Maternal Newborn CMS
A nurse is caring for a client who is experiencing preterm labor and has a prescription for 4 doses of dexamethasone 6 mg IM every 12-hr. Available is dexamethasone 10 mg/mL. How many mL of dexamethasone should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use as trailing zero.)
0.6 mL
A nurse in a provider's office is assessing a client at her first antepartum visit. The client states that the first day of her last menstrual period was March 8. Use the Nagele's rule to calculate the estimated date of delivery. (use the MMDD format with four numerals and no spaces or punctuation.)
1215
A nurse is preparing to administer metronidazole 2 g PO to a client who has pelvic inflammatory disease. Available is metronidazole 500mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
4 tablets
A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statement should the nurse make? A. "You can bathe and dress your baby if you'd like to." B. "If you don't hold the baby, it will make letting go much harder." C. "You should name the baby so she can have an identity." D. "I'm sure you will be able to have another baby when you're ready."
A. "You can bathe and dress your baby if you'd like to."
A nurse is reviewing signs of effective breastfeeding with a client who is 5 days postpartum. Which of the following information should the nurse include in the teaching? A. "You should feel a tugging sensation when the baby is sucking. B. "You should expect your baby to have two to three wet diapers in 24hour period". C. "Your baby's urine should appear dark and concentrated". D. "Your breast should stay firm after the baby breastfeeds".
A. "You should feel a tugging sensation when the baby is sucking.
A nurse is providing teaching to a client who is at 38 weeks of gestation and has a prescription to receive misoprostol intravaginally. Which of the following statement should the nurse make? A. "You will need to stay in a side-lying position for 30 minutes after each dose." B. "You will receive an IV infusion of oxytocin 1 hour after your last dose." C. "You will receive a magnesium supplement immediately following therapy." D. "You will need to have a full bladder before the therapy begins."
A. "You will need to stay in a side-lying position for 30 minutes after each dose."
A nurse is caring for a client who is receiving prenatal care and is at her 24-week appointment. Which of the following laboratory tests should the nurse plan to conduct? A. 1-hr glucose tolerance test B. Blood type and Rh C. Group B step culture D. Rubella titer
A. 1-hr glucose tolerance test
A nurse is assessing a client following an amniocentesis. Which of the following findings should the nurse recognize as complications? (select all that apply). A. Amnionitis B. Urinary tract infection C. Polyhydramnios D. Leakage of amniotic fluid E. Preterm labor
A. Amnionitis D. Leakage of amniotic fluid E. Preterm labor
A charge nurse is teaching a group of staff nurses about fetal monitoring during labor. Which of the following findings should the charge nurse instruct the staff nurses to report to the provider? A. Contraction durations of 95 to 100 seconds B. Fetal heart rate is 140/min C. Absent early deceleration of fetal heart rate D. Contraction frequency of 2 to 2 min apart
A. Contraction durations of 95 to 100 seconds
A nurse is caring for a client following an amniocentesis. The nurse should observe the client for which of the following complications? A. Hemorrhage B. Hyperemesis C. Proteinuria D. Hypoxia
A. Hemorrhage
A nurse is teaching a prenatal class about immunizations that newborns receive following birth. Which of the following immunizations should the nurse include in the teaching? A. Hepatitis B B. Rotavirus C. Pneumococcal D. Varicella
A. Hepatitis B
a nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements by the parent indicates an understanding of the teaching? A. I should position baby car sear at 45 degree angle in car B. I should place the harness snuggly in a slot above my baby shoulders C. I should position the retainer clip at the top of my baby abdomen D> I should place the car seat rear facing until my baby is 12 months
A. I should position baby car sear at 45 degree angle in car
A nurse is caring for a client who is 14 weeks of gestation. At which the following locations should the nurse place the Doppler device when assessing the fetal heart rate? A. Midline 2 to 3 cm (0.8 to 1.2 in) above the symphysis pubis B. Left Upper Abdomen C. Two fingerbreadths above the umbilicus D. Lateral at the Xiphoid Process
A. Midline 2 to 3 cm (0.8 to 1.2 in) above the symphysis pubis
A nurse is reviewing laboratory results for a client who is pregnant. The nurse should expect which of the following laboratory values to increase? A. RBC count B. Fasting blood glucose C. BUN D. Bilirubin
A. RBC count
A nurse is assessing a newborn immediately following a vaginal birth. For which of the following findings should the nurse intervene? A. Sternal retractions B. Vernix caseosa C. Acrocyanosis D. Molding
A. Sternal retractions
A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect? A. Uterine tenderness B. Scant lochia C. Temperature 37.4 c (99.3 f) D. WBC count 9,000/mm 3
A. Uterine tenderness
A nurse is caring for four newborns. Which of the following newborns should the nurse assess first? A. newborn who has nasal flaring B. newborn who has subconjunctival hemorrhage of the left eye C. A newborn who has overlapping suture lines D. A newborn who has not rust-stained urine
A. newborn who has nasal flaring
A nurse is providing teaching to a client about exercise safety during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply). A. "I will limit my time in the hot tub to 30 minutes after exercise." B. "I should consume three 8-ounce glasses of water after I exercise." C. "I will check my heart rate every 15 minutes during exercise sessions." D. "I should limit exercise sessions to 30 minutes when the weather is humid." E. "I should rest by lying on my side for 10 minutes following exercise."
