following occurs? a. Contractions last 60 Seconds b. non-repetitive early decelerations c. 6 contractions in 10 minutes d. moderate variability of the fetal heart rate
c. 6 contractions in 10 minutes
A nurse is providing discharge instructions to a client is 24 hours post partum and has decided not to breastfeed. Which of the following instruction should the nurse include in the teaching? a. Wear loose-fitting non-binding bra for 72 hours b. shower daily allow warm water to run directly over your dress c. Apply ice packs to your breast using a 15 minutes on, 45 minutes off schedule d. Pump your breast twice-daily to relieve discomfort from engorgement
c. Apply ice packs to your breast using a 15 minutes on, 45 minutes off schedule
A nurse is caring for a client who is at 30 weeks of gestation. The nurse should plan to immunize the client which of the following vaccinations? Select all the apply a. Varicella c. Diphtheria - acellular pertussis d. inactivated influenza b. human papillomavirus e. measles, mumps, and rubella
c. Diphtheria - acellular pertussis d. inactivated influenza
A nurse is providing teaching to a client who is receiving medroxyprogesterone IM for contraception. Which of the following statements by the client indicates an understanding of the teaching? a. I should discontinue this medication if I experience spotting b. I will need to return to the clinic in the next eight weeks for my next injection c. I should increase my calcium intake while taking this medication d. I will get two shots each time I receive this medication
c. I should increase my calcium intake while taking this medication
A nurse is using Niagele's rule to calculate the expected delivery date of a client who reports the first day of the last menstrual cycle was July 28th. Which of the following dates should the nurse document as a client expected delivery date? 07/28 a. April 21st b. April 4th c. May 5th d. May 21st
c. May 5th
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lap. Which of the following actions should the nurse include? a. Apply a thin layer lotion to the newborn skin every 8 hours b. trust in you born in a thin layer clothing during the therapy c. ensure the newborn's eyes are closed beneath the shield d. give the newborn 1 oz of glucose water every 4 hours
c. ensure the newborn's eyes are closed beneath the shield
A nurse is reviewing the laboratory results of a newborn. Which of the following findings should the nurse report to the provider? a. Blood glucose 58 mg / DL b. hematocrit 48% c. platelets 100,000/ mm 3 d. hemoglobin 16 G / DL
c. platelets 100,000/ mm3
A nurse is caring for a newborn Boys 6 hours old and has a bedside glucose meter reading of 65 mg / DL. The New Orleans mother has Type 2 diabetes mellitus. Which of the following actions should the nurse take? a. Administer 50 mL of dextrose solution IV b. obtain a blood sample of serum glucose level c. reassess the blood glucose level prior to the next feeding d. Feed the newborn immediately
c. reassess the blood glucose level prior to the next feeding
A nurse is providing teaching about the expected effects of magnesium sulfate to a client was at 28 weeks of gestation and has preeclampsia. Which of the following responses by the nurse is appropriate? a. This medication stabilizes the fetal heart rate b. this medication improves tissue perfusion c. this medication prevents seizures d. this medication increases cardiac output
c. this medication prevents seizures
A nurse is caring for a client who is at 30 weeks of gestation and receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication? a. Respiratory rate a 16 / minutes b. Hypertension c. urine output 20 ml / hour d. Hyperglycemia
c. urine output 20 ml / hour
A client who is 16 weeks of gestation asks the nurse how to prepare her father to a younger sibling. Statements should the nurse make? a. You should hold your newborn in your arms when you introduce him to your toddler b. you should move your toddler out of her crib 2 weeks prior to your due date c. you should give your toddler a gift from the baby when she visit you in the facility d. You should place your toddler in timeout if she exhibits regressive Behavior after the baby is born
c. you should give your toddler a gift from the baby when she visit you in the facility
A nurse is providing teaching to a client who is primigravid and is scheduled to have an abdominal ultrasound. Which of the following statements by the client indicates an understanding of the teaching? a. I need to take a stool softener the night before the test b. I can't have anything to eat after midnight c. I won't apply perfumed lotion to my abdomen before the test d. I will drink water before the test until my bladder feels full
d. I will drink water before the test until my bladder feels full
A nurse is caring for a client who has preterm labor and receiving magnesium sulfate by continuous IV infusion. Which of the following laboratory values should the nurse review during tocolytic therapy? a. indirect Coombs test b. liver enzymes c. uric acid level d. Serum medication level
d. Serum medication level
A nurse is assessing the results of a non-stress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing? a. 3 fetal movements perceived by the client in a 20-minute testing period b. No late deceleration in the fetal heart rate loaded with 3 uterine contractions of 60 seconds in duration within a 10-minute testing period c. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client d. an increase in fetal heart rate to 150/minute above baseline of 140 minutes lasting 1- seconds in response to fetal movement with a 40 minutes testing period.
