Final maternity practice nclex

After the first four months of pregnancy, the chief source of estrogen and progesterone is the: A: Placenta B: Adrenal cortex C: Corpus luteum D: Anterior hypophysis

1

Clients with gestational diabetes are usually managed by which of the following therapies? 1. diet 2. long acting insulin 3. oral hypoglycemic drugs 4. oral hypoglycemic drugs/insulin

1

43. A laboring client is to have a pudendal block. The nurse plans to tell the client that once the block is working she: A. Will not feel the episiotomy B. May lose bladder sensation C. May lose the ability to push D. Will no longer feel contractions

A

44. Which of the following observations indicates fetal distress? A. Fetal scalp pH of 7.14 B. Fetal heart rate of 144 beats/minute C. Acceleration of fetal heart rate with contractions D. Presence of long-term variability

A

45. Which of the following fetal positions is most favorable for birth? A. Vertex presentation B. Transverse lie C. Frank breech presentation D. Posterior position of the fetal head

A

The nurse is preparing to apply a thermistor probe to a newborn to monitor the newborn's temperature. At which location would the nurse most likely apply the probe? a) Upper left arm b) Right upper abdominal quadrant c) Lower back d) Right great toe

B

A pregnant client tells the clinic nurse that she wants to know the gender of her baby as soon as it can be determined. The nurse understands that the client should be able to find out the gender at 12 weeks' gestation because of which factor? 1. The appearance of the fetal external genitalia 2. The beginning of differentiation in the fetal groin 3. The fetal testes are descended into the scrotal sac 4. The internal differences in males and females become apparent

1

The nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The health care provider has documented the presence of Goodell's sign. This finding is most closely associated with which characteristic? 1. A softening of the cervix 2. The presence of fetal movement 3. The presence of human chorionic gonadotropin in the urine 4. A soft blowing sound that corresponds to the maternal pulse during auscultation of the uterus

1

The nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Which are probable signs of pregnancy? Select all that apply. 1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Braxton Hicks contractions 5. Fetal heart rate detected by a nonelectronic device 6. Outline of fetus via radiography or ultrasonography

1,2,3,4

The nursing instructor asks a nursing student to list the characteristics of the amniotic fluid. The student responds correctly by listing which as characteristics of amniotic fluid? Select all that apply. 1. Allows for fetal movement 2. Surrounds, cushions, and protects the fetus 3. Maintains the body temperature of the fetus 4. Can be used to measure fetal kidney function 5. Prevents large particles such as bacteria from passing to the fetus 6. Provides an exchange of nutrients and waste products between the mother and the fetus

1,2,3,4

A nurse is monitoring a pregnant client with pregnancy induced hypertension who is at risk for Preeclampsia. The nurse checks the client for which specific signs of Preeclampsia (select all that apply)? A:Elevated blood pressure B: Negative urinary protein C: Facial edema D: increased respirations

1/3

Before the placenta functions, the corpus luteum is the primary source for synthesis of which of the following hormones? 1. cortisol and thyroxine 2. estrogen and progesterone 3. LH and FSH 4. T4 and T3

2

A 17 y.o. primpigravida with severe PIH has been receiving mag sulfate IV for 3 hours. The latest assessment reveals DTR of +1, BP 150/100 mmgHg, pulse 92 bpm, respiratory rate 10bpm and urine output 20ml/hr. Which of the following actions would be most approp? 1. Continue monitoring per standards of care 2. Stop the mag sulfate infusion 3. Increase infusion by 5gtt/min 4. Decrease infusion by 5gtt/min

2

A 21 y.o. has arrives to the ER with c/o cramping abdominal pain and mild vaginal bleeding. Pelvic exam shows a left adnexal mass that's tender when palpated. Culdocentesis shows blood in the culdesac. This client probably has which of the following conditions? 1. Abruptio placentae 2. Ecoptic pregnancy 3. Hydatidiform mole 4. Pelvic Inflammatory Disease

2

A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last menstrual period was October 19, 2014. Using Nägele's rule, which expected date of delivery should the nurse document in the client's chart? 1. July 12, 2014 2. July 26, 2015 3. August 12, 2015 4. August 26, 2015

2

A client is 33 weeks pregnant and has had diabetes since she was 21. When checking her fasting blood sugar level, which values indicate the clients disease was controlled. 1. 45 mg/dl 2. 85 mg/dl 3. 120 mg/dl 4. 136 mg/dl

2

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse would determine whether this method of family planning would be most appropriate? 1. "Has either of you ever had surgery?" 2. "Do you plan to have any other children?" 3. "Do either of you have diabetes mellitus?" 4. "Do either of you have problems with high blood pressure?"

2

The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and expects which finding? 1. 22 cm 2. 30 cm 3. 36 cm 4. 40 cm

2

The nurse should include which statement to a pregnant client found to have a gynecoid pelvis? 1. "Your type of pelvis has a narrow pubic arch." 2. "Your type of pelvis is the most favorable for labor and birth." 3. "Your type of pelvis is a wide pelvis, but has a short diameter." 4. "You will need a cesarean section because this type of pelvis is not favorable for a vaginal delivery."

2

50. Fetal presentation refers to which of the following descriptions? A. Fetal body part that enters the maternal pelvis first B. Relationship of the presenting part to the maternal pelvis C. Relationship of the long axis of the fetus to the long axis of the mother D. A classification according to the fetal part

A

A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is most appropriate? 1. Contact the health care provider. 2. Instruct the client to maintain bed rest for the remainder of the pregnancy. 3. Inform the client that these contractions are common and may occur throughout the pregnancy. 4. Call the maternity unit and inform them that the client will be admitted in a prelabor condition.

3

A nursing student is assigned to care for a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement is correct regarding the ductus venosus? 1. Connects the pulmonary artery to the aorta 2. Is an opening between the right and left atria 3. Connects the umbilical vein to the inferior vena cava 4. Connects the umbilical artery to the inferior vena cava

3

52. Upon completion of a vaginal examination on a laboring woman, the nurse records 50%, 6 cm, -1. Which of the following is a correct interpretation of the data? A. Fetal presenting part is 1 cm above the ischial spines B. Effacement is 4 cm from completion C. Dilation is 50% completed D. Fetus has achieved passage through the ischial spines

A

17. A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes. Which statement if made by the client indicates a need for further education? A: "I need to stay on the diabetic diet." B: "I will perform glucose monitoring at home." C: "I need to avoid exercise because of the negative effects of insulin production." D: "I need to be aware of any infections and report signs of infection immediately to my health care provider.

3

23. A woman with preeclampsia is receiving magnesium sulfate. The nurse assigned to care for the client determines that the magnesium therapy is effective if: A: Ankle clonus in noted B: The blood pressure decreases C: Seizures do not occur D: Scotoma's are present

3

A nurse in the labor room is caring for a client in the active phases of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing action is to: 1.Place the mother in the supine position 2.Document the findings and continue to monitor the fetal patterns 3.Administer oxygen via face mask 4.Increase the rate of pitocin IV infusion

3

Which explanation should the nurse provide to the prenatal client about the purpose of the placenta? 1. It cushions and protects the baby. 2. It maintains the temperature of the baby. 3. It is the way the baby gets food and oxygen. 4. It prevents all antibodies and viruses from passing to the baby

3

During the last 6 weeks of gestation, which of the following tests isnt used to determine FWB? 1. BPP 2. NST 3. Maternal blood count 4. FM count

3

The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response? 1. "It promotes the fertilized ovum's chances of survival." 2. "It promotes the fertilized ovum's exposure to estrogen and progesterone." 3. "It promotes the fertilized ovum's normal implantation in the top portion of the uterus." 4. "It promotes the fertilized ovum's exposure to luteinizing hormone and follicle-stimulating hormone."

3

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate is 174 beats/minute. On the basis of this finding, what is the priority nursing action? 1. Document the finding. 2. Check the mother's heart rate. 3. Notify the health care provider (HCP). 4. Tell the client that the fetal heart rate is normal.

3

The nursing student is preparing to teach a prenatal class about fetal circulation. Which statement should be included in the teaching plan? "One artery carries oxygenated blood from the placenta to the fetus." 2."Two arteries carry oxygenated blood from the placenta to the fetus." 3. "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta." 4. "Two veins carry blood that is high in carbon dioxide and other waste products away from the fetus to the placenta."

3

24. A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate. Select all nursing interventions that apply in the care for the client. A: Monitor maternal vital signs every 2 hours B: Notify the physician if respirations are less than 18 per minute. C: Monitor renal function and cardiac function closely D: Keep calcium gluconate on hand in case of a magnesium sulfate overdose e: Monitor deep tendon reflexes hourly F: Monitor I and O's hourly G: Notify the physician if urinary output is less than 30 ml per hour.

