Exam 3 Med Surg ATI Q's

A provider tells a client at 12 weeks gestation who practices Hinduism that she 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 also high in protein that you could substitute for meat." B. "Eating meat during pregnancy provides necessary protein and does not c

"Let's discuss other foods that are also high in protein that you could substitute for meat."

A nurse is providing discharge teaching to a client following the removal of a hydatidiform mole. Which of the following statements should the nurse include in the teaching? A. "Do not become pregnant for at least 1 year." B. "Seek genetic counseling for yourself and your partner prior to getting pregnant again." C. "You should have an hCG level drawn in 6 weeks." D. "Have your blood pressure checked weekly for the next month."

A. "Do not become pregnant for at least 1 year." Hydatidiform moles are uncontrolled growths in the uterus arising from placental or fetal tissue in early pregnancy. There is an increased incidence of choriocarcinoma associated with molar pregnancies. Pregnancy must be avoided for 1 year so the client can be closely monitored for manifestations of this condition.

A nurse is talking with a client during her initial prenatal visit. The client reports a history of trisomy 13 syndrome in her family and is concerned her fetus mig be at risk. Which of the following statements should the nurse provide? A. "If you sign an informed consent form, we can perform genetic screening to see if your baby has this disorder." B. "If the genetic screening shows that your baby has this disorder, I can provide you with information about an abortion clinic." C. Screening for

A. "If you sign an informed consent form, we can perform genetic screening to see if your baby has this disorder." Genetic screening has multiple legal and ethical considerations that must be addressed prior to testing. The client will need to sign an informed consent form prior to the screening.

A nurse is caring for a client who is scheduled to undergo an amniocentesis to assess fetal lung maturity. The client is G2P1 and at 36 weeks of gestation, and she has an O-positive blood type. Which of the following interventions should the nurse perform? • A. Apply an external fetal monitor to the client • B. Instruct the client to drink fluids and not to void prior to the procedure C. Administer Rho(D) immunoglobin after the procedure D. Instruct the client to take a deep breath and hold

A. Apply an external fetal monitor to the client The nurse should assess fetal heart tones and uterine tone prior to and throughout the procedure to establish a baseline and monitor for changes.

A nurse is caring for a client who is at 33 weeks of gestation and reports dark red vaginal bleeding and contractions that do not stop. Which of the following actions should the nurse take first? A. Check the fetal heart tones B. Assess the uterine contraction pattern C. Measure maternal vital signs ) D. Obtain a biophysical profile

A. Check the fetal heart tones The greatest risk to this client is fetal mortality from placental abruption; therefore, the priority assessment is immediate auscultation of fetal heart tones to determine the status of the fetus.

A nurse is caring for a client who is in labor. Which of the following assessment findings should the nurse report to the provider? • A. Fetal heart rate baseline of 90 bpm • B. Maternal temperature of 37.8°C (100°F) • C. Uterine relaxation for 1 min between contractions • D. Uterine contractions increasing in intensity

A. Fetal heart rate baseline of 90 bpm A fetal heart rate baseline of 90 bpm is considered bradycardia and should be reported to the provider. Fetal bradycardia is associated with fetal cardiac defects, maternal hypoglycemia, and fetal viral infections.

A nurse is reviewing risk factors for postpartum depression with a newly licensed nurse. Which of the following risk factors should the nurse include? A. Gestational diabetes B. Planned pregnancy C. Being married • D. Post-term birth

A. Gestational diabetes Gestational diabetes increases the risk of postpartum depression. Other risk factors include infertility treatment, pregnancy complications, preterm birth, and a history of mood disorder.

A nurse is reviewing the laboratory report of a newborn who has a blood type of B-negative. The mother's blood type is O-positive. The laboratory results indicate the direct antiglobulin test is positive. Which of the following complications should the nurse anticipate? • A. Hyperbilirubinemia • B. Central cyanosis • C. Intracranial hemorrhage • D. Cardiomyopathy

A. Hyperbilirubinemia The nurse should identify that some infants of mothers with type O blood are at an increased risk for developing hyperbilirubinemia because these mothers possess naturally occurring A and B antibodies, which are transferred across the placenta to the fetus.

A nurse is planning care for a newborn who was born at 30 weeks gestation. The nurse should plan to assess the newborn for which of the following potential complications associated with prematurity? A. Intraventricular hemorrhage B. Hyperglycemia C. Hyperthermia D. Meconium aspiration syndrome

A. Intraventricular hemorrhage When an infant is born before 34 weeks gestation, the blood vessels in the brain are fragile. Additionally, premature infants have an impaired coagulation process and fluctuating blood pressure. Combined, these factors increase the risk of bleeding into the ventricles of the brain and subsequent neurological damage.

