MATERNAL NEWBORN COMPLETE STUDY SET

A woman who is 35 weeks pregnant has a total placenta previa. She asks the nurse, "Will I be able to deliver vaginally?" What explanation by the nurse is the most appropriate? a. "Yes, you can deliver vaginally until 36 weeks." b. "A vaginal delivery can be attempted, but if bleeding occurs, a cesarean section will be done." c. "A cesarean section is performed when the mother has a total placenta previa." d. "There is no reason why you cannot have a vaginal delivery."

"A cesarean section is performed when the mother has a total placenta previa."

The nurse is caring for a laboring patient who is not reporting pain. What sign would alert the nurse of the need for pain relief? a. Frequently asking for ice chips b. Facial grimacing c. Changing positions in bed d. Covering her face with her hands

Facial grimacing

A patient who is 28 weeks pregnant presents with consistent hypertension. What need would the home health nurse make the first priority? a. Activity restriction b. Balanced nutrition c. Increased fluid intake to ensure adequate hydration d. Instruction about the effect of diuretics

Activity restriction

One hour after a Plastibell circumcision, the nurse notes a small amount of blood oozing from the area. Which is the appropriate initial nursing response to this observation? A. Continue to observe for increased bleeding B. Apply pressure with a gauze pad and gloved fingers C. Call the health care provider who performed the procedure D. Wrap petroleum jelly gauze around the penis

Apply pressure with a gauze pad and gloved fingers

Postoperative nursing care of the infant following surgical repair of a cleft lip would include: a. Feeding the infant with a spoon to avoid sucking. b. Positioning the infant on the abdomen to facilitate drainage. c. Applying elbow restraints to protect the surgical area. d. Providing minimal stimulation to prevent injury to the incision.

Applying elbow restraints to protect the surgical area.

Which technique is likely to be most effective for back labor? A. stimulating the abdomen by effleurage B. Applying firm pressure in the sacral area C. Blowing out in short breaths during each contraction D. Rocking from side to side at the peak of each contraction

Applying firm pressure in the sacral area

The nurse is providing education to parents of a child with cleft palate. What will the nurse instruct the parents to report immediately? a. Facial paralysis b. Ear infections c. Increased intracranial pressure (ICP) d. Drooling

Ear infections

What does the nurse explain can affect the survival of the X- and Y-bearing sperm after intercourse? a. Age b. Estrogen level c. Body temperature d. Level of feminine hygiene

Estrogen level

What does meconium-stained amniotic fluid indicate when the infant is in a vertex presentation? a. Fetal distress b. Fetal maturity c. Intact gastrointestinal tract d. Dehydration in the mother

Fetal distress

The physician performs an amniotomy on a laboring woman. What will be the nurse's priority assessment immediately following this procedure? a. Fetal heart rate b. Fluid amount c. Maternal blood pressure d. Deep tendon reflexes

Fetal heart rate

A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which occurrence indicates an abnormal physical finding that necessitates further testing? 1. Quickening 2. Braxton Hicks contractions 3. Consistent increase in fundal height 4. Fetal heart rate of 180 beats per minute

Fetal heart rate of 180 beats per minute

An infant is delivered with the use of forceps. What should the nurse assess for in the newborn? a. Loss of hair from contact with forceps b. Sacral hematoma c. Facial asymmetry d. Shoulder dislocation

Facial asymmetry

A woman tells the nurse that she is quite sure she is pregnant. The nurse recognizes which as a positive sign of pregnancy? a. Amenorrhea b. Uterine enlargement c. HCG detected in the urine d. Fetal heartbeat

Fetal heartbeat

The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. What should the nurse's next assessment be? a. Fullness of the bladder b. Amount of lochia c. Blood pressure d. Level of pain

Fullness of the bladder

It is determined that the presenting part of the fetus is the buttocks. At delivery the fetus's hips are flexed and the knees are extended. How would the nurse record this presentation? a. Complete breech b. Frank breech c. Double footling d. Buttocks presentation

Frank breech

The nurse is preparing a community education program on preventive health care for women. What common screening test will the nurse plan on explaining to the women attending the program? a. Breast examination by a health professional b. Breast self-examination c. Breast biopsy d. Mammography

Mammography

An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily available if respiratory depression occurs? 1. Naloxone 2. Morphine sulfate 3. Betamethasone 4. Meperidine hydrochloride

Naloxone

What drug should be immediately available for emergency use when a woman receives narcotics during labor? A. Fentanyl (Sublimaze) B. Diphenhydramine (Benadryl) C. Lidocaine (Xylocaine) D. Naloxone (Narcan)

Naloxone (Narcan)

Which narcotic antagonist is used to reverse narcotic-induced respiratory depression? a. Hydroxyzine (Vistaril) b. Phenobarbital c. Naloxone (Narcan) d. Nitrous oxide

Naloxone (Narcan)

The prepared childbirth technique that is most likely to relieve back pain during labor is: A. effleurage B. sacral pressure C. thermal stimulation D. patterned breathing

Sacral pressure.

The nurse knows that a postterm infant may experience which potential problems? (Select all that apply.) a. Seizures b. Asphyxia c. Paralysis d. Visual defects e. Polycythemia

a. Seizures b. Asphyxia e. Polycythemia

A nurse is assisting the nurse manager with an educational session about way to prevent TORCH infection during pregnancy with a group of newly licensed nurses. Which of the following statements by one of the session participants indicates understanding? A. "Obtain an immunization against rubella early in the pregnancy." B. "Seek prophylactic treatment of cytomegalovirus is detected during pregnancy." C. "A client should avoid crowded places during pregnancy." D. "A client should avoid consuming undercooked meat while pregnant."

"A client should avoid consuming undercooked meat while pregnant."

A nurse in a health clinic is reinforcing teaching about contraceptive use with a group of clients. Which of the following client statements demonstrates understanding? A. "A water-soluble lubricant should be used with condoms." B. "A diaphragm should be removed 2 hours after intercourse." C. "Oral contraceptives can worsen a case of acne." D. "A contraceptive patch is replaced once a month."

"A water-soluble lubricant should be used with condoms."

What is the most appropriate statement from the nurse when coaching the laboring woman with a fully dilated cervix to push? a. "At the beginning of a contraction, hold your breath and push for 10 seconds." b. "Take a deep breath and push between contractions." c. "Begin pushing when a contraction starts and continue for the duration of the contraction." d. "At the beginning of a contraction, take two deep breaths and push with the second exhalation."

"At the beginning of a contraction, take two deep breaths and push with the second exhalation."

The nurse instructed a postpartum woman about storing and freezing breast milk. What statement by the woman leads the nurse to determine that the teaching was effective? a. "I can thaw frozen breast milk in the microwave." b. "I'll put enough breast milk for one day in a container." c. "Breast milk can be stored in glass containers." d. "Breast milk can be kept in the refrigerator for up to 3 months."

"Breast milk can be stored in glass containers."

A 4-week postpartum patient with mastitis asks the nurse if she can continue to breastfeed. What is the nurse's most helpful response? a. "Stop breastfeeding until the infection clears." b. "Pump the breasts to continue milk production, but do not give breast milk to the infant." c. "Begin all feedings with the affected breast until the mastitis is resolved." d. "Breastfeeding can continue unless there is abscess formation."

"Breastfeeding can continue unless there is abscess formation."

A primipara tells the nurse, "My afterpains get worse when I am breastfeeding." What is the most appropriate nursing response? a. "I'll get you some aspirin to relieve the cramping that you feel." b. "Afterpains are more intense with your first baby." c. "Breastfeeding releases a hormone that causes your uterus to contract." d. "A change of position when you're breastfeeding might help."

"Breastfeeding releases a hormone that causes your uterus to contract."

A woman has prostaglandin vaginal insert placed the day before she is scheduled for induction of labor at 40 wks. Which is the most appropriate teaching immediately after the procedure? a. "We will check your baby's heartrate after you walk for 30 minutes." b. "Expect vigorous and frequent contractions in about 30 minutes." c. "Call your nurse if you notice fluid leaking from your vagina." d. "Stay in bed on your left side until oxytocin infusion is started."

"Call your nurse if you notice fluid leaking from your vagina."

A nurse is reinforcing teaching with a client who is breastfeeding and has mastitis. Which of the following responses should the nurse make? A. "Limit the amount of time the infant nurses on each breast." B. "Nurse the infant only on the unaffected breast until resolved." C. "Completely empty each breast at each feeding or use a pump." D. "Wear a tight-fitting bra until lactation has ceased."

"Completely empty each breast at each feeding or use a pump."

A nurse is discussing intermittent fetal heart monitoring with a newly licensed nurse. Which of the following statements should the nurse include? A. "Count the fetal heart rate for 15 seconds to determine the baseline." B. "Auscultate the fetal heart rate every 5 minutes during the active phase of the first stage of labor." C. "Count the fetal heart rate after a contraction to determine baseline changes." D. "Auscultate the fetal heart rate every 30 minutes during the second stage of labor."

"Count the fetal heart rate after a contraction to determine baseline changes."

The parents of a child diagnosed with cystic fibrosis ask the nurse what caused this disorder. What is the most appropriate response? a. "Cystic fibrosis is a chromosomal defect." b. "Cystic fibrosis is a metabolic defect." c. "Cystic fibrosis is a malformation present at birth." d. "Cystic fibrosis is a blood disorder."

"Cystic fibrosis is a metabolic defect."

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

"Do you plan to have any other children?"

What will the nurse advise when a woman asks what she can do to reduce the discomfort of hot flashes? a. "Aerobic exercise helps control hot flashes." b. "Increase the amount of calcium and vitamin D in your diet." c. "Dress in layers of cotton clothing." d. "Drink plenty of fluids, particularly caffeinated beverages."

"Dress in layers of cotton clothing."

A new mother is concerned because her 3 day old daughter has a slightly blood-tinged mucus vaginal discharge. How should the nurse respond to this mother's concern? A. "The baby could have a minor abnormality in her vagina." B. "Has there been any kind of injury to this area?" C. "Effects of your pregnancy hormones cause this response." D. "This should be reported to the pediatrician right away."

"Effects of your pregnancy hormones cause this response."

A nursing student assisting a woman in labor asks the instructor, "What does it mean when the baby is at minus 1 station?" After being given an explanation by the nursing instructor, what statement by the student indicates an accurate understanding of station? a. "Fetal head is above the ischial spines." b. "Fetal head is below the ischial spines." c. "Fetal head is engaged in the mother's pelvis." d. "Fetal head is visible at the perineum."

"Fetal head is above the ischial spines."

A newborn has a heelstick for studies. The mother is concerned because the baby is crying loudly. The best response of the nurse is A. "That's the only way the baby can communicate with us." B. "Hold the baby close and comfort him by gentle rocking." C. "Babies cannot feel pain because they are immature." D. "The baby will only cry for a few minutes at most."

"Hold the baby close and comfort him by gentle rocking."

The mother of a 2 week old newborn who is going to have a cleft lip repair asks if she will be able to hold her baby after surgery. The nurse should reply A. "The baby can be held when she no longer needs the restraints." B. "The baby cannot be held but you can talk to her and stroke her." C. "Holding your baby helps keep her content." D. "You should hold your baby only during feedings."

"Holding your baby helps keep her content."

A postpartum client is getting ready for discharge. The nurse suspects that the client needs further teaching related to breastfeeding when she makes which statement? 1. "I don't need birth control because I will be breastfeeding." 2. "I need to increase my caloric intake by 500 calories a day." 3. "I shouldn't use soap to wash my breasts because I will be breastfeeding." 4. "I need to be sure that I increase my fluid intake and take my prenatal vitamins while breastfeeding."

"I don't need birth control because I will be breastfeeding."

A nurse is reinforcing postpartum discharge teaching to a client who had no immunity to varicella and was given the varicella vaccine. Which of the following statements by the client indicates understanding? A. "I will need to use contraception for 3 months before considering pregnancy." B. "I need a second vaccination at my postpartum visit." C. "I was given the vaccine because my baby is O-positibe D. "I will be tested in 3 months to see if I have developed immunity."

"I need a second vaccination at my postpartum visit."

During a prenatal visit, the nurse is explaining diabetes mellitus. The nurse determines that the teaching has been effective when the client makes which statement? 1. "I can eat more sweets now because I need more calories." 2. "I need more fat in my diet so that the baby can gain enough weight." 3. "I need to eat a high-protein, low-carbohydrate diet now to control my blood glucose." 4. "I need to increase the fiber in my diet to control my blood glucose."

"I need to increase the fiber in my diet to control my blood glucose."

Which statement indicates a woman understands activity limitations for the management of preterm labor? a. "After my shower in the morning, I do the laundry and straighten up the house; then I rest." b. "I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day." c. "I have a 2-year-old to care for, but I try to rest as much as I can." d. "I get really bored at home, so I go to the shopping mall for just a little while."

"I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day."

A nurse is reviewing a new prescription of ferrous sulfate with a client who is at 12 weeks of gestation. Which of the following statements by the client indicates understanding of the teaching? A. "I will take this pill with my breakfast." B. "I will take this medication with a glass of milk." C. "I plan to drink more orange juice while taking this pill." D. "I plan to add more calcium-rich foods to my diet while taking this medication."