B. "I should consume three 8-ounce glasses of water after I exercise." C. "I will check my heart rate every 15 minutes during exercise sessions." E. "I should rest by lying on my side for 10 minutes following exercise."
A nurse is teaching a client who is at 41 weeks of gestation about a non stress test. Which of the following information should the nurse include in the teaching? A. "This test will confirm fetal lung maturity ". B. "This test will determine adequacy of placental perfusion". C. "This test will detect fetal infection". D. "This test will predict maternal readiness for labor".
B. "This test will determine adequacy of placental perfusion".
A nurse is providing teaching about expected changes during pregnancy to a client who is at 24 weeks of gestation. Which of the following information should the nurse include? A. "Your stomach will empty rapidly" B. "You should expect your uterus to double in size" C. "You should anticipate nasal stuffiness." D. "Your nipples will become lighter in color".
B. "You should expect your uterus to double in size"
A nurse on the labor and delivery unit is assessing four clients. Which of the following clients is a candidate for an indication of labor with misoprostol? A. A client who has placenta previa B. A client who has gestational diabetes mellitus C. A client who has a previous uterine incision D. A client who has active genital herpes
B. A client who has gestational diabetes mellitus
A nurse is caring for newborn who is 1 hr old and has a respiratory rate of 50/min, a heart rate of 130/min, and an auxiliary temperature of 36.1*C (97F). Which of the following actions should the nurse take?A. Give the newborn a warm bath. B. Apply a cap to the newborn head. C. Reposition the newborn. D. Obtain an oxygen saturation level
B. Apply a cap to the newborn head.
See the answer A nurse is caring for a client who is in the transition phase of labor and reports a pain level of 7 on a scale of 0 to 10. Which of the following actions should the nurse take? A. Instruct the client to use effleurage B. Apply counter pressure to the client sacral. C. Assist the client with patterned-paced breathing. D. Teach the client the technique of biofeedback.
B. Apply counter pressure to the client sacral.
A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care? A. Keep the newborn supine throughout treatment B. Avoid using lotion or ointment on the newborn's skin C. Measure the newborn's temperature every 8 hr D. Dress the newborn in lightweight clothing
B. Avoid using lotion or ointment on the newborn's skin
A nurse in women's health clinic is obtaining a health history from a client. Which of the following findings should the identify as increasing the client's risk for developing pelvic inflammatory disease (PID)? A. Frequent alcohol use B. Chlamydial infection C. Recurrent cystitis D. Use of oral contraceptives
B. Chlamydial infection
A nurse is caring for newborn immediately following birth and notes a large amount of mucus in the newborn's mouth and nose. Identify the sequence the nurse should follow when performing suction with a bulb syringe. (Move the streps into the box on the placing them in the selected order of performance. Use all the streps.): A. Assess the newborn for reflex bradycardia. B. Compress the bulb syringe. C. Place the bulb syringe in the newborn's mouth. D. Use the bulb syringe to suction the newborn's nose.
B. Compress the bulb syringe. C. Place the bulb syringe in the newborn's mouth. D. Use the bulb syringe to suction the newborn's nose. A. Assess the newborn for reflex bradycardia.
A nurse is caring for a client who is experiencing sore nipples from breastfeeding. Which of the following actions should the nurse take?A. Place a snug dressing on the client's nipple when not breastfeeding. B. Ensure the newborn's mouth is wide open before latching to the breast. C. Encourage the client to limit the newborn's feeding to 10 min on each breast. D. Instruct the client to begin the feeding with the nipple that is most tender.
B. Ensure the newborn's mouth is wide open before latching to the breast.
A nurse is caring for a client who is 4hr postpartum and is experiencing hypovolemic shock. Which of the following actions should the nurse take? A. Administer indomethacin B. Insert a second using a 22-gauge IV catheter, C. Insert an indwelling urinary catheter. D. Administer oxygen at 4L/min via nasal cannula
B. Insert a second using a 22-gauge IV catheter
A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors places the client at risk for an infection? A. Placenta previa B. Midline episiotomy C. Gestational hypertension D. Meconium-stained fluid
B. Midline episiotomy
A nurse is assessing a newborn who was born postterm. Which of the following findings should the nurse expect? A. Thin covering of fine hair on shoulders and back B. Nails extending over tips of fingers C. Pale, translucent skin D. Large deposits of subcutaneous fat
B. Nails extending over tips of fingers
A community health nurse is providing education on gestational diabetes mellitus (GDM) to a group of clients who are pregnant when discussing risk factors, which of the following ethnicities should the nurse identify as having the lowest incidence of GDM? A. Asian B. Non-Hispanic White American C. Hispanic D. African American
B. Non-Hispanic White American
A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations of the fetal heart rate on the monitor Tracing. Which of the following action should the nurse take? A. Decrease maintenance IV solution infusion rate. B. Place the client in lateral position. C. Administer misoprostol 25 mcg vaginally D. Administer oxygen via face mask at 2 L/min
B. Place the client in lateral position.
A nurse is developing an educational program about hemolytic diseases in newborns for a group of newly licensed nurses. Which of the following genetic information should the nurse include in the program as a cause of hemolytic disease? A. The mother is Rh positive and the father is Rh negative B. The mother is Rh negative and the father is Rh positive C. The mother and the father are both Rh positive D. The mother and the father are both Rh negative
B. The mother is Rh negative and the father is Rh positive
A nurse on a labor and delivery unit is providing teaching to a client who plans to use hypnosis to control labor pain. Which of the following information should the nurse include? A. "Focusing on controlling body functions" B. "Synchronized breathing will be required during hypnosis" C. "Hypnosis can be beneficial in you practiced it during the prenatal period" D. "Hypnosis does not work for controlling pain associated with labor".
C. "Hypnosis can be beneficial in you practiced it during the prenatal period"
A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first? A. A client who has diabetes mellitus and an HbA1c of 5.8% B. A client who has preeclampsia and a creatinine level of 1.1 mg/ dL C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L D. A client who has placenta previa and a hematocrit of 36%
C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L
A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider? A. A client who has a urinary output of 300 ml in 8 hr B. A client who reports abdominal cramping during breastfeeding C. A client who is receiving magnesium sulfate and has absent deep tendon reflexes D. A client who reports lochia rubra requiring changing perineal pads every 3 hr
C. A client who is receiving magnesium sulfate and has absent deep tendon reflexes
A nurse is caring for a client who has active genital herpes simplex virus type 2. Which of the following medications should the nurse plan to administer? A. Metronidazole B. Penicillin C. Acyclovir D. Gentamicin
C. Acyclovir
A nurse is caring for a client who is in labor and request nonpharmacological pain management. Which of the following nursing actions promotes client comfort? A. Applying fundal pressure during contractions B. Having the client lie in a supine position C. Assisting the client into a squatting position D. Encouraging the client to void every 6 hr
C. Assisting the client into a squatting position
A nurse is caring for a client who is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication? A. Hypnosis B. Polyuria C. Bilateral Crackles D. Hyperglycemia
C. Bilateral Crackles
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan? A. Apply a thin layer of lotion to the newborn skin every 8 hrs. B. Give the newborn 1oz of glucose water every 4 hrs C. Ensure the newborn eyes are closed beneath the shield. D. Dress the newborn in a thin layer of clothing during therapy
C. Ensure the newborn eyes are closed beneath the shield.
A nurse is assessing a newborn following a forceps-assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of this birth method? A. Polycythemia B. Hypoglycemia C. Facial palsy D. Bronchopulmonary dysplasia
C. Facial palsy
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take? A. Provide a stimulating environment B. Monitor blood glucose level every hr. C. Initiate seizure precautions. D. Place the infants on his back with legs extended.
C. Initiate seizure precautions.
A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse take? A. Measure the abdominal circumference at the level for the newborn's umbilicus ever 12 hr. B. Administer nitric oxide inhalation therapy to the newborn C. Provide the newborn with an iron-rich formula containing vitamin B12 every 2 hr D. Inset an orogastric decompression tube with low wall suction
C. Provide the newborn with an iron-rich formula containing vitamin B12 every 2 hr
A nurse is monitoring a client who has preeclampsia and is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse reports to the provider? A. Blood pressure 148/94mm Hg B. Respiratory rate 14mm C. Urinary output 20 mL/hr D. 2+deep tendon reflexes
C. Urinary output 20 mL/hr
A nurse is providing discharge teaching to a client following tubal ligation. Which of the following statements by the client indicates an understanding of the teaching? A. "Premenstrual tension will no longer be present B. " My monthly menstrual period will be shorter" C. Hormone replacements will be needed following this procedure" D. "Ovulation will remain same
D. "Ovulation will remain same
A nurse is providing teaching about terbutaline to a client who is experiencing preterm labor. Which of the following statements by the client indicates an understanding of the teaching? A. "This medication could cause me to experience ringing in my ears." B. "This medication could cause me to experience frequent urination." C. "This medication could cause me to experience blurred vision." D. "This medication could cause me to experience heart palpitations."
D. "This medication could cause me to experience heart palpitations."
A nurse is providing nutritional guidance to a client who is pregnant and follows a vegan diet. The client asks the nurse which foods she should eat to ensure adequate calcium intake. The nurse should instruct the client that which of the following foods has the highest amount of calcium? A. ½ cup cubed avocado B. 1 large banana C. 1 medium potato D. 1 cup cooked broccoli
D. 1 cup cooked broccoli
A nurse is caring for four clients. For which of the following clients should the nurse auscultate the fetal heart rate during the prenatal visit? A. A client who has an ultrasound that confirms a molar pregnancy B. A client who has a crown-rump length of 7 weeks gestation C. A client who has a positive urine pregnancy test 1 week after missed menses D. A client who has felt quickening for the first time
D. A client who has felt quickening for the first time
A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care? A. Instruct the client to stop taking the antiretroviral medication at 32 weeks of gestation. B. Use a fetal scalp electrode during labor and delivery. C. Administer a pneumococcal immunization to the newborn within 4 hr following birth. D. Bathe the newborn before initiating skin-to-skin contact
D. Bathe the newborn before initiating skin-to-skin contact
A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effects should the nurse include? A. Chills B. Urinary frequency C. Tinnitus D. Breast tenderness
D. Breast tenderness
A nurse is receiving laboratory results for a term newborn who is 24 hr old. Which of the following results require intervention by the nurse? A. WBC count 10,000/mm3 B. Platelets 180,000/mm3 C. Hemoglobin 20g/dL D. Glucose 20 mg/dL
D. Glucose 20 mg/dL
A nurse is caring for a client who has bacterial vaginosis. Which of the following medication should the nurse expect to administer? A. Metronidale B. Fluconazole C. Acyclovir D. Metronidazole
D. Metronidazole
A nurse on a labor and delivery unit is receiving infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures? A. Assisting a mother with breastfeeding B. Performing a newborn's initial bath C. Administering the measles, mumps, rubella vaccine D. Performing umbilical cord care
D. Performing umbilical cord care
A nurse is caring for a newborn who is 6 hr old and has a bedside glucometer reading of 65 mg/ dL. The newborn's mother has type 2 diabetes mellitus. Which of the following actions should the nurse take? A. Obtain a blood sample for a serum glucose level B. Feed the newborn immediately C. Administer 50 mL of dextrose solution IV D. Reassess the blood glucose level prior to the next feeding
D. Reassess the blood glucose level prior to the next feeding
A nurse is teaching a client who is 28 weeks of gestation and not up-to date on current immunization. Which of the following immunizations should the nurse inform the client to anticipate receiving following birth. A. Pneumococcal B. Hepatitis C. Human papillomavirus D. Rubella
D. Rubella
A nurse is assessing a preterm newborn who is at 32 weeks of gestation. Which of the following findings should the nurse expect? A. Minimal arm recoil B. Creases over the entire sole C. Popliteal angle of less than 90 degree D. Sparse lanugo
D. Sparse lanugo
A nurse is planning care for a newborn who has neonatal abstinence syndrome. Which of the following interventions should the nurse include in the plan of care. A. Increase the newborn's visual stimulation B. Weigh the newborn every other day C. Discourage parental interaction until after a social evaluation D. Swaddle the newborn in a flexed position
D. Swaddle the newborn in a flexed position
A nurse is caring for a client who is in the second stage of labor. Which of the following manifestations should the nurse expect? A. The client expels the placenta B. The client experiences gradual dilation of the cervix C. The client begins have regular contractions. D. The client delivers the newborn
D. The client delivers the newborn
A nurse is caring for a newborn who is 24 hr old. Which of the following Laboratory findings should the nurse report to the provider? A. Hgb 20 g/dL B. Bilirubin 2mg/dL C. Platelets 200 .000/mm3 D. WBC count 32.000/mm3
D. WBC count 32.000/mm3
. A nurse is assessing a client who is at 39 weeks of gestation and determines that the fetus is in a left occipitoanterior positi7on. On which of the following sites should the nurse place the external fetal monitor to hear the point of maximum impulse of the fetal heart rate?
LLQ
A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B streptococcus B-hemolytic (GBS). The client ismultigravida and multipara with no history of GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse? a. "We need to know if you are positive for GBS at the time of delivery." b. "There was no indication of GBS in your earlier prenatal testing." c. "You didn't report any symptoms of GBS during your pregnancy." d. "Your previous deliveries were all negative for GBS."
a. "We need to know if you are positive for GBS at the time of delivery."
A nurse is providing teaching about expected changes during pregnancy to a client who is at 24 weeks of gestation. Which of the following information should the nurse include? a. "You should expect your uterus to double in size." b. "Your stomach will empty rapidly." c. "Your nipples will become lighter in color." d. "You should anticipate nasal stiffness."
a. "You should expect your uterus to double in size."
A nurse is providing education to a client who is to receive misoprostol for induction of labor. Which of the following instructions should the nurse include in the teaching? a. "You will lie on your side for 40 minutes after I administer the medication." b. "I will begin an oxytocin infusion within 2 hours of your last dose of medication." c. "You will receive an antacid containing magnesium before the medication." d. "I will insert a urinary catheter before I administer the medication."
a. "You will lie on your side for 40 minutes after I administer the medication."
A nurse in a prenatal clinic is reviewing the laboratory results for a client who is at 12 weeks gestation. Which of the following actions should the nurse take? (Click in the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) a. Administer ceftriaxone IM. b. Administer rubella vaccine. c. Obtain a maternal serum alpha-fetoprotein specimen. d. Obtain a blood culture.
a. Administer ceftriaxone IM.
A nurse is providing discharge instructions to a client who is breast feeding her newborn. Which of the following instructions should the nurse include? a. Allow the baby to feed at least every 3 hours b. Offer the newborn 30 mL (1 oz) of water between feedings c. Expect two to four wet diapers every 24 hrs d. Feed the newborn 5 to 10 min each breast
a. Allow the baby to feed at least every 3 hours
A nurse is caring for a client who has bladder distention following a vaginal birth. Which of the following actions should the nurse take first? a. Assist the client to the bathroom. b. Offer the client a sitz bath. c. Insert a urinary catheter. d. Pour warm water over the client's perineum.
a. Assist the client to the bathroom.
. A nurse is caring for a client who is in active labor and has gonorrhea. For which of the following potential complications of gonorrhea should the nurse monitor? a. Chorioamnionitis b. Vaginal laceration during birth c. Excessive bleeding after birth d. Oligohydramnios
a. Chorioamnionitis
A nurse is observing an adolescent client who is offering her newborn a bottle while he is lying in the bassinet. When the nurse offers to pick the newborn up and place him in the client's arms, the mother states, "No, the baby is too tired to be held." Which of the following actions should the nurse take? a. Demonstrate how to hold the newborn and allow client to practice. b. Persuade the client to breasfeed the newborn to promote bonding. c. Offer to take the newborn to the nursery to finish his feeding. d. Insist that the mother pick up the newborn to feed him.
a. Demonstrate how to hold the newborn and allow client to practice.
. A nurse is assessing a client who is 2 days postpartum. Which of the following findings indicates a complication? a. Hypotonic uterus b. Hct 36% c. Platelet count 370,000/mm3 d. Perineal edema
a. Hypotonic uterus
A nurse is planning care for a client who is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan? a. Increase the infusion rate every 30 to 60 min. b. Maintain the client in a supine position. c. Limit IV intake to 4 L per 24 hr. d. Titrate the infusion rate by 4 milliunits/min.
a. Increase the infusion rate every 30 to 60 min.
A nurse is caring for a client who is 2 weeks postpartum following a cesarean birth. Which of the following clinical fndings should the nurse identify as an indication of postpartum infection? a. Unilateral breast pain b. Persistent abdominal striae c. Lochia alba d. WBC count 12,000/mm3
a. Unilateral breast pain
A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take? a. Verify that the informed consent is obtained prior to administration. b. Allow the medication to reach room temperature prior to administration. c. Instruct the client to avoid urinary elimination until after administration. d. Place the client in a semi-Fowler's position for 1 hr after administration.
a. Verify that the informed consent is obtained prior to administration.
. A nurse is providing discharge instructions to a client who is 24 hr postpartum and has decided not to breast feed. Which of the following instructions should the nurse include in the teaching? a. "Shower daily, allowing warm water to run directly over your breasts." b. "Apply ice packs to your breasts using a 15 minutes on, 45 minutes off schedule." c. "Wear a loose-5mng, nonbinding bra for 72 hours." d. "Pump your breasts twice daily to relieve discomfort from engorgement."
b. "Apply ice packs to your breasts using a 15 minutes on, 45 minutes
. A nurse in the antepartum clinic is teaching a client who is at 28 weeks of gestation and has preeclampsia. Which of the following instructions should the nurse include in the teaching? a. "Limit your fluid intake to four 8-ounce glasses per day." b. "Count your baby's movements daily." c. "Reduce your calcium intake to less than 1 gram per day." d. "Alternate arms each time you check your blood pressure."
b. "Count your baby's movements daily."
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching? a. "Mothers will receive prophylactic treatment with acyclovir prior to delivery." b. "Transmission can occur via the saliva and urine of the newborn." c. "This infection requires airborne precautions are initiated for the newborn." d. "Lesions are visible on the mother's genitalia."
b. "Transmission can occur via the saliva and urine of the newborn."
A nurse is teaching a client who is at 8 weeks of gestation about self-care during pregnancy. Which of the following statements should the nurse make? a. "You can take 400 milligrams of ibuprofen for discomfort." b. "You should take 600 micrograms of folic acid per day." c. "You can take black cohosh once a day for insomnia." d. "You should limit your daily fluid intake to 1,000 milliliters per day."
b. "You should take 600 micrograms of folic acid per day."
A nurse is teaching a client about the basal body temperature method of contraception. Which of the following statements should the nurse include in the teaching? (pg 4) a. "Your risk of pregnancy is greatest on days 21 to 28 of your cycle." b. "You should take your temperature before getting up for the day." c. "You should abstain from intercourse when your temperature is above 100 F." d. "Your temperature may increase slightly immediately prior to ovulation."
b. "You should take your temperature before getting up for the day."
A nurse is teaching a prenatal class regarding false labor. Which of the following information should the nurse include? a. "You will have dilation and effacement of the cervix." b. "Your contractions will become temporarily regular." c. "You will have bloody show." d. "Your contractions will become more intense when walking."
b. "Your contractions will become temporarily regular."
A nurse is providing vehicle safety education to parents of a premature newborn. Which of the following statements should the nurse include in the teaching? a. "You should secure your newborn's car seat at a 60 degree angle." b. "Your newborn will need to have a car seat test prior to discharge." c. "Place your newborn in a front-facing car seat in the back seat of the vehicle." d. "Position the retainer clip at the level of your newborn's abdomen."
b. "Your newborn will need to have a car seat test prior to discharge."
A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend for an interdisciplinary care conference? a. A client who is at 37 weeks of gestation and has an L/S ratio 2:1 b. A client who is at 35 weeks of gestation and has a biophysical profile of 6 c. A client who is at 39 weeks of gestation and has a negative contraction stress test d. A client who is at 28 weeks of gestation and has a negative Coombs titer
b. A client who is at 35 weeks of gestation and has a biophysical profile of 6
A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client? a. Intense contractions lasting 45 to 60 seconds b. An urge to have a bowel movement during contractions c. A sense of excitement and warm, flushed skin d. Progressive sacral discomfort during contractions
b. An urge to have a bowel movement during contractions
A nurse is preparing to administer methylergonovine 0.2 mg orally to a client who is 2 hr postpartum and has a boggy uterus. For which of the following assessment findings should the nurse withhold the medication? a. Respiratory rate 14/min b. Blood pressure 142/92 mm Hg c. Urine output 100 mL in 3 hr d. Pulse 58/min 42
b. Blood pressure 142/92 mm Hg
A nurse is caring for a newborn immediately following birth notes a large amount of mucus in the newborn's mouth and nose. Identify the sequence the nurse should follow when performing suction with a bulb syringe. a. Lace the bulb syringe in the newborn's mouth (2) b. Compress the bulb syringe (1) c. Assess the newborn for reflex bradycardia (4) d. Set the bulb syringe suction the newborn's nose (3)
b. Compress the bulb syringe (1) a. Lace the bulb syringe in the newborn's mouth (2) d. Set the bulb syringe suction the newborn's nose (3) c. Assess the newborn for reflex bradycardia (4)
A nurse is caring for a client who is postpartum and experiencing hypovolemic shock. Which of the following findings should the nurse expect? a. Respiratory rate 18/min b. Cool, clammy skin c. Urinary output 30 mL/hr d. Bounding pulses
b. Cool, clammy skin
A nurse is caring for a client who is at 20 weeks of gestation and reports constipation. Which of the following recommendations should the nurse make to help retrieve this common discomfort of pregnancy? a. Include 18 g of fiber in the diet each day. b. Drink 2 to 3 L of water each day. . c. Add 30 mL of mineral oil to each meal. d. Tale 60 mL of magnesium hydroxide once daily.
b. Drink 2 to 3 L of water each day
A nurse is assessing the fetal heart rate for a client who is at 38 weeks of gestation. When using an ultrasound device, the nurse hears blood rushing through the umbilical vessels in synchronization with the fetal heart beat. Which of the following terms should the nurse use to document this finding? a. Goodell's sign b. Funic souffle c. Quickening d. Hegar's sign
b. Funic souffle
A nurse is caring for a client who is 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect? a. Thick white vaginal discharge b. Malodorous discharge c. Vulva lesions d. Urinary frequency
b. Malodorous discharge
A nurse is providing teaching about increasing dietary fiber to an antepartum client who reports constipation. Which of the following food selections has the highest fiber content per cup? a. Lentils b. Oatmeal c. Cabbage d. Asparagus
b. Oatmeal
. A nurse manager in a newborn nursery is reviewing infection control procedures with a group of newly hired nurses. Which of the following instructions should the nurse manager include in the teaching? a. Allow parents to enter the nursery if they are wearing a mask b. Place newborn bassinets at least 3 feet apart. c. Place the newborn's foot on a sterile field during a heel stick. d. Maintain airborne precautions in the nursery.
b. Place newborn bassinets at least 3 feet apart.
A nurse is admitting a client to the birthing unit who reports her contractions started 1 hour ago. The nurse determines client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions? a. Hyperemesis gravidarum b. Postpartum hemorrhage c. Incompetent cervix d. Ectopic pregnancy
b. Postpartum hemorrhage
A nurse is planning care for a client in the postpartum unit. Which of the following goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment? a. The client will identify individual family member roles. b. The client will have adequate nutritional intake. c. The client will verbalize appropriate car seat safety. d. The client will demonstrate proper bathing of the infant.
b. The client will have adequate nutritional intake.
A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider? a. Single palmar creases b. Transient circumoral cyanosis c. Rust-stained urine d. Subconjunctival hemorrhage
b. Transient circumoral cyanosis
A nurse is reviewing the medical record of a client who had vaginal delivery 3 hr ago. Which of the following findings place the client at risk for postpartum hemorrhage? (SATA) a. History of human papillomavirus b. Vacuum-assisted delivery c. Labor induction with oxytocin d. Newborn weight 2.948 kg (6 lb 8 oz) e. History of uterine atony
b. Vacuum-assisted delivery c. Labor induction with oxytocin e. History of uterine atony
A nurse is caring for a client who is 2 days postpartum and states "I want to continue breast feeding, but my nipples are sore." Which of the following responses should the nurse make? a. "Removing breast shields from your bra ll decreased discomfort." b. "You should switch your infant to formula until the soreness goes away." c. "Allow expressed milk to air dry on the nipples after feeding your infant." d. "Apply an antibiotic ointment to the nipples prior to each feeding."
c. "Allow expressed milk to air dry on the nipples after feeding your infant."
. A nurse is planning to teach a group of clients who are pregnant about breast feeding after returning to work. Which of the following information should the nurse include in the teaching? a. "Thawed breast milk that is unused can be refrozen." b. "Breast milk can be stored at room temperature for up to 12 hours." c. "Breast milk can be stored in a deep freezer for 12 months." d. "Thawed breast milk can be refrigerated for up to 72 hours."
c. "Breast milk can be stored in a deep freezer for 12 months."
A nurse is teaching a client about using a diaphragm. Which of the following instructions should the nurse include in the teaching? a. "Insert the diaphragm up to 12 hours before intercourse." b. "Remove the diaphragm 2 hours after intercourse." c. "Replace the diaphragm every 2 years." d. "Use 2 teaspoons baby oil to lubricate the diaphragm before insertion."
c. "Replace the diaphragm every 2 years."
. A nurse in a provider's office is caring for a 20-year-old client who is at 12 weeks of gestation and requests an amniocentesis to determine the gender of the fetus. Which of the following responses should the nurse take? a. "We can schedule the procedure for later today if you'd like." b. "You cannot have an amniocentesis until you are at least 35 years of age." c. "This procedure determines if your baby has genetic or congenital disorders." d. "Your provider will schedule a chorionic villus sampling to determine the sex of your baby."
c. "This procedure determines if your baby has genetic or congenital disorders."
A nurse is caring for four newborns. Which of the following findings should the nurse report to the provider? a. A newborn who has molding with overlapping suture lines b. A female newborn who has blood-tinged vaginal discharge c. A newborn who has a high-pitched cry with exaggerated Moro reflex d. A male newborn who has a scrotal edema
c. A newborn who has a high-pitched cry with exaggerated Moro reflex
A nurse is reviewing the laboratory report of a client who is 24 hr postpartum vaginal delivery. The client has a hemoglobin level of 9.0 g/dL and hematocrit of 25%. Which of the following actions should the nurse take? a. Initiate IV access for isotonic solution with an 18-gauge catheter. b. Prepare the client for a blood transfusion. c. Administer an iron supplement to the client. d. Instruct the client that the provider will check for placental fragments.
c. Administer an iron supplement to the client.
A nurse is caring for a client who is in labor. The nurse observes late decelerations of the fetal heart rate on the external fetal monitor. After placing the client in a side-lying position, which of the following actions should the nurse take? a. Decrease the rate of IV fluids. b. Elevate the client's head. c. Administer oxygen via a face mask. d. Perform fetal scalp stimulation.
c. Administer oxygen via a face mask.
A nurse is caring for a client who is postpartum. The client reports no relief in perineal pain following the administration of oxycodone/acetaminophen. Which of the following actions should the nurse take first? a. Reposition the client. b. Apply an ice pack to the client's perineum. c. Assess the client's perineal area for swelling. d. Administer ibuprofen to the client.
c. Assess the client's perineal area for swelling.
A nurse is assessing a newborn upon admission to the nursery. Which of the following findings should the nurse expect? a. Length from head to heel of 40 cm (15.7 in) b. Bulging fontanels c. Chest circumference 2 cm (0.8) smaller than the head circumference d. Nasal Raring
c. Chest circumference 2 cm (0.8) smaller than the head
. A nurse is caring for a newborn who has exstrophy of the bladder. Which of the following actions should the nurse take prior to the beginning of surgical correction? a. Keep the newborn in a side-lying position. . Restrict the newborn's fluid intake. c. Cover the newborn's bladder with a sterile, non-adherent dressing. d. Exert gentle pressure on the newborn's bladder with sterile gauze.
c. Cover the newborn's bladder with a sterile, non-adherent dressing.
A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse report to the provider? a. Respiratory rate 11/min b. Urine output 130 mL /4 hr c. Deep tendon reflexes absent d. Fetal heart rate 120/min e. Flushing of face
c. Deep tendon reflexes absent
. A nurse is reviewing laboratory findings a client who is at 20 weeks of gestation. Which of the following findings should the nurse report to the provider? a. Creatinine 0.9 mg/dL . WBC count 11,000/mm3 c. Fasting blood glucose 180 mg/dL d. Hematocrit 35%
c. Fasting blood glucose 180 mg/dL
A nurse is caring for a client who is at 35 weeks of gestation and is on bed rest due to preeclampsia. Which of the following is an important action for the nurse to take? a. Maintain NPO status b. Obtain BP every 8 hours c. Keep the lights dimmed in the room. d. Auscultate fetal heart tones twice per day
c. Keep the lights dimmed in the room.
A nurse is calculating estimated date of birth using Naegele's rule for a client who is pregnant and whose last menstrual cycle started June 21. Which of the following is the estimated delivery in the next year? a. March 14 b. March 21 c. March 28 d. April 4
c. March 28
A nurse is planning care for a newborn who is to undergo a circumcision using a plastic bell device. Which of the following interventions should the nurse include in the plan of care? a. Wash the circumcision site with mild soap and water 24 hr following the procedure. b. Take off the plastic bell 2 hr after the procedure. c. Monitor for bleeding every 15 min for the first hour. d. Remove the yellow drainage on the second postoperative day.
c. Monitor for bleeding every 15 min for the first hour.
. A nurse is reviewing the immunization status of a client who is pregnant. The nurse should inform the client that it is safe for her to receive which of the following immunizations during pregnancy? a. Varicella b. Rubella c. Tetanus d. Rubeola
c. Tetanus
A nurse in a prenatal clinic is caring for a client who has hyperemesis gravidarum. Which of the following is the initial laboratory testused to evaluate this condition? a. Liver enzymes b. Complete blood count c. Urine ketones d. Thyroid levels
c. Urine ketones
A nurse is assessing client who has preeclampsia during a prenatal visit. Which of the following findings should the nurse report to the provider? a. Blood glucose 110 mg/dL b. Deep tendon reRexes of 2+ c. Urine protein of 3+ d. Hemoglobin 13 g/dL
c. Urine protein of 3+
. A nurse is performing a heel stick on a newborn. Which of the following actions should the nurse take? a. Place an ice pack on the newborn's heel 5 min before the procedure. b. Cleanse the newborn's heel with an alcohol swab after the procedure. c. Use an automatic puncture device on the heel. d. Puncture the heel in the inner aspect of the foot.
c. Use an automatic puncture device on the heel.
. A nurse is in a clinic caring for a client who is in her second trimester pregnancy. The client expresses concern about preparing her 2- year- old- child for a new sibling. Which of the following is an appropriate response by the nurse? a. "Move your toddler to his new bed 2 months before the baby comes home." b. "Let the toddler see you carrying the baby into the home for the first time." c. "Avoid bringing your toddler to prenatal visits." d. "Required scheduled interactions between toddler and the baby."
d. "Required scheduled interactions between toddler and the baby."
A nurse is providing teaching about the expected effects of magnesium sulfate to a client who is at 28 weeks of gestation and has preeclampsia. Which of the following responses by the nurse is appropriate? a. "This medication improves tissue perfusion." b. "This medication increases cardiac output." c. "This medication stabilizes the fetal heart rate." d. "This medication prevents seizures."
d. "This medication prevents seizures."
A nurse is receiving report on four postpartum clients. Which of the following clients should the nurse plan to attend to first? a. A client who reports abdominal pain during breast feeding b. A client who reports changing her perineal pad every 2 hours c. A client who has urine output of 250 mL in 6 hr d. A client who as hyporeflexia while receiving IV magnesium sulfate
d. A client who as hyporeflexia while receiving IV magnesium sulfate
. A nurse is providing discharge instructions to a client who is postpartum and has engorged breasts. Which of the following nonpharmacological comfort measures should the nurse include in the teaching? a. Wear nipple shields during the feeding. b. Use a breast binder for 2 days. c. Use plastic-lined breast pads. d. Apply cabbage leaves a^er feedings
d. Apply cabbage leaves a^er feedings
A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion. The nurse notes a respiratory rate of 8/min and absent deep-tendon reflexes. Which of the following medications should the nurse administer? a. Phytonadione b. Acetylcysteine c. Protamine sulfate d. Calcium gluconate
d. Calcium gluconate
A nurse is caring for a client who is 8 hr postpartum following vaginal delivery and is unable to void. Which of the following interventions should the nurse use to promote voiding? a. Apply supra pubic pressure. b. Administer a diuretic to the client. c. Insert an indwelling urinary catheter. d. Encourage the client to void in the shower.
d. Encourage the client to void in the shower.
A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take? a. Apply an ice pack to the incision site. b. Replace the surgical dressing. c. Administer 500 mL lactated Ringer's IV bolus. d. Evaluate urinary output.
d. Evaluate urinary output.
A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect? a. Erythema toxicum b. Periauricular papillomas c. Telangiectatic nevi d. Facial petechiae
d. Facial petechiae
A nurse is assessing a full-term newborn. Which of the following findings should the nurse report to the provider? a. Temperature 36.5 degrees C (97.7 degrees F) b. Blood pressure 80/50 mm Hg c. Respiratory rate 55/min d. Heart rate 72/min
d. Heart rate 72/min
A nurse is caring for a client following an amniocentesis. The nurse should observe the client for which of the following complications? a. Proteinuria b. Hyperemesis c. Hypoxia d. Hemorrhage
d. Hemorrhage
A nurse is assessing current medication use with a client who is at 6 weeks of gestation. The nurse should recognize that pregnancy is a contraindication the administration of which of the following medications? a. Azithromycin b. Metformin c. Diphenhyamine d. Isotretinoin
d. Isotretinoin
A nurse in a clinic is preparing to measure the fundal height of a client who is pregnant. Which of the following actions should the nurse take? a. Lay the tape measure horizontally over the middle of the client's abdomen. b. Place the client in a left-lateral position to obtain the measurement. c. Ensure that the client has a full bladder before taking the measurement. d. Measure from the upper border of the pubis to the upper border of the fundus.
d. Measure from the upper border of the pubis to the upper border of the fundus.
A nurse manager is revising a maternal unit policy to ensure proper identification of newborns. Which of the following should the nurse include in the policy? a. Check the newborn's identification using the crib card. b. Replace the infant's identification band after his name has been recorded. c. Require visitors to wear an identification band. d. Obtain an imprint of the infant's feet prior to taking him to the nursery.
d. Obtain an imprint of the infant's feet prior to taking him to the nursery.
A nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider? a. Hemoglobin 14.8 g/dL b. Urine protein concentration 200 mg/24 hr c. Creatinine 0.8 mg/dL i. normal d. Platelet count 60,000/mm3
d. Platelet count 60,000/mm3
A nurse is assisting with a precipitous delivery of a term newborn. After the head emerges, the nurse palpates the cord around the newborn's neck. Which of the following actions should the nurse take? a. Apply fundal pressure. b. Place the client in the knee-chest position. c. Apply a water-based lubricant to the cord. d. Slip the cord over the newborn's head.
d. Slip the cord over the newborn's head.
A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion for severe preeclampsia. Which of the following findings should the nurse report to the provider? a. Deep tendon reflex 2+ b. Absence of clonus c. Facial Rushing d. Urine output 20 mL/hr
d. Urine output 20 mL/hr
A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take? a. Inform the client that the law requires her to name the fetus. b. Limit the amount of time the fetus is in the client's room. c. Instruct the client that an autopsy should be performed within 24 hr. d. prepare the client for what to expect the fetus to look like
d. prepare the client for what to expect the fetus to look like
A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse the nurse takes? (Click on the "Exhibit" Button for additional information about the newborn. There are three tabs that contain separate categories of date.)
measure abdominal circumference