A nurse is caring for a client who had a spontaneous miscarriage at 9 weeks gestation. The nurse walks into the client's room and finds her crying uncontrollably. Which of the following statements should the nurse make? A. "It is hard to deal with the loss of a pregnancy. Here is the number of a local support group that you can attend." в. "When a pregnancy ends spontaneously, there is often something wrong with the fetus." c. "You are young and will have other children." D. "The best thing for

Answer: A. "It is hard to deal with the loss of a pregnancy. Here is the number of a local support group that you can attend." This is a therapeutic response because the nurse is offering empathy and providing information regarding a support network that the client can access.

A nurse is teaching a client who is at 12 weeks gestation about manifestations of potential complications that she should report to her provider. Which of the following pieces of information should the nurse include in the teaching? A. Facial swelling • B. Urinary frequency • c. White vaginal discharge D. Intermittent nausea

Answer: A. Facial swelling The nurse should instruct the client to report facial swelling because this can indicate a hypertensive disorder or preeclampsia.

A nurse is teaching a client who is at 10 weeks gestation about self-care management for common discomforts during pregnancy. Which of the following instructions should the nurse include? • A. Douche every other day to minimize leukorrhea • B. Consume frequent snacks to decrease episodes of nausea C. Refrain from scheduling dental procedures until the third trimester D. Decrease fluid intake to reduce urinary frequency

Answer: B. Consume frequent snacks to decrease episodes of nausea

A nurse is assessing a newborn. Which of the following findings suggests the newborn is post-mature? A. Pale, translucent skin B. Nails extending over fingers C. Weak gag reflex D. Thin covering of fine hair on shoulders and back

Answer: B. Nails extending over fingers This is an expected finding for a post-term infant.

A nurse is teaching a client at 13 weeks gestation about the treatment of incompetent cervix with cervical cerclage. Which of the following statements by the client indicates an understanding of the teaching? A. "I am sad that I won't be able to get pregnant again." B. "I can resume having sex as soon as I feel up to it." • C. "I should go to the hospital if I think I may be in labor." D. "I should expect bright red bleeding while the cerclage is in place."

Answer: C. "I should go to the hospital if i think I may be in labor." Cervical cerclage prevents premature opening of the cervix during pregnancy. The client should immediately go to a facility for evaluation if she experiences any manifestations of labor while the cerclage is in place. If the client experiences preterm uterine contractions, she might require tocolytic therapy.

A nurse is reviewing the medical record of a client at 39 weeks gestation who has polyhydramnios. Which of the following findings should the nurse expect? A. Fundal height of 34 cm (13.4 in) B. Total pregnancy weight gain of 3.6 kg (8 Ib) C. Gestational hypertension D. Fetal gastrointestinal anomaly

Answer: D. Fetal gastrointestinal anomaly Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus. Gastrointestinal malformations and neurological disorders are expected findings for a fetus experiencing the effects of polyhydramnios.

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 (PID)

Answer: D. Pelvic inflammatory disease (PID) An ectopic pregnancy occurs when the fertilized egg implants in tissue outside of the uterus and the placenta, and the fetus begin to develop in this area. The most common site is within a fallopian tube, but ectopic pregnancies can occur in the ovary or the abdomen. Most cases are a result of scarring caused by a previous tubal infection or tubal surgery. Therefore, PID places the client at risk of an ectopic pregnancy.

A nurse is assessing a client who is at 20 weeks gestation and reports frequent episodes of indigestion and heartburn. Which of the following instructions should the nurse give to the client? A. "Limit your intake of food to twice per day." B. "Decrease your intake of spicy foods." • C. "Rest in a supine position for a few minutes after eating." D. "Increase your intake of water and carbonated beverages."

B. "Decrease your intake of spicy foods."

A nurse is assessing a client who is at 26 weeks of gestation and has mild preeclampsia. Which of the following findings should the nurse report to the provider? • A. Platelet count 97,000/mm^3 • B. Deep tendon reflexes 4+ • C. Urine protein 1+ • D. BUN 22 mg/dL

B. Deep tendon reflexes 4+ Hyperactive deep tendon reflexes demonstrate a progression from mild preeclampsia to severe gestational hypertension or preeclampsia with severe features. This finding indicates the need for hospitalization and treatment with magnesium sulfate to prevent eclamptic seizures.

A nurse is preparing to administer an IV infusion of oxytocin for labor induction to a client who is at 41 weeks of gestation. Which of the following actions should the nurse plan to take? • A. Administer the oxytocin with manual IV tubing • B. Monitor the fetal heart rate every 15 minutes initially • C. Begin the infusion at 10 milliunits/min • D. Titrate the dosage until the client has 1 contraction every minute

B. Monitor the fetal heart rate every 15 minutes initially The nurse should plan to monitor the fetal heart rate (FHR) every 15 minutes through the first stage of labor and then every 5 minutes duri the second stage. Additionally, the nurse should document the FHR with every change of the oxytocin dosage.