"I plan to drink more orange juice while taking this pill."

What statement indicates the parent understands the guidelines for bathing a newborn? a. "I'll use a mild soap to clean all of the body parts." b. "I am going to add bath oil to the water to keep the baby's skin soft." c. "I should shampoo the head after washing the rest of the body." d. "I'll wash from the feet upward and change the washcloth for the face."

"I should shampoo the head after washing the rest of the body."

Which statement indicates the new mother is breastfeeding correctly? a. "I will alternate breasts when feeding the baby." b. "I keep the baby on a 4-hour feeding schedule." c. "I let the baby stay on the first breast only 5 minutes." d. "I put only the nipple in the baby's mouth when I am breastfeeding."

"I will alternate breasts when feeding the baby."

A pregnant human immunodeficiency virus (HIV)-positive woman delivers a baby. The nurse provides guidance to help the client make decisions regarding newborn care. Which statement by the woman indicates that additional guidance is needed? 1. "I will be sure to wash my hands before feeding the newborn." 2. "I will breastfeed, especially for the firs 6 weeks postpartum." 3. "I will be sure to wash my hands before and after bathroom use." 4. "I will administer the prescribed antiviral medication to the newborn for the first 6 weeks after delivery."

"I will breastfeed, especially for the firs 6 weeks postpartum."

A nurse in an obstetrical clinic is reinforcing teaching with a client about using an IUD for contraception. Which of the following statements by the client indicates an understanding of the teaching? A. "An IUD should be replaced annually during a pelvic exam." B. "I cannot get an IUD until after I've had a child." C. "I should plan on regaining fertility 5 months after the IUD is removed." D. "I will check to be sure the strings of the IUD are still present after my periods."

"I will check to be sure the strings of the IUD are still present after my periods."

A nurse is reinforcing discharge teaching to the parents of a newborn regarding circumcision care. Which of the following statements made by a parent indicates an understanding of the teaching? A. "The circumcision will heal within a couple of days." B. "I should remove the yellow mucus that will form." C. "I will clean the penis with each diaper change." D. "I will give him a tub bath within a couple of days."

"I will clean the penis with each diaper change."

A nurse is assisting the charge nurse with reviewing postpartum nutrition needs with a group of clients who have begun breastfeeding their newborns. Which of the following statements by a member of the group indicates an understanding of the teaching? A. "I am glad I can have my morning coffee." B. "I should take folic acid to increase my milk supply." C. "I will continue adding 330 calories per day to my diet." D. "I will continue my calcium supplements because I don't like milk."

"I will continue my calcium supplements because I don't like milk."

The nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed? 1. "I will flush the eyes after instilling the ointment." 2. "I will clean the newborn's eyes before instilling ointment." 3. "I need to administer the eye ointment within 1 hour after delivery." 4. "I will instill the eye ointment into each of the newborn's conjunctival sacs."

"I will flush the eyes after instilling the ointment."

What statement by the patient leads the nurse to determine a woman with mastitis understands treatment instructions? a. "I will apply cold compresses to the painful areas." b. "I will take a warm shower before nursing the baby." c. "I will nurse first on the affected side." d. "I will empty the affected breast every 8 hours."

"I will take a warm shower before nursing the baby."

The client at 28 weeks' gestation is Rh negative and Coombs antibody negative. The nurse determines that the client understands what the nurse has taught her about Rh sensitization when the client makes which statement? 1. "I know I can never have another child." 2. "I am glad that I won't have to have these shots if I have another child." 3. "I will have to have an injection once a month until the baby is born." 4. "I will tell the nurse at the hospital that I had an Rh shot during pregnancy."

"I will tell the nurse at the hospital that I had an Rh shot during pregnancy."

What statement by a man considering a vasectomy indicates a need for further information? a. "Sterility does not occur immediately after the procedure." b. "We will need to use some form of birth control for about a month afterward." c. "The procedure involves the use of local anesthesia." d. "I'll need to remain in the hospital for a few days."

"I'll need to remain in the hospital for a few days." *takes about 20 min and is performed as an outpatient procedure under local anesthesia.

A woman requests a pudendal block to manage her labor pain. What statement by the woman indicates a need for further explanation about the pudendal block? a. "I'm having a contraction. Can I get the pudendal block now?" b. "I'll get the pudendal block right before I deliver." c. "The nurse-midwife will insert the needles into my vagina." d. "It takes a few minutes after the medicine is administered to make me feel numb."

"I'm having a contraction. Can I get the pudendal block now?"

The nurse finds a woman crying after she has undergone a dilation and evacuation (D&E) for a missed abortion. What is the most appropriate statement by the nurse? a. "There is usually something wrong with the fetus when this happens early in pregnancy." b. "Now there. You can try to conceive on your next cycle." c. "I'm here if you need to talk." d. "You are young and strong. I know you can have a healthy pregnancy."

"I'm here if you need to talk."

What statement made by a new mother indicates she needs additional information about breastfeeding? a. "I let the baby nurse 10 to 15 minutes on the first breast and then switch to the other breast." b. "The baby needs to nurse at least 5 minutes on the breast to get the hindmilk." c. "The baby has been nursing every 2 to 3 hours." d. "If the baby gets fussy between feedings, I give her a bottle of water."

"If the baby gets fussy between feedings, I give her a bottle of water."

A nurse is assisting with the care of a client who is pregnant and undergoing a nonstress test. The client asks why the nurse is using an acoustic vibration device. Which of the following responses should the nurse make? A. "It is used to stimulate uterine contractions." B. "It will decrease the incidence of uterine contractions." C. "It lulls the fetus to sleep." D. "It awakens a sleeping fetus."

"It awakens a sleeping fetus."

A client who is at 8 weeks of gestation tells the nurse, "I am not sure I am happy about being pregnant." Which of the following responses should the nurse make? A. "I will inform the provider that you are having these feelings." B. "It is normal to have these feelings during the first few months of pregnancy." C. "You should be happy that you are going to bring new life into the world." D. "I am going to make an appointment with the counselor for you to discuss these thoughts."

"It is normal to have these feelings during the first few months of pregnancy."

The nursing instructor asks a nursing student to describe the process of quickening. Which statement indicates an understanding of this term? 1. "It is the fetal movement that is felt by the mother." 2. "It is the compressibility of the lower uterine segment." 3. "It is the irregular, painless contractions that occur throughout pregnancy." 4. "It is the soft blowing sound that can be heard when the uterus is auscultated."

"It is the fetal movement that is felt by the mother."

The mother of a 4-month-old infant, born prematurely, asks the nurse if her daughter will always be small for her age. What is the most appropriate nursing response? a. "Preterm infants usually remain smaller than term infants throughout childhood." b. "Your daughter will be the same size as other children by the time she is 1 year old." c. "Prematurity is associated with short stature but does not affect weight gain." d. "It takes about two years for the preterm infant to catch up to a full-term infant."

"It takes about two years for the preterm infant to catch up to a full-term infant."

The young prenatal patient with gestational diabetes mellitus (GDM) says, "I am frightened that I will have to deal with insulin injections for the rest of my life." What is the best response by the nurse? a. "After delivery your doctor will prescribe oral hypoglycemic medication to control your disease. Pills are so much simpler than insulin injections." b. "Have you considered an insulin pump?" c. "After a while those insulin injections won't seem so bad." d. "It will most likely resolve 6 weeks or so after the baby is born."

"It will most likely resolve 6 weeks or so after the baby is born."

What is the best response to a postpartum woman who tells the nurse she feels "tired and sick all of the time since I had the baby 3 months ago"? a. "This is a normal response for the body after pregnancy. Try to get more rest." b. "I'll bet you will snap out of this funk real soon." c. "Why don't you arrange for a babysitter so you and your husband can have a night out?" d. "Let's talk about this further. I am concerned about how you are feeling."

"Let's talk about this further. I am concerned about how you are feeling."

A woman has been taking oral contraceptives for 4 months. She is concerned because her periods are much lighter than before she started the pills. How should the nurse counsel this woman? a. "You will probably have to stop the pill unless your periods become more like they were before." b. "We can switch you to a barrier contraceptive; your periods should return to normal in a few months." c. "Lighter periods are expected when you are on the pill, but you should tell us if they stop entirely." d. "Stop taking the pills immediately. We want to do a pregnancy test before you resume them."

"Lighter periods are expected when you are on the pill, but you should tell us if they stop entirely."

The nurse has explained physiological changes that occur during pregnancy. Which statement indicates that the woman understands the information? a. "Blood pressure goes up toward the end of pregnancy." b. "My breathing will get deeper and a little faster." c. "I'll notice a decreased pigmentation in my skin." d. "There will be a curvature in the upper spine area."

"My breathing will get deeper and a little faster."

Which statement indicates to the nurse on a postpartum home visit that the patient understands the signs of late postpartum hemorrhage? a. "My discharge would change to red after it has been pink or white." b. "If I have a postpartum hemorrhage, I will have severe abdominal pain." c. "I should be alert for an increase in bright red blood." d. "I would pass a large clot that was retained from the placenta."

"My discharge would change to red after it has been pink or white."

A client asks the nurse why her newborn baby needs an injection of vitamin K (phytonadione). The nurse should make which statement to the client? 1. "Your newborn needs vitamin K to develop immunity." 2. "The vitamin K will protect your newborn from becoming jaundiced." 3. "Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding." 4. "Newborns have sterile bowels. The vitamin K will give the bowel the necessary bacteria."

"Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding."

The mother of a 2-week-old infant tells the nurse, "I think the baby is constipated. I've noticed she strains when she has a bowel movement." What is nurse's most helpful response? a. "Give the baby one serving of fruit per day." b. "Increase the amount and frequency of her feedings." c. "It sounds like the baby is uncomfortable because she is constipated." d. "Newborns might strain with bowel movements because their muscles aren't fully developed."

"Newborns might strain with bowel movements because their muscles aren't fully developed."

At her 6-week postpartum checkup, a woman states, "I am wondering about birth control. I used oral contraceptives before, and I'm breastfeeding now. Can I use the pill again?" What is the nurse's best response? a. "You should know that oral contraceptives increase your milk production." b. "Oral contraceptives can be taken once lactation is well established." c. "You don't need to use any form of birth control as long as you are breastfeeding." d. "Oral contraceptives are contraindicated for the lactating woman."

"Oral contraceptives can be taken once lactation is well established." *OC decrease breast milk production

The mother of a 2-week-old infant tells the nurse that she thinks he is sleeping too much. What is the most appropriate nursing response to this mother? a. "Tell me how many hours per day your baby sleeps." b. "It is normal for newborns to sleep most of the day." c. "Newborns generally sleep 12 to 15 hours per day." d. "You will find as the baby gets older, he sleeps less."

"Tell me how many hours per day your baby sleeps."

Three weeks after delivering her first child, a woman tells the nurse, "I waited so long for this baby and now that she is here, I can't believe how different my life is from what I expected." What is the best nursing response to the woman's statement? a. "How is your partner adjusting to the change?" b. "I hear this from a lot of first-time mothers." c. "Have you told anyone else about your feelings?" d. "Tell me how things are different."

"Tell me how things are different."

What is the nurse's best response to a mother who is voicing concern about the molding of her 2-day-old infant? a. "Molding doesn't cause any problems. Don't worry about it." b. "Did you deliver vaginally or by cesarean section?" c. "The baby's head conformed to the shape of the birth canal. It will go away soon." d. "A traumatic delivery can cause molding."

"The baby's head conformed to the shape of the birth canal. It will go away soon."

A woman who is 8 weeks pregnant becomes concerned when she has light vaginal bleeding accompanied by abdominal pain. An ectopic pregnancy is confirmed by ultrasound. Which statement indicates that the woman understands the explanation of an ectopic pregnancy? a. "The chorionic villi develop vesicles within the uterus." b. "The placenta develops in the lower part of the uterus." c. "The fetus dies in the uterus during the first half of the pregnancy." d. "The embryo is implanted in the fallopian tube."

"The embryo is implanted in the fallopian tube."

In the birthing room, a first time father asks the nurse why the baby's head is "long and pointy." The nurse should respond A. "The head changes shape so it can pass through the mother's pelvis during birth." B. "Fluid builds up within the head before and during birth; it will go away in a few days." C. "Labor causes slight bleeding into the space between the skull bones and their covering." D. "We will notify the pediatrician, who will probably order an MRI of the baby's head."

"The head changes shape so it can pass through the mother's pelvis during birth."

The nurse has a teaching session with a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which statement indicates successful learning? 1. "Iron supplements will give me diarrhea." 2. "The iron is needed for the red blood cells." 3. "Meat does not provide iron and should be avoided." 4. "My body has all the iron it needs and I don't need to take supplements."

"The iron is needed for the red blood cells."

Parents ask the nursery staff what the light does for their jaundiced infant. What is the nurse's best response? a. "The light increases the infant's metabolism." b. "The light stimulates liver function." c. "The light dilates blood vessels." d. "The light breaks down bilirubin."