d. an increase in fetal heart rate to 150/minute above baseline of 140 minutes lasting 10 seconds in response to fetal movement with a 40 minutes testing period.
A nurse is caring for a client who was in active labor and has gonorrhea. Which of the following potential complications of Gonorrhea should the nurse monitor? a. oligohydramnios b. vaginal laceration during birth c. excessive bleeding after birth d. chorioamnionitis
d. chorioamnionitis
A nurse is caring for a client who is 6 weeks of gestation and reports nausea and vomiting. Which of the following Recommendations should the nurse make? a. avoid Eating snacks before bedtime b. eat high-fat snack before getting out of bed c. drink additional liquids with each meal d. consume food served at cool temperatures
d. consume food served at cool temperatures
A nurse is caring for a newborn who has an exstrophy of the bladder. Which of the following actions should the nurse take prior to the beginning of the surgical correction? a. keep the newborn in a side-lying position b. restricted newborns fluid intake c. Exert gentle pressure on the newborn splattered with sterile gauze d. cover the newborns bladder with a sterile non-adherent dressing
d. cover the newborns bladder with a sterile non-adherent dressing
A nurse is performing an assessment of a newborn's but Babinski reflex. Which of the following findings should the nurse expect? a. Flexion of the forearm b. extension of the leg c. Downward curl of the toes d. dorsiflexion of the greater toes
d. dorsiflexion of the greater toes
A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which of the following clinical findings should the nurse instruct the client to report? a. Increased urinary output b. increased respiratory rate c. increased fetal movement d. increased muscle weakness
d. increased muscle weakness
A nurse is providing discharge teaching to a postpartum client about caring for her five-year 5- day old male newborn at home. Which of the following statements should the nurse make to the client? a. Retract the foreskin to clean your baby's penis during each bath b. use triple antibiotic ointment on your baby's umbilical cord twice per day c. Swaddle your baby tightly with legs extended before laying him down to sleep d. notify your baby's pediatrician if he urinates less than 6 times per day
d. notify your baby's pediatrician if he urinates less than 6 times per day
A nurse is providing teaching to the parents of a newborn about the plastibell circumcision technique. Which of the following? a. the plastibell will be removed 4 hours after the procedure b. notify the provider is the end of your penis appears dark red c. make sure the newborn's diaper is snug d. yellow exudate will form at the surgical site in 24 hours
d. yellow exudate will form at the surgical site in 24 hours
A nurse is conducting a class for a group A client's about birth control. Which of the following information should the nurse include in the teaching? a. Your fertility will return six months after your provider removes your IUD b. you should use spermicide 3 hours prior to sexual intercourse c. you will not need to use birth control for one month after receiving emergency contraception d. you should have an annual examination to assess your diaphragm
d. you should have an annual examination to assess your diaphragm
A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include? a. You should use an oil based vaginal lubricant when inserting your diaphragm b. you should store your diaphragm in sterile water after each use c. you should keep the diaphragm in place for at least 4 hours after intercourse d. you should have your provider refit you for a new diaphragm
d. you should have your provider refit you for a new diaphragm
The nurse is teaching a client and her partner about the technique of counter pressure during labor. Which of the following statements by the nurse is appropriate? a. your partner will apply upward pressure on your lower abdomen between contractions b. your partner will apply continuous from pressure between your thumb and index finger c. your partner will apply pressure to the top of your uterus during contractions d. your partner will apply steady pressure with a tennis ball to your lower back
d. your partner will apply steady pressure with a tennis ball to your lower back
A nurse is caring for newborn who is 1 hour old and has a respiratory rate of 50/min, a heart rate of 130/minute, and an axillary temperature of 36.1 (97). Which of the following actions should the nurse take? A) Apply a cap to the newborns head B) Obtain an oxygen saturation level C) Reposition the newborn D) Give the newborn a warm bath