A nurse is caring for a client who is receiving oxytocin to induce labor. Which of the following actions should the nurse take? A. Perform continuous fetal heart rate monitoring • B. Measure maternal temperature every hour • C. Evaluate the maternal contraction pattern every hour D. Check blood pressure every 5 min

A. Perform continuous fetal heart rate monitoring

A nurse is caring for a preterm newborn who is receiving oxygen therapy. Which of the following findings should the nurse identify as a potential complication of the oxygen therapy? A. Atelectasis B. Retinopathy C. Interstitial emphysema D. Necrotizing enterocolitis

B. Retinopathy Oxygen therapy can cause retinopathy of prematurity, especially in preterm newborns. It is a disorder of retinal blood vessel development in premature newborns. In newbors who develop retinopathy of prematurity, the vessels grow abnormally from the retina into the clear gel that fils the back of the eye. This condition can reduce vision or result in complete blindness.

A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For which of the following findings should the nurse monitor to identify a cervical laceration? a.Continuous lochia flow and a flaccid uterus b. Report of increasing pain and pressure in the perineal area c. Slow trickle of bright vaginal bleeding and a firm fundus d. Gush of rubra lochia when the uterus is massaged

C. Slow trickle of bright vaginal bleeding and a firm fundus The nurse should monitor for bright red bleeding in the form of a slow trickle, oozing or outright bleeding, and a firm fundus to identify a cervical laceration:

A nurse is caring for a client who experienced a spontaneous rupture of membranes and has prolonged decelerations on the fetal monitor. Which of the following conditions should the nurse expect? • A. Uterine rupture • B. Placental abruption C. Prolapsed umbilical cord D. Amniotic fluid embolus

C. prolapsed umbilical cord.

A nurse is caring for a client who is attempting a trial of labor (TOL) after several cesarean births. The client reports a sudden onset of constant abdominal pain, and the nurse observes a prolonged deceleration on the fetal heart rate tracing. Which of the following actions should the nurse take? • A. Assist the client to the bathroom to empty her bladder B. Place the client in a knee-chest position C. Plan to administer calcium gluconate • D. Prepare the client for an emergency cesarean d

D. Prepare the client for an emergency cesarean delivery A sudden onset of abdominal pain in a laboring client who previously delivered by cesarean section, accompanied by a prolonged fetal deceleration, is a manifestation of a uterine rupture, which requires an emergency cesarean delivery.

A provider tells a client at 12 weeks gestation who practices Hinduism that she 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 also high in protein that you could substitute for meat." B. "Eating meat during pregnancy provides necessary protein and does not c

Correct Answer: A. "Let's discuss other foods that are also high in protein that you could use to substitute for meat Many cultures have beliefs about food that the nurse should respect. Discussing non-animal protein sources can help the client identify foods that do not conflict with her religious and cultural beliefs.

A nurse is reviewing the medical record of a client who is scheduled for induction of labor and has a prescription for misoprostol. Which of the following conditions should the nurse identify as a contraindication to administering this medication? A. Gestational diabetes B. Past cesarean delivery C. Preeclampsia D. Genital herpes

Correct Answer: B. Past cesarean delivery

A nurse is caring for a client who is at 35 weeks of gestation and is scheduled to undergo an amniocentesis. Which of the following statements should the nurse make? A. "You will have to drink 3 to 5 8-oz glasses of water to fill your bladder." B. "This procedure will not rupture your membranes or cause premature labor." C. "You might feel light pressure during the collection of a blood sample from the baby." D. "You will feel some mild discomfort during the procedure."

D you will feel some mild discomfort during the procedure

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 (PID)

D) pelvic inflammatory disease (PID). An ectopic pregnancy occurs when the fertilized egg implants in tissue outside of the uterus and the placenta, and the fetus begin to develop in this area. The most common site is within a fallopian tube, but ectopic pregnancies can occur in the ovary or the abdomen. Most cases are a result of scarring caused by a previous tubal infection or tubal surgery. Therefore, PID places the client at risk of an ectopic pregnancy.

A nurse is caring for a client who is at 39 weeks gestation and shows manifestations of labor. Which of the following findings will alert the nurse that the client is in true labor? A. Contractions felt in the upper abdomen • B. A small amount of bloody discharge • C. Contractions occurring every 2 to 10 min • D. Changes in cervical dilation or effacement

D. Changes in cervical dilation or effacement Cervical changes are signs of true labor

A nurse is preparing to provide umbilical cord care for a newborn 12 hours after delivery. Upon inspection, the nurse notes moderate bleeding from a blood vessel. Which of the following actions should the nurse take? A. Check the newborn's heart rate B. Place a pressure dressing on the cord stump C. Administer vitamin K D. Check the integrity of the cord clamp

D. Check the integrity of the cord clamp

A nurse is assessing a client at 34 weeks gestation who has a mild placental abruption. Which of the following findings should the nurse expect? A. Increased platelet count • B. Fetal distress • C. Decreased urinary output D. Dark red vaginal bleeding

D. Dark red vaginal bleeding

A charge nurse is teaching newly licensed nurses about teratogens that affect fetal development. The nurses should recognize that which of the following is an example of a teratogen? • A. Consuming caffeine during pregnancy •в. A family history of a genetic disorder • C. Gum disease in a pregnant client D. Drinking alcohol during pregnancy

D. Drinking alcohol during pregnancy Alcohol is an outside substance that, if ingested by a client who is pregnant, can cause abnormal fetal development. Alcohol consumption during pregnancy can cause central nervous system disorders, abnormal craniofacial features, and cognitive impairment.