"The light breaks down bilirubin."

A nurse is assisting with an in-service for newly licensed nurses about neonatal abstinence syndrome in newborns. Which of the following statement by a newly licensed nurse indicates an understanding of the teaching? A. "The newborn will have decreased muscle tone." B. "The newborn will have a continuous high-pitched cry." C. "The newborn will sleep for 2 to 3 hours after a feeding." D. "The newborn will have mild tremors when disturbed."

"The newborn will have a continuous high-pitched cry."

The mother of a postterm infant asks the nurse why the infant is being watched so closely. What is the nurse's most appropriate response? a. "The placenta does not function adequately as it ages." b. "Infants born postmaturely are generally large." c. "Delivery of the postterm infant is more difficult." d. "There is less amniotic fluid."

"The placenta does not function adequately as it ages."

A contraction stress test is scheduled for the client. The woman asks the nurse about the test. Which response describes the most accurate description of the test? 1. "Uterine contractions are stimulated by Leopold's maneuvers." 2. "The uterus is stimulated to contract by either small amounts of oxytocin or by nipple stimulation." 3. "An internal fetal monitor is attached, and you will walk on a treadmill until contractions begin." 4. "Small amounts of oxytocin are administered during internal fetal monitoring to stimulate uterine contractions."

"The uterus is stimulated to contract by either small amounts of oxytocin or by nipple stimulation."

The nursing student is asked to describe the size of the uterus in a nonpregnant client. Which response indicates an understanding of the anatomy of this structure? 1. "The uterus weighs about 2 ounces." 2. "The uterus weighs about 2.2 pounds." 3. "The uterus has a capacity of about 50 milliliters." 4. "The uterus is round in shape and weighs approximately 1000 grams."

"The uterus weighs about 2 ounces."

The mother states that her newborn has white pinpoint "pimples" on his nose and chin, and she plans to squeeze them to make them disappear. The best response of the nurse would be A. "Be sure to wipe the area with an alcohol sponge to avoid infection." B. "Ask your health care provider to prescribe an antibiotic ointment for the pimples." C. "These pimples are called "Epstein's pearls' and are a normal occurrence." D. "These pimples are called 'millia' and will disappear on their own in a week or two."

"These pimples are called 'millia' and will disappear on their own in a week or two."

The normal volume of amniotic fluid is approximately _______________ mL at 37 weeks' gestation

1000

A new mother asks why her term newborn sometimes "shakes" when he cries. Choose the best nursing response. A. "Why not ask the baby's doctor about this when she makes rounds?" B. "The baby is easily upset and waves his arms to show his irritation." C. "A newborn's muscles are too weak to move steadily." D. "This is a normal newborn behavior during crying."

"This is a normal newborn behavior during crying."

A nurse in a prenatal clinic is caring for a client who is pregnant and experiencing episodes of maternal hypotension. The client asks the nurse what causes these episodes. Which of the following responses should the nurse make? A. "This is due to an increase in blood volume." B. "This is due to pressure from the uterus on the diaphragm." C. "This is due to the weight of the uterus on the vena cava." D. "This is due to increased cardiac output."

"This is due to the weight of the uterus on the vena cava."

A nurse is reinforcing teaching with new parents on bathing a newborn and observes a bluish brown marking across the newborn's lower back. Which of the following statements should the nurse make concerning the variation? A. "This is more commonly seen in newborns who have dark skin." B. "This is a finding indicating hyperbilirubinemia." C. "This is a forceps mark from an operative delivery." D. "This is related to prolonged birth or trauma during delivery."

"This is more commonly seen in newborns who have dark skin."

A woman required a cesarean section for safe delivery of her newborn. She is planning to breastfeed and verbalized concern about pain. What is the best suggestion by the nurse? a. "Consider formula feeding for the first few days." b. "Pumping breast milk would be best for now." c. "Take pain medication 30 to 40 minutes prior to nursing." d. "Use the football hold when breastfeeding."

"Use the football hold when breastfeeding."

Which statement indicates that parents understand how to feed their infant who had a surgical repair for a cleft lip? a. "We are feeding the baby with a dropper for 2 weeks." b. "We resumed bottle feeding after discharge." c. "We started the baby on solid food yesterday." d. "The baby is drinking well from a straw."

"We are feeding the baby with a dropper for 2 weeks."

What will the nurse begin with when asking a patient about drug use during a prenatal history? a. "Do you smoke, drink alcohol, or use drugs?" b. "Do you ever use prescription or street drugs?" c. "What over-the-counter and prescription drugs have you taken in the past 3 months?" d. "We need to know if you take drugs so we can help your baby."

"What over-the-counter and prescription drugs have you taken in the past 3 months?"

While discussing labor and delivery during a prenatal visit, a primigravida asks the nurse when she should go to the hospital. What is the nurse's most informative response? a. "When you feel increased fetal movement" b. "When contractions are 10 minutes apart" c. "When membranes have ruptured" d. "When abdominal or groin discomfort occurs"

"When membranes have ruptured"

A woman pregnant for the first time asks the nurse, "When will I begin to feel the baby move?" What is the nurse's best response? a. "You may notice the baby moving around the 4th or 5th month." b. "Quickening varies with every woman." c. "You'll feel something by the end of the first trimester." d. "The baby will be big enough for you to feel in your 8th month."

"You may notice the baby moving around the 4th or 5th month."

A nurse is reinforcing teaching with a client who is of 22 weeks gestation about the amniocentesis procedure. Which of the following statements should the nurse make? A. "You will lay on your right side during the procedure." B. You should not eat anything for 24 hours prior to the procedure." C. "You should empty your bladder prior to the procedure." D. "The test is done to determine gestational age."

"You should empty your bladder prior to the procedure."

A nurse in a clinic receives a phone call from a client who would like information about pregnancy testing. Which of the following information should the nurse provide to the client? A. "You should wait 4 weeks after conception to be tested for pregnancy." B. "You should be off any medications for 24 hours prior to the pregnancy test." C. "You should not eat or drink for at least 8 hors prior to the pregnancy test." D. "You should use your first morning urination specimen for a home pregnancy test."

"You should use your first morning urination specimen for a home pregnancy test."

A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which information to the client? 1. "You will be isolated from your newborn after deliver." 2. "There is little risk to your baby during your pregnancy, birth, and after delivery." 3. "Vaginal deliveries can reduce neonatal infection risk, even if you have an active lesion at birth." 4. "You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed."

"You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed."

The nurse is talking to a pregnant client with human immunodeficiency virus (HIV) infection regarding care for the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? 1. "You will need to bottle-feed your newborn." 2. "You will need to feed your newborn by nasogastric tube feeding." 3. "You will be able to breast-feed for 6 months and then you will need to switch to bottle-feeding." 4. "You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding."

"You will need to bottle-feed your newborn."

A nurse is assisting with the care of a client who is at 42 weeks gestation and in labor. The client asks the nurse what to expect because the baby is postmature. Which of the following statements should the nurse make? A. "Your baby will have excess baby fat." B. "Your baby will have flat areola without breast buds." C. "Your baby's heels will easily move to his ears." D. "Your baby's skin will have a leathery appearance."

"Your baby's skin will have a leathery appearance."

A nurse is assisting with caring for a client who is 2 days postpartum. The client states, "My 4 year old old son was toilet trained and now he is frequently wetting himself." Which of the following statements should the nurse provide to the client? A. "Your son was probably not ready for toilet training and should wear training pants." B. "Your son is showing an adverse sibling response." C. "Your son may need counseling." D. "You should try sending your son to preschool to resolve the behavior."

"Your son is showing an adverse sibling response."

An Rh-negative mother who gives birth to an Rh-positive newborn should receive Rho(D) immune globulin (RhoGAM) no later than ________ hours after birth. A. 4-8 B. 16 C. 24-36 D. 72

72

The Rh-negative mother should receive a dose of RhoGam within _____ hours after giving birth to an Rh-positive infant.

72

A nurse is collecting data from a newborn following birth. Which of the following physical findings indicate the newborn is adapting to extrauterine life? (select all that apply) A. Expiratory grunting B. Inspiratory nasal flaring C. Apnea for 10 second periods D. Obligatory nose breathing E. Crackles and wheezing

1. Apnea for 10 second periods 2. Obligatory nose breathing

The nurse is instructing a Lamaze class on abdominal breathing and tells a patient that her baseline respiratory rate is 22 breaths per minute. What should be the patient's rate while performing slow breathing? a. 9 b. 11 c. 15 d. 20

. 11

The nurse caring for a preterm infant will record the intake and output. The nurse is aware that what is the optimum output for this infant? a. 1 to 3 mL/kg/hr b. 4 to 6 mL/kg/hr c. 7 to 9 mL/kg/hr d. 10 to 14 mL/kg/hr

1 to 3 mL/kg/hr

A 3-month-old infant is diagnosed with developmental hip dysplasia. The nurse knows that what is the usual treatment for an infant with this diagnosis? a. A Pavlik harness b. A body spica cast c. Traction d. Triple-diapering

A Pavlik harness

Which statements are accurate about what the nurse should tell the mom to expect in the postpartum period? (Select all that apply.) A. "By the third day, your breasts will become firm from mild production." B. "Your uterus should return to pre-pregnancy size by 6 months." C. "You should call the doctor if your discharge returns to bright red rubra after progressing to the clear discharge of alba." D. "Afterpains should decrease rapidly within 48 hours postpartum." E. "You may need to use a water-soluble lubricant for intercourse." F. "You might see a temporary increase of blood flow during ambulation."

1. "By the third day, your breasts will become firm from mild production." 2. "You should call the doctor if your discharge returns to bright red rubra after progressing to the clear discharge of alba." 3. "Afterpains should decrease rapidly within 48 hours postpartum." Correct 4. "You may need to use a water-soluble lubricant for intercourse." Correct 5. "You might see a temporary increase of blood flow during ambulation."

A nurse is reinforcing teaching with a client about the benefits of internal fetal heart monitoring. Which of the following statements should the nurse include? (select all that apply) A. "It is considered a noninvasive procedure." B. "It can detect abnormal fetal heart tones early." C. "It can determine the amount of amniotic fluid you have." D. "It allows for accurate readings with maternal movement." E. "It can measure uterine contraction intensity."

1. "It can detect abnormal fetal heart tones early." 2. "It allows for accurate readings with maternal movement." 3. "It can measure uterine contraction intensity."

A nurse in a clinic is reinforcing teaching with a client about a new prescription for medroxyprogesterone. Which of the following information should the nurse include in the teaching? (Select all that apply) A. "Weigh fluctuations can occur." B. "You are protected against STIs." C. "You should increase your intake of calcium." D. "You should avoid taking antibiotics." E. "Irregular vaginal spotting can occur."

1. "Weigh fluctuations can occur." 2. "You should increase your intake of calcium." 3. "Irregular vaginal spotting can occur."

The nurse assesses the perineal pad placed on a 3-hour postdelivery patient and finds that there is no lochia on it. What would the nurse expect to find on further assessment? (Select all that apply.) a. A firm fundus the size of a grapefruit b. A full bladder c. Retained placental fragments d. Vital signs indicative of shock e. A soft, boggy fundus

1. A full bladder 2. A soft, boggy fundus

What do late decelerations indicate? (Select all that apply.) a. A nonreassuring pattern b. Uteroplacental insufficiency c. Fetal heart depression d. Cord compression e. Head compression

1. A nonreassuring pattern 2. Uteroplacental insufficiency 3. Fetal heart depression

The nurse instructs a woman taking oral contraceptives to report which possible side effects? (Select all that apply.) a. Abdominal pain b. Weight gain c. Headache d. Eye or visual problems e. Speech disturbances

1. Abdominal pain 2. Headache 3. Eye or visual problems 4. Speech disturbances

What postpartum exercises should the nurse teach a patient who had a vaginal delivery yesterday? (Select all that apply.) a. Abdominal tighteners b. Head lift c. Pelvic tilt d. Kegel exercises e. Leg lifts

1. Abdominal tighteners 2. Head lift 3. Pelvic tilt 4. Kegel exercises

The patient who has been dealing with urge incontinence tells the nurse that the symptoms have gotten worse lately. The nurse reminds the patient that which food(s) and drug(s) can increase incontinence? (Select all that apply.) a. Antihypertensive drugs b. Coffee c. Alcohol d. Diuretics e. NSAIDs

1. Antihypertensive drugs 2. Coffee 3. Alcohol 4. Diuretics

A woman is diagnosed with a urinary tract infection in the postpartum period. What foods can the nurse encourage to increase the acidity of urine? (Select all that apply.) a. Apricots b. Cranberry juice c. Plums d. Prunes e. Apples

1. Apricots 2. Cranberry juice 3. Plums 4. Prunes

The nurse is caring for a woman with epidural anesthesia for pain control during a vaginal delivery. A risk for injury related to epidural anesthesia has been identified by the nursing staff. What interventions are appropriate for the nurse to implement related to this diagnosis? (Select all that apply.) a. Assess leg movement and sensation before ambulating. b. Administer antibiotic as ordered. c. Observe for signs of impending birth. d. Provide sacral pressure as needed. e. Assess fetal position frequently.