3,4,5,6,7

22. A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines the client is experiencing toxicity from the medication if which of the following is noted on assessment? A: Presence of deep tendon reflexes B: Serum magnesium level of 6 mEq/L C: Proteinuria of +3 D: Respirations of 10 per minute

4

18. A nurse is monitoring a client in labor who is receiving Pitocin and notes that the client is experiencing hypertonic uterine contractions. List in order of priority the actions that the nurse takes. A. Stop of Pitocin infusion B. Perform a vaginal examination C. Reposition the client D. Check the client's blood pressure and heart rate E. Administer oxygen by face mask at 8 to 10 L/min

ADBEC

1. The nurse is aware than an adaptation of pregnancy is an increased blood supply to the pelvic region that results in a purplish discoloration of the vaginal mucosa, which is known as: A: Ladin's sign B: Hegar's sign C: Goodell's sign D: Chadwick's sign

4

The health care provider (HCP) is assessing the client for the presence of ballottement. To make this determination, the HCP should take which action? 1. Auscultate for fetal heart sounds. 2. Assess the cervix for compressibility. 3. Palpate the abdomen for fetal movement. 4. Initiate a gentle upward tap on the cervix.

4

The nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. Which instruction should the nurse provide to the client? 1. Total abstinence from sexual intercourse is necessary during the entire pregnancy. 2. Sitz baths need to be taken every 4 hours while awake if vaginal lesions are present. 3. Daily administration of acyclovir (Zovirax) is necessary during the entire pregnancy. 4. A cesarean section will be necessary if vaginal lesions are present at the time of labor.

4

The AGPAR score is based on which 5 parameters? a) Heart rate, respiratory effort, temperature, tone, and color b) Heart rate, breaths per minute, irritability, reflexes, and color c) Heart rate, muscle tone, reflex irritability, respiratory effort, and color d) Hear rate, breaths per minute, irritability, tone, and color

C

25. A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action? A. Place the client in Trendelenburg's position B. Call the delivery room to notify the staff that the client will be transported immediately C. Gently push the cord into the vagina D. Find the closest telephone and stat page the physician

A

26. A maternity nurse is caring for a client with abruptio placenta and is monitoring the client for disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with disseminated intravascular coagulation? A. Swelling of the calf in one leg B. Prolonged clotting times C. Decreased platelet count D. Petechiae, oozing from injection sites, and hematuria

A

3. A nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate a need to contact the physician? A. Fetal heart rate of 180 beats per minute B. White blood cell count of 12,000 C. Maternal pulse rate of 85 beats per minute D. Hemoglobin of 11.0 g/dL

A

31. A client is admitted to the birthing suite in early active labor. The priority nursing intervention on the admission of this client would be: A. Auscultating the fetal heart B. Taking an obstetric history C. Asking the client when she last ate D. Ascertaining whether the membranes were ruptured

A

38. When monitoring the fetal heart rate of a client in labor, the nurse identifies an elevation of 15 beats above the baseline rate of 135 beats per minute lasting for 15 seconds. This should be documented as: A. An acceleration B. An early elevation C. A sonographic motion D. A tachycardic heart rate

A

40. The breathing technique that the mother should be instructed to use as the fetus' head is crowning is: A. Blowing B. Slow chest C. Shallow D. Accelerated-decelerated

A

60. Parents can facilitate the adjustment of their other children to a new baby by: A. Having the children choose or make a gift to give to the new baby upon its arrival home B. Emphasizing activities that keep the new baby and other children together C. Having the mother carry the new baby into the home so she can show the other children the new baby D. Reducing stress on other the by limiting their involvement in the care of the new baby

A

9. A nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which of the following actions is most appropriate? A. Document the findings and tell the mother that the monitor indicates fetal well-being B. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen. C. Notify the physician or nurse-midwife of the findings. D. Reposition the mother and check the monitor for changes in the fetal tracing

A

A newborn has a heart rate of 90 beats per minute, a regular respiratory rate of 40 breaths per minute, tight flexion of the extremities, a grimace when stimulated, and acrocyanosis. The nurse assigns an Apgar score of: a) 7 b) 6 c) 5 d) 8

A

A patient expresses concern to the nurse that her baby is dehydrated and is not getting enough milk from breastfeeding. What is the best response from the nurse? a) "You can tell that your baby is adequately hydrated because he is making 8 wet diapers a day." b) "We will give him some water through a bottle in the nursery tonight while you rest." c) "Does he pass urine that is a light amber color right after eating?" d) "You should supplement with formula because your baby is 24 hours old and has not passed meconium yet."

A

As you are examining the newborn female, you notice a small pinkish discharge from the vaginal area. What should you suspect? a) Pseudomenstruation, a normal finding b) Impending hemorrhage from a congenital defect c) Infection d) Evidence of birth trauma

A

Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen? a) 24 hours after the newborn's first protein feeding. b) When the infant is 48 hours old. c) Just before discharge home.. d) 36 hours before the infant is discharged home with its parents.

A

Newborn Ming has secretions in his mouth and nose. What are the first steps the nurse should take to clear his airways? a) Position Ming on his side with his head slightly below his body; use a bulb syringe to clear his mouth. b) Position Ming on his side with his head slightly below his body; use a bulb syringe to clear his nose. c) Position Ming on his side and guide his caregivers in suctioning his mouth with a bulb syringe. d) Position Ming on his side with his head slightly below his body; use a small suction catheter to clear his nose.

A

On examining a newborn's eyes, which of the following would you expect to assess? a) Follows a light to the midline b) Has a white rather than a red reflex c) Follows your finger a full 180 degrees d) Produces tears when he cries

A

On inspecting a newborn's abdomen, which finding would you note as abnormal? a) Clear drainage at the base of the umbilical cord b) Bowel sounds present at two to three per minute c) Liver palpable 2 cm under the right costal margin d) Abdomen slightly protuberant (rounded)

A

The nurse cares for the client immediately after normal vaginal delivery.. What action should the nurse take FIRST? A: observe the locial flow B: Palpate the fundus C: obtain a warning blanket D: obtain vital signs

A

The nurse is providing discharge education on newborn care at home. The nurse provides instructions that infants need to be placed on their back to sleep. What is the nurse reducing the risk for with this education? a) Sudden infant death syndrome b) Gastroesophageal reflux c) Apnea episodes d) Waking at night

A

The pituitary hormone that stimulates the secretion of milk from the mammary glands is: A: Prolactin B: Oxytocin C: Estrogen D: Progesterone

A

What is the most important thing the nurse can teach the family of a newborn to prevent abduction while the baby is in the hospital? a) Check the identification badge of any health care worker before he or she takes the baby from the room. b) Check the number on the baby's identification bracelet. c) Check the name on the baby's identification bracelet. d) Learn to recognize the baby's cry.

A

When auscultating the newborn's heart, the nurse would place the stethoscope at which area to auscultate the point of maximal impulse? a) Lateral to the midclavicular line at the fourth intercostal space b) At the fifth intercostal space at the right midclavicular line c) At the third intercostal space adjacent to the midclavicular line d) At the midsternum, just below the suprasternal notch

A

When caring for a newborn who is jittery and irritable 30 minutes after birth, what should the nurse do? a) Take blood, using a heel stick, to check for hypoglycemia. b) Place the child beneath a radiant warmer. c) Assess the baby's temperature with a thermal skin probe. d) Rule out hypoglycemia by checking the mother's chart for diabetes or other risk factors.

A

When evaluating neurologic maturity to determine gestational age, which of the following is not part of the assessment? a) Rooting b) Popliteal angle c) Square window d) Posture

A

While examining a 2-day old newborn, a nurse notices that the skin and sclera of the eyes appear yellow. The nurse recognizes this condition as which of the following? a) Jaundice b) Pallor c) Harlequin sign d) Cyanosis

A

When performing Ortolani's maneuver, which of the following should occur? Select all that apply. a) Attempt to abduct the hips 180 degrees while applying upward pressure. b) The newborn should be in a supine position. c) A click should be heard when the legs are abducted. d) Attempt to abduct the hips 90 degrees while applying upward pressure. e) The newborn should be in a prone position.

A/B/

A 25-year-old P3023 spontaneously ruptured clear fluid at home and has had a normal labor progression. The nurse and the midwife do not anticipate any complications. What should the nurse do to prepare for the birth? Select all that apply. a) Document events as they are happening. b) Check the functionality of the oxygen source and equipment. c) Open the newborn crash cart or box to ensure easy access to all supplies. d) Move the newborn warmer to the delivery area and turn it on. e) Connect the meconium aspirator to the wall suction and turn it on.