A nurse is reviewing the provider's admission orders for a client who is at 37 weeks of gestation and is HIV positive. Which of the following orders should the nurse clarify with the provider? A. Intermittent auscultation • B. Biophysical profile • C. Non-stress test (NST) D. Fetal scalp electrode

D. Fetal scalp electrode The placement of a fetal scalp electrode is an invasive procedure that requires ruptured membranes. The electrode is inserted into the fetal scalp, which will increase the fetus's exposure to HIV and is contraindicated.

A nurse is caring for a client who is pregnant and has a rupture of membranes. The nurse notes the presence of meconium-stained fluid. Which of the following actions should the nurse take? • A. Prepare for emergency cesarean delivery B. Discontinue oxytocin infusion C. Position the parent to facilitate the McRoberts maneuver D. Gather equipment for neonatal resuscitation

D. Gather equipment for neonatal resuscitation

A nurse is caring for a client who has a soft uterus and increased lochial flow. Which of the following medications should the nurse plan to administer to promote uterine contractions? • A. Terbutaline B. Nifedipine C. Magnesium sulfate D. Methylergonovine

D. Methylergonovine The nurse should administer methylergonovine, an ergot alkaloid, which promotes uterine contractions.

A nurse is caring for a client who is attempting a trial of labor (TOL) after several cesarean births. The client reports a sudden onset of constant abdominal pain, and the nurse observes a prolonged deceleration on the fetal heart rate tracing. Which of the following actions should the nurse take? A. Assist the client to the bathroom to empty her bladder B. Place the client in a knee-chest position C. Plan to administer calcium gluconate D. Prepare the client for an emergency cesarean delivery

D. Prepare the client for an emergency cesarean delivery A sudden onset of abdominal pain in a laboring client who previously delivered by cesarean section, accompanied by a prolonged fetal deceleration, is a manifestation of a uterine rupture, which requires an emergency cesarean delivery.

A nurse in a clinic is assessing a client who was diagnosed with mononucleosis 2 weeks ago. Which of the following findings should the nurse report to the provider immediately? A. Headache and fatigue B. Swollen lymph nodes in the neck C. Abdominal pain in the left upper quadrant D. Fever and sore throat

C. Abdominal pain in the left upper quadrant When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is left upper-quadrant pain, which can indicate an enlarged spleen. An enlarged spleen can rupture, leading to internal hemorrhaging. The nurse should encourage the client to refrain from engaging in strenuous activities until the splenomegaly is resolved.

A nurse is assessing a newborn at birth who was delivered at 32 weeks gestation. Which of the following findings should the nurse anticipate? A. Heel creases over the entire sole of the foot B. Pendulous testes C. Extended extremities D. Leathery cracked skin

C. Extended extremities

A nurse is caring for a client who is in 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

C. Fetal asphyxia Oxytocin may cause tachysystole, which can lead to uteroplacental insufficiency. Inadequate oxygen transfer to the placenta will result in fetal asphyxia.

A nurse is providing care to a client who is in labor and experienced a spontaneous rupture of membranes. Which of the following findings requires intervention by the nurse? • A. Intense contractions lasting less than 30 seconds B. Rest periods between contractions lasting longer than 90 seconds • C. Fetal heart rate decreased by 15/min • D. Maternal temperature of 37.8°C (100°F) after ruptured membranes

C. Fetal heart rate decreased by 15/min A tetal heart rate decrease of 15/min is known as variable decelerations and requires intervention by the nurse due to cord compression. The cord can prolapse after the rupture of membranes, compromising the fetus. The fetal heart rate and pattern should be monitored for several minutes after the rupture of membranes to assess the wellbeing of the fetus.

A nurse is caring for a client who just had a spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and a prolapsed umbilical cord. Which of the following actions should the nurse take first? • A. Place the client in an extreme Trendelenburg position x• B. Increase the IV fluid infusion rate • C. Manually apply upward pressure intravaginally on the presenting part • D. Administer 8 to 10 L/min of oxygen via a nonrebreather face mask

C. Manually apply upward pressure intravaginally on the presenting part The gréatest risk to this client is fetal CNS injury or death from fetal hypoxia due to cord compression. Therefore, the first action the nurse should take is to insert a gloved hand into the vagina and apply upward pressure to the presenting part to move it away from the cord.

A nurse is assessing an 18-month-old infant who is postoperative. Which of the following pain scales should the nurse use? A. FACES B. CRIES C FLACC D. PIPP

FLACC The nurse should use the FLACC pain scale to monitor the infant for pain. The FLACC scale monitors facial expression, leg movement, activity, cry, and consolability in children 2 months to 7 years of age.