1. Assess leg movement and sensation before ambulating. 2. Observe for signs of impending birth.

The nurse is obtaining intake information on a new patient being seen for preconception care and notes a family history of neural tube defects. What interventions can the nurse suggest to this woman to help prevent neural tube anomalies in a developing fetus? (Select all that apply.) a. Avoid drug use. b. Follow a low-calorie, low-protein diet. c. Take a folic acid supplement every day. d. Exercise daily. e. Maintain bed rest during the first trimester.

1. Avoid drug use. 2. Take a folic acid supplement every day.

Select the two most important nursing assessments immediately after a woman receives an epidural block (select all that apply) A. Bladder distention B. Condition of IV site C. Respiratory rate D. Blood pressure

1. Bladder distention 2. blood pressure

The nurse is aware that a full-term infant is born with which reflexes? (Select all that apply.) a. Blinking b. Sneezing c. Gagging d. Sucking e. Pincer grasping

1. Blinking 2. Sneezing 3. Gagging 4. Sucking

A nurse is discussing risk factors for postpartum shock with a childbirth preparation class. What will the nurse include in this education session? (Select all that apply.) a. Hypertension b. Blood clotting disorders c. Anemia d. Infection e. Postpartum hemorrhage

1. Blood clotting disorders 2. Anemia 3. Infection 4. Postpartum hemorrhage

The nurse in the newborn nursery is watchful for neonatal abstinence syndrome in the newborn of a mother who took opioids during pregnancy. What would be the manifestations of this syndrome? (Select all that apply.) a. Body tremors b. Excessive sneezing c. Hyperirritability d. Drowsiness e. Excessive appetite

1. Body tremors 2. Excessive sneezing 3. Hyperirritability

How might the nurse instruct the patient to stimulate her nipples in an attempt to increase the quality of uterine contractions? (Select all that apply.) a. Place a warm, moist washcloth over the breast. b. Brush the nipples with a dry washcloth. c. Gently pull on the nipples. d. Apply suction to the nipples with a breast pump. e. Press the palms of her hands down on her breasts.

1. Brush the nipples with a dry washcloth. 2. Gently pull on the nipples. 3. Apply suction to the nipples with a breast pump.

How does the pain of childbirth differ from other types of pain? (Select all that apply.) a. Childbirth pain is part of a normal process. b. Childbirth pain seldom needs narcotic relief. c. Position changes relieve pain and facilitate delivery. d. Childbirth pain declines following birth. e. Childbirth pain is self-limited.

1. Childbirth pain is part of a normal process. 2. Position changes relieve pain and facilitate delivery. 3. Childbirth pain declines following birth. 4. Childbirth pain is self-limited.

What would the nurse include in a teaching plan for the pregnant patient who has iron deficiency anemia and has been placed on iron supplements? (Select all that apply.) a. Citrus fruits enhance absorption of iron. b. Bran products support iron deficiency. c. Milk will disguise the taste of the iron. d. The iron therapy will continue for about 3 months. e. Tea should be avoided while taking iron.

1. Citrus fruits enhance absorption of iron. 2. The iron therapy will continue for about 3 months. 3. Tea should be avoided while taking iron.

A nurse in a prenatal clinic is caring for a client who is in the first trimester of pregnancy. The client's health record includes this data: G3 T1 P0 A1 L1. How should the nurse interpret this information? (select all that apply) A. Client has delivered one newborn at term B. Client has experienced no preterm labor C. Client has been through active labor D. Client has had two prior pregnancies E. Client has one living child

1. Client has delivered one newborn at term 2. Client has experienced no preterm labor 3. Client has had two prior pregnancies 4. Client has one living child

What characteristics are typical in a child diagnosed with Down syndrome? (Select all that apply.) a. Close-set eyes b. Simian creases c. Wide-spaced front teeth d. Protruding tongue e. Curved, small fingers

1. Close-set eyes 2. Simian creases 3. Protruding tongue 4. Curved, small fingers

A nurse is assisting with the care of a client who is pregnant and is to undergo a contraction stress test (CST). Which of the following findings are indications for this procedure? (Select all that apply) A. Decreased fetal movement B. Intrauterine growth restriction (IUGR) C. Postmaturity D. Placenta previa E. Amniotic fluid emboli

1. Decreased fetal movement 2. Intrauterine growth restriction (IUGR) 3. Postmaturity

A nurse is assisting with care for a client who is 1 day postpartum. The nurse is collecting data for maternal adaptation and parent-infant bonding. Which of the following behaviors by the client indicates a need for the nurse to intervene? (Select all that apply) A. Demonstrates apathy when the newborn cries B. Touches the newborn and maintains close physical proximity C. Views the newborn's behavior as uncooperative during diaper changing D. Identifies and relates newborn's characteristics to those of family members E. Interprets and relates newborn's characteristics to those of family members

1. Demonstrates apathy when the newborn cries 2. Views the newborn's behavior as uncooperative during diaper changing

A nurse is caring for a client who is at 14 weeks of gestation and has hyperemesis gravidarum. The nurse should identify that which of the following are risk factors for the client? (select all that apply) A. Diabetes B. multifetal pregnancy C. maternal age greater than 40 D. gestational trophoblastic disease E. Oligohydramnios

1. Diabetes 2. multifetal pregnancy 3. gestational trophoblastic disease

What would be considered risk factor(s) for low blood glucose after birth? (Select all that apply.) A. Hypothermia B. Large size for gestational age C. Congenital heart defects D. Preterm E. Maternal diabetes

1. Hypothermia 2. Large size for gestational age 3. Preterm 4. Maternal diabetes

The nurse emphasizes to a patient with a high-risk pregnancy that the impact of such a pregnancy might result in which problems? (Select all that apply.) a. Disruption of family roles b. Financial pressures c. Excessive attachment to infant d. Frustration with activity restriction e. Alteration in child care practices

1. Disruption of family roles 2. Financial pressures 3. Frustration with activity restriction 4. Alteration in child care practices

A patient at the obstetric office has just learned she is pregnant with dizygotic twins. What facts will the nurse include when educating this patient? (Select all that apply.) a. Dizygotic twins are the same sex. b. Dizygotic twins share a placenta. c. Dizygotic pregnancies tend to repeat in families. d. Dizygotic twins have separate chorions. e. Dizygotic twin incidence decreases with maternal age.

1. Dizygotic pregnancies tend to repeat in families. 2. Dizygotic twins have separate chorions.

The physician has ordered Fentanyl (Sublimaze) for a woman in labor and has asked the nurse to provide patient education. What will the nurse include in the educational plan? (Select all that apply.) a. Onset is slow. b. Duration is short. c. Administration is by mouth. d. No known side effects. e. It is not the same drug as sufentanil.

1. Duration is short. 2. It is not the same drug as sufentanil.

A nurse is teaching a lesson on fetal development to a class of high school students and explains the primary germ layers. What are the germ layers? (Select all that apply.) a. Ectoderm b. Endoderm c. Mesoderm d. Plastoderm e. Blastoderm

1. Ectoderm 2. Endoderm 3. Mesoderm

The nurse is instructing a woman at 6 months postpartum on weaning her infant from breastfeeding. What interventions will the nurse suggest? (Select all that apply.) a. Omit newborn's favorite feeding first. b. Eliminate one feeding at a time. c. Expect the need for comfort feeding. d. Formula will need to be provided to substitute for feeding. e. Pump breasts in place of eliminated feeding.

1. Eliminate one feeding at a time. 2. Expect the need for comfort feeding. 3. Formula will need to be provided to substitute for feeding.

What will the nurse teach a nursing mother to do to reduce the risk of mastitis? (Select all that apply.) a. Limit fluid intake to 1 liter per day. b. Empty both breasts with each feeding. c. Take warm showers. d. Wear a supportive bra. e. Pump breasts to ensure emptying.

1. Empty both breasts with each feeding. 2. Take warm showers. 3. Wear a supportive bra. 4. Pump breasts to ensure emptying

A nurse is assisting with the care for a client who is at 40 weeks of gestation and experiencing contractions every 3 to 5 min and becoming stronger. A vaginal exam by the registered nurse reveals that the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client asks for pain medication. Which of the following actions should the nurse prepare to take? (Select all that apply) A. Encourage use of patterned breathing techniques B. Insert an indwelling urinary catheter C. Administer opioid analgesic medication D. Suggest application of cold E. Provide ice chips

1. Encourage use of patterned breathing techniques 2. Administer opioid analgesic medication 3. Suggest application of cold

Which interventions could a nurse apply to help stimulate contractions? (Select all that apply.) a. Encouraging the patient to sit upright b. Assisting the patient to ambulate c. Stimulating the nipples d. Offering emotional support e. Allowing the patient to vent frustration

1. Encouraging the patient to sit upright 2. Assisting the patient to ambulate 3. Stimulating the nipples

A nurse is discussing risk factors for urinary tract infections with a newly licensed nurse. Which of the following conditions should the nurse include in the teaching? (Select all that apply) A. Epidural anesthesia B. Urinary bladder catherization C. Frequent pelvic examinations D. History of UTIs E. Vaginal birth

1. Epidural anesthesia 2. Urinary bladder catherization 3. Frequent pelvic examinations 4. History of UTIs

The nurse is caring for a woman in labor. Which of the following observations require immediate nursing intervention? (select all that apply) A. FHR of 90 beats/min between contractions B. maternal tachysystole C. contractions lasting 60 seconds with an interval of 90 seconds D. FHR baseline variability

1. FHR of 90 beats/min between contractions 2. maternal tachysystole

A nurse is reviewing findings of client's biophysical profile (BPP). The nurse should expect which of the following variables to be included in this test? (select all that apply) A. Fetal weight B. Fetal breathing movement C. Fetal tone D. Fetal position E. Amniotic fluid volume

1. Fetal breathing movement 2. Fetal tone 3. Amniotic fluid volume

A nurse is assisting with the care for a client who has a prescription for magnesium sulfate. The nurse should recognize that which of the following are contraindications for use of this medication? (select all that apply) A. Fetal distress B. Preterm labor C. Vaginal bleeding D. Cervical dilation greater than 6 cm E. Severe gestational hypertension

1. Fetal distress 2. Vaginal bleeding 3. Cervical dilation greater than 6 cm

What breathing techniques would the nurse teach the prenatal patient to help her focus during labor in order to reduce pain? (Select all that apply.) a. First-stage breathing b. Abdominal breathing c. Fourth-stage breathing d. Modified paced breathing e. Patterned paced breathing

1. First-stage breathing 2. Abdominal breathing 3. Modified paced breathing 4. Patterned paced breathing

What are the anonymous sperm donors screened for? (Select all that apply.) a. Particular physical features b. Genetic defects c. Infections d. High-risk behaviors e. Nationality

1. Genetic defects 2. Infections 3. High-risk behaviors

The nurse is obtaining history and physical information on a new patient attending her first prenatal visit. After recording current height, weight, and BMI, it is determined that the patient is obese. What complications related to obesity will the nurse assess this patient for during pregnancy? (Select all that apply.) a. Gestational diabetes b. RH incompatibility c. Hypertension d. Pre-eclampsia e. Infection

1. Gestational diabetes 2. Hypertension 3. Pre-eclampsia

A nurse is assisting with caring for a client who is in labor. The nurse should identify that which of the following infections can be treated during labor or immediately following birth? (Select all that apply) A. Gonorrhea B. Chlamydia C. HIV D. Group B streptococcus beta-hemolytic E. TORCH infection

1. Gonorrhea 2. Chlamydia 3. HIV 4. Group B streptococcus beta-hemolytic

A nurse is reviewing the health record of a client who is pregnant. The provider indicated the client exhibits probable signs of pregnancy. Which of the following findings should the nurse expect? (select all that apply) A. Montgomery's glands B. Goodell's sign C. Ballottement D. Chadwick's sign E. Quickening

1. Goodell's sign 2. Ballottement 3. Chadwick's sign

The nurse assesses the progress from the announcement stage of fatherhood to the acceptance stage when the patient reports which actions by the father? (Select all that apply.) a. Goes fishing every afternoon. b. Has revised his financial plan. c. Spends leisure time with his friends. d. Traded his sports car for a sedan. e. Helped select a crib.

1. Has revised his financial plan. 2. Traded his sports car for a sedan. 3. Helped select a crib.

What manifestations of increasing ICP in the hydrocephalic child should the nurse be aware of? (Select all that apply.) a. High-pitched cry b. Unequal pupils c. Bulging fontanelles d. Diarrhea e. Hiccups

1. High-pitched cry 2. Unequal pupils 3. Bulging fontanelles

What are the advantages of a freestanding birth center? (Select all that apply.) a. Homelike setting b. Designed for high-risk pregnancies c. Lower costs d. Attended by certified obstetricians e. Immediate emergency access

1. Homelike setting 2. Lower costs

A nurse is reviewing contraindications for circumcision with a newly hired nurse. Which of the following conditions are contraindications? (Select all that apply) A. Hypospadias B. Hydrocele C. Family history of hemophilia D. Hyperbilirubinemia E. Epispadias

1. Hypospadias 2. Family history of hemophilia 3. Epispadias

What typical types of classes are available to help expectant parents prepare for parenthood? (Select all that apply.) a. Infant care b. Breastfeeding c. Gestational diabetes d. Sources of financial aid e. Yoga

1. Infant care 2. Breastfeeding 3. Gestational diabetes

A woman is preparing for administration of a cervical ripening agent. What nursing actions will the nurse anticipate implementing? (Select all that apply.) a. Insert IV. b. Record a baseline fetal heart rate. c. Explain procedure to patient. d. Instruct patient to ambulate immediately afterward. e. Ensure a tocolytic is available.