A/B/D

16. A nurse explains the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage is: A. A form of biofeedback to enhance bearing down efforts during delivery B. Light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus C. The application of pressure to the sacrum to relieve a backache D. Performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest

B

15. A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction? A. Early decelerations B. Variable decelerations C. Late decelerations D. Short-term variability

B

17. A nurse is caring for a client in the second stage of labor. The client is experiencing uterine contractions every 2 minutes and cries out in pain with each contraction. The nurse recognizes this behavior as: A. Exhaustion B. Fear of losing control C. Involuntary grunting D. Valsalva's maneuver

B

10. A nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the monitor, the initial nursing assessment is which of the following? A. Identifying the types of accelerations B. Assessing the baseline fetal heart rate C. Determining the frequency of the contractions D. Determining the intensity of the contractions

B

14. A client arrives at a birthing center in active labor. Her membranes are still intact, and the nurse-midwife prepares to perform an amniotomy. A nurse who is assisting the nurse-midwife explains to the client that after this procedure, she will most likely have: A. Less pressure on her cervix B. Increased efficiency of contractions C. Decreased number of contractions D. The need for increased maternal blood pressure monitoring

B

The nurse has completed the initial assessment and vital signs for an infant born at 12 noon. The assessment and vital signs were completed at 1:30pm. What time will the nurse plan to complete the next set of vital signs? a) 1:45pm b) 2:00pm c) 2:30pm d) 3:30pm

B

20. A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention would be to: A. Monitor the Pitocin infusion closely B. Provide pain relief measures C. Prepare the client for an amniotomy D. Promote ambulation every 30 minutes

B

29. An ultrasound is performed on a client at term gestation that is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that an abruptio placenta is present. Based on these findings, the nurse would prepare the client for: A. Complete bed rest for the remainder of the pregnancy B. Delivery of the fetus C. Strict monitoring of intake and output D. The need for weekly monitoring of coagulation studies until the time of delivery

B

30. A nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse would monitor the client closely for the risk of uterine rupture if which of the following occurred? A. Hypotonic contractions B. Forceps delivery C. Schultz delivery D. Weak bearing down efforts

B

37. When examining the fetal monitor strip after the rupture of the membranes in a laboring client, the nurse notes variable decelerations in the fetal heart rate. The nurse should: A. Stop the oxytocin infusion B. Change the client's position C. Prepare for immediate delivery D. Take the client's blood pressure

B

41. During the period of induction of labor, a client should be observed carefully for signs of: A. Severe pain B. Uterine tetany C. Hypoglycemia D. Umbilical cord prolapse

B

54. Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1 1/2 to 2 minutes. The nurse's immediate action would be to: A. Change the woman's position B. Stop the Pitocin C. Elevate the woman's legs D. Administer oxygen via a tight mask at 8 to 10 liters/minute

B

6. A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued? A. Three contractions occurring within a 10-minute period B. A fetal heart rate of 90 beats per minute C. Adequate resting tone of the uterus palpated between contractions D. Increased urinary output

B

7. A nurse is beginning to care for a client in labor. The physician has prescribed an IV infusion of Pitocin. The nurse ensures that which of the following is implemented before initiating the infusion? A. Placing the client on complete bed rest B. Continuous electronic fetal monitoring C. An IV infusion of antibiotics D. Placing a code cart at the client's bedside

B

A father asks the nurse what medication is in the baby's eyes and why it is needed. Which of the following is the appropriate explanation? a) Destroy an infectious exudate of the vaginal canal. b) Prevent infection of the baby's eyes by bacteria which may have been in the vaginal canal. c) Prevent potentially harmful virus from invading the tear ducts. d) Prevent the baby's eyelids from sticking together to help see.

B

A new mother asks the nurse why her baby's back and groin have a red and raised rash. Which of the following does the nurse correctly identify as the name of this condition? a) Acrocyanosis. b) Erythema toxicum. c) Mumps. d) Yeast infection.

B

A newborn male is circumcised. Which of the following instructions would you include in the discharge teaching plan for his parents? a) Cleanse the glans daily with alcohol. b) Cover the glans generously with Vaseline. c) Notify her physician if it appears red and sore. d) Soak the penis daily in warm water.

B

A very healthy mother delivered a newborn with an immediate Apgar score of 10. The newborn was cradled in a kangaroo hold by both her mother and her father for 45 minutes. The parents feel ready to get cleaned up and let the newborn be taken care of by the health care personnel for a little while. What eye care action will the nurse now take? a) Instill 1 percent erythromycin eye drops b) Instill antibiotic 0.5 percent erythromycin c) Instill 0.5 percent silver nitrate eye drops d) Wait to see if the eyes show signs of irritation before any eye care treatment is completed

B

A woman comes to the nursery and states "Mrs. Smith is ready for her baby. I will be glad to take the baby to her." The woman is dressed in hospital scrub attire but has no name badge showing. What is the best response by the nurse caring for the baby? a) "Leave immediately! I'm calling security." b) "May I see your identification, please?" c) "I don't know you. Are you trying to take a baby?" d) "You must be Mrs. Smith's sister. She said her sister is a nurse."

B

Baby Tarik has been circumcised, his temperature is stable, his breathing and heart rate are healthy, and he is ready to be discharged from the hospital. What can the nurse tell his parents to be on the lookout for that might indicate that Tarik needs medical attention? a) Straining when he is passing stools b) Redness at the base of the umbilical cord c) A yellowish crusty substance on the circumcision site d) Crying for 2 hours or more each day

B

Following birth, a newborn is placed on the mother's abdomen for a period of skin-to-skin contact. a) False b) True

B

How should the nurse counsel the postpartum patient about sleep and her newborn? a) "In the first few days at home, you can expect your newborn to sleep 22 hours in a 24-hour period." b) "Using a fan in the baby's room or opening a window may reduce the incidence of sudden infant death syndrome (SIDS)." c) "Always put the baby on his back or side to sleep until he is able to hold his neck up." d) "Introducing solid foods early will help the baby sleep at night."

B

Infants receive vitamin K within the first hour after delivery. What is the rationale for administering the vitamin? a) Administered to give the infant better eye sight. b) Is a routine vitamin needed by the infant. c) Helps in formation of clotting factors, to prevent bleeding. d) Used to help infant fight infections.

B

On examination, the hands and feet of a 12-hour-old infant are cyanotic without other signs of distress. The nurse should document as: a) Cold stress. b) Acrocyanosis. c) Potential for respiratory distress. d) Poor oxygenation.

B

The nurse is providing discharge education to a first time mother and father on their newborn female infant. The father notes the infant has a yellow skin color. How should the nurse explain what the father is noting? a) Yellow is the normal color for a newborn b) The tint is yellow from jaundice c) The infant needs to be in the sunlight to clear the skin d) This might be a sign of a bleeding problem

B

The nurse observes tiny white pinpoint papules on a newborn's nose. The nurse documents this finding as: a) Lanugo b) Milia c) Harlequin sign d) Vernix caseosa

B

When counseling a patient about the advantages of circumcision, which should NOT be included in the nurse's teaching? a) "Circumcision decreases rates of penile cancer." b) "Circumcision decreases risks of skin dehiscence, adhesions, and urethral fistulas." c) "Males who are circumcised have lower rates of sexually transmitted infection." d) "Circumcision decreases rates of urinary tract infection."

B

Which of the following interventions would a nurse implement to best prevent heat loss in a 1 day of age newborn? a) Bathe and wash the newborn when temperature is 36.4 C (97.5F) b) Warm all surfaces and objects that come in contact with the newborn. c) Keep the newborn under the radiant heater when not with mom. d) Cover the newborn with several blankets while under the warmer.

B

Which of the following statements by the parents of a newborn indicate that they understand how to soothe their newborn if he becomes upset? a) "We'll place him on his belly on a blanket on the floor." b) "We'll turn the mobile on that's hanging above his head in his crib." c) "We'll vigorously rub his back as we play some music." d) "We'll hold off on feeding him for a while because he might be too full."