A nurse is preparing to administer oxytocin to a client who is at 41 weeks gestation and is experiencing ineffective labor. Which of the following: the nurse plan to take? • A. Place the oxytocin from a pre-filled syringe into the posterior fornix of the vagina every 10 min until effective labor occurs B. Check the client's blood pressure and pulse every 15 min while induction of labor is occurring • C. Stop oxytocin for contractions that continue for more than 30 sec D. Increase the dose o

Increase the dose of oxytocin to obtain uterine contractions that occur every 2 to 3 min Effective uterine contractions should occur every 2 to 3 minutes.

A nurse is reviewing laboratory results for a client who is at 37 weeks gestation. The nurse notes that the client is rubella non-immune, is positive for group A beta-hemolytic streptococcus, and has a blood type of 0 negative. Which of the following actions should the nurse take? A. Administer a dose of Rho (D) immune globulin B. Request a prescription for an antibiotic until delivery • C. Instruct the client to obtain a rubella immunization after delivery • D. Inform the client that she wi

Instruct the client to obtain a rubella immunization after delivery This client is not immune to rubella and should receive this immunization after delivery

A nurse is caring for a client who requests an intrauterine device (IUD) for contraception. Which of the following findings is a contraindication for this device? A. Hypertension • B. Menorrhagia • C. History of multiple gestations • D. History of thromboembolic disease

Menorrhagia An IUD is a small plastic or copper device placed inside the uterus that changes the uterine environment to prevent pregnancy. An IUD is contraindicated for women who have menorrhagia, severe dysmenorrhea, or a history of ectopic pregnancy.

A nurse in a prenatal clinic is reviewing the laboratory results of a client who is at 33 weeks of gestation. For which of the following results should the nurse notify the provider? • A.Hgb 11.3 g/dL B. Platelet count 135,000/mm^3 • C. WBC count 10,500/mm^3 D. Het 38%

Platelet count 135,000/mm^3

A nurse is performing an initial physical assessment of a newborn following a vaginal birth. Which of the following findings should the nurse report to the provider? • A. Small, pinpoint, reddish-purple spots on the chest B. Bluish coloring of the feet • C. Overlapping suture lines • D. White, cheese-like substance covering the skin

Small pinpoint reddish purple spots on the chest These marks are petechiae, which are commonly found above the neck if the umbilical cord was around the newborn's neck at birth. Petechiae in any other circumstance should be reported because this finding can indicate infection or a low platelet count.

A nurse is caring for a client who is at 33 weeks of gestation and reports dark red vaginal bleeding and contractions that do not stop. Which of the following actions should the nurse take first? A. Check the fetal heart tones •В. Assess the uterine contraction pattern • C. Measure maternal vital signs • D. Obtain a biophysical profile

A. Check the fetal heart tones

A nurse in the labor and delivery suite is planning care for a group of 4 clients. Which of the following clients should the nurse see first? A. A client who is in active labor and has late decelerations on the fetal heart monitor strip B. A client who is in transition and screaming and disturbing other clients C. A client who has epidural analgesia and is reporting breakthrough pain D. A client who has received an oxytocin infusion and is experiencing contractions every 2 min lasting 60 sec

A. A client who is in active labor and has late decelerations on the fetal heart monitor strip The nurse should apply the safety and risk-reduction priority-setting framework when caring for clients. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Late decelerations are nonreassuring patters that reflect impaired placental exchange or placental insufficiency. Because late decelerations indicate fetal hypoxia, the nurse should assess and intervene immediately by changing the client's position, administering oxygen, increasing IV fluids, and preparing for the possibility of an immediate cesarean birth.

A nurse is assisting with fetal heart monitoring during labor for a client who is at 40 weeks of gestation. The nurse should identify that which of the following findings on the fetal monitoring tracing requires intervention? A. A fetal heart rate of 180/min for 15 minutes B. A deceleration that returns to baseline at the end of the contraction C. An acceleration of 20/min for 18 seconds during a contraction D. An occasional variable deceleration in fetal heart rate

A. A fetal heart rate of 180/min for 15 minutes A heart rate of more than 160/min for 10 minutes or longer is considered fetal tachycardia, which can indicate fetal hypoxemia; therefore, this finding requires intervention by the nurse.

A nurse is assisting with an amniotomy for a client who is in active labor. Which of the following actions should the nurse take? • A. Assess the fetal heart rate before and after the procedure • B. Monitor the client's temperature every 4 hr after the procedure • C. Medicate the client for pain 30 min prior to the procedure • D. Perform cervical assessments every 2 hr after the procedure

A. Assess the fetal heart rate before and after the procedure The nurse should assess the fetal heart rate for the presence of variable decelerations or bradycardia, which can occur after rupturing of the membranes if the umbilical cord has prolapsed.