B) Obtain an oxygen saturation level
A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse asses first? A) A client who has hyperemesis gravidarum and a sodium level of 110 B) A client who has preeclampsia and a creatine level of 1.1 C) A client who has diabetes mellitus and an HbA1c of 5.8 D) A client who has placenta previa a hematocrit of 36
A) A client who has hyperemesis gravidarum and a sodium level of 110
A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client? A) An urge to have a bowel movement during contractions B) Progressive sacral discomfort during contractions C) A sense of excitement and warm, flushed skin D) Intense contractions lasting 45 to 60 seconds
A) An urge to have a bowel movement during contractions
A nurse is reviewing the laboratory results of a client who is at 20 weeks of gestation and has type 1 diabetes. Which of the following findings should the nurse report to the provider? A) BUN 25 B) HbA1c 6% C) Hct 34% D) Platelets 170,000
A) BUN 25
A nurse is providing teaching to a client about postpartum care. Which of the following information should the nurse include? A) Breasts will be firm and tender 3 to 5 days after delivery B) Bleeding will remain bright red for the next 6 to 8 weeks C) You don't need to use birth control if you are exclusively breastfeeding D) You should begin performing Kegel exercises 6 to 7 weeks after delivery
A) Breasts will be firm and tender 3 to 5 days after delivery
A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following should the nurse expect? A) Facial petechiae B) Telangiectatic nevi C) Erythema toxicum D) Periauricular papilloma's
A) Facial petechiae
A nurse is reviewing the medical records of a client who had a vaginal delivery 3 hours ago. Which of the following findings place the client at risk for post-partum hemorrhage? SATA A) History of uterine atony B) Vacuum assisted birth C) Labor induction with oxytocin D) Normal weight E) History of HPV
A) History of uterine atony C) Labor induction with oxytocin
A nurse is assessing a client who is at 39 weeks of gestation and determines that the fetus is in a left occipitoanterior position. On which of the following sites should the nurse place the external fetal monitor to hear the point of maximum impulse of the fetal heart rate? A) LLQ B) LUQ C) RLQ D) RUQ
A) LLQ
A nurse is caring for a 2-day old newborn who was born at 35 weeks gestation. Which of the following actions should the nurse take? A) Measure the abdominal circumference at the level of the newborn's umbilicus every 12 hours B) Provide the newborn with an iron rich formula containing vitamin b12 every 12 hours C) Administer nitric oxide inhalation therapy to the newborn D) Insert an orogastric decompression tube with low suction
A) Measure the abdominal circumference at the level of the newborn's umbilicus every 12 hours
A nurse manager on the labor and deliver unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Information included in teaching? A) Mothers will receive prophylactic treatment with acyclovir prior to delivery B) Lesions are visible on the mother genitalia C) Transmission can occur via the saliva and urine of the newborn D) The infection requires that airborne precautions be initiated
A) Mothers will receive prophylactic treatment with acyclovir prior to delivery
A nurse is caring for a client who is at 8 weeks of gestation and has an ectopic pregnancy. Which of the following manifestations should the nurse expect? A) Sharp pelvic pain B) Bright red vaginal discharge C) Elevated blood pressure D) Scaphoid abdomen
A) Sharp pelvic pain
A nurse is assessing a client who is requesting a combined oral contraceptive. Which of the following findings should indicate to the nurse that the client has a contraindication? A) The client is breastfeeding her 4-week-old newborn B) The client is 25 years old C) The client weighs 115 kg D) The client drinks 240 ml of wine a day
A) The client is breastfeeding her 4-week-old newborn
Which of the following assessment findings in an infant should indicate to a nurse that suctioning of the nasopharynx is needed? A) The infant is beginning to cough B) The newborns pulse oximetry is 91C) The infant's respiratory rate is 32/min. D) The infant's respiratory rate is irregular
A) The infant is beginning to cough
A nurse is teaching a newly licensed nurse about the use of ultrasonography in the first trimester. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A) Ultrasound is used to determine gestational age in the first trimester B) Ultrasound is used to perform biophysical profile in the first trimester C) Ultrasound is used to observe for placental maturity in the first trimester D) Ultrasound is used to detect IUGR in the first trimester
A) Ultrasound is used to determine gestational age in the first trimester
A nurse is assessing a client who has preeclampsia during a prenatal visit. Which of the following findings should the nurse report to the provider? A) Urine protein of 3+ B) Deep tendon reflexes of 2+ C) Hemoglobin 13 D) Blood glucose 110
A) Urine protein of 3+
A nurse is monitoring a client who is undergoing a nonstress test at 35 weeks gestation. Which of the following findings requires an intervention by the nurse? A) Uterine contractions lasting 20 to 30 seconds each B) An FHR that peaks 20 beats above baseline C) Three uterine contractions within a 20-minute period D) One acceleration of the FHR within a 20-minute period
A) Uterine contractions lasting 20 to 30 seconds each
A nurse is caring for a client who is 1-day post-partum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take? A) Have the client limit the length of breastfeeding to 5 minutes per breast B) Assess the newborns latch while breastfeeding C) Offer supplemental formula between the newborn's feedings D) Instruct the client to wait 4 hours between daytime feedings
B) Assess the newborns latch while breastfeeding
A nurse is caring for a client who has pregestational diabetes. Which of the following findings should indicate to the nurse the client has hyperglycemia? A) Dizziness B) Increased urination C) Sweating D) Double vision
B) Increased urination
A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect? A) Increased muscle tone B) Jitteriness C) Petechiae D) Abdominal distension
B) Jitteriness
A nurse is providing teaching to a postpartum client who has type 1 diabetes and is breastfeeding her newborn. Which of the following instructions should the nurse give to the client? A) Take more insulin with each meal that you did prior to pre pregnancy B) Maintain scheduled mealtimes for yourself C) Check your blood glucose levels every 8 hours D) Limit your carbohydrate intake to 30 grams per day
B) Maintain scheduled mealtimes for yourself
A nurse is assessing the reflexes of a term newborn. After placing the newborn in a supine position, which of the following would the nurse use to elicit the Moro reflex A) Turn the newborn's head to one side B) Make a loud noise above the newborn C) Tap the newborns forehead with a finger D) Touch the newborns cheek with a finger
B) Make a loud noise above the newborn
A nurse is caring for a client who is experiencing uterine atony immediately following delivery. The client fails to respond to oxytocin. The nurse should anticipate the use of which of the following medications? A) Hydralazine B) Methylergonovine C) Terbutaline D) Betamethasone
B) Methylergonovine
A nurse is providing teaching about increasing dietary fiber to an antepartum client who reports constipation. Highest in fiber content? A) Cabbage B) Oatmeal C) Asparagus D) Lentils
B) Oatmeal
A nurse is caring for a client who is 12 hours postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take? A) Apply a moist, warm compress to the perinium B) Provide the client with a cool sitz bath C) Apply povidone-iodine to the client's perineum site D) Administer methylergonovine 0.2 mg IM
B) Provide the client with a cool sitz bath
A charge curse is teaching a newly licensed nurse about Rh immune globulin administration. Which of the following should the charge nurse include as an indication for the administration of Rh immune globulin? A) Hyperemesis gravidarum B) Rh-positive blood test results C) Prescription for amniocentesis D) Anemia
B) Rh-positive blood test results
A nurse in a provider's office is caring for a 20-year-old client who is at 12 weeks gestation. The nurse should report which of the following findings to the provider as an indication of an imminent spontaneous abortion? A) Elevated hCG B) Scant, bright red spotting C) Cervical dilation D) Slight abdominal cramps
B) Scant, bright red spotting
A nurse is developing an educational program about hemolytic disease in newborns. Which genetic information should be included in the program? A) The mother and father are both rh positive B) The mother is rh negative and the father is rh positive C) The mother and father are rh negative D) The mother is rh positive and the father is rh negative
B) The mother is rh negative and the father is rh positive
A nurse in a provider's office is caring for a 20-year-old client who is at 12 weeks gestation and requests an amniocentesis to determine the sex of the baby. How should the nurse respond? A) We can schedule the procedure for later today if you would like B) This procedure determines if your baby has genetic or congenital disorders C) Your provider will schedule a chorionic villus sampling D) You cannot have an amniocentesis until you are 35 years old
B) This procedure determines if your baby has genetic or congenital disorders
A nurse is caring for a client who is at 30 weeks of gestations and receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication? A) Hyperglycemia B) Urine output 20 mL/hour C) Hypertension D) Respiratory rate 16/min
B) Urine output 20 mL/hour
A nurse is assessing a client who is 6 hours postpartum and has endometritis. Which of the following clinical findings should the nurse expect? A) Temperature 37.4/99.3 B) Uterine tenderness C) Scant lochia D) WBC 9,000
B) Uterine tenderness
A nurse is teaching a prenatal client about listeriosis and dietary modifications during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? A) I can have a mid-day snack with soft cheese B) I can purchase a seafood salad from the grocery store C) I can eat grilled chicken on a bun at lunch time D) I can still have a hot dog at the ballpark
C) I can eat grilled chicken on a bun at lunch time
A nurse on an antepartum unit is receiving change of shift report for four clients. Which of the following should the nurse assess first? A) A client who is at 38 weeks gestation and is experiencing painful urination B) A client who is at 12 weeks gestation and is experiencing nausea and vomiting C) A client who is at 34 weeks gestation and is experiencing epigastric pain and headache D) A client who is at 39 weeks gestation and is experiencing cramping and spotting
C) A client who is at 34 weeks gestation and is experiencing epigastric pain and headache
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care? A) Monitor the rectal temperature every 4 hours B) Cleanse the site with povidone-iodine C) Administer broad spectrum antibiotics D) Prepare for surgical closure after 72 hours
C) Administer broad spectrum antibiotics
A nurse is caring for a client who has developed eclampsia. Which of the following actions should the nurse implement after the client experiences a convulsion? A) Place the client in a Trendelenburg position B) Assist the client to void C) Administer oxygen to the client via face mask D) Give calcium gluconate to the client
C) Administer oxygen to the client via face mask
A nurse is caring for a client who has maternal hypotension following the placement of an epidural. Which of the following actions should the nurse take? A) Position the client in a knee-chest position B) Give terbutaline subcutaneously C) Apply oxygen via nonrebreather face mask D) Administer a bolus infusion of lactated Ringer's
C) Apply oxygen via nonrebreather face mask
A nurse is caring for a client who has bladder distension following a vaginal birth. Which of the following actions should the nurse take first? A) Insert a urinary catheter B) Pour warm water over the client's perineum C) Assist the client to the bathroom D) Offer the client a sitz bath
C) Assist the client to the bathroom
A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care? A) Dress the newborn in lightweight clothing B) Measure the newborns temperature every 8 hours C) Avoid using lotion or ointment on the newborns skin D) Keep the newborn supine throughout the treatment
C) Avoid using lotion or ointment on the newborns skin
A nurse is caring for a client who is in active labor and is receiving oxytocin via continuous IV infusion. The nurse has applied an internal fetal heart monitor and recognizes an early deceleration. Which of the following actions should the nurse take? A) Assist the client to lay on her right side B) Discontinue the oxytocin C) Continue to monitor the client D) Administer oxygen at 8 l/minute per mask
C) Continue to monitor the client
A nurse is caring for a client who had a pudendal nerve block. The nurse should monitor for which of the following findings as an adverse effect? A) Fetal bradycardia B) Maternal hypertension C) Decreased ability to bear down D) Uterine hyperstimulation
C) Decreased ability to bear down
A nurse is assessing a newborn whose mother had a primary cytomegalovirus infection during pregnancy. The newborns acquired CMV trans placentally. Which of the following findings should the nurse expect the newborn to exhibit? A) Urinary tract infection B) Cataracts C) Hearing loss D) Macrosomia
C) Hearing loss
A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which of the following clinical findings should the nurse instruct the client to report? A) Increased respiratory rate B) Increased fetal movement C) Increased muscle weakness D) Increased urine output
C) Increased muscle weakness
A nurse is performing an assessment for a newborn and notes breast tissue that has a flat areola with no bud. The nurse should identify that this finding indicates which of the following? A) Decreased maternal hormones during pregnancy B) Congenital anomaly C) Preterm gestational age D) Ambiguous secondary sex characteristics
C) Preterm gestational age
A nurse in a clinic is caring for a client who is in her second trimester of pregnancy. The client expresses concerns about preparing her 2-year-old for a new sibling. A) Move your toddler to his new bed 2 months before the baby comes home B) Avoid bringing your toddler to prenatal visits C) Require scheduled interactions between the toddler and the baby D) Let your toddler see you carry the baby into the home for the first time
C) Require scheduled interactions between the toddler and the baby
A nurse is teaching a newly hired nurse about Apgar scoring. Which of the following statements indicate an understanding of the teaching? A) The nurse should wait for the first Apgar score before initiating resuscitation efforts B) The nurse should identify that the newborn is in severe distress with an Apgar score of 8 C) The nurse should measure the newborns muscle tone when assigning an Apgar score D) The nurse should determine the Apgar score at 2 and 7 minutes after birth
C) The nurse should measure the newborns muscle tone when assigning an Apgar score
A nurse is providing teaching to a client about the purpose of her upcoming indirect Coomb's test. Which of the following statements should the nurse include in the teaching? A) The test determines if your baby is at risk for developing hypoglycemia B) This test studies blood flow in the fetus and placenta using ultrasound waves C) This test will detect the presence of RH positive antibodies in your blood D) This test will determine the amount of amniotic fluid around the fetus
C) This test will detect the presence of RH positive antibodies in your blood
A nurse is caring for a client who is in active labor and reports sudden, severe lower abdominal pain. The nurse observes a drop in the client's blood pressure and notes cool skin and pallor. The fetal heart rate tracing shows prolonged bradycardia. Which of the following complications should the nurse expect? A) Placenta Previa B) Amniotic fluid embolism C) Uterine rupture D) Umbilical cord prolapse
C) Uterine rupture
A nurse is admitting a client who is in active labor and has had two prior cesarean births. The nurse should identify that the client is at an increased risk for which of the following complications? A) Uterine rupture B) Precipitous labor C) Failure to progress D) Abruptio placentae
D) Abruptio placentae
A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include? A) Expect two to four wet diapers every 24 hours B) Offer the newborn 30 ml of water between feedings C) Feed the newborn 5 to 10 minutes per breast D) Allow the baby to feed at east every 3 hours
D) Allow the baby to feed at east every 3 hours
A nurse is assisting the provider to administer dinoprostone insert to induce labor. Which of the following actions should the nurse take? A) Verify informed consent is obtained B) Place the client in a semi-fowlers position C) Instruct the client to avoid urinary elimination until after administration D) Allow the medication to reach room temperature prior to administration
D) Allow the medication to reach room temperature prior to administration
A nurse on the labor and delivery unit is planning care for a client who has human immunodeficiency virus. Which of the following is an appropriate action for the nurse to take following the birth of the newborn? A) Initiate contact precautions for the newborn B) Administer IV antibiotics for the newborn C) Encourage the mother to breastfeed the newborn D) Cleanse the newborn immediately after delivery
D) Cleanse the newborn immediately after delivery
A nurse is providing teaching to a client who reports that her baby has yellow discharge forming at the circumcision cite. Which of the following is an appropriate response by the nurse? A) Apply povidone iodine 2x daily to site B) I will need to obtain a sample for testing C) Wipe the discharge away gently with a washcloth and warm water for the next 48 hours D) Discharge is common during the first 24-72 hours following a circumcision
D) Discharge is common during the first 24-72 hours following a circumcision
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan? A) Give the newborn 1 oz of glucose water every 4 hours B) Apply a thin layer of lotion to the newborns skin every 8 hours C) Dress the newborn in a thin layer of clothing during the therapy D) Ensure the newborns eyes are closed beneath the shield
D) Ensure the newborns eyes are closed beneath the shield