B

You are assisting with the circumcision of a 16-hour-old male infant. Immediately after the procedure, what kind of dressing would you apply to the surgical area? a) Sterile 2×2s and paper tape b) Petrolatum gauze dressing c) Steri strips d) Small pressure dressing

B

When assessing a newborn's gestational age, the nurse evaluates which of the following parameters to indicate physical maturity? Select all that apply. a) Posture b) Lanugo c) Arm recoil d) Scarf sign e) Genitals

B, E

Which of the following findings would the nurse identify as normal when assessing a newborn? Select all that apply. a) Chest circumference of 35 cm b) Length of 54 cm c) Temperature of 37 degrees C d) Weight of 3,300 grams e) Head circumference of 30 cm f) Apical pulse rate of 100 beats/minute

B/C/D

19. A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the physician's orders and would expect to note which of the following prescribed treatments for this condition? A. Medication that will provide sedation B. Increased hydration C. Oxytocin (Pitocin) infusion D. Administration of a tocolytic medication

C

2. A nurse in the labor room is caring for a client in the active phases of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing action is to: A. Place the mother in the supine position B. Document the findings and continue to monitor the fetal patterns C. Administer oxygen via face mask D. Increase the rate of Pitocin IV infusion

C

21. A nurse is developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan of care and selects which of the following nursing interventions as the highest priority? A. Keeping the significant other informed of the progress of the labor B. Providing comfort measures C. Monitoring fetal heart rate D. Changing the client's position frequently

C

22. A maternity nurse is preparing to care for a pregnant client in labor who will be delivering twins. The nurse monitors the fetal heart rates by placing the external fetal monitor: A. Over the fetus that is most anterior to the mother's abdomen B. Over the fetus that is most posterior to the mother's abdomen C. So that each fetal heart rate is monitored separately D. So that one fetus is monitored for a 15-minute period followed by a 15 minute fetal monitoring period for the second fetus

C

27. A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present? A. Absence of abdominal pain B. A soft abdomen C. Uterine tenderness/pain D. Painless, bright red vaginal bleeding

C

28. A maternity nurse is preparing for the admission of a client in the 3rd trimester of pregnancy that is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the physician's orders and would question which order? A. Prepare the client for an ultrasound B. Obtain equipment for external electronic fetal heart monitoring C. Obtain equipment for a manual pelvic examination D. Prepare to draw a Hgb and Hct blood sample

C

32. A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100% effaced, and she is dilated to 3 cm. Her fetus is at +1 station. The nurse is aware that the fetus' head is: A. Not yet engaged B. Entering the pelvic inlet C. Below the ischial spines D. Visible at the vaginal opening

C

33. After doing Leopold's maneuvers, the nurse determines that the fetus is in the ROP position. To best auscultate the fetal heart tones, the Doppler is placed: A. Above the umbilicus at the midline B. Above the umbilicus on the left side C. Below the umbilicus on the right side D. Below the umbilicus near the left groin

C

34. The physician asks the nurse the frequency of a laboring client's contractions. The nurse assesses the client's contractions by timing from the beginning of one contraction: A. Until the time it is completely over B. To the end of a second contraction C. To the beginning of the next contraction D. Until the time that the uterus becomes very firm

C

35. The nurse observes the client's amniotic fluid and decides that it appears normal, because it is: A. Clear and dark amber in color B. Milky, greenish yellow, containing shreds of mucus C. Clear, almost colorless, and containing little white specks D. Cloudy, greenish-yellow, and containing little white specks

C

47. A laboring client is in the first stage of labor and has progressed from 4 to 7 cm in cervical dilation. In which of the following phases of the first stage does cervical dilation occur most rapidly? A. Preparatory phase B. Latent phase C. Active phase D. Transition phase

C

48. A multiparous client who has been in labor for 2 hours states that she feels the urge to move her bowels. How should the nurse respond? A. Let the client get up to use the potty B. Allow the client to use a bedpan C. Perform a pelvic examination D. Check the fetal heart rate

C

49. Labor is a series of events affected by the coordination of the five essential factors. One of these is the passenger (fetus). Which are the other four factors? A. Contractions, passageway, placental position and function, pattern of care B. Contractions, maternal response, placental position, psychological response C. Passageway, contractions, placental position, and function, psychological response D. Passageway, placental position and function, paternal response, psychological response

C

51. A client is admitted to the L & D suite at 36 weeks' gestation. She has a history of C-section and complains of severe abdominal pain that started less than 1 hour earlier. When the nurse palpates tetanic contractions, the client again complains of severe pain. After the client vomits, she states that the pain is better and then passes out. Which is the probable cause of her signs and symptoms? A. Hysteria compounded by the flu B. Placental abruption C. Uterine rupture D. Dysfunctional labor

C

57. Which measure would be least effective in preventing postpartum hemorrhage? A. Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered B. Encourage the woman to void every 2 hours C. Massage the fundus every hour for the first 24 hours following birth D. Teach the woman the importance of rest and nutrition to enhance healing

C

58. When making a visit to the home of a postpartum woman one week after birth, the nurse should recognize that the woman would characteristically: A. Express a strong need to review events and her behavior during the process of labor and birth B. Exhibit a reduced attention span, limiting readiness to learn C. Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn D. Have reestablished her role as a spouse/partner

C

A nurse is observing respiratory effort in a newborn as part of Apgar scoring. Which of the following methods should he use to do this? a) Observing resistance to any effort to extend the newborn's extremities b) Observing and counting the pulsations of the umbilical cord c) Observing chest movement d) Observing response to a suction catheter in the nostrils

C

A nurse is performing Apgar scoring on a newborn. The newborn demonstrates the following: a heart rate of 110; a good, strong cry; muscles of the extremities well flexed; a grimace in response to a slap to the sole of the foot; and normal pigment in most of the body, with blue at the extremities. Which of the following would be the total Apgar score for this newborn? a) 7 b) 6 c) 8 d) 9

C

A nurse tests a newborn's nervous functioning by stroking the sole of the baby's foot in an inverted "J" curve from the heel upward. The baby responds by fanning his toes. Which reflex has just been demonstrated? a) Extrusion b) Moro c) Babinski reflex d) Rooting reflex

C

All of the following are characteristics of an infant abductor EXCEPT a) Married and/or lives with a male partner b) Lives near the hospital c) Targets a specific infant d) A woman of childbearing age

C

All of the following are ways the nurse can encourage bonding between the parents and the newborn EXCEPT a) Asking the parents' permission to pick up the newborn b) Encouraging parents to provide care while you are there to observe them c) Telling the mother that the best way to bond with her baby is to breastfeed d) Talking to the newborn in front of the parents

C

The infant's temperature is 97.2F axillary an hour after birth. Which intervention is the appropriate for the nurse? a) Administer a warm bath with temperature slightly higher than usual b) Place a second stockinette on the baby's head c) Place the infant under a radiant warmer or in a heated isolette. d) Take the infant to the mother for bonding.

C

The nurse notices while holding him upright that a day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the physician. What does this finding most likely indicate? a) Cyanosis b) Vernix caseosa c) Dehydration d) Increased intracranial pressure

C

The parents of a newborn baby boy ask you about circumcising their son. They are undecided as to what to do. Which response by the nurse is best? a) "If you do not circumcise your baby, he will always have difficulty maintaining adequate hygiene." b) "It is best not to circumcise your baby because the procedure is very painful." c) "There are pros and cons to circumcision. Let me ask the pediatrician to come and talk to you about the procedure." d) "Circumcision is best in order to protect the baby from diseases like cancer."

C

To indicate that the infant is making a successful transition immediately after birth, the nurse checks the heart rate for 6 seconds. What should the count minimally be? a) 9 b) 10 c) 11 d) 12

C

To prevent misidentification of a newborn identification bands are placed on the newborn and on the parents before the newborn is separated from the parents. What information is on all the bands? a) Father's name and date and time of birth b) Hospital number, attending physician, and father's name c) Newborn's sex and date and time of birth d) Mother's name and date and time of her birth

C

What is the best thing the nurse can do to manage pain in a neonate? a) Teach the infant's caregivers ways to soothe and comfort the child during any episode of pain. b) Adhere carefully to the plan for administration of any analgesics to the child. c) Advocate to the physician to use effective treatment methods that cause no pain or less pain. d) Provide a soothing environment, swaddling, and holding to the newborn experiencing pain.

C

When educating patients in a maternal-newborn unit about prevention of infant abduction, what is essential in the effectiveness of prevention of abduction? a) Use of monitor attached to babies b) Policy posted about security c) Cooperation by the parents with the hospital policies d) Staff awareness of infant abduction profiles

C

When instructing a new mom on providing skin care to her newborn, which of the following should NOT be included in the teaching? a) "Change diapers frequently." b) "Give the newborn sponge baths until the umbilical cord falls off." c) "Use talc powders to prevent diaper rash." d) "Daily tub baths are not necessary."

C

Which is the best place to perform a heel stick on a newborn? a) The front of the heel (the outer arch) b) The vascularized flat surface of the foot c) The fat pads on the lateral aspects of the foot d) The calcaneus

C

With an HBV-positive mother, what should the newborn receive? a) The HBV vaccination and 2 doses of hepatitis B immunoglobulin within 24 hours of birth b) The HBV vaccination and 1 dose of hepatitis B immunoglobulin within 24 hours of birth c) The HBV vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth d) Two doses of the hepatitis B immunoglobulin within 24 hours of birth

C

You are doing discharge teaching with the parents of a newborn baby girl. You know that it is important to teach them about diarrhea and dehydration. When should the parents notify the physician about diarrhea in the newborn.? a) If the infant has more than three episodes of diarrhea in one day b) If the infant has more than four episodes of diarrhea in one day c) If the infant has more than two episodes of diarrhea in one day d) If the infant has more than one episode of diarrhea in one day

C

1. A nurse is caring for a client in labor. The nurse determines that the client is beginning in the second stage of labor when which of the following assessments is noted? A. The client begins to expel clear vaginal fluid B. The contractions are regular C. The membranes have ruptured D. The cervix is dilated completely

D

12. A pregnant client is admitted to the labor room. An assessment is performed, and the nurse notes that the client's hemoglobin and hematocrit levels are low, indicating anemia. The nurse determines that the client is at risk for which of the following? A. A loud mouth B. Low self-esteem C. Hemorrhage D. Postpartum infections

D

13. A nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of: A. Hematoma B. Placenta previa C. Uterine atony D. Placental separation

D

23. A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa? A. Disseminated intravascular coagulation B. Chronic hypertension C. Infection D. Hemorrhage

D

24. A nurse in the delivery room is assisting with the delivery of a newborn infant. After the delivery of the newborn, the nurse assists in delivering the placenta. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery? A. The umbilical cord shortens in length and changes in color B. A soft and boggy uterus C. Maternal complaints of severe uterine cramping D. Changes in the shape of the uterus 25

D

36. At 38 weeks gestation, a client is having late decelerations. The fetal pulse oximeter shows 75% to 85%. The nurse should: A. Discontinue the catheter, if the reading is not above 80% B. Discontinue the catheter, if the reading does not go below 30% C. Advance the catheter until the reading is above 90% and continue monitoring D. Reposition the catheter, recheck the reading, and if it is 55%, keep monitoring

D

39. A laboring client complains of low back pain. The nurse replies that this pain occurs most when the position of the fetus is: A. Breech B. Transverse C. Occiput anterior D. Occiput posterior

D

4. A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is transferred to the delivery room table, and the nurse places the client in the: A. Trendelenburg's position with the legs in stirrups B. Semi-Fowler position with a pillow under the knees C. Prone position with the legs separated and elevated D. Supine position with a wedge under the right hip 5

D

42. A client arrives at the hospital in the second stage of labor. The fetus' head is crowning, the client is bearing down, and the birth appears imminent. The nurse should: A. Transfer her immediately by stretcher to the birthing unit B. Tell her to breathe through her mouth and not to bear down C. Instruct the client to pant during contractions and to breathe through her mouth D. Support the perineum with the hand to prevent tearing and tell the client to pant

D

46. A laboring client has external electronic fetal monitoring in place. Which of the following assessment data can be determined by examining the fetal heart rate strip produced by the external electronic fetal monitor? A. Gender of the fetus B. Fetal position C. Labor progress D. Oxygenation

D

5. A nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a Doppler ultrasound device. The nurse most accurately determines that the fetal heart sounds are heard by: A. Noting if the heart rate is greater than 140 BPM B. Placing the diaphragm of the Doppler on the mother's abdomen C. Performing Leopold's maneuvers first to determine the location of the fetal heart D. Palpating the maternal radial pulse while listening to the fetal heart rate

D

53. Which of the following findings meets the criteria of a reassuring FHR pattern? A. FHR does not change as a result of fetal activity B. Average baseline rate ranges between 100 - 140 BPM C. Mild late deceleration patterns occur with some contractions D. Variability averages between 6 - 10 BPM

D

55. The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia would be: A. Severe postpartum headache B. Limited perception of bladder fullness C. Increase in respiratory rate D. Hypotension

D

56. Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: A. Uses soap and warm water to wash the vulva and perineum B. Washes from symphysis pubis back to episiotomy C. Changes her perineal pad every 2 - 3 hours D. Uses the peri bottle to rinse upward into her vagina

D

59. Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should: A. Tell the woman she can rest after she feeds her baby B. Recognize this as a behavior of the taking-hold stage C. Record the behavior as ineffective maternal-newborn attachment D. Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time

D

A father is asking questions about the circumcision of his son. He is asking the nurse if there are any disadvantages to the procedure. How should the nurse respond? a) Lower rate of urinary tract infections b) Fewer complications than if done later in life c) Reduced risk of penile cancer d) Pain administration may not be effective during the procedure

D

A newborn is discharged from the hospital before undergoing metabolic screening. A community health nurse scheduling a follow-up home visit knows that the most appropriate time to perform the heel stick is: a) Before the baby has received 8 feeds of breast milk or formula. b) Within 24 hours of birth. c) At least 36 hours after birth. d) At least 24 hours after birth.

D

A nurse is discussing breastfeeding with a new mother and demonstrates that when she strokes the baby's cheek, the baby turns his head in that direction. This reflex is known as which of the following? a) Moro reflex b) Babinski reflex c) Extrusion reflex d) Rooting reflex

D

An African American baby has discoloring which appears similar to bruising on his buttock after a normal vaginal delivery. This assessment should be documented as: a) Lanugo. b) Bruising. c) Vascular nevi. d) Mongolian spots.

D

Baby Eliza is 7 minutes old. Her heart rate is 92, her cry is weak, her muscles are limp and flaccid, she makes a face when she is stimulated, and her body and extremities are pink. What would the nurse assign as her Apgar score? a) 3 b) 4 c) 6 d) 5

D

Discharge teaching is an important part of the labor and delivery room nurse's position. New parents need to know the basics of baby care, like how to monitor fluid volume and when to call the physician. What are the parameters for calling the physician in regards to an infants' temperature? a) less than 96.7 °F or greater than 99.5 °F. b) less than 96 °F or greater than 101 °F c) less than 97 °F or greater than 100.5 °F. d) Less than 97.7 °F or greater than 100 °F.

D

How can the nurse be instrumental in preventing hypoglycemia in the newborn? Choose the best answer. a) Assessing the newborn's blood pressure within 1 hour of delivery b) Encouraging skin to skin for the first few minutes after birth c) Administering vitamin K within 1 hour of birth d) Encouraging early and frequent feedings

D

How should the nurse counsel the postpartum patient about sleep and her newborn? a) "Introducing solid foods early will help the baby sleep at night." b) "Always put the baby on his back or side to sleep until he is able to hold his neck up." c) "In the first few days at home, you can expect your newborn to sleep 22 hours in a 24-hour period." d) "Using a fan in the baby's room or opening a window may reduce the incidence of sudden infant death syndrome (SIDS)."

D

Newborn Isaac has been taken to the nursery after delivery. He has been cleaned in the labor and delivery suite and swaddled in a blanket. The nurse is going to check his pulse. What must the nurse do? a) Perform a 3-minute surgical type scrub before touching him. b) Use infection transmission precautions. c) Clean his or her hands with a betadine scrub. d) Wear gloves

D

On an Apgar evaluation, reflex irritability is tested by which of the following? a) Dorsiflexing a foot against pressure resistance b) Raising the infant's head and letting it fall back c) Tightly flexing the infant's trunk and then releasing it d) Slapping the soles of the feet and observing the response

D

Ophthalmia neonatorum is contracted when a mother has which sexually transmitted infection(s)? a) Chlamydia b) Gonorrhea c) Trichomonas d) Both A and B e) Both B and C

D

Shortly after the birth of a newborn, the mother notices a gray patch across the baby's buttocks. She is immediately concerned that the baby has been bruised during the birth and asks the nurse about this. The nurse recognizes patch as a birth mark and explains this to the mother. Which type of birth mark is this most likely to be? a) Cavernous hemangioma b) Nevus flammeus c) Strawberry hemangioma d) Mongolian spot

D

The American Academy of Pediatrics and the American Dietetic Association recommend breastfeeding exclusively for how long? a) The first 28 days b) The first 3 months c) The first 4 months d) The first 6 months

D

The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience? a) Radiating b) Conductive c) Convective d) Evaporative

D

The nurse measures a newborn's temperature immediately after birth and finds it to be 99°F. An hour later, it has dropped several degrees. The nurse understands that this heat loss can be explained in part by which of the following in the newborn? a) Continual crying b) Continual kicking c) Constriction of blood vessels d) Lack of subcutaneous fat

D

The standard of care and recommendation by the Centers for Disease Control is to administer an immunization to all newborns. Which immunization is recommended to be administered prior to discharge? a) Prevnar b) DTaP c) HiB d) Hep B

D

What is the expected range for respirations in a newborn? a) 20-40 breaths per minute b) 40-80 breaths per minute c) 10-30 breaths per minute d) 30-60 breaths per minute

D

When assessing the umbilical cord of a newborn, which of the following would the nurse expect to find? a) Three arteries and no veins b) Two arteries and two veins c) One artery and two veins d) Two arteries and one vein

D

Which of the following is FALSE regarding bathing the newborn? a) Mild soap should be used on the body and hair, but not on the face. b) While bathing the newborn, the nurse should wear gloves. c) Bathing should not be done until the newborn is thermally stable. d) To reduce the risk of heat loss, the bath should performed by the nurse, not the parents, within 2-4 hours of birth.

D

Which of the following nursing diagnosis would be highest in priority for a newborn? a) Ineffective thermoregulation related to heat loss to the environment. b) Altered nutrition less than body requirement related to limited formula intake. c) Altered urinary elimination related to post-circumcision status. d) Ineffective airway clearance related to mucous obstruction.

D

Which of the following would the nurse do first after the birth of a newborn? a) Obtain footprints. b) Administer vitamin K. c) Apply identification bracelet. d) Suction the mouth and nose.

D

You are admitting a 10-pound newborn to the nursery. You know that it will be important to monitor what during the transition period? a) Temperature b) Heart rate c) Apgar score d) Blood sugar

D

You record a newborn's Apgar score at birth. A normal 1-minute Apgar score is a) 5 to 9. b) 1 to 2. c) 12 to 15. d) 7 to 10.

D

Which vital sign is not routinely assessed in a term, healthy newborn with 9/9 AGPARs? a) Pain b) Pulse c) Respirations d) Temperature e) Blood pressure

E

11. A nurse is reviewing the record of a client in the labor room and notes that the nurse midwife has documented that the fetus is at (-1) station. The nurse determines that the fetal presenting part is: A. 1 cm above the ischial spine B. 1 fingerbreadth below the symphysis pubis C. 1 inch below the coccyx D. 1 inch below the iliac crest

a

8. A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 BPM. Which of the following nursing actions is most appropriate? A. Encourage the client's coach to continue to encourage breathing exercises B. Encourage the client to continue pushing with each contraction C. Continue monitoring the fetal heart rate D. Notify the physician or nurse midwife

d

13. A pregnant client in the last trimester has been admitted to the hospital with a diagnosis of severe preeclampsia. A nurse monitors for complications associated with the diagnosis and assesses the client for: Any bleeding, such as in the gums, petechiae, and purpura. Enlargement of the breasts Periods of fetal movement followed by quiet periods Complaints of feeling hot when the room is cool

1

A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement, if made by the client, indicates a need for further education? "I will maintain strict bedrest throughout the remainder of pregnancy." "I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of bleeding." "I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad." "I will watch for the evidence of the passage of tissue."

1

A nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The physician has documented the presence of a Goodell's sign. The nurse determines this sign indicates: A softening of the cervix A soft blowing sound that corresponds to the maternal pulse during auscultation of the uterus. The presence of hCG in the urine The presence of fetal movement

1

Which of the following changes in resp functioning during pregnancy is considered normal? 1. increased tidal volume 2. increases expiratory volume 3. decreased inspiratory capacity 4. decreased oxygen consumption.

1

10. A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Select all probable signs of pregnancy. a: Uterine enlargement B:Fetal heart rate detected by nonelectric device C:Outline of the fetus via radiography or ultrasound D:Chadwick's sign e: Braxton Hicks contractions f: Ballottement

1,4,5,6

A nurse has provided discharge instructions to a client who delivered a healthy infant by cesarean delivery. Which statement made by the client indicates a need for further instructions? A. "I will begin abdominal exercises immediately." B. " I will notify the physician if I develop a fever." C. "I will turn on my side and push up with my arms to get out of bed." D. " I will lift nothing heavier than the newborn infant for at least 2 weeks."

A

18. A primagravida is receiving magnesium sulfate for the treatment of pregnancy induced hypertension (PIH). The nurse who is caring for the client is performing assessments every 30 minutes. Which assessment finding would be of most concern to the nurse? A: Urinary output of 20 ml since the previous assessment B: Deep tendon reflexes of 2+ C: Respiratory rate of 10 BPM D: Fetal heart rate of 120 BPM

3

19. A nurse is caring for a pregnant client with Preeclampsia. The nurse prepares a plan of care for the client and documents in the plan that if the client progresses from Preeclampsia to eclampsia, the nurse's first action is to: A: Administer magnesium sulfate intravenously B: Assess the blood pressure and fetal heart rate C: Clean and maintain an open airway D: Administer oxygen by face mask

3

6. A homecare nurse visits a pregnant client who has a diagnosis of mild Preeclampsia and who is being monitored for pregnancy induced hypertension (PIH). Which assessment finding indicates a worsening of the Preeclampsia and the need to notify the physician? ABlood pressure reading is at the prenatal baseline b: Urinary output has increased C: The client complains of a headache and blurred vision D: Dependent edema has resolved

3

During a prenatal visit at 38 weeks, a nurse assesses the fetal heart rate. The nurse determines that the fetal heart rate is normal if which of the following is noted? 80 BPM 100 BPM 150 BPM 180 BPM

3

The chief function of progesterone is the: A: Development of the female reproductive system B: Stimulation of the follicles for ovulation to occur C: Preparation of the uterus to receive a fertilized egg D: Establishment of secondary male sex characteristics

3

The nurse receives an order to start an infusion for a client whos hemorrhaging due to a placenta previa. What supplies will be needed? 1. Y tubing, normal saline solution, and 20G cathether 2. Ytubing, lactated Ringers solution and 18G cath 3. Y tubing, normal saline, 18G cath 4. Y tubing, lactated RIngers, 20G cath

3

The nurse recognizes that an expected change in the hematologic system that occurs during the 2nd trimester of pregnancy is: A: A decrease in WBC's B: In increase in hematocrit C: An increase in blood volume D: A decrease in sedimentation rate

3

Which drug would the nurse choose to utilize as an antagonist for magnesium sulfate? 1. Oxytocin 2. Terbutaline 3. Calcium gluconate 4. Narcan

3

Which of the following conditions isnt dx by abdominal US during the prenatal period? 1. fetal presentation 2. fetal heart activity 3. maternal diabetes 4. amniotic fluid volume

3

An expected cardiopulmonary adaptation experienced by most pregnant women is: A:TAachycardia BDyspnea at rest C";Progression of dependent edema DShortness of breath on exertion

4

A nurse is teaching a postpartum client about breast-feeding. Which of the following instructions should the nurse include? A. The diet should include additional fluids B. Prenatal vitamins should be discontinued C. Soap should be used to cleanse the breasts. D. Birth control measures are unnecessary while breast-feeding.

A

A nurse observes four newborns, Which characteristic are MOST common in a preterm infant A: red, wrinkled skin, lanugo, and hypotonic muscles B: vernix caseosa, silky hair, and facial edema C: absent nose bridge, depressed fontanels, and absent lanugo D: mottled skin, meconium stools, and hypertonic muscles

A

A nurse obtains the vital signs on a mother who delivered a healthy newborn infant 2 hours ago and notes that the mother's temperature is 102 F. The appropriate nursing action would be to: A. Notify the physician B. Remove the blanket from the client's bed C. Document the finding and recheck the temperature in 4 hours. D. Administer Acetaminophen (Tylenol) and recheck the temperature in 4 hours.

A

It has been 12 hours since the client's delivery of a newborn. The nurse assesses the client for the process of involution and documents that it is progressing normally when palpation of the client's fundus is noted at which level? A. At the umbilicus B. One fingerbreadth below the umbilicus C. Two fingerbreadth above the umbilicus D. Two fingerbreadth below the umbilicus

A

A nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which of the following instructions would be included on the list? A. Wear a supportive bra B. Rest during the acute phase C. Maintain a fluid intake of at least 3000 ml D Continue to breast-feed if the breasts are not too sore. E. Take the prescribed antibiotics until the soreness subsides. F. Avoid decompression of the breasts by breast-feeding or breast pump.

ABCD

A 15-year old client who is 14 weeks pregnant and is gravida I comes to the clinic for the first prenatal visit. During the interview, the nurse discovers that the client has had type 1 diabetes mellitus since the age of 9 years She tells the nurse, "I'm trying not to eat much so I won't show. I have cut out my insulin, so it is OK that I don't eat." The nurse formulates which important nursing diagnosis at this time? a) Disturbed body image related to fear of gaining weight b) Impaired nutrition: less than body requirements related to a voluntary decrease in food intake c) Risk for impaired skin integrity related to skin stretching from a growing uteru d) Risk for injury to the fetus related to the teenage pregnancy

B

A 27 year-old pregnant women had a pre conceptual body mass index (BMI) of 18.0. The nurse knows that this woman's total recommended weight gain during pregnant should be at least? A) 27.5 lbs B) 35 lbs C) 44 lbs

B

A nurse accidentally bumps into a newborns bassinet. The newborn jumps and pulls the extremities into the trunk. The nurse identifies the newborn is demonstrating which reflex? A: tonic neck B: Moro C: Babinski D: rooting

B

A nurse is performing an assessment of a primapira who is being evaluated in a clinic during her second trimester of pregnancy. Which of the following indicates an abnormal physical finding necessitating further testing? a: Consistent increase in fundal height b: Fetal heart rate of 180 BPM c: Braxton hicks contractions d:Quickening

B

A nurse is responsible for screening prenatal clients for potential complications and referring them to specific high-risk clinics. Which client is at least risk for developing gestational hypertension? a) a client that was diagnosed with diabetes mellitus 10 years ago b) a 20 year old, gravida II, weighing 115 pounds c) a client who has been diagnosed with chronic hypertension d) a client with a previous history of gestational hypertension

B

A nurse provides instructions to a new mother who is about to breast-feed her newborn infant. The nurse observes the new mother as she breast-feeds fo the first time and intervenes if the new mother: A. Turns the newborn infant on his side, facing the mother B. Tilts up the nipple or squeezes the areola, pushing it into the newborn's mouth C. Draws the newborn the rest of the way onto the breast when the newborn opens his mouth D. Places a clean finger in the side of the newborn's mouth to break the suction before removing the newborn from the breast.

B

A discharge nurse is discussing mastitis with a postpartum client. Which of the following statements by the client would indicate a need for further instruction? A. "If I develop a hot, reddened, triangle-shaped area on my breast, I should contact my healthcare provider." B. " I may develop mastitis if I wear underwire bras, experience excessive fatigue, or suddenly decrease the number of feedings." C."If I develop a fever, chills, or body aches at any time after discharge I should stop breast feeding immediately." D. "Antibiotics, rest, warm compresses, and adequate fluid intake are all important for the treatment of mastitis."

C

A 21y.o. client has been diagnosed with hydatidiform mole. Which of the following factors is considered a risk factor for developing hydatidiform mole? 1. age in 20s or 30s 2. high in SES 3. Primigravida 4. prior molar gestation

D

A client who is breast-feeding her newborn infant is experiencing nipple soreness. To relieve the soreness, the nurse suggests that the client: A. Avoid rotating breast-feeding positions. B. Stop nursing until the nipples heal C. Substitute a bottle-feeding until the nipples heal. D. Position the infant with the ear, shoulder, and hip in straight alignment with the infant's stomach against the mother.

D

A nurse is preparing to measure the fundal height of a client whose fetus is 28 weeks' gestation. To perform the procedure, the nurse should place the client: a) in a standing position b) in the trendelenburg position c) supine with the head of the bed elevated to 45 degrees d) supine with her head on a pillow and knees slightly flexed

D

A nurse is reviewing a nutritional plan of care with a pregnant client and is identifying the food items highest in folic acid. The nurse determines that the client understands the foods that supply the highest amount of folic acid if the client states that she will include which of the following in the diet? A) Milk B) Yogurt C) Bananas D) Leafy green vegetables

D

A nurse performs a prenatal assessment on a client in the first trimester of pregnancy and discovers that the client frequently consumes beverages containing alcohol The nurse initiated interventions to assist the client to avoid alcohol consumption in order to: a) reduce the potential for fetal growth restriction in utero b) promote the normal psychosocial adaptation of the mother to pregnancy c) minimize the potential for placental abruptions during the intrapartum period d) reduce the risk of teratogenic effects to developing fetal organs, tissues, and structures

D

The nurse cares for a client in labor. The client suddenly shouts "I have to push! I have to push! " the nurse determines that the client is 8 cm dilated. Which action should the nurse take first? A: instruct the client to take a deep breath and bear down B: apply pressure to the clients fundus C: coach the client in relaxation techniques D: Encourage the client to pant with pursed lips

D

Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized swelling on the right side of his head. In a newborn, what is the most likely cause of this accumulation of blood between the periosteum and skull that does not cross the suture line? A.Cephalhematoma, which is caused by forceps trauma B.Subarachnoid hematoma, which requires immediate drainage C.Molding, which is caused by pressure during labor D.Subdural hematoma, which can result in lifelong damage

a

breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client? A.Breastfeed the infant, ensuring that both breasts are completely emptied. B.Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast. C.Breastfeed on the unaffected breast only until the mastitis subsides. D.Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant.

a

After a precipitous delivery, a nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. The nurse should do which of the following to help the woman process what has happened? A. Encourage the mother to breast-feed soon after birth. B. Support the mother in her reaction to the newborn infant. C. Tell the mother that it is important to hold the newborn infant. D. Document a complete account of the mother's reaction on the birth record.

b

When involved in prenatal teaching, the nurse should advise the clients that an increase in vaginal secretions during pregnancy is called leukorrhea and is caused by increased: A: Metabolic rates B: Production of estrogen C: Functioning of the Bartholin glands D: Supply of sodium chloride to the cells of the vagina

b

The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of ectopic pregnancy? a. Painless vaginal bleeding b. Abdominal cramping c. Throbbing pain in the upper quadrant d. Sudden, stabbing pain in the lower quadrant

d

A nurse midwife is performing an assessment of a pregnant client and is assessing the client for the presence of ballottement. Which of the following would the nurse implement to test for the presence of ballottement? A: Auscultating for fetal heart sounds Palpating the abdomen for fetal movement Assessing the cervix for thinning Initiating a gentle upward tap on the cervix

4

Which of the following symptoms occurs with a hydatidiform mole? A: Heavy, bright red bleeding every 21 days B: Fetal cardiac motion after 6 weeks gestation C:Benign tumors found in the smooth muscle of the uterus D: "snowstorm" pattern on ultrasound with no fetus or gestational sac

4

A nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 1 hour. The nurse reports the amount of lochial flow as: A. Scant B. Light C. Heavy D. Excessive

C

A nurse is performing an assessment on a 2-day postpartum mother. The mother complains of severe pain and an intense feeling of swelling and pressure in the vulvar area. After hearing these complaints the nurse specifically checks the client's... A. Episiotomy for drainage B. Rectum for hemorrhoids C. Vulva for a hematoma D. Vagina for lacerations

C

A woman who is 32 weeks pregnant is informed by the nurse that a danger sign of pregnant could be: A) Edema in the ankles and feet at the end of the day B) Heart palpitations C) Alternation in the pattern of fetal movement D) Constipation

C

Cardiovascular system changes occur during pregnancy. Which finding would be considered normal for a woman in her second trimester? A) Increased blood pressure B) Less audible heart sounds (S1, S2) C) Increased pulse rate D) Decreased red blood cell (RBC) production

C

Methylergonovine (Methergine) is prescribed for a woman who has just delivered a healthy newborn infant. The priority assessment before administering the medication is to check the clients: A. Lochia B. Uterine tone C. Blood pressure D. Deep tendon reflexes

C

On assessment of a client who is 30 minutes into the fourth stage of labor, the nurse finds the client's perineal pad saturated with blood and blood soaked into the bed linen under the client's buttocks. The nurse's initial action is which of the following. A. Call the physician B. Assess the client's vital signs C. Gently massage the uterine fundus D. Administer a 300ml bolus of a 20 units/L Oxytocin(Pitocin) solution

C

Prior to discharge, what instructions should the nurse give to parents regarding the newborn's umbilical cord care at home? A.Wash the cord frequently with mild soap and water. B.Cover the cord with a sterile dressing. C.Allow the cord to air-dry as much as possible. D.Apply baby lotion after the baby's daily bath

C

The nurse in the prenatal clinic assesses a client at 31 weeks gestation. The clients blood pressue is 150/96, serum albumin level is 3g/dL, edema of the face and hands is noted, and 3+ protein is found in the urine. Which instruction by the nurse is MOST important? a: the client should decrease caloric intake b: the client should eliminate all salt from the diet C: the client should ensure adequate protein D: the client shoul dincrease the intake of iron

C

The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure is completed, it is most important for the nurse to obtain which information? A.Maternal blood pressure B.Maternal temperature C.Fetal heart rate (FHR) D.White blood cell count (WBC)

C

The nurse prepares a client for an abdominal hysterectomy. The client asks why a foley catheter is required. Which statement by the nruse is most appropriate A: This will help you since you will be temporaily incontenient B: This will enable us to measure your output accurately C: this will allow you to heal by keeping your bladder decompressed D: This will allow your bladder to recover after the surgery

C

performing an assessment on a client during her first prenatal visit to the clinic takes the client's temperature and notes that the temperature is 99.2F. Which nursing action is appropriate? a) notify the physician b) retake the temperature by the rectal route c) document the temperature d) inform the client that the temperature is elevated, and antibiotics may be required

C

A pregnant client is seen in a health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions, and the nurse determines that she is experiencing Braxton Hicks contractions. Based on this finding, which nursing action is appropriate? a) contact the physician b) instruct the client to maintain bedrest for the remainder of the pregnancy c) inform the client that these contractions are common and may occur throughout the pregnancy d) call the maternity unit and inform them that the client will be admitted in a pre-labor condition.

D

A client arrives at the hospital in labor. The health care provider states the client is 4 cm dilated and 60% effaced. The nurse explains the meaning to the client of this information? A: The opening of the cervix if 4cm wide and the cervical canal is 60% shorter than normal B: The cervix is 4cm short in dilation and 60% thinner than normal C: The walls of the cervix are 4 cm thick and 60% shorter than normal D: The cervix is 4 cm long and 60% wider than normal

A

A pregnant woman's last menstrual period began on April 8, 2005, and ended on April 13. Using Nägele's rule her estimated date of birth would be: A: January 15, 2006 B: January 20, 2006 C: July 1, 2006 D: November 5, 2005

A

A primigravida patient asks the nurse how much iron she needs during her pregnancy. The correct response from the nurse is A: 30 mg per day B: 1 gram per day C: 150 mg per day D: 18 mg per day

A

A second-day postpartum client with diabetes mellitus has scant lochia with a foul odor and a temperature of 101.6 degrees F. The physician suspects infection and writes orders to treat the client. Which of the following orders written by the physician would the nurse complete first? A. Obtain culture and sensitivity of lochia and urine B. Administer Ceftriaxone (Rocephin) C. Check the client's temperature D. Increase the intake of oral fluids.

A

A woman's cousin gave birth to an infant with congenital heart abnormality. The woman ask the nurse when such abnormalities occur during development. Which response by the nurse is the most accurate? A) "They occur between the third and fifth week of development." B) "We don't really know when such defects occur." C) "It depends on what caused the defect" D) "They usually occur in the first 2 weeks of development"

A

Clients with gestational diabetes are usually managed by which of the following therapies? A: Diet B: NPH insulin (long-acting) C: Oral hypoglycemic drugs D: Oral hypoglycemic drugs and insulin

A

The nurse admits a patient to the postpartum unit two hours after a vaginal delivery. Three hours after admission the nurse ambulates the patient to the bathroom, and the patient states there is a sudden gush of bleeding from her vagina. The nurse understands that the increase in the amount of bleeding is due to which of the following? A: the lochia pooled in the patients vaginal when she was lying in bed B: The patient has a tear in her cervix that needs to be repaired C: the patients fundus can cause bleeding, but this patients increased lochia is due to pooling D: distended bladder causes fundus to rise about the umbilicus

A

The nurse instructs a client to the prenatal clinic about nutrition during pregnancy. The nurse determines teaching is successful if the client selects which foods from a menu? -Two eggs and 8oz milk -a 2oz steak and 10 oz of beer - lettuce and tomato salad and 12 oz of orange juice -One bag of potato chips and 16 oz of soda

A

hich statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn? A."Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period." B."Breastfeeding my baby immediately after drinking alcohol is safer than waiting for the alcohol to clear my breast milk." C."I can start smoking cigarettes while breastfeeding because it will not affect my breast milk." D."When I take a warm shower after I breastfeed, it relieves the pain from being engorged between breastfeedings.

A

A client comes to the prenatal clinic for the first visit. the nursing history reveals the clients last menstural period was five months ago, and the client is sure she is pregnant because she has been feeling the baby move. Which is the best response by the nurse? A: sincy you have felt fetal movement, I am sure that you are pregnant B: Lie down so that I can listen for fetal heart tones with the Doppler C: We'll collect a urine specimen for testing to confirm that you are pregnant D: Have you noticed feeling more fatigued lately?

B

A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instructions? a) "I will watch for the evidence of the passage of tissue." b) " I will maintain strict bedrest throughout the remainder of the pregnancy." c) "I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad." d) " I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of bleeding."

B

A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? A. Infection B. Hemorrhage C. Chronic hypertension D. Disseminated intravascular coagulation

B

A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5 year old child who was delivered at 38 weeks and tells the nurse that she does not have a history or any type of abortion or fetal demise. The nurse would document the GTPAL for this client as : a) G=3, T=2, P=0, A=0, L=1 b) G=2, T=1, P=0, A=0, L=1 c) G=1, T=1, P=1, A=0, L=1 d) G=2, T=0, P= 0, A=0, L=1

B

A nurse is evaluating the mother-infant bonding process during the postpartum period. An indication of a maladaptive interaction would be if the mother: A. Expressed discomfort with the role of motherhood B. Encouraged the nurse to feed the baby because she continues to be too tired C. Showed that she was willing to learn how to care for the umbilical cord D. Talked to the baby

B

A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In developing a plan of care, the nurse should give the highest priority to which finding? A.Cyanosis of the hands and feet B.Skin color that is slightly jaundiced C.Tiny white papules on the nose or chin D.Red patches on the cheeks and trunk

B

A patient comes to the clinic stating that she may be pregnant. The nurse knows that a pregnancy can be confirmed by A: An hCG blood test B: ultrasound fetal visulaization C: quickening D: a positive urine test

B

A postpartum client is diagnosed with cystitis .The nurse plans for which priority nursing intervention in the care of the client? A. Providing Sitz baths B. Encouraging fluid intake C. Placing ice on the perineum D. Monitoring hemoglobin and hematocrit levels.

B

A woman is in active labor. As labor progresses, she becomes irritable and complains of feeling increasingly uncomfortable. She is 8cm dilated. Which of these actions should the nurse take FIRST? A: contact the physician B: Coach the patient in proper breathing and relaxation techniques C: Administer an analgesic D: remove the fetal monitor to allow the client to move around

B

The nurse caring for a primigravida complaining of lightheadedness, fainting, cold clammy skin, and palpitations after lying supine. th eappropratie nursing intervention is A: ambulation B: left side lying position C: lie on her backside with head raised D: reassure the patient that this is a normal phenomenon during pregnancy

B

The nurse evaluates a newborn immediately after birth to have a heart rate of 90, blue hands and feet, no response to a catheter in the naris, weak respiratory effort, and no muscle tone. The nurse should document the APGAR as A: 2 B: 3 C: 5 D: 1

B

The nurse is caring for a woman in labor. The woman becomes irritable, restless, complains of nausea, and has heavier show. The membranes just ruptured spontaneously. The nurse understands that this indicates A: Impending uterine rupture B: she is the transition phase of labor C: the woman is experiencing an arrest of cervial dilation D: She is having a complication and the doctor should be notified

B

The nurse should place the highest priority on monitoring a woman after a C-section for which of the following A: infection and pain B: hemorrhage and shock C: hemorrhage and pain management D: dehydration and infection

B

A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in preterm labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her labor contractions. What are the primary side effects of terbutaline sulfate? A.Drowsiness and paroxysmal bradycardia B.Depressed reflexes and increased respirations C.Tachycardia and a feeling of nervousness D.A flushed warm feeling and dry mouth

C

A client arrives at a prenatal clinic for the first prenatal assessment. The client tells a nurse that the first day of her last menstrual period was September 19th, 2005. Using Nagele's rule, the nurse determines the estimated date of confinement as: July 26, 2006 June 12, 2007 June 26, 2006 July 12, 2007

C

A mother expresses fear about changing the infant's diaper after circumcision. What information should the nurse include in the teaching plan? A.Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. B.Wash off the yellow exudate on the glans once every day to prevent infection. C.Place petroleum ointment around the glans with each diaper change and cleansing. D.Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding occurs.

C

A nurse assigned to care for a postpartum client plans to promote parental-infant bonding by encouraging the parents to: A. Use a low-pitched voice to speak to the infant B. Allow the nursing staff to assume the infant care during hospitalization so they may rest C. Hold and cuddle the infant closely D. Allow the infant to sleep in the parental bed between the parents

C

A nurse is caring for a 3-day-old infant with hyperbilirubinemia who is receiving phototherapy. A nursing action that would put the patient at risk would be to A: allow the parent to hold the infant to promote bleeding B: keep the eyes and genitalia covered throughout C: Swaddle the infant to maintain body temp D: Feed the infant every 2 horus

C

A nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which of the following signs, if noted, would be an early sign of excessive blood loss? A. A temperature of 100.4 F B. A blood pressure change from 130/88 to 124/80mmHg C. An increase in the pulse rate from 88 to 102 D. An increase in the RR from 18 to 22 breaths/min

C

On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. A nurse instructs the client regarding measures to take for the treatment of the infection. Which of the following statements, if made by the client, would indicate a need for further instructions? A. "The prescribed medication must be taken until it is finished." B. "My fluid intake should be increased to at least 3000ml/day" C. "I need to urinate frequently throughout the day." D. "Foods and fluids that will increase urine alkalinity should be consumed"

D

The nurse cares for the client in labor. which method does the nurse use to measure the frequency of the uterine contractions A: times the contractions from the end of one contraction to the end of the next contraction. B times the contractions from the beginning of one contraction to the end of the same contraction. C: times the contractions from the peak of one contraction to the beginning of the next contraction. D: times the contractions from the beginning of one contraction to the beginning of the next contraction.

D

The nurse instucts the women how to prevent conception using the basal body temperature method. The nurse explains that during ovulation, the womans basal body temperature will change in which direction? A: lowers significantly B: rises signficantly C: is unchanged D: rises slightly

D

A nursing instructor asks a nursing student who is preparing to assist with the assessment of a pregnant client to describe the process of quickening. Which of the following statements if made by the student indicates an understanding of this term? "It is the irregular, painless contractions that occur throughout pregnancy." "It is the soft blowing sound that can be heard when the uterus is auscultated." "It is the fetal movement that is felt by the mother." "It is the thinning of the lower uterine segment."

c