A nurse is caring for a client at 32 weeks gestation who is experiencing preterm labor. Which of the following medications should the nurse plan to administer? A. betamethasone B. Misoprostol C. Methylergonovine D. Poractant alta

A. Betamethasone The nurse should plan to administer betamethasone IM, a glucocorticoid, to stimulate fetal lung maturity and prevent respiratory depression.

A nurse is assessing a client at 27 weeks of gestation. The client has placenta previa and reports vaginal bleeding. Which of the following additional manifestations should the nurse expect? A. The fundal height measures greater than gestational age. B. A rigid abdomen is noted on palpation. C. The client reports a pain level of 8 on a 0-to-10 pain scale. D. A urine drug screen is positive for cocaine.

A. The fundal height measures greater than gestational age

A nurse is caring for a client in active labor whose membranes have ruptured. The fetal monitor tracing reveals late decelerations. Which of the following actions should the nurse take first? A. Turn the client onto her left side B. Palpate the client's uterus C. Administer oxygen to the client D. Increase the client's IV fluids

A. Turn the client onto her left side When applying the urgent versus nonurgent priority-setting framework, the nurse should consider urgent needs to be the priority because they pose more of a threat to the client. The nurse should turn the client onto her left side since late decelerations indicate uteroplacental insufficiency. The client might be experiencing pressure on the inferior vena cava, which decreases the oxygen to the placenta and thus to the fetus. Turning the client onto her left side will relieve the pressure and facilitate better blood flow to the placenta, thereby increasing the fetal oxygen supply. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent.

A nurse in a clinic is providing education to a client at 32 weeks of gestation who has pruritus gravidarum. Which of the following pieces of information should the nurse provide? A. "You should slightly increase your exposure to sunlight." B. "You will need extensive dermatological treatment for this condition after you deliver your baby." C. "Your provider will schedule weekly lab testing to monitor your liver function." D. "Your provider will prescribe isotretinoin cream."

A. You should slightly increase your exposure to sunlight

A nurse is teaching a client who has active genital herpes simplex virus, type 2. Which of the following statements should the nurse include in the teaching? A. "You will have a cesarean birth prior to the onset of labor." B. "Your baby will receive erythromycin eye ointment after birth to treat the infection." C. "You should take oral metronidazole for 7 days prior to 37 weeks gestation." D. "You should schedule a cesarean birth after your water breaks."

A. You will have a cesarean birth prior to the onset of labor Whenever possible, the cesarean birth should be scheduled prior to the onset of labor or rupture of membranes to reduce the risk of neonatal transmission of herpes.

A nurse is admitting a client who is in post-term labor. Which of the following statements should the nurse identify as the priority? A. "I had blood-streaked discharge a few hours ago." B. "When my water broke, it was not clear." C. "I have not felt my baby move as much today." • D. "I feel like I cannot breathe when I walk up the stairs."

B. "When my water broke, it was not clear!" The greatest risk to this client is an injury to the newborn from meconium aspiration; therefore, addressing this statement is the nurse's priority.

A nurse is caring for a client who is in labor and received meperidine for pain 1 hr prior to entering the second stage of labor. Which of the following actions a. Assess the client's reflexes b. Assess the newborn for respiratory depression c. Assess the client for bradycardia d. Assess the newborn for signs of opiate withdrawal

B. Assess the newborn for respiratory depression Meperidine should not be administered to laboring clients who are expected to deliver within 4 hours of the medication administration. This medication crosses the placenta and causes respiratory depression in the newborn, which peaks in 2 to 3 hours after administration. Narcan is ineffective at reversing the respiratory depression caused by this medication.

A nurse is assisting a provider with an amniotomy on a client who is in labor. Which of the following is the priority nursing assessment following the procedure? A. Color of amniotic fluid B. Fetal heart rate C. Uterine contraction pattern D. Odor of amniotic fluid

B. Fetal heart rate The greatest risk to this client is an injury from umbilical cord prolapse following artificial rupture of the membranes; therefore, the nurse should monitor the fetal heart rate for bradycardia, which can indicate an increased risk of umbilical cord prolapse.

A nurse is caring for a term newborn 90 minutes after a scheduled cesarean birth. The newborn's 1-minute Apgar score was 9. The newborn's heart rate is 120/min, and his respiratory rate is 70/min. There are no indications of retractions, grunting, or nasal flaring. Which of the following actions should the nurse take? • A. Request a prescription for continuous positive airway pressure (PAP) B. Initiate close observation of the newborn for indications of respiratory distress • C. Consult a re

B. Initiate close observation of the newborn for indications of respiratory distress The newborn has manifestations of transient tachypnea of the newborn (TTN). This condition is thought to be a result of an incomplete clearance of fluid from the lungs at birth. Newborns born by cesarean are more likely to have TTN because the thoracic cavity is not compressed as in a vaginal birth. It usually resolves spontaneously, and close observation of the newborn is indicated.

A nurse is caring for a client who is in preterm labor and has a new prescription for nifedipine. The client states she is concerned because her father takes nifedipine for his angina pectoris. The nurse should explain that nifedipine works for clients who are pregnant through which of the following mechanisms? A. It decreases the incidence of bacterial vaginosis, thus preventing uterine contractions. B. It inhibits uterine contractions by blocking the entry of calcium into uterine cells. C. It

B. It inhibits uterine contractions by blocking the entry of calcium into uterine cells. Nifedipine, a calcium channel blocker, causes uterine relaxation by blocking the flow of calcium to the myometrial cells of the uterus.

A nurse is preparing to administer an IV infusion of oxytocin for labor induction to a client who is at 41 weeks of gestation. Which of the following actions should the nurse plan to take? • A. Administer the oxytocin with manual IV tubing • B. Monitor the fetal heart rate every 15 minutes initially • C. Begin the infusion at 10 milliunits/min • D. Titrate the dosage until the client has 1 contraction every minute

B. Monitor the fetal heart rate every 15 minutes initially

A nurse is reviewing the laboratory values of a client who is pregnant and has a low progesterone level. Which of the following complications should the nurse expect? A. Gestational diabetes B. Preterm labor C. Inadequate milk supply D. Inadequate uterine growth

B. Preterm labor Progesterone maintains the lining of the uterus, which maintains the pregnancy. It also reduces uterine contractility. A client who has a low progesterone level is at risk for preterm labor.

A nurse is providing teaching for 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

C. "You should expect to decrease your insulin dosage immediately after you deliver your baby." The client will immediately lose insulin resistance upon the delivery of the placenta. Clients who have type 1 diabetes mellitus should expect to need only 50% to 60% of the pre-delivery dosage of insulin.

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)

C. Impaired placental perfusion

A nurse at a prenatal clinic is assessing an adult client who had genital cutting performed as a child as part of her cultural practices. The nurse notes the clier clitoris and labia minora were removed, and she has scarring in the vaginal area. Which of the following actions should the nurse take? • A. Report the findings to the local authorities B. Ask the client who performed the cutting • C. Inform the client that giving birth vaginally might not be possible D. Prepare the client for the

C. Inform the client that giving birth vaginally might not be possible The nurse should recognize that female genitat cutting is done in early adolescence as a part of some religious and cultural practices. The scarring that can result from this practice may necessitate a cesarean delivery.

A nurse is assessing 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

C. Nasal flaring Nasal flaring, grunting, and respiratory muscular retractions signal serious breathing problems that should be reported to the provider.

A nurse is discussing risk factors for necrotizing enterocolitis (NEC) in newbors with a newly licensed nurse. Which of the following risk factors should the nurse include? / A. Post-term birth B. Macrosomia • C. Respiratory distress syndrome • D. Maternal gestational diabetes

C. Respiratory distress syndrome Respiratory distress syndrome is a risk factor for NEC. Respiratory distress causes intestinal ischemia secondary to hypoxia.

A nurse is discussing risk factors for necrotizing enterocolitis (NEC) in newbors with a newly licensed nurse. Which of the following risk factors should the nurse include? A. Post-term birth B. Macrosomia C. Respiratory distress syndrome D. Maternal gestational diabetes

C. Respiratory distress syndrome Respiratory distress syndrome is a risk factor for NEC. Respiratory distress causes intestinal ischemia secondary to hypoxia.

A nurse is caring for a client in active labor who has meconium staining of the amniotic fluid. The nurse notes a reassuring fetal heart rate (FHR) tracing from the external fetal monitor. Which of the following actions should the nurse perform? • A. Prepare the client for an ultrasound examination • B. Prepare the client for an emergency cesarean birth • C. Prepare equipment needed for newborn resuscitation D. Perform endotracheal suctioning as soon as the fetal head is delivered

C. Prepare equipment needed for newborn resuscitation The nurse should ensure that all supplies and equipment needed for resuscitation of the newborn are readily avallable for every delivery. Endotracheal suctioning is recommended in cases of meconium staining only if the newborn has poor respiratory effort, decreased muscle tone, and bradycardia after delivery.

A nurse is caring for a client at 39 weeks of gestation who has gestational hypertension. The client has a new prescription for misoprostol for cervical ripening and induction of labor. Which of the following findings in the client's medical history should the nurse identify as increasing the client's risk of complications due to the use of this medication? • A. Positive bacterial vaginosis culture • B. History of failure to progress • C. Previous cesarean delivery • D. Positive serum Rh

C. Previous cesarean delivery The nurse should identify that misoprostol is a prostaglandin that promotes cervical ripening. An adverse effect of misoprostol is uterine tachysystole (excessively frequent uterine contractions). Therefore, this medication should be used with extreme caution and is contraindicated in clients who have experienced a previous cesarean delivery.

A nurse is caring for a client who experienced a spontaneous rupture of membranes and has prolonged decelerations on the fetal monitor. Which of the following conditions should the nurse expect? • A. Uterine rupture B. Placental abruption C. Prolapsed umbilical cord D. Amniotic fluid embolus

C. Prolapsed umbilical cord The nurse should identify that prolonged deceleration during a uterine contraction is a sign of cord prolapse. This is an emergent condition that should be reported to the provider immediately.

A nurse is assessing a client who is in the fourth stage of labor. Which of the following findings should the nurse expect? • A. Breast engorgement B. Hypothermia C. Urinary retention • D. Rupture of membranes

C. Urinary retention

A nurse is teaching a client who is at 30 weeks gestation about warning signs of complications that she should report to her provider. Which of the following findings should the nurse include in the teaching? A. Mild constipation B. Nasal congestion C. Vaginal bleeding D. 10 fetal movements per hour

C. Vaginal bleeding

A nurse is caring for a client who has a BMI of 22.6 and expresses concern about weight gain during pregnancy. Which of the following responses should the SE ma A. "You're eating for 2, so you should double your caloric intake." B. "You'll lose weight easily after the birth of your baby." • C. "Plan to gain a total of 15 to 20 pounds during pregnancy." D. "Gaining weight will promote a healthy pregnancy."

D. "Gaining weight will promote a healthy pregnancy" A weight gain of 11.3 to 15.9 kg (25 to 35 lb) during pregnancy is essential for supporting the growth and development of the fetus. Limiting caloric intake can result in using fat stores for energy and developing ketonemia, which is a risk factor for preterm labor.

A nurse is caring for a client who is at 34 weeks gestation and has a prescription for terbutaline for preterm labor. Which of the following statements by the client is the priority? A. "My ankles are swollen at the end of the day!" B. "I can feel the baby kicking my ribs, and it is very uncomfortable." C. "I'm growing more and more worried every day." D. "My heart feels like it is racing."

D. "My heart feels like it is racing." The nurse should apply the urgent versus nonurgent priority-setting framework. Using this framework, the nurse should consider urgent needs to be the priority need because they pose more of a threat to the client. The nurse should assess the client's heart rate. The primary action of terbutaline involves bronchodilation and relaxation of smooth muscles. However, an adverse effect is tachycardia. If the pulse is Greater than 130/min, the terbutaline needs to be held until the provider is notified. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent.

A nurse is planning care for a client who has a prescription for oxytocin. Which of the following is a contraindication to the use of this medication? • A. Prolonged rupture of membranes at 38 weeks gestation • B. Intrauterine growth restriction • C. Post-term pregnancy • D. Active genital herpes

D. Active genital herpes Peer The use of oxytocin is contraindicated for clients who have an active genital herpes infection. The newborn can acquire the infection while passing through the birth canal. Therefore, a cesarean birth is recommended for clients who have an active genital herpes infection.

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. HbAlc

D. HbA1c HbAlc measures average plasma glucose concentration over the 12 weeks preceding the test. A female client whose BMI is >30 and who has a history of delivering a baby weighing over 4,082.33 grams (9 lb) is at risk for impaired glucose metabolism and should be screened at the end of the first trimester

The fundus is approximately 2 cm (0.79 in) above the level of the umbilicus at the end of the third stage of labor. B. The fundus is approximately 3 cm (1.18 in) above the umbilicus within 12 hours after delivery. • C. The fundus is located halfway between the umbilicus and mons pubis on the sixth day postpartum. D. The fundus is not palpable abdominally at 2 weeks postpartum.

D. The fundus is not palpable abdominally at 2 weeks postpartum.

A nurse is assisting with an amniocentesis for a client who is Rh-negative. Which of the following actions should the nurse take following the procedure? A. Send a sample of amniotic fluid to the laboratory to screen the client for chlamydia • B. Send a sample of amniotic fluid to the laboratory to test for an elevated Rh-negative titer • C. Administer immune globulin to the client to prevent fetal isoimmunization • D. Administer intravenous antibiotics to prevent an infection

• C. Administer immune globulin to the client to prevent fetal isoimmunization

A nurse is caring for a client who experienced a spontaneous rupture of membranes and has prolonged decelerations on the fetal monitor. Which of the following conditions should the nurse expect? • A. Uterine rupture • B. Placental abruption • C. Prolapsed umbilical cord D. Amniotic fluid embolus

• C. Prolapsed umbilical cord

A nurse is assessing a pregnant client who is at 38 weeks gestation. The client reports that her breathing has become easier but notes an increased frequency of urination. The nurse should document this occurrence as which of the following? A. Effacement B. Dilation C. Lightening D. Quickening

c. lightening Lightening describes the engagement of the fetal head into the pelvis. When this occurs, breathing becomes easier, but urination is more frequent.

A nurse is reviewing recent laboratory values during a prenatal visit for a client who is pregnant. The nurse notes a hemoglobin level of 10 g/dL. Which of the following actions should the nurse take? A. Review the medical record for a history of gastric bypass surgery • B. Advise the client to start iron and vitamin C supplementation • C. Review the medication list to determine if the client is taking an anticonvulsant • D. Request an order for sickle cell anemia screening

• B. Advise the client to start iron and vitamin C supplementation