Hesi V1
After instructing a multigravida client diagnosed with mild preeclampsia how to keep a record of fetal movement patterns at home, the nurse determines that the teaching has been effective when the client says that she will count the number of times the baby moves during which of the following times spans?
1-hour period each day
A client has just had a cesarean section for a prolapsed cord. In reviewing the client's history, which of the following factors places a client at risk for cord prolapse?
2 station, low birth weight infant, rupture of membranes, breech presentation
The nurse is receiving shift report on four clients on an antenatal unit. The four clients are: (1) a 35-week-gestation mother with severe pre-eclampsia started on a maintenance dose of magnesium sulfate 1 hour ago; (2) a 30-week-gestation patient with preterm labor on oral nifedipine and having no contractions in 6 hours (3) a hyperemesis client with emesis four times in the past 12 hours; and (4) a 33-week-gestation client with placenta previa who began to feel pelvic pressure during change of shift report. In what order should the nurse see these clients?
3, 1, 4, 2
The nurse is planning care for a group of pregnant clients. Which of the following clients should be referred to a health care provider immediately?
A woman at 32 weeks' gestation and is preeclamptic with +3 proteinuria
A primiparous client is on a regular diet 24 hours postpartum. She is from Guatemala and speaks only Spanish. The client's mother asks the nurse if she can bring her daughter some "special foods from home." The nurse responds based on the understanding about which of the following?
the mother can bring the daughter any foods that she desires
Which of the following best identifies the reason for assessing a neonate weight 1,500 g at 32 weeks' gestation for retinopathy of prematurity (ROP)?
the neonate is at risk because of multiple factors
The primary health care provider prescribes an amnioinfusion for a primigravid client at term who is diagnosed with oligohydramnios. Which of the following should the nurse include in the client's teaching plan about the purpose of this procedure?
to decrease the frequency and severity of variable decelerations
After instructing a mother about normal reflexes of term neonates, the nurse determines that the mother understands the instruction when she describes the tonic neck reflex as occurring when the neonate does which of the following?
turns head to the left, extends left extremities, and flexes right extremities
A primiparous client with a neonate who is 36 hours old asks the nurse, "Why does my baby spit up a small amount of formula after feeding?" The nurse explains that the regurgitation is thought to result from which of the following?
An immature cardiac sphincter
A multigravid client in active labor has been diagnosed with class II heart disease and has had a prosthetic valve replacement. When developing the plan of care for this client, the nurse should anticipate that the primary health care provider most likely prescribe which of the following medications?
Antibiotics
A client at 28 weeks' gestation presents to the emergency department with a "splitting headache." What actions are indicated by the nurse at this time?
Assess the client the vision changes or epigastric pain, Obtain a nonstress test, Assess the client's reflexes and presence of clonus
The nurse and a nursing assistant are caring for clients in a birthing center. Which of the following tasks should the nurse delegate to the nursing assistant?
Assisting an active labor client with breathing and relaxation; Ambulating a post cesarean client to the bathroom
After a vaginal birth, a preterm neonate is to receive oxygen via mask. While administering the oxygen, the nurse would place the neonate in which of the following positions?
Back, with the neck slightly extended
A neonate has a large amount of secretions. After vigorously suctioning the neonate, the nurse should assess for what possible result?
Bradycardia
When reviewing the prenatal history for a newly born neonate, the nurse notes that the mother has neurofibromatosis. The nurse should further assess the neonate for:
Cafe au lait spots
The nurse is working with four clients on the obstetrical unit. Which client will be the highest priority for a cesarean section?
Client at 38 weeks' gestation with active herpes lesions
For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which of the following assessment findings would alert the nurse to suspect hypermagnesemia?
Decreased deep tendon reflexes
The nurse is caring for several mother-baby couplets. In planning the care for each of the couplets, which mother would the nurse expect to have the most severe afterbirth pains?
G3, P3 client who is breast-feeding her infant
After a dilatation and curettage (D&C) to evacuate a molar pregnancy, assessing the client for signs and symptoms of which of the following would be most important?
Hemorrhage
The primary health care provider determines that outlet forceps are needed to assist in the birth of a primigracid client in active labor with a large-for-gestational-size fetus. The nurse reinforces the primary health care provider's explanation for using forceps based on the understanding about which of the following concerning the location of the fetal skull?
It is visible at the perineal floor
Which of the following subjects should the nurse include when teaching the mother of a neonate diagnosed with retinopathy of prematurity (ROP) about possible treatment for complications?
Laser Therapy
A 30-year-old multigravida client has missed three periods and now visits the prenatal clinic because she assumes she is pregnant. She is experiencing enlargement of her abdomen, a positive pregnancy test, and changes in the pigmentation on her face and abdomen. These assessment findings reflect this woman is experiencing a cluster of which signs of pregnancy?
Probable
Assessment of a term neonate at 2 hours after birth reveals a heart rate of less than 100 bpm, periods of apnea approximately 25 to 30 seconds in length, and mild cyanosis around the mouth. The nurse notifies the primary health care provider based on the interpretation that these findings may lead to which condition?
Respiratory Arrest
A multigravid client in labor at 38 weeks' gestation has been diagnosed with Rh sensitization and probable fetal hydrops and anemia. When the nurse observes the fetal heart rate pattern on the monitor, which of the following patterns is most likely?
Sinusoidal pattern
Which of the following observation is expected when the nurse is assessing the gestational age of a neonate born at term?
Sole creases covering the entire food
Two hours ago, a neonate at 38 weeks' gestation and weighing 3,175 g (7 lb) was born to a primiparous client who tested positive for beta-hemolytic Streptococcus. Which of the following would alert the nurse to notify the primary health care provider?
Temperature instability
After instructing a primigravid client about the functions of the placenta, the nurse determines that the client needs additional teaching when she says that which of the following hormones is produced by the placenta?
Testosterone
A client at 33 weeks' gestation is admitted in preterm labor. She is given betamethasone 12 mg IM every 23 hours x 2. What is the expected outcome of this drug therapy?
The neonate will be born with mature lungs
Which of the following client statements indicates effective teaching about burping a breast-fed neonate?
When i switch to the other breast, i'll burp the baby
As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. which of the following should the nurse do first?
call for immediate assistance
A 20-year-old nulligravid client expresses a desire to learn more about the symptothermal method of family planning. which of the following would the nurse include in the teaching plan?
cervical mucus is carefully monitored for changes
During a visit to the prenatal clinic, a pregnant client at 32 weeks' gestation has heartburn. The client needs further instruction when she says she must do what?
consume liquids only between meals
Following a positive pregnancy test, a client begins discussing the changes that will occur in the next several months with the nurse. The nurse should include which of the following information about changes the client can anticipate in the first trimester?
experiencing ambivalence about pregnancy
A multigracid client is admitted to the labor area from the emergency room. At the time of admission, the fetal head is crowning, and the client yells, "The baby's coming!" To help the client remain calm and cooperative during the imminent birth, which of the following responses by the nurse is most appropriate?
i'll explain what's happening to guide you as we go along
When preparing a 20-year-old client who reports missing one menstrual period and suspects that she is pregnant for a radioimmunoassay pregnancy test, the nurse should tell the client which of the following about this test?
it has a high degree of accuracy within 1 week after ovulation
Soon after admission of a primigravid client at 38 weeks' gestation severe preeclampsia, the primary health care provider prescribes a continuous intravenous infusion of 5% dextrose in Ringer's solution and 4 g of magnesium sulfate. While the medication is being administered, which of the following assessment findings should the nurse report immediately?
respiratory rate of 12 breaths/min
While performing a physical assessment on a term neonate shortly after birth, which of the following would cause the nurse to notify the primary health care provider?
single crease on each of the palms
After the birth of a neonate, a quick assessment is completed. The neonates is found to be apneic. After quickly dying and positioning the neonate, what should the nurse do next?
start postive pressure ventilation
which of the following instructions about activities during menstruations would the nurse include when counseling an adolescent who has just begun to menstrual?
take a mild analgesic if needed for menstrual pain
The nurse is explaining the medication options available for pain relief during labor. The nurse realizes the client needs further teaching when the client states which of the following?
"I can have epidural as soon as I start contracting"
After the nurse counsels a primiparous client who is breast-feeding her neonate about diet and nutritional needs during the lactation period, which of the following client statements indicates a need for additional teaching?
"I should drink at least five glasses of fluid daily"
A primigravid client at 38 weeks' gestation diagnosed with mild preeclampsia calls the clinic nurse to say she has a continuous headache for the past 2 days accompanied by nausea. The client does not want to take aspirin. The nurse should tell the client:
"I think the doctor should see you today. Can you come to the clinic this morning?"
After conducting a class for female adolescents about human reproduction, which of the following statements indicates that the school nurse's teaching has been effective?
"Under ideal conditions, sperm can reach the ovum in 15 to 30 minutes, resulting in pregnancy."
A 20-year-old primigravid client tells the nurse that her mother had a friend who died from hemorrhage about 10 years ago during a vaginal birth. Which of the following responses would be most helpful?
"What is it that concerns you about pregnancy, labor, and childbirth?
A 29-year-old multigravida at 37 weeks' gestation is being treated for severe preeclampsia and has magnesium sulfate infusing at 3 g/h. to maintain safety for this client, the priority intervention is to:
assess reflexes, clonus, visual disturbances, and headache
During a home visit, a breast-feeding client asks the nurse what contraception method she and her husband should use until she has her 6-weeks postpartal examination. Which of the following would be most appropriate for the nurse to suggest?
condom with spermicide
the nurse is teaching a new prenatal client about her iron deficiency anemia during pregnancy. Which statement indicates that the client needs further instruction about her anemia?
i may have anemia because my family is of asian descent
A 1-day-old breast-fed infant has a bilirubin level that is at an intermediate risk for jaundice. Which statement by the infant's mother indicates an understanding of the teaching regarding jaundice?
i should breast-feed my baby as often as possible
A primigravid client at 16 weeks' gestation has had an amniocentesis and has received teaching concerning signs and symptoms to report. which statement indicates that the client needs further teaching?
if my baby does not move, i need to call my health care provider
The nurse is instructing a preeclamptic client about monitoring the movements of her fetus to determine fetal well-being. Which statement by the client indicates that she needs further instruction about when to call the health care provider concerning fetal movement?
if the fetus moves more often than 3 times an hour
A multigravida client will be using medroxyprogesterone acetate (Depo-Provera) as a family planning method. After the nurse instructs the client about this method, which of the following client statements indicates effective teaching.
one possible adverse effect is absence of a menstrual period
Which of the following would be important to include in the teaching plan for the client who wants more information on ovulation and fertility management?
ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle
When instructing a client about the proper use of condoms for pregnancy preventions, which of the following instructions would be included to ensure maximum effectiveness?
place the condom over the erect penis before coitus
The nurse is caring for a multigracid client who speaks only a foreign language. As the nurse enters the client's room, the nurse observes the client squatting on the bed and the fetal head crowning. After calling for assistance and helping the client lie down, which of the following actions should the nurse do next?
provide gentle support to the fetal head
Following an epidural and placement of internal monitors, a client's labor is augmented. Contractions are lasting greater than 90 seconds and occurring ever 1 1/2 minutes. The uterine resting tone is greater than 20 mm mercury with an abnormal fetal heart rate and pattern. Which of the following actions should the nurse take first?
turn off the oxytocin infusion
After instructing a 40-year-old woman about osteoporosis after menopause, the nurse determines that the client needs further instruction when the client states which of the following?
women of African descent are at the greatest risk for osteoporosis
A couple is inquiring about vasectomy as a permanent method of contraception. Which teaching statement would the nurse include in the teaching plan?
"Another method of contraception is needed until the sperm count is 0"
A postpartum primiparous client is having difficult breast-feeding her infant. The infant latches on the breast, but the mother's nipples are extremely sore during and after each feeding. The client needs further instruction about breast-feeding when she states:
"As long as some of my nipple is in the baby's mouth, the baby will receive enough milk"
A diabetic postpartum client plans to breast-feed. The nurse determines that the client's understanding of breast-feeding instructions is sufficient when she states:
"Breast-feeding will assist in lowering maternal blood glucose"
a client has obtained Plan B (levonorgestrel 0.75 mg, 2 tablets) as emergency contraception. after unprotected intercourse, the client calls the clinic to ask about taking the contraceptives. The nurse realizes the client needs further explanation when she makes which of following response?
"I can wait 3 to 4 days after intercourse to start taking these to prevent pregnancy,"
A nurse is discussing discharge instructions with a client. Which of the following statements indicate that the client understands the resources and information available if needed after discharge?
"I have the hospital phone number if I have an question"; "If I have any breathing problems, chest pain, or pounding fast heart rate, I will seek medical assistance"; "I know if i get fever or chills or change in lochia to call the physician"; "I will continue my prenatal vitamins until my postpartum checkup or longer"
A client in sickle cell crisis has been hospitalized during her pregnancy. After giving discharge instructions, the nurse determines the client needs further teaching when she makes which statement?
"I have this disease because I don't eat enough food with iron"
After being examined and fitted for a diaphragm, a 24-year-old client receives instructions about its use. Which of the following client statements indicates a need for further teaching?
"If I gain or lose 20 lb (9.1 kg), I can still use the same diaphragm"
After the nurse instructs a 20-year-old nulligravid client on how to perform a breast self-examination, which of the following client statements indicates that the teaching has been successful?
"If there is discharge from my nipples, I should call my health care provider"
Metabolic screening of an infant revealed a high phenylketonuria (PKU) level. Which of the following statements by the infant's mother indicates understanding of the disease and its management?
"My baby can't have milk-based formula"; "We have to follow a strict phenylalanine diet"; "A dietitian can help me plan a diet that keeps a safe phenylalanine level but lets my baby grow"
A 39-year-old multigravida client asks the nurse for information about female sterilization with a tubal ligation. Which of the following client statements indicates effective teaching?
"My fallopian tubes will be tied off through a small abdominal incision"
The nurse is reviewing discharge instructions with a postpartum breast-feeding client who is going home. She has chosen medroxyprogesterone (Depo-Provera) as birth control. Which statement by the client identifies that she needs further instruction concerning birth control?
"You will give me my first Depo-Provera shot before I leave today"
The nurse assesses a woman at 24 weeks' gestation and is unable to find the fetal heart beat. The fetal heart beat was heard at the client's last visit 4 weeks ago. According to priority, the nurse should do the following tasks in which order?
*Ask the client if the baby is or has been moving; *Obtain different equipment and recheck; *Explain that the fetal heart beat could not be found at this time; *Call the health care provider
As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. The nurse should do which in order of priority from first to last?
*Call for immediate assistance; *Assess for ruptured membranes; *Turn the client to her side; *Maintain airway
A client with pregnancy induced hypertension is to receive magnesium sulfate to run at 3 g/h with normal saline to maintain the total IV rate at 125 mL/h. The nurse giving end of shift report stated that the client's blood pressures have been elevated during the night. The oncoming nurse checked the client and found magnesium sulfate running at 2 g/h. Identify the nursing actions to be taken from first to last.
*Correct the IV rates; *Assess the client's current status; *Notify the primary health care provider of the incident; *Initiate an incident report
The nurse is discussing kangaroo care with the parents of a premature neonate. The nurse should tell the parents that the advantages of kangaroo care include which of the following?
*Enhanced bonding; *Improved physiologic stability; *Decreased length of stay in the neonatal intensive care unit; *Improved breast-feeding
The nurse notices that a client who has just given birth is short of breath, ashen in color, and begins to cough. She becomes limp on the birthing table. At last assessment 1/2 hour ago, her temperature was 98 (36.7), pulse 78, respirations 16. Determine the nursing actions in the order the should occur.
*Establish unresponsiveness, *Ask staff to activate emergency response system *Begin compression *Open airway using head tilt-chin lift *Give breaths
A primiparous client at 10 weeks' gestation questions the nurse about the need for an ultrasound. She states 'I don't have health insurance and I can't afford it. I feel fine, so why should I have the test?" The nurse should incorporate which statements as the underlying reason for performing the ultrasound now?
*We must view the gross anatomy of the fetus; *We need to determine gestational age.
After suction and evacuation of a complete hydatidiform mole, the 28-year-old multigravid client asks the nurse when she can become pregnant again. The nurse would advise the client not to become pregnant again for at least which of the following time spans?
12 months
A new mother asks, "When will the soft spot near the front of my baby's head close? The nurse should tell the mother the soft spot will close in about:
12 to 18 months
A 6-lb, 8-oz (2,948 g) neonate was born vaginally at 38 weeks' gestation. At 5 minutes of life, the neonate has the following signs: heart rate 110, intermittent grunting with respiratory rate of 70, flaccid tone, no response to stimulus, and overall pale white in color. The apgar score is:
4
A primigravid client with severe preeclampsia exhibits hyperactive, very brisk patellar reflexes with two beats of ankle clonus present. The nurse documents the patellar reflexes as which of the following?
4+
A laboring client with preeclampsia is prescribed magnesium sulfate 2 g/h IV piggyback. The pharmacy sends the IV to the unit labeled magnesium sulfate 20 g/500 mL normal saline. To deliver the correct dose, the nurse should set the pump to deliver how many milliliters per hour?
50 mL
A primiparous client who is bottle-feeding her neonate ask, "When should I start giving the baby solid foods?" The nurse instructs the client to introduce solid foods no sooner than at which age?
6 months
When teaching a primiparous client about the growth and development of the neonate, which of the following should the nurse include as the usual age at which most babies are able to drink from a cup independently?
8 to 10 months
Several pregnant clients are waiting to be seen in the triage area of the obstetrical unit. Which client should the nurse see first?
A client at 32 weeks' gestation who has preeclampsia and +3 proteinuria who is returning for evaluation of epigastric pain
The nurse is admitting a primigracid client at 37 weeks' gestation who has been diagnosed with preeclampsia to the labor and birth area. Which of the following client care rooms is most appropriate for this client?
A darkened private room as close to the nurses' station as possible
At 24 hours of age, assessment of the neonate reveals the following: eyes closed, skin pink, no sign of eye movements, heart rate of 120 bpm, and respiratory rate of 35 breaths/min. The nurse interprets these findings as indicating that this neonate is most likely experiencing which of the following?
A state of deep sleep
While caring for a neonate born at 32 weeks' gestation, the nurse assesses the neonate daily for symptoms of necrotizing enterocolitis (NEC). Which of the following would alert the nurse to notify the neonatologist?
Abdominal distention
Which of the following would the nurse identify as the priority to achieve when developing the plan of care for a primigravid client at 38 week's gestation who is hospitalized with severe preeclampsia and receiving intravenous magnesium sulfate?
Absence of any seizure activity during the first 48 hours
The primary health care provider determines that the fetus of a multiparous client in active labor is in distress, necessitating a cesarean birth with general anesthesia. Before the cesarean birth, the anesthesiologist prescribes cimetidine (Tagament) 300 mg PO. After administering the drug, the nurse should assess the client for reduction in which of the following?
Acid level of the stomach contents
At 32 weeks' gestation, a 15-year-old primigravid client who is 5 feet, 2 inches (151.7 cm) has gained a total of 20 lb (9.1kg), with a 1-lb (0.45-K) gain in the last 2 weeks. Urinalysis reveals negative glucose and a trace of protein. The nurse should advise the client that which of the following factors increases her risk for preeclampsia?
Adolescent age group
Shortly after birth, the nurse measures the circumference of a term neonate's head and chest. When the two measurements are compared, which of the following would the nurse expect to find about the head circumference?
Approximately 2 cm larger than the chest
A 19-year-old nulligravid client visiting the clinic for a routine examination asks the nurse about cervical mucus changes that occur during the menstrual cycle. Which of the following statements would the nurse expect to include in the client's teaching plan?
As ovulation approaches, cervical mucus is abundant and clear
When preparing for discharge a 15-year-old primipara who is bottle-feeding her neonate, the nurse instructs the client not to "prop" the bottle while feeding the neonate because this can lead to which of the following?
Aspiration of the formula
A primigravid client at 39 weeks' gestation is admitted to the hospital for induction of labor. The primary health care provider has prescribed prostaglandin E2 gel (Dinoprostone) for the client. Before administering prostaglandin E2 gel to the client, which of the following should the nurse do first?
Assess the frequency of uterine contractions
A 24-year-old woman is being assessed for a malformation of the uterus. The figure below indicates which of the following uterine malformations?
Bicornuate Uterus
A client is admitted with a suspected abruptio placentae. The nurse should assess the client for which of the following signs and symptoms?
Bleeding that is concealed or apparent; Abdominal rigidity; Painful abdomen
A 17-year-old client at 33 weeks' gestation diagnosed with mild preeclampsia is treated as an outpatient. The nurse instructs the client to contact the health care provider immediately if she experiences which of the following?
Blurred Vision
After explaining to a primiparous client about the causes of her neonate's cranial molding, which of the following statements by the mother indicates the need for further instruction?
Brain damage may occur if the molding doesn't resolve quickly
An antenatal G2, T1, P0, Ab0, L1 client is discussing her postpartum plans for birth control with her health care provider. In analyzing the available choices, which of the following factors has the greatest impact on her birth control options?
Breast- or Bottle-feeding plan
While assisting a primiparous client with her first breast-feeding session, which of the following actions should the nurse instruct the mother to do to stimulate the neonate to open the mouth and grasp the nipple?
Brush the neonate's lips lightly with the nipple
Which of the following would the nurse most expect to assess in a neonate born at 28 weeks' gestation who is diagnosed with intraventricular hemorrhage (IVH)?
Bulging fontanels
The primary health care provider prescribes intravenous magnesium sulfate for a primigravid client at 38 weeks' gestation diagnosed with severe preeclampsia. Which of the following medications should the nurse have readily available at the client's bedside?
Calcium gluconate
A client has experienced a postpartum hemorrhage. The primary health care provider verbally ordered carboprost tromethamine (Hemabate) 0.25 mg IM stat at the time of the hemorrhage and this was given by the nurse. The primary health care provider put a prescription into the electronic medical record for 0.25 mg carboprost tromethamine IV stat. When seeing the prescription, how should the nurse administering the carbboprost tromethamine respond?
Call the primary health care provider, discuss the prescription, and request revision if heard correctly
After vaginal birth of a term neonate, the nurse observes that the neonate has one artery and one vein in the umbilical cord. The nurse notifies the primary health care provider based on the analysis that his may be indicative of which anomalies?
Cardiovascular anomalies
When developing a teaching plan for an 18-year-old client who asks about treatments for sexually transmitted disease, the nurse should explain that:
Ceftriaxone sodium (Rocephin) may be used to treat Neisseria gonorrhoeae
When preparing a multigravid client who has undergone evacuation of a hydatidiform mole for discharge, the nurse explains the need for follow-up care. The nurse determines that the client understands the instruction when she says that she is at risk for developing which of the following?
Choriocarcinoma
A client is admitted at 30 weeks' gestation with contractions every 3 minutes. Her cervix is 1 to 2 cm dilated and 75% effaced. Following a 4-g bolus dose, IV magnesium sulfate is infusing at 2 g/h. How will the nurse know the medication is having the intended effect?
Contractions will decrease in frequency, intensity, and duration
Three days after admission of a neonate born at 30 weeks' gestation, the neonatologist plans to assess the neonate for interventricular hemorrhage (IVH). The nurse should plan to assist the neonatologist by preparing the neonate for which of the following?
Cranial Ultrasonography
A couple visiting the infertility clinic for the first time states that they have been trying to conceive for the past 2 years without success. After a history and physical examination of both partners, the nurse determines that an appropriate outcome for the couple would be to accomplish which of the following by the end of this visit?
Describe each of the potential causes and possible treatment modalities
Which of the following would the nurse include in the teaching plan for a 32-year-old female client requesting information about using a diaphragm for family planning?
Diaphragms should not be used if the client develops acute cervicitis
A full-term client is admitted for induction of labor. When admitted, her cervix is 25/0. The initial goal is cervical ripening prior to labor induction. Which drug will prepare her cervix for induction?
Dinoprostone
A client is induced with oxytocin. The fetal heart rate is showing accelerations lasting 15 seconds and exceeding the baseline with fetal movement. What action associated with this finding should the nurse take?
Document fetal well-being
Twelve hours after a vaginal birth with epidural anesthesia, the nurse palpates the fundus of a primiparous client and finds it to be firm, above the umbilicus, and deviated to the right. Which of the following would the nurse do next?
Encourage the client to ambulate to the bathroom and void
The nurse in the labor and birth area receives a telephone call from the emergency room announcing that a multigravid client in active labor is being transferred to the labor area. The client has had no prenatal care. When the client arrives by stretcher, she says, "I think the baby's coming... Help!" The fetal skull is crowning. The nurse should obtain which of the following information first?
Estimated date of birth
While performing a complete assessment of a term neonate, which of the following findings would alert the nurse to notify the primary health care provider?
Expiratory grunt
During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client that before nursing her baby, the client should do which of the following?
Express a small amount of breast milk
A breast-feeding primiparous client asks the nurse how breast milk differs from cow's milk. The nurse responds by saying that breast milk is higher in which of the following?
Fat
Using Nagele's rule for a client whose last normal menstrual period began on May 10, the nurse determines that the client's estimated date of childbirth would be which of the following?
February 17
The nurse is assessing a client at her postpartum check 6 weeks after a vaginal birth. The mother is bottle-feeding her baby. Which client finding indicates a problem at this time?
Firm fundus at the symphysis
A 24-year-old primipara who has given birth to a healthy neonate plans to bottle-feed her neonate. What information regarding normal weight gain should the nurse include in the teaching plan?
Gaining 30 g/day is a normal weight gain pattern
A multigravid client in active labor at term is diagnosed with polyhydramnios. The primary health care provider has instructed the client about possible neonatal complications related to the polyhydramnios. The nurse determines that the client has understood the instructions when the client states that polyhydramnios is associated with which of the following in the fetus or neonate?
Gastrointestinal disorders
A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks' gestation is placed in an oxygenated isolette. The neonates' mother tells the nurse that she was planning to breast-feed the neonate. Which of the following instructions about breast-feeding would be most appropriate?
Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing
Which of the following should the nurse include in the teaching plan for a primiparous client who asks about weaning her neonate?
Gradually eliminate one feeding at a time
An antenatal primigravid client has just been informed that she is carrying twins. The plan of care includes educating the client concerning factors that put her at risk for problems during the pregnancy. The nurse realizes the client needs further instruction when she indicates carrying twins puts her at risk for which of the following?
Group B Streptococcus
A 24-hour-old, full-term neonate is showing signs of possible sepsis. The nurse is assisting the primary health care provider with a lumbar puncture on this neonate. What should the nurse do to assist in this procedure?
Hold the neonate steady in the correct position; Ensure a patent airway; Maintain a sterile field
A new father indicates he feels left out of the new family relationship since he is not able to bond the same way as the breast-feeding mother. What is the most appropriate response by the nurse?
Holding, talking to, and playing with the infant will facilitate bonding between baby and Dad
After instructing female client about the radioimmunoassay pregnancy test, the nurse determines that the client understands the instructions when the client states that which of the following hormones is evaluated by this test?
Human chorionic gonadotropin (hCG)
A preterm neonate who has been stabilized is placed in a radiant warmer and is receiving oxygen via an oxygen hood. While administering oxygen in this manner, the nurse should do which of the following?
Humidify the air being delivered
After instructing a primigravid client at 38 weeks' gestation about how preeclampsia can affect the client and the growing fetus, the nurse realizes that the client needs additional instruction when she says that preeclampsia can lead to which of the following?
Hydrocephalic infant
Before advising a 24-year-old client desiring oral contraceptives for family planning, the nurse would assess the client for signs and symptoms of which of the following?
Hypertension
The nurse is caring for a primiparous client and her neonate immediately after birth. The neonate was born at 41 weeks' gestation and weighs 4,082 g (9lb). Assessing for signs and symptoms of which of the following conditions should be a priority in this neonate?
Hypoglycemia
Which of the following would alert the nurse to suspect that a neonate born at 34 weeks' gestation who is currently in an isoletter with humidified oxygen and receiving intravenous fluids has developed overhydration?
Hypoproteinemia
While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The primary health care provider is notified because the nurse suspects which of the following?
Hypospadias
After the nurse teaches a primiparous client planning to return to work in 6 weeks about storing breast milk, which of the following client statements indicates the need for further teaching?
I can safely store the milk for 3 days in the refrigerator
A client gave birth 2 days ago and has been given instructions on breast care for bottle-feeding mothers. Which of the following statements indicates that the nurse should reinforce the instructions to the client?
I will use a breast pump to remove any milk that may appear
After instructing a primiparous client who is bottle-feeding about burping, which of the following client statements indicates that the client needs further teaching?
I'll burp him after 15 minutes of feeding him formula
A client is scheduled to have in vitro fertilization (IVF) as an infertility treatment. Which of the following client statements about IVF indicates that the client understands this procedure?
IVF involves bypassing the blocked or absent fallopian tubes
A full-term neonate is admitted to the noraml newborn nursery. The nurse notes a Moro reflex. What should the nurse do next?
Identify this reflex as a normal finding
An antenatal client receives education concerning medications that are safe to use during pregnancy. The nurse evaluates the client's understanding of the instructions and determines that she needs further information when she states which of the following?
If i need to have a bowel movement, sennosides (Ex-Lax) are preferred
A breast-feeding primiparous client with a midline episiotomy is prescribed ibuprofen (Motrin) 200 mg orally. The nurse instructs the client to take the medication:
Immediately after a feeding
A preterm infant born 2 hours ago at 34 weeks' gestation is experiencing rapid respirations, grunting, no breath sounds on one side, and a shift in location of heart sounds. The nurse should prepare to assist with which of the following?
Insertion of a chest tube into the neonate
A 22-year-old client tells the nurse that she and her husband are trying to conceive a baby. When teaching the client about reducing the incidence of neural tube defects, the nurse would emphasize the need for increasing the intake of which of the following foods?
Leafy green vegetables; Strawberries; Beans; Sunflower seeds; Lentils
A multigravid client in active labor at 39 weeks' gestation has a history of smoking one to two packs of cigarettes daily. For which of the following should the nurse be alert when assessing the client's neonate?
Low birth weight
Which of the following actions should the nurse take when performing external chest compressions on a neonate born at 28 weeks' gestation?
Maintain a compression to ventilation ratio of 3:1
The nurse is asked to develop an in-service to explain documents guiding professional nursing practice on the obstetrical unit. One of the documents included is the Code of Ethics. The nurse correctly explains that the Code of Ethics asks nurses to demonstrate which of the following?
Maintain the integrity of practice and shape social policy; Develop, maintain, and improve health care environments; Be responsible and accountable for individual practice; Increase professional competence and personal growth
Which of the following forms the basis for the teaching plan about avoiding medication use unless prescribed for a primiparous client who is breast-feeding?
Medications may be excreted in breast milk to the nursing neonate
The nurse is caring for a primipara who gave birth yesterday and has chosen to breast-feed her neonate. Which assessment finding is considered unusual for the client at this point postpartum?
Milk Production
A multigravid client is receiving oxytocin augmentation. When the client's cervix is dilated to 6 cm, her membranes rupture spontaneously with meconium-stained amniotic fluid. Which of the following actions should the nurse do first?
Monitor the fetal heart rate continuously
Which of the following statements by the mother of a neonate diagnosed with bronchopulmonary dysplasia (BPD) indicates effective teaching?
My baby may require long-term respiratory support
A multigravid client at 39 weeks' gestation diagnosed with insulin-dependent diabetes is admitted for induction of labor with oxytocin. Which of the following should the nurse include in the teaching plan as a possible disadvantage of this procedure?
Neonatal Jaundice
A viable male neonate born to a 28-year-old multiparous client by cesarean section because of placenta previa is diagnosed with respiratory distress syndrome (RDS). Which of the following would the nurse explain as the factor placing the neonate at the greatest risk for this syndrome?
Neonate born preterm
A primiparous client expresses concern, asking the nurse why her neonate's eyes are crossed. Which of the following would the nurse include when teaching the mother about neonatal strabismus?
Neonates commonly lack eye muscle coordination
Assessment of a 2-day-old neonate born at 34 weeks' gestation reveals absent apical pulse left the midclavicular line, cyanosis, grunting, and diminished breath sounds. The priority intervention is to:
Obtain a prescription for a stat chest x-ray
A primiparous client, 48 hours after a vaginal births, is to be discharged with a prescription for vitamins with iron because she is anemic. To maximize absorption of the iron, the nurse instructs the client to take the medication with which of the following?
Orange juice
The nurse is assessing the perineal changes of a multigravid client in the second stage of labor. The illustration below represents which of the following perineal changes?
Oval opening
After instructing a 20-year-old nulligravid client about adverse effects of oral contraceptives, the nurse determines that further instruction is needed when the client states which of the following as an adverse effect?
Ovarian Cancer
While the nurse is caring for a neonate at 32 weeks' gestation in an isolette with continuous oxygen administration, the neonate's mother asks why the neonates' oxygen is humidified. The nurse should tell the mother:
Oxygen is drying to the mucous membranes unless it is humidified
During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she is aware of a "let-down sensation" in her breasts and asks what causes it. The nurse explains that the let-down sensation is stimulated by which of the following?
Oxytocin
A full-term client is admitted for an induction of labor. The health care provider has assigned a Bishop score of 10. Which drug would the nurse anticipate administering to this client?
Oxytocin 30 units in 500 mL D5W
When preparing the room for admission of a multigravida client at 36 weeks' gestation diagnosed with severe preeclampsia, which of the following should the nurse obtain?
Padding for the side rails
A multiparous client gives birth to dizygotic twins at 37 weeks' gestation. The twin neonates require additional hospitalization after the client is discharged. In planning the family's care, an appropriate goal for the nurse to formulate is that, while the twins are hospitalized, the parents will do which of the following?
Participate in care of the twins as much as possible
A primiparous client who is beginning to breast-feed her neonate asks the nurse, "Is it important for my baby to get colostrum?" When instructing the client, the nurse would explain that colostrum provides the neonate with:
Passive immunity from maternal antibodies
A nurse and an LPN are working in the labor and birth unit. Of the following assessments and interventions that must be done immediately, which should the nurse assign to the LPN?
Perform a straight catheterization for protein analysis
The nurse is caring for a full-term primiparous client who is in the transition stage of labor. The client is writhing in pain and asking "help me, help!" The epidural redose was 3/4 hour ago, and she was catheterized just prior to the epidural redose. Her last vaginal exam 1 hour ago showed that she was 8 cm dilated, +1 station, and in what appeared to be a comfortable position. What does the nurse anticipate as the highest priority intervention in caring for this client?
Perform a vaginal exam to determine if the client is fully dilated
A primigravida is experiencing a prolonged second stage of labor with a fetus suspected of weighing over 4 kg. Which of the following interventions is most important?
Performing the McRoberts maneuver
The triage nurse is giving a telephone report to the receiving nurse in the labor and birth unit. The client is a G4 P3 who is 8 cm dilated and is being transferred to the labor and birth unit. How should the labor and birth nurse manage the next ten minutes with the client?
Place client on the fetal and contraction monitor; Call other staff to set up the birthing table; Assess comfort needs of client; Determine support systems for client
A laboring client at -2 station has a spontaneous rupture of the membranes and a cord immediately protrudes from the vagina. The nurse should first:
Place gentle pressure upward on the fetal head
The nurse is to assess a newborn for incurving of the trunk. Which illustration indicates the position in which the nurse should place the newborn
Places the infant horizontally and in a prone position with one hand
A 25-year-old primiparous client who gave birth 2 hours ago has decided to breast-feed her neonate. Which of the following instructions should the nurse address as the highest priority in the teaching plan about preventing nipple soreness?
Placing as much of the areola as possible into the baby's mouth
During a home visit to a breast-feeding primiparous client at 1 week postpartum, the client tells the nurse that her nipples have become sore and cracked from the feedings. Which of the following should the nurse instruct the client to do?
Position the baby with the entire areola in the baby's mouth
A client at 4 weeks postpartum tells the nurse the that she can't cope any longer and is overwhelmed by her newborn. The baby has old formula on her clothes and under her neck. The mother does not remember when she last bathed the baby and states she dose not want to care for the infant. The nurse should encourage the client and her husband to call their health care provider because the mother should be evaluated further for:
Postpartum depression
A multigravid client is in active labor with twins at 38 weeks' gestation. The nurse should monitor the client closely for symptoms of which of the following?
Preeclampsia
As a nurse begins her shift on the obstetrical unit, there are several new admissions. The client with which of the following conditions would be a candidate for induction?
Preeclampsia
A 32-year-old multigravida returns to the clinic for a routine prenatal visit at 36 weeks' gestation. The assessments during this visit include: blood pressure 140/90 mm Hg; pulse 80 beats/min; respiratory rate 16 breaths/min. What further information should the nurse obtain to determine if this client is becoming preeclamptic?
Proteinuria
An infant born premature at 34 weeks is receiving gavage feedings. The client holding her infant asks why the nurse places a pacifier in the infant's mouth during these feedings. The nurse replies that the pacifier helps in what ways?
Provides oral stimulation, Reminds the infant how to suck, Stimulates secretions that help gastric emptying
A breast-feeding client is seen at home by the visiting nurse 10 days after a vaginal birth. The client has a warm, red, painful breast; a temperature of 100F (37.7C); and flulike symptoms. What should the nurse do?
Refer the woman to her primary health care provider
When teaching a multigravida client diagnosed with mild preeclampsia about nutritional needs, which of the following types of diet should the nurse discuss?
Regular diet
The nurse is caring for a multiparous client after vaginal birth of a set of male twins 2 hours ago. The nurse should encourage the mother and husband to:
Relate to each twin individually to enhance the attachment process
After the nurse counsels a primiparous client who is breast-feeding her neonate about diet and nutritional needs during the lactation period, which of the following client statements indicates a need for additional teaching?
Release of oxytocin during the breast-feeding session
A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. To ensure cardiac emptying and adequate oxygenation during labor, the nurse plans to encourage the client to do which of the following?
Remain in a side-lying position with the head elevated
A nurse and a nursing assistant are caring for clients in a labor and birth unit. Which task should the registered nurse assign to the nursing assistant?
Remove a fetal monitor and assist a client to the bathroom
A nurse notices repetitive late decelerations on the fetal heart monitor. The best initial actions by the nurse include:
Reposition patient, apply oxygen, and increase IV fluids
A woman who is Rh-negative has given birth to an Rh-positive infant. The nurse explains to the client that she will receive Rho(D) Immune Globulin (RhoGAM). The nurse determines that the client understands the purpose of RhoGAM when she states:
RhoGAM will prevent antibody formation in my blood
A primigravid client at 41 weeks' gestation is admitted to the hospital's labor and birth unit in active labor. After 25 hours of labor with membranes ruptured for 24 hours, the client gives birth to a healthy neonate vaginally with a midline episiotomy. Which of the following problems should the nurse identify as the priority for the client?
Risk for infection
A woman who has given birth to a health neonate is being discharged. As part of discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the health care provider about:
Saturating a pad in an hour
A couple is visiting the clinic because they have been unable to conceive a baby after 3 years of frequent coitus. After discussing the various causes of male infertility, the nurse determines that the male partner needs further instruction when he states which of the following as a cause?
Seminal fluid with an alkaline pH
Which of the following instructions should the nurse include in the teaching plan for a 30-year-old multiparous client who will be using an intrauterine device (IUD) for family planning?
Severe cramping may occur when the IUD is inserted
The nurse prepares a client for lumbar epidural anesthesia. Before anesthesia administration, the nurse instructs the client to assume which of the following positions?
Side-Lying
A breast-feeding primiparous client who gave birth 8 hours ago asks the nurse, "How will I know that my baby is getting enough to eat?" Which of the following guidelines should the nurse include in the teaching plan as evidence of adequate intake?
Six to eight wet diapers by the fifth day
The triage nurse in the pediatrician's office returns a call to a mother who is breast-feeding her 4-day-old infant. The mother is concerned about the yellow seedy stool that has developed since discharge home. What is the best reply by the nurse?
Soft seedy unformed stools with each feeding are normal for this age infant and will continue through breast-feeding. The postpartal client who bottle-feeds
A primiparous client who will be bottle-feeding her neonate asks, "What is the best position for the baby after feeding?" Which of the following positions should the nurse recommend to aid digestion?
Supine position
Twenty-four hours after cesarean birth, a neonate at 30 weeks' gestation is diagnosed with respiratory distress syndrome (RDS). When explaining to the parents about the cause of this syndrome, the nurse should include a discussion about an alteration in the body's secretion of which of the following?
Surfactant
The nurse is administering intravenous magnesium sulfate as prescribed for a client at 34 weeks' gestation with severe preeclampsia. which of the following are desired outcomes of this therapy?
T98 (36.7), P72, R14
After administering hydralazine (Apresoline) 5 mg intravenously as prescribed for a primigravid client with severe preeclampsia at 39 weeks' gestation, the nurse should assess the client for:
Tachycardia
When developing the plan of care for a multigravid client with class III heart disease, which of the following areas should the nurse expect to assess frequently?
Tachycardia
A 23-year-old nulliparous client visiting the clinic for a routine examination tells the nurse that she desires the use the basal body temperature method for family planning. The nurse should instruct the client to do which of the following?
Take her temperature at the same time every morning before getting out of bed
A primigravid client who has had a prolonged labor but now is completely dilated has received epidural anesthesia. Which of the following should the nurse include in the teaching plan about pushing?
The client should be urged to push with an open glottis
A laboring client smiles pleasantly at the nurse when asking simple questions. The client speaks only Mandarin and the interpreter is busy with an emergency situation. At her last vaginal examination, the client was 5 cm dilated, 100% effaced, and at 0 station. While working with this client, which of the following responses indicates that the client may be approaching birth?
The fetal monitor strip shows early decelerations
Two weeks after a breast-feeding primiparous client is discharged, she calls the birthing center and says that she is afraid she is "losing my breast milk. The baby had been nursing every 4 hours, but now she's crying to be fed every 2 hours." The nurse interprets the neonate's behavior as most likely caused by which of the following?
The neonate's temporary growth spurt, which requires more feedings
The health care provider has performed an amniotomy on a laboring client. Which of the following details must be included in the documentation of this procedure?
Time of rupture; Color and clarity of fluid; Fetal heart rate (FHR) and pattern before and after the procedure; Odor and amount of fluid
Which of the following assessment findings in a term neonate would cause the nurse to notify the primary health care provider?
Unequally sized corneas
A 22-year-old nulligravid client tells the nurse that she and her husband have been considering using condoms for family planning. Which of the following instructions should the nurse include about the use of condoms as a method for family planning?
Using a spermicide with the condom offers added protection against pregnancy
During the first hour after a precipitous birth, the nurse should monitor a multiparous client for signs and symptoms of which of the following?
Uterine atony