1. Insert IV. 2. Record a baseline fetal heart rate. 3. Explain procedure to patient

A nurse is reinforcing teaching with a client about potential adverse effects of implantable progestins. Which of the following adverse effects should the nurse include? (select all that apply) A. Tinnitus B. Irregular vaginal bleeding C. Weight gain D. Nausea E. Gingival hyperplasia

1. Irregular vaginal bleeding 2. Weight gain 3. Nausea

The nurse is caring for a patient planning to undergo a uterine fibroid embolization. What information can the nurse provide? (Select all that apply.) a. It involves laser destruction of fibroids. b. It has fewer physiological effects than drug therapy. c. It is nonsurgical. d. It is associated with more psychological effects than surgery. e. It has a faster recovery time than surgery.

1. It has fewer physiological effects than drug therapy. 2. It is nonsurgical 3. It has a faster recovery time than surgery.

A nurse in an antepartum clinic is collecting data from a client who has a TORCH infection. Which of the following findings should the nurse expect? (select all that apply) A. Joint pain B. Malaise C. Rash D. Urinary frequency E. Tender lymph nodes

1. Joint pain 2. Malaise 3. Rash 4. Tender lymph nodes

What would be included in the plan of care for a child just returned to the floor from surgery in which a clubfoot was repaired? (Select all that apply.) a. Keep cast uncovered to allow drying. b. Check toes for capillary refill. c. Circle with a pen any area of bleeding on the cast. d. Keep casted leg lowered. e. Observe for skin irritation.

1. Keep cast uncovered to allow drying. 2. Check toes for capillary refill. 3. Circle with a pen any area of bleeding on the cast. 4. Observe for skin irritation.

What will the nurse include in the plan of care when caring for an infant with an intracranial hemorrhage? (Select all that apply.) a. Keep positioned with head elevated. b. Feed slowly to reduce possibility of vomiting. c. Stimulate often to maintain level of consciousness. d. Hold and coddle frequently to stimulate. e. Observe for increased intracranial pressure.

1. Keep positioned with head elevated. 2. Feed slowly to reduce possibility of vomiting. 3. Observe for increased intracranial pressure.

A nurse is assisting with the care of a newborn who was born at 32 weeks of gestation. The newborn's birth weight is 1,100 g. Which of the following are expected findings in this newborn? (select all that apply) A. Lanugo B. Long nails C. Weak grasp reflex D. Translucent skin E. Plum face

1. Lanugo 2. Weak grasp reflex 3. Translucent skin

The nurse instructs the postpartum patient that her nutritional intake should include which food(s) particularly supportive to healing? (Select all that apply.) a. Legumes b. Potatoes and pasta c. Citrus fruits d. Rice e. Cantaloupe

1. Legumes 2. Citrus fruits 3. Cantaloupe

What are the functions of amniotic fluid? (Select all that apply.) a. Maintaining an even temperature b. Impeding excessive fetal movement c. Lubricating fetal skin d. Acting as a reservoir for nutrients e. Acting as a cushion for the fetus

1. Maintaining an even temperature 2. Acting as a cushion for the fetus

What are the rationales for labor induction? (Select all that apply.) a. Placenta previa b. Prolapse of cord c. High station of fetus d. Maternal diabetes e. Placental insufficiency

1. Maternal diabetes 2. Placental insufficiency

The nurse cautions that women with a history of which disorders are not candidates for HRT? (Select all that apply.) a. Melanoma b. Estrogen-dependent breast cancer c. Hepatitis C d. Thromboembolic disease e. Hyperthyroidism

1. Melanoma 2. Estrogen-dependent breast cancer 3. Hepatitis C 4. Thromboembolic disease

A woman delivered her newborn several hours previously, and her uterus remains soft and boggy. Which of the following medications should the nurse anticipate that the health care provider would prescribe to increase uterine tone and firm the uterus? (select all that apply) A. Methylergonovine (Methergine) B.) Carboprost (Hemabate) C.) Magnesium Sulfate D.) Oxytocin (Pitocin)

1. Methylergonovine (Methergine) 2. Carboprost (Hemabate) 3. Oxytocin (Pitocin)

The nurse should be alert to subinvolution of the uterus as a cause of late postpartum bleeding. Signs to report and document include (select all that apply) A. Fundal height than expected for date B. Persistence of lochia rubra C. Low blood pressure D. Persistence of lochia alba

1. Persistence of lochia rubra 2. Low blood pressure

The nurse is caring for a woman who gave birth to a preterm infant. The nurse is aware that what are possible causes of preterm delivery? (Select all that apply.) a. Placenta previa b. Gestational diabetes c. Pregnancy-induced hypertension d. Hyperemesis gravidarum e. Chloasma

1. Placenta previa 2. Gestational diabetes 3. Pregnancy-induced hypertension

What nursing interventions are appropriate for the prenatal patient in terms of prenatal care? (Select all that apply.) a. Offer nutritional counseling. b. Reinforce responsibility of parenthood. c. Reduce risk factors. d. Improve health practices. e. Make financial arrangements for delivery.

1. Offer nutritional counseling. 2. Reinforce responsibility of parenthood. 3. Reduce risk factors. 4. Improve health practices.

A nurse is assisting with the care for a client who is at 42 weeks of gestation and is having an ultrasound. For which of the following conditions should the nurse prepare for an autoinfusion? (Select all that apply) A. Oligohydramnios B. Hydramnios C. Fetal cord compression D. Hydration E. Fetal immaturity

1. Oligohydramnios 2. Fetal cord compression

A pregnant woman arrives at the emergency department (ED) and reports she is in labor. After a thorough examination and diagnostic testing, it is determined to be false (prodromal) labor. What signs and symptoms would lead the nurse to suspect false (prodromal) labor? a. Leaking of vaginal fluid b. Contractions intensify with ambulation c. Pink spotting d. Painless tightening of abdominal muscles e. Cervix thick and not effaced

1. Painless tightening of abdominal muscles 2. Cervix thick and not effaced

The nurse assesses a preterm infant in the NICU. What signs should be reported to the physician? (Select all that apply.) a. Paleness b. Transparent skin c. Superficial scalp veins d. Vomiting e. Bulging fontanelles

1. Paleness 2. Vomiting 3. Bulging fontanelles

Which position(s) and exercise(s) will the nurse teach as beneficial in combating discomfort in the later stages of pregnancy? (Select all that apply.) a. Leg lifts b. Pelvic rock c. Tailor sitting d. Sit-ups e. Shoulder curling

1. Pelvic rock 2. Tailor sitting 3. Shoulder curling

A nurse is providing information to a group of clients who are pregnant about measures to relieve backache during pregnancy. Which of the following measures should the nurse include? (select all that apply) A. Avoid any lifting B. Perform Kegel exercises twice a day C. Perform the pelvic rock exercise every day D. Use proper mechanics E. Avoid constrictive clothing

1. Perform the pelvic rock exercise every day 2. Use proper mechanics

The nurse is assessing Apgar score on a newborn. What will be evaluated? (Select all that apply.) a. Reflexes b. Color c. Heart rate d. Respiration e. Weight

1. Reflexes 2. Color 3. Heart rate 4. Respiration

A woman is 37 weeks pregnant and questioning the nurse about possible induction of labor at term. What conditions would contraindicate labor induction? (Select all that apply.) a. Maternal gynecoid pelvis b. Placenta previa c. Horizontal cesarean incision d. Prolapsed cord e. Gestational diabetes

1. Placenta previa 2. Prolapsed cord

The nurse is giving a shower to a patient who had a cesarean section 2 days previously. What interventions should be included before, during, and after the shower? (Select all that apply.) a. Leave abdominal dressing open to air. b. Position patient with back to water stream. c. Cover infusion site with rubber glove. d. Provide a shower chair. e. Confirm ambulation ability.

1. Position patient with back to water stream. 2. Cover infusion site with rubber glove. 3. Provide a shower chair. 4. Confirm ambulation ability.

A patient who is 30 weeks pregnant delivers a stillborn child in the emergency department (ED). What should the ED nurse offer the patient? (Select all that apply.) a. Privacy b. An opportunity to hold the infant c. Materials about support groups d. A memento (footprint or lock of hair) e. A warm beverage

1. Privacy 2. An opportunity to hold the infant 3. Materials about support groups 4. A memento (footprint or lock of hair)

While caring for an Arab woman in labor, the nurse should provide cultural sensitivity through which interventions? (Select all that apply.) a. Provide for extreme modesty. b. Assign a male caregiver. c. Arrange for the husband/partner to participate in labor. d. Provide adequate pain control. e. Respect protective amulets.

1. Provide for extreme modesty. 2. Provide adequate pain control. 3 Respect protective amulets.

A woman, gravida 3, para 2, is attending her fourth prenatal visit and confides in the nurse that she is battered by her husband. She is assessed to have multiple bruises at various stages of healing. What nursing actions are appropriate for the nurse to implement? (Select all that apply.) a. Tell the husband that authorities will be notified immediately. b. Provide privacy for the assessment. c. Determine if children are being hurt. d. Communicate in a nonjudgmental way. e. Determine factors that increase the risk of injury.

1. Provide privacy for the assessment. 2. Determine if children are being hurt. 3. Communicate in a nonjudgmental way. 4. Determine factors that increase the risk of injury.

A postpartum patient is experiencing hypovolemic shock. What interventions can the nurse anticipate? (Select all that apply.) a. Provision of IV fluids b. Placement of an indwelling Foley catheter c. Assessment of oxygen saturation d. Administration of anticoagulants e. Blood transfusion

1. Provision of IV fluids 2. Placement of an indwelling Foley catheter 3. Assessment of oxygen saturation 4. Blood transfusion

While instructing a new mother on formula preparations, the nurse would include what types? (Select all that apply.) a. Ready-to-feed formula b. Concentrated liquid formula c. Powdered formula d. Cow's milk e. Canned evaporated milk

1. Ready-to-feed formula 2. Concentrated liquid formula 3. Powdered formula

A woman who is 36 weeks pregnant tells the nurse she plans to take a 12-hour flight to Hawaii. What would the nurse recommend that the patient do during the flight? (Select all that apply.) a. Wear tight-fitting clothing to promote venous return. b. Eat a large meal before boarding the flight. c. Request a seat with greater leg room. d. Drink at least 4 ounces of water every hour. e. Get up and walk around the plane frequently.

1. Request a seat with greater leg room. 2. Drink at least 4 ounces of water every hour. 3. Get up and walk around the plane frequently.

The nurse recognizes which behavior characteristic(s) of women in their first trimester of pregnancy? (Select all that apply.) a. Showing off her sonogram photos b. Ambivalence about pregnancy c. Emotional and labile mood d. Focusing on her infant e. Fatigue

1. Showing off her sonogram photos 2. Ambivalence about pregnancy 3. Emotional and labile mood 4. Fatigue

Which are nonpharmacological forms of pain relief? (Select all that apply.) a. Skin stimulation b. Diversion and distraction c. Breathing techniques d. Exercise e. Yoga

1. Skin stimulation 2. Diversion and distraction 3. Breathing techniques

The nurse takes into consideration that newborns are especially prone to dehydration because of which aspects of their physiology? (Select all that apply.) a. Small glomeruli b. Minimal renal blood flow c. Inactive gastrointestinal (GI) tract d. Excessive fluid loss from the sweat glands e. Immature renal tubules that do not concentrate urine

1. Small glomeruli 2. Minimal renal blood flow 3. Immature renal tubules that do not concentrate urine

What noninvasive forms of pain relief might a nurse implement with a newborn? (Select all that apply.) a. Swaddling b. Rocking c. Offering a pacifier d. Distraction e. Cuddling

1. Swaddling 2. Rocking 3. Offering a pacifier 4. Cuddling

Which of the following is a nursing intervention that does not require the written order of the health care provider? (select all that apply) A. Administer an analgesic for pain B. Teach the patient how to perform perineal care C. Apply topical anesthetic for perineal suture pain D. turn patient q2h

1. Teach the patient how to perform perineal care 2. turn patient q2h

A nurse is assisting with caring for a client who is postpartum. Which of the following maternal characteristics should the nurse identify as the takin-in phase of maternal postpartum adjustment? A. The client is excited and talkative B. The client is independent with caring for baby C. The client requires assistance with meeting basic needs D. The client is eager to learn new tasks E. The client is desiring to take charge of their care

1. The client is excited and talkative 2. The client requires assistance with meeting basic needs

The nurse is providing a conference on nonpharmacological pain control methods. What major advantages of nonpharmacological pain control methods will the nurse include in the presentation? (Select all that apply.) a. They sedate the mother. b. They do not slow labor. c. They do not dull the excitement of the birth experience. d. They do not have the potential to cause allergic reactions. e. They do not have to be delayed until labor is well established.

1. They do not slow labor. 2. They do not dull the excitement of the birth experience. 3. They do not have the potential to cause allergic reactions. 4. They do not have to be delayed until labor is well established.

Which assessments would lead the nurse to determine the gestational age of the infant as preterm? (Select all that apply.) a. Thin, transparent skin b. Vernix only in the body creases c. Folded ear springs back slowly d. Breast tissue under the nipple e. Creases over entire sole

1. Thin, transparent skin 2. Folded ear springs back slowly

The nurse educates prenatal patients about the threat of TORCH infections. Which infections are included in this classification? (Select all that apply.) a. Toxoplasmosis b. Toxemia c. Cytomegalovirus d. Rubella e. Herpes simplex

1. Toxoplasmosis 2. Cytomegalovirus 3. Rubella 4. Herpes simplex

A nurse is assisting with the care for a client who reports manifestations of preterm labor. Which of the following findings are risk factors of this condition? (select all that apply) A. Urinary tract infection B. Multifetal pregnancy C. Oligohydramnios D. Diabetes mellitus E. Uterine abnormalities

1. Urinary tract infection 2. Multifetal pregnancy 3. Diabetes mellitus 4. Uterine abnormalities

A nurse is preparing to reinforce education to a client who is 2 hr postpartum and has perineal laceration. Which of the following information should the nurse include? (select all that apply) A. Use a perineal squeeze bottle to cleanse the perineum B. Sit on the perineum while resting in bed C. Apply a topical anesthetic cream or spray to the perineum D. Wipe the perineum thoroughly with a back and forth motion E. Apply cold or ice packs to the perineum

1. Use a perineal squeeze bottle to cleanse the perineum 2. Apply a topical anesthetic cream or spray to the perineum 3. Apply cold or ice packs to the perineum

A nurse is assisting with admitting a client who is in labor and has HIV. Which of the following interventions should the nurse identify as contraindicated for this client? (select all that apply) A. Vacuum extractor B. Oxytocin infusion C. Forceps D. Cesarean birth E. Internal fetal monitoring

1. Vacuum extractor 2. Forceps 3. Internal fetal monitoring

The nurse takes into consideration that the patient with placenta previa is at risk for postpartum infection for what reasons? (Select all that apply.) a. Vaginal organisms can invade the placenta. b. The undernourished placenta becomes necrotic. c. The amniotic fluid can become infected. d. The placenta is an excellent growth medium. e. The misplaced placenta weakens the uterine wall.

1. Vaginal organisms can invade the placenta. 2. The placenta is an excellent growth medium.

The nurse reminds new parents that newborns must be protected from environments that are too cold or too hot because of which aspects of the newborn's physiology? (Select all that apply.) a. Very little subcutaneous fat b. Low metabolic rates c. Ineffective sweat glands d. Small fluid reserves e. Low red blood cell counts

1. Very little subcutaneous fat 2. Ineffective sweat glands

The nurse cautions the patient that, because of hormonal changes in late pregnancy, the pelvic joints relax. What does this result in? (Select all that apply.) a. Waddling gait b. Joint instability c. Urinary frequency d. Back pain e. Aching in cervical spine

1. Waddling gait 2. Joint instability

Which interventions would be included in the nursing care of the newly circumcised infant? (Select all that apply.) a. Wash penis with warm water. b. Wipe with alcohol swab. c. Gently remove the yellow crust formation. d. Apply diaper loosely. e. Dress with simple bandage.

1. Wash penis with warm water. 2. Apply diaper loosely.

What complications of overstimulation of uterine contractions may occur? (Select all that apply.) a. Water intoxication b. Impaired placental exchange of oxygen and nutrients c. Increased blood pressure d. Convulsions e. Uterine rupture

1. Water intoxication 2. Impaired placental exchange of oxygen and nutrients 3. Uterine rupture

The nurse is caring for a macrosomic newborn of a woman diagnosed with gestational diabetes immediately after birth. What assessment findings can the nurse anticipate? (Select all that apply.) a. High blood glucose levels b. Weight of 9 pounds or more c. Decreased subcutaneous fat d. Hypocalcemia e. Hyperbilirubinemia

1. Weight of 9 pounds or more 2. Hypocalcemia 3. Hyperbilirubinemia

The postoperative care for a newborn who has had a ventriculoperitoneal shunt includes observing for increased intracranial pressure, which is manifested by (select all that apply) A. a high-pitched cry B. bulging fontanelles C. a personality change D. unequal eye pupil size

1. a high-pitched cry 2. bulging fontanelles 3. unequal eye pupil size

Which of the following observations of the newborn infant should be promptly reported to the health care provider? (Select all that apply) A. a respiratory rate of 24/min B. temperature of 36.90 C (98.4 F) C. pulse rate of 50/min D. nasal flaring

1. a respiratory rate of 24/min 2. pulse rate of 50/min 3. nasal flaring

The patient who has been dealing with urge incontinence tells the nurse that the symptoms have gotten worse lately. The nurse reminds the patient that which food(s) and drug(s) can increase incontinence? (select all that apply) a. antihypertensive drugs b. coffee c. alcohol d. diuretics e. anticholinergics

1. antihypertensive drugs 2. coffee 3. alcohol 4. diuretics 5. anticholinergics *antidepressants, ACE inhibitors, caffeine, alcohol, diuretics, & anticholinergics increase the symptoms of urge incontinence

The postop nursing care of an infant who has had a cheiloplasty include (select all that apply) A. feed formula using a soft nipple B. apply elbow restraints C. provide pain relief measures D. position infant on its abdomen

1. apply elbow restraints 2. provide pain relief measures

When caring for an infant with developmental dyplasia of the hip, the nurse would be alert and document which of the following characteristic signs (select all that apply)? A. asymmetrical gluteal folds B. absence of Ortolani click on hip manipulation C. limited adduction of the hip D. extra thigh crease in one leg

1. asymmetrical gluteal folds 2. extra thigh crease in one leg

A nurse is assisting with care for a client who has a marginal abruptio placentae. Which of the following findings are risk factors for developing the condition? (select all that apply) A. Fetal position B. blunt abdominal trauma C. Cocaine use D. Maternal age E. Cigarette smoking

1. blunt abdominal trauma 2. Cocaine use 3. Cigarette smoking

A nurse is providing reinforcement to a client who is at 6 weeks of gestation about common discomforts of pregnancy. Which of the following findings should the nurse include? (select all that apply) A. breast tenderness B. Urinary frequency C. Epistaxis D. Dysuria E. Epigastric pain

1. breast tenderness 2. Urinary frequency 3. Epistaxis

The nurse should teach the woman who is experiencing menopause that (select all that apply) a. calcium is best absorbed when vitamin D intake is adequate b. weight-bearing exercise is important c. lying down and resting after each meal is important d. an increased intake of vitamin C will enhance calcium absorption

1. calcium is best absorbed when vitamin D intake is adequate 2. weight-bearing exercise is important

When caring for an infant with Down syndrome, the nurse would document the following characteristic symptoms (select all that apply) A. seizures B. curved pinky finger C. straight simian crease D. intellectual impairment

1. curved pinky finger 2. straight simian crease

Following a vacuum extraction delivery, the nurse notices the newborn's head is not symmetrical with chignon over the posterior fontanelle. The appropriate nursing action would be to (select all that apply) a. apply cold compresses to the swollen area b. notify the charge nurse or health care provider c. document and continue routine observation d. explain to the parents the swelling will resolve without treatment e. all of the above

1. document and continue routine observation 2. explain to the parents the swelling will resolve without treatment

pelvic examination

1. exam scheduled between menstrual cycles 2. do not have sexual intercourse within 48 hours of the procedure 3. no douching *can alter the results of the pap exam

The nurse advises the woman with pelvic floor dysfunction that she can do what for relief of the associated discomfort? (select all that apply) a. lie down with feet elevated b. practice Kegel exercises c. assume knee-chest position periodically d. perform leg lift exercises e. prevent constipation

1. lie down with feet elevated 2. practice Kegel exercises 3. assume knee-chest position periodically 4. prevent constipation

Aroma therapy in the NICU is accomplished by (select all that apply) A. placing a sweet-smelling room deodorizer in the room that has a calming effect B. using baby oil on the infant's skin C. placing an article of the mother's clothing in the infant's crib D. using gentle touch to calm the infant

1. placing an article of the mother's clothing in the infant's crib 2. using gentle touch to calm the infant

A nurse is assisting with the care of a client who has severe preeclampsia who is receiving magnesium sulfate IV. Which of the following findings should the nurse identify and report as magnesium sulfate toxicity? (select all that apply) A. respirations less than 12/min B. Urinary output less than 25 mL/hr C. Hyperreflexic deep-tendon reflexes D. Decreased level of consciousness E. Flushing and sweating

1. respirations less than 12/min 2. Urinary output less than 25 mL/hr 3. Decreased level of consciousness

A woman who is the early first stage of labor asks how she can relieve her discomforts. The nurse knows that nonpharmacological techniques that can relieve discomforts include (select all that apply) A. sacral pressure B. effleurage C. sitz bath D. laxatives

1. sacral pressure 2. effleurage

What is a reliable temporary (reversible) birth control method? (select all that apply) a. douching b. breastfeeding c. transdermal patch d. vasectomy e. IUD

1. transdermal patch 2. IUD

Characteristic signs of developmental hip dysplasia that the nurse should observe and report include (select all that apply) A. inability to move legs B. unequal skin folds in the upper thigh C. straight simian crease D. limited ability to abduct legs

1. unequal skin folds in the upper thigh 2. limited ability to abduct legs

The nurse documents the following observations on a newly born infant. Which of the following should be immediately reported to the health care provider? A. unilateral Moro reflex B. small, blood-tinged mucuous discharge from the vagina C. drooling D. acrocyanosis

1. unilateral Moro reflex 2. drooling

Factors that change the normal flora of the vagina and predispose to vaginal infection include: (select all that apply) a. use of antibiotics b. douching c. sexual intercourse d. daily baths

1. use of antibiotics 2. douching 3. sexual intercourse

What are the following ways to prevent vaginal infections? (select all that apply) a. wear nylon underwear b. wipe from front to back c. avoid douching d. exercise

1. wipe front to back 2. avoid douching 3. exercise

During the second prenatal visit, the nurse attempts to locate the fetal heartbeat with an electronic Doppler device. How early might fetal heart tones be detected with an electronic Doppler device? a. 4 weeks b. 8 weeks c. 10 weeks d. 14 weeks

10 weeks

A couple just learned they are expecting their first child and are curious if they are having a boy or a girl. At what point of development can the couple first expect to see the sex of their child on ultrasound? a. 4 weeks' gestational age b. 6 weeks' gestational age c. 10 weeks' gestational age d. 16 weeks' gestational age

10 weeks' gestational age

The nurse weighs a saturated perineal pad and finds it to weigh 15 grams. The nurse is aware that this indicates a blood loss of _____ mL.

15

During a prenatal visit, the nurse checks the fetal heartrate (FHR) of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which heart rate is noted? 1. 80 beats per minute 2. 100 beats per minute 3. 150 beats per minute 4. 180 beats per minute

150 beats per minute

A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse response by telling the mother that fetal movements will be noted between which weeks of gestation? 1. 6 and 8 weeks' gestation 2. 8 and 10 weeks' gestation 3. 10 and 12 weeks' gestation 4. 16 and 20 weeks' gestation

16 and 20 weeks' gestation

At her initial prenatal visit, a woman asks, "When can I hear the baby's heartbeat?" At what gestational age can the fetal heartbeat be auscultated with a specially adapted stethoscope or fetoscope? a. 4 weeks b. 12 weeks c. 18 weeks d. 24 weeks

18 weeks

Of what is the normal umbilical cord comprised? a. 1 artery carrying blood to the fetus and 1 vein carrying blood away from the fetus b. 1 artery carrying blood to the fetus and 2 veins carrying blood away from the fetus c. 2 arteries carrying blood away from the fetus and 1 vein carrying blood to the fetus d. 2 arteries carrying blood to the fetus and 2 veins carrying blood away from the fetus

2 arteries carrying blood away from the fetus and 1 vein carrying blood to the fetus

The nurse is educating a class of expectant parents about fetal development. What is considered fetal age of viability? a. 14 weeks b. 20 weeks c. 25 weeks d. 30 weeks

20 weeks

What is the total number of chromosomes contained in a mature sperm or ovum? a. 22 b. 23 c. 44 d. 46

23

A term newborn should pass the first meconium stool no later than how many hours after birth? A. 6 B. 12 C. 24 D. 36

24

A woman's prepregnant weight is determined to be average for her height. What will the nurse advise the woman regarding recommended weight gain during pregnancy? a. 10 to 20 pounds b. 15 to 25 pounds c. 25 to 35 pounds d. 28 to 40 pounds

25 to 35 pounds

At what point in prenatal development do the lungs begin to produce surfactant? a. 17 weeks b. 20 weeks c. 25 weeks d. 30 weeks

25 weeks

The nurse is collecting date from a pregnant client who is currently at 28 weeks' gestation. At her prior prenatal visit, Her fundal height measured 22 cm. The nurse measures the fundal height at this visit in centimeters and should expect which finding? 1. 22 cm 2. 26 cm 3. 32 cm 4. 40 cm

26 cm

The nurse in a pediatrician's office is preparing to do a developmental assessment on a 3-month-old infant who was born at 36 weeks. The nurse knows that the infant should be evaluated in what month of achievement to adjust for the preterm birth? a. 1st b. 2nd c. 3rd d. 4th

2nd

A nurse in a prenatal clinic is assisting with caring for four clients. Which of the following clients' weight gain should the nurse report to the provider? A. 1.8 kg (4 lb) weight gain and in the first trimester B. 3.6 kg (8 lb) weight gain and is in the first trimester C. 6.8 kg (15 lb) weight gain and is in the second trimester D. 11.3 kg (25 lb) weight gain and is in the third trimester

3.6 kg (8 lb) weight gain and is in the first trimester

A full-term newborn weighs 3600 grams at birth. What would the nurse expect the newborn to weigh in grams 3 days later? a. 2900 b. 3100 c. 3300 d. 3800

3300 *In the first 3 to 4 days of life, a newborn generally loses 5% to 10% of his or her birth weight.

The nurse clarifies that a fetus has enough surfactant to breathe on its own at the age of _____ weeks.

34

The nurse arrives at the start of a shift on the labor unit to find a census of four patients in active labor. Which laboring patient should the nurse attend to first? a. 18-year-old primigravida with a fetal breech presentation b. 25-year-old multigravida with history of previous cesarean section c. 35-year-old multigravida with history of precipitate birth d. 16-year-old primigravida with a twin pregnancy

35-year-old multigravida with history of precipitate birth

On day 13 of a 28-day cycle, a woman's basal body temperature is 36.5° C (97.7° F). What will her temperature measurement most likely be if ovulation takes place on day 14? a. 35.9° C (96.7° F) b. 36.3° C (97.3° F) c. 36.7° C (98.1° F) d. 37.1° C (98.9° F)

36.7° C (98.1° F) *At the time of ovulation, body temperature will increase slightly, about 0.2° C (0.4° F).

Choose the normal blood glucose level for a preterm infant. A. 28 mg/dL B. 39 mg/dL C. 55 mg/dL D. 150 mg/dL

39 mg/dL

The nurse can anticipate that which of the following patients may be scheduled for induction of labor? A woman is: a. 38 weeks' gestation with fetus in transverse lie b. 40 weeks' gestation with fetal macrosomia c. 40 weeks' gestation with gestational hypertension d. 40 weeks' gestation with a fetal prolapsed cord

40 weeks' gestation with gestational hypertension

The nurse is presenting a conference on gene dominance. What does the nurse report as the percentage of children carrying the dominant gene if one parent has a dominant gene and the other parent does not? a. 10% b. 25% c. 50% d. 100%

50%

The nurse reminds the prenatal patient that she should add ________ kcal to her daily intake to nourish the fetus

500

A frustrated patient in labor has been affected by decreased uterine muscle tone and reports, "My doctor won't induce my labor because of some silly score. He said I was a 4. What kind of magic number do I need?" What is the lowest Bishop score the patient should have prior to induction? a. 6 b. 8 c. 10 d. 12

6

The embryo is termed a fetus at which stage of prenatal development? a. 2 weeks b. 4 weeks c. 9 weeks d. 16 weeks

9 weeks

A woman will be discharged 48 hours after a vaginal delivery. When planning discharge teaching, the nurse would include what information about lochia? a. Lochia should disappear 2 to 4 weeks postpartum. b. It is normal for the lochia to have a slightly foul odor. c. A change in lochia from pink to bright red should be reported. d. A decrease in flow will be noticed with ambulation and activity.

A change in lochia from pink to bright red should be reported.

The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn. The nurse is monitoring for signs of placental separation knowing that which indicates that the placenta has separated? 1. A change in the uterine contour 2. Sudden and sharp abdominal pain 3. A shortening of the umbilical cord 4. A decrease in blood loss from the introitus

A change in the uterine contour

The perinatal client is admitted to the obstetrical unit during an exacerbation of a heart condition. When planning for the nutritional requirements of the client, the nurse should consult with the dietician to ensure which dietary measure? 1. A low-calorie diet to ensure the absence of weight gain 2. A diet that is high in fluids and fiber to decrease constipation 3. A diet that is low in fluids and fiber to decrease blood volume 4. Unlimited sodium intake to increase the circulating blood volume

A diet that is high in fluids and fiber to decrease constipation

Why should the nurse encourage the mother to void during the fourth stage of labor? a. A full bladder could interfere with cervical dilation. b. A full bladder could obstruct progress of the infant through the birth canal. c. A full bladder could obstruct the passage of the placenta. d. A full bladder could predispose the mother to uterine hemorrhage.

A full bladder could predispose the mother to uterine hemorrhage.

The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that which routine labor procedure is contraindicated? 1. Leopold's maneuvers 2. A manual pelvic examination 3. Hemoglobin and hematocrit evaluation 4. External electronic fetal heart rate monitoring

A manual pelvic examination

The nurse is reinforcing instructions to a new mother about cord care and how to monitor for the presence of an infection. The nurse should tell the mother that which is a sign of infection? 1. A darkened drying stump 2. A moist cord with discharge 3. A purple stump that shows pinkness around the base 4. A purple stump that shows some moistness at the base

A moist cord with discharge

During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On data collection, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus. Which of the following findings should the nurse interpret this data as being? A. Evidence of a possible vaginal hematoma B. An indication of a cervical or perineal laceration C. A normal postural discharge of lochia D. Abnormally excessive lochia rubra flow

A normal postural discharge of lochia

What postpartum assessment does the acronym REEDA help a nurse remember how to complete thoroughly? A. A perineum or an incision (C-section) B. Breasts for a lactating mom C. Risk of a blood clot D. Breasts for a lactating patient

A perineum or an incision (C-section) *Episiotomy healing assessment: Redness Edema Ecchymosis Discharge (Drainage) Approximation

An ultrasound confirms that a 16-year-old girl is pregnant. How does the need for prenatal care and counseling for adolescents differ from other age populations? a. A pregnant adolescent is experiencing two major life transitions at the same time. b. Adolescents who get pregnant are more likely to have other chronic health problems. c. Adolescents are at greater risk for multifetal pregnancies. d. At this age, a pregnant adolescent will accept the nurse's advice.

A pregnant adolescent is experiencing two major life transitions at the same time.

A pregnant woman inquires about exercising during pregnancy. What information should the nurse include when planning to educate this woman? a. Exercise elevates the mother's temperature and improves fetal circulation. b. Exercise increases catecholamines, which can prevent preterm labor. c. A regular schedule of moderate exercise during pregnancy is beneficial. d. Pregnant women should limit water intake during exercise.

A regular schedule of moderate exercise during pregnancy is beneficial.

The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The nurse notes that the health care provider has documented the presence of Goodell's sign. The nurse determines that this signs is indicative of which change that occurs with pregnancy? 1. A softening of the cervix 2. The presence of fetal movement 3. The presence of human chorionic gonadotropin in the urine 4. A soft blowing sound that corresponds with the maternal pulse that is heard while auscultating the uterus

A softening of the cervix

What should the parents be taught about caring for the umbilical cord? A. Bathe the baby in a small basin to cleanse the cord on all surfaces B. A sponge bath is easy and allows the cord to remain dry until healed C. Use an oil-based cleanser to speed healing of the baby's cord site D. Baths are not needed until the cord has healed to reduce infection

A sponge bath is easy and allows the cord to remain dry until healed

What should a woman expect after insertion of an intrauterine device (IUD)? a. Menstrual flow will be lighter. b. Menstrual cramps will be eliminated. c. A string should be felt in the vagina. d. The device should be changed every 2 years.

A string should be felt in the vagina.

Which observation of the newborn should be reported to the health care provider as soon as possible? A. A swelling beneath the scalp on one side of the head B. A respiratory rate of 60 breaths/min C. A unilateral Moro reflex D. Cyanosis of the hands and feet

A unilateral Moro reflex

The nurse observes on the fetal monitor a pattern of a 15-beat increase in the fetal heart rate that lasts 15 to 20 seconds. What does this pattern indicate? a. A well-oxygenated fetus b. Compression of the umbilical cord c. Compression of the fetal head d. Uteroplacental insufficiency

A well-oxygenated fetus

The nurse is collecting data from a client who has been diagnosed with placenta previa. Which findings should the nurse expect to note? (Select all that apply) 1. Uterine rigidity 2. Uterine tenderness 3. Severe abdominal pain 4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus

A. Bright red vaginal bleeding B. Soft, relaxed, nontender uterus

The nurse is checking a client's record for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse should note? (select all that apply) 1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Braxton Hicks contractions 5. Outline of fetus via radiography or ultrasound 6. Fetal heart rate detected by a nonelectronic device

A. Ballottement B. Chadwick's sign C. Uterine enlargement D. Braxton Hicks contractions

A newborn has just been circumcised and is being discharged home in 2 hours. Which instructions should be provided by the nurse to the parents? (select all that apply) 1. Use only baby wipes to cleanse the penis 2. Remove the yellow exudate which forms by 24 hours post circumcision 3. Do not wash penis with soap until the circumcision is healed, which takes 5 to 6 days 4. Change the diaper every 4 hours or more often to inspect the penis for drainage or infection 5. Monitor the circumcision; penis may appear reddened with small amount of bloody drainage shortly after the procedure

A. Do not wash penis with soap until the circumcision is healed, which takes 5 to 6 days B. Change the diaper every 4 hours or more often to inspect the penis for drainage or infection C. Monitor the circumcision; penis may appear reddened with small amount of bloody drainage shortly after the procedure

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? (select all that apply) 1. Flushing 2. Hypertension 3. Increased urine output 4. Depressed respirations 5. Extreme muscle weakness 6. Hyperactive deep tendon reflexes

A. Flushing B. Depressed respirations C. Extreme muscle weakness

Which findings indicate to the nurse that placental separation has occurred? (select all that apply) 1. Lengthening of umbilical cord 2. Sudden trickle or spurt of blood 3. Fundus is boggy following separation 4. Change from globular to discoid shape 5. Fetal membranes are seen at the introitus

A. Lengthening of umbilical cord B. Sudden trickle or spurt of blood C. Fetal membranes are seen at the introitus

The nurse is preparing for a newborn who is receiving phototherapy. Which measures should be implemented? (select all that apply) 1. Avoid stimulation 2. Decrease fluid intake 3. Expose all of the newborn's skin 4. Monitor the skin temperature closely 5. Reposition the newborn every 2 hours 6. Cover the newborn's eyes with shields or patches

A. Monitor the skin temperature closely B. Reposition the newborn every 2 hours C. Cover the newborn's eyes with shields or patches

The nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student needs further teaching if which responses are made? (select all that apply) 1. Allows for fetal movement 2. Is a measure of kidney function 3. Surrounds, cushions, and protects the fetus 4. Maintains the body temperature of the fetus 5. Prevents large particles such as bacteria from passing to the fetus 6. Provides an exchange of nutrients and waste products between the mother and the fetus

A. Prevents large particles such as bacteria from passing to the fetus B. Provides an exchange of nutrients and waste products between the mother and the fetus

The nurse is monitoring a pregnant client with gestational hypertension (GH) who is at risk for preeclampsia. The nurse should check the client for which signs of preeclampsia? (Select all that apply) 1. Proteinuria 2. Hypertension 3. Low-grade fever 4. Increased pulse rate 5. Increased respiratory rate

A. Proteinuria B. Hypertension

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted during assessment? (select all that apply) 1. Proteinuria of 3+ 2. Respirations of 10 breaths/minute 3. Presence of deep tendon reflexes 4. Urine output of 20 mL in an hour 5. Serum magnesium level of 6 mEq/L. (3 mmol/L)

A. Respirations of 10 breaths/minute B. Urine output of 20 mL in an hour

The nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Which instructions should be included on the list? (select all that apply) 1. Rest during the acute phase 2. Wear a supportive, non-underwire bra 3. Maintain a fluid intake of at least 3000 mL 4. Continue to breastfeed if the breasts are not too sore 5. Take prescribed antibiotics until the soreness subsides 6. Avoid decompression of the breasts by breastfeeding or breast pumping

A. Rest during the acute phase B. Wear a supportive, non-underwire bra C. Maintain a fluid intake of at least 3000 mL D. Continue to breastfeed if the breasts are not too sore

The nurse is working in a prenatal clinic reviews a client's chart and notes that the primary health care provider documents that the client has a gynecoid pelvis. The nurse plans care understanding that which findings are characteristic of this type of pelvis? (select all that apply) 1. Round shape 2. Shallow depth 3. Narrow pubic arch 4. Diagonal conjugate measures 12.5 cm to 13 cm 5. Blunt, somewhat widely separated ischial spines

A. Round shape B. Diagonal conjugate measures 12.5 cm to 13 cm C. Blunt, somewhat widely separated ischial spines

Which of the following observations of a preterm neonate would indicate the presence of respiratory distress? (select all that apply) A. Substernal retractions B. Respiratory rate of 70/min C. Grunting D. Lethargy

A. Substernal retractions B. Respiratory rate of 70/min C. Grunting

The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings should cause the nurse to immediately discontinue the oxytocin infusion. (select all that apply) 1. Fatigue 2. Drowsiness 3. Uterine hyperstimulation 4. Late decelerations of the fetal heart rate 5. Early decelerations of the fetal heart rate

A. Uterine hyperstimulation B. Late decelerations of the fetal heart rate

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full term newborn after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which additional sign us consistent with FAS? 1. A length of 19 in 2. Abnormal palmar creases 3. A birth weight of 6 pounds and 14 ounces 4. A head circumference that is appropriate for gestational age

Abnormal palmar creases

The nurse is assessing a preterm infant. To what does the infant's level of maturation refer? a. Actual time the fetus remained in the uterus b. Age on the Dubowitz scoring system c. Infant's weight as compared to the gestational age d. Ability of the organs to function outside of the uterus

Ability of the organs to function outside of the uterus

When a pregnant woman arrives at the labor suite, she tells the nurse that she wants to have an epidural for delivery. What is a contraindication to an epidural block? a. Abnormal clotting b. Previous cesarean delivery c. History of migraine headaches d. History of diabetes mellitus

Abnormal clotting

The nurse is providing sexual education to a group of high school students. What will the nurse explain is the most effective choice of birth control for preventing pregnancy and sexually transmitted diseases? a. Abstain from sex. b. Use the male condom. c. Use the female condom. d. Use the barrier method.

Abstain from sex.

The nurse suspects that the client has a pulmonary embolism. Which is the most important nursing action? 1. Monitor the vital signs 2. Elevate the head of the bed 3. Increase the intravenous flow rate 4. Administer oxygen by face mask, as prescribed

Administer oxygen by face mask, as prescribed

After delivery, a mother asks the nurse about newborn screening tests. The nurse explains that what is the optimal time for testing for phenylketonuria? a. In the first 24 hours of life b. After 2 to 3 days c. At 4 to 6 weeks of age d. At 2 months of age

After 2 to 3 days

At what age is a woman who becomes pregnant for the first time described as an "elderly primip"? a. After 25 years old b. After 28 years old c. After 30 years old d. After 35 years old

After 35 years old

A postpartum patient experiences anaphylactic shock. What is the most likely cause? a. Pulmonary embolism b. Hypertension c. Allergy d. Blood clotting disorder

Allergy

Which nursing assessment suggests infection of an epsiotomy? A. Allows better estimation of the woman's fluid volume B. Identifies bloody urine that suggests bladder trauma C. Limits the need for the woman to ambulate to the bathroom D. Applies constant pressure against the bleeding uterus

Allows better estimation of the woman's fluid volume

The nurse is assigned to care for a client after a cesarean section. To prevent thrombophlebitis, the nurse should encourage the woman to take which priority action? 1. Ambulate frequently 2. Wear support stockings 3. Apply warm, moist packs to the legs 4. Remain on bed rest, with the legs elevated

Ambulate frequently

What nursing assessment should be reported immediately after an amniotomy? a. Fetal heart rate is regular at 154 beats/minute. b. Amniotic fluid is clear with flecks of vernix. c. Amniotic fluid is watery and pale green. d. Maternal temperature is 37.8° C.

Amniotic fluid is watery and pale green.

The nurse is measuring the vital signs of a calm, full-term newborn. Which finding is abnormal? a. An axillary temperature of 36.6° C (98° F) b. An apical pulse rate of 178 beats/minute c. Respirations of 35 breaths/minute d. Blood pressure of 80/50 mm Hg

An apical pulse rate of 178 beats/minute

A nurse is reinforcing teaching with a client who is in labor about an episiotomy. Which of the following information should the nurse include? A. An episiotomy is a perineal tear that is created while pushing during labor B. A fourth degree episiotomy extends into the rectal area C. An episiotomy is an incision that is made by the provider to facilitate delivery of the fetus D. A mediolateral episiotomy is easier to repair than a median episiotomy

An episiotomy is an incision that is made by the provider to facilitate delivery of the fetus

In what situation will the physician order RhoGAM? a. An unsensitized Rh-negative mother has an Rh-positive infant. b. An Rh-negative mother becomes sensitized. c. A sensitized infant has a rising bilirubin level. d. An unsensitized infant exhibits no outward signs.

An unsensitized Rh-negative mother has an Rh-positive infant.

During a postpartum assessment, a woman reports her right calf is painful. The nurse observes edema and redness along the saphenous vein in the right lower leg. Based on this finding, what does the nurse explain the probable treatment will involve? a. Anticoagulants for 6 weeks b. Application of ice to the affected leg c. Gentle massage of the affected leg d. Passive leg exercises twice a day

Anticoagulants for 6 weeks

The nurse is providing an informational session on oral contraceptives. Which of the following decrease effectiveness of oral contraceptives? a. Antihistamines for seasonal allergies b. Iron preparations for treatment of anemia c. Appetite suppressants for weight reduction d. Anticonvulsants for treatment of epilepsy

Anticonvulsants for treatment of epilepsy

According to the gate control theory, which technique should be most helpful in interrupting transmission pain to the brain? A. Rapid, shallow breathing B. Application of heat C. Focusing on a point in the room D. Deep, cleaning breaths

Application of heat.

A nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g and is in the 60th percentile for weight. Based on the weight and gestation age, the nurse should assign the newborn which of the following classifications? A. Low-birth weight B. Appropriate for gestational age C. Small for gestational age D. Large for gestational age

Appropriate for gestational age

A nurse is caring for a client who has postpartum psychosis. Which of the following actions is the nurse's priority? A. Reinforce the need to take antipsychotics as prescribed B. Ask the client if they have thoughts of harming themselves or their infant C. Monitor the infant for indications of failure to thrive D. Review the client's medical record for a history of bipolar disorder

Ask the client if they have thoughts of harming themselves or their infant

How will the nurse safely ensure tube placement when preparing to initiate a gavage feeding? a. Check tube placement by injecting air into the stomach. b. Weigh the infant before the feeding. c. Aspirate stomach contents. d. Check serum glucose level

Aspirate stomach contents.

What nursing action will the nurse implement for a preterm infant who is being gavage fed and has a bloody stool? a. Assess for abdominal distention. b. Decrease the amount of the next feeding. c. Institute enteric precautions. d. Get a culture of the next stool.

Assess for abdominal distention.

What is the most important nursing intervention during the fourth stage of labor? a. Monitor the frequency and intensity of contractions. b. Provide comfort measures. c. Assess for hemorrhage. d. Promote bonding

Assess for hemorrhage.

The new mother who had a vaginal delivery yesterday has a white blood cell count of 30,000 cells/dL. What action should the nurse implement? a. Notify the charge nurse of a possible infection. b. Prepare to put the patient in isolation. c. Have the infant removed from the room and returned to the nursery. d. Assess the patient further.

Assess the patient further.

A woman's membranes rupture during labor. The nurse notes that the fluid is yellowish and cloudy. The priority nursing response related to this assessment is to: A. remove wet under pads and replace them with dry ones B. perform a vaginal examination to assess labor progress C. reassure the woman that membrane rupture is expected D. Assess the woman's temperature and the fetal heart rate

Assess the woman's temperature and the fetal heart rate.

Immediately after birth, nursing care for a woman who had subarachnoid block anesthesia for a repeat cesarean birth should include: A. ambulating within 2 hours of birth B. assessing for return of sensation C. supports normal blood pressure D. enhances the woman's urge to push

Assessing for return of sensation.

A nurse is assisting with caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should identify that the registered nurse should take? A. Assist the client into the left-lateral position B. Apply a fetal scalp electrode C. Insert an IV catheter D. Perform a vaginal exam

Assist the client into the left-lateral position

The nurse is caring for a woman who had a cesarean birth yesterday. Varicose veins are visible on both legs. What nursing action is the most appropriate to prevent thrombus formation? a. Have the woman sit in a chair for meals. b. Monitor vital signs every 4 hours and report any changes. c. Tell the woman to remain in bed with her legs elevated. d. Assist the woman with ambulation for short periods of time.

Assist the woman with ambulation for short periods of time.

What assessment made by the nurse would lead the nurse to suspect hip dysplasia? a. Asymmetrical gluteal folds b. Limited adduction of the affected side c. Foot turned inward d. Deep inguinal creases

Asymmetrical gluteal folds

After delivery the nurse checks the height of the uterine fundus. Which position of the fundus should the nurse expect to note? 1. To the right of the abdomen 2. At the level of the umbilicus 3. About 4 cm above the level of the umbilicus 4. One fingerbreadth above the symphysis pubis

At the level of the umbilicus

During general anesthesia, cricoid pressure is applied to: A. reduce stomach acid secretion B. avoid aspiration of gastric contents C. prevent excessive blood loss D. limit musculoskeletal injuries

Avoid aspiration.

Choose the correct teaching for breast self-examination (BSE): a. monthly BSE eliminates the need for a professional examination until after age 40 years b. BSE should be done 1 week after the beginning of each menstrual period c. dry fingers make it easier to feel very small lumps that are just under the skin d. use the palm of the hand to palpate the breast

BSE should be done 1 week after the beginning of each menstrual period

A woman has given birth to an unresponsive newborn that NICU staff are attempting to revive. The patient and her husband are grief stricken and request the child be baptized immediately. What is the nurse's most appropriate action? a. Contact the hospital chaplain. b. Request the couple's clergy. c. Baptize the newborn. d. Ask the physician to baptize the newborn.

Baptize the newborn.

The nurse is assigned to care for a client who is in early labor. When collecting data from the client, which should the nurse check first? 1. Baseline fetal heart rate 2. Intensity of contractions 3. Maternal blood pressure 4. Frequency of contractions

Baseline fetal heart rate

What should the nurse's first action be when postpartum hemorrhage from uterine atony is suspected? a. Teach the patient how to massage the abdomen and then get help. b. Start IV fluids to prevent hypovolemia and then notify the registered nurse. c. Begin massaging the fundus while another person notifies the physician. d. Ask the patient to void and reassess fundal tone and location.

Begin massaging the fundus while another person notifies the physician.

The nurse is reinforcing measures regarding the care of the newborn with a mother. To bathe the newborn, the mother should be taught which intervention? 1. Begin with the eyes and face 2. Start with the dirtiest area first 3. Begin with the feet and work upward 4. Only wash the diaper area, because this is the only part of the baby that gets soiled

Begin with the eyes and face

Rho(D) immune globulin is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition? 1. Having Rh-positive blood 2. Developing a rubella infection 3. Developing physiological jaundice 4. Being affected by Rh incompatibility

Being affected by Rh incompatibility

Below what blood glucose level is the newborn considered hypoglycemic? a. Below 70 mg/dL b. Below 60 mg/dL c. Below 50 mg/dL d. Below 45 mg/dL

Below 45 mg/dL

A client in preterm labor )31 weeks) who is dilated to 4 cm has been started on magnesium sulfate and her contractions have stopped. If the client's labor can be inhibited for the next 4 hours, the nurse anticipates a prescription for which medication? 1. Nalbuphine 2. Betamethasone 3. Rho(D) immune globulin 4. Dinoprostone vaginal insert

Betamethasone

A nurse is assisting with providing care for a client who is in preterm labor at 32 weeks of gestation. Which of the following medications should the nurse anticipate the provider will prescribe to hasten fetal lung maturity? A. Calcium gluconate B. Indomethacin C. Nifedipine D. Betamethasone

Betamethasone

A nurse is assisting with the care of a client who is at 32 weeks of gestation and has a placenta previa. The nurse notes that the client is actively bleeding. Which of the following medications should the nurse expect the provider will prescribe? A. Betamethasone B. Indomethacin C. Nifedipine D. Methylergonovine

Betamethasone

The pediatric clinic nurse receives lab results on several newborn patients. Which of the following should be brought to the physician's attention first? a. White blood cell count of 18,000 b. Hemoglobin of 18.5 c. Hematocrit of 56 d. Bilirubin of 15

Bilirubin of 15

The nurse is assisting in caring for a post-term neonate immediately after admission to the nursey. The priority nursing action should be to monitor which clinical parameter? 1. Urinary output 2. Blood glucose level 3. Total bilirubin level 4. Hemoglobin and hematocrit levels

Blood glucose level

A woman in labor has had an epidural block for pain relief. The nurse will be assessing carefully for what associated side effect of this type of regional anesthesia? a. Reduced fetal heart rate b. Long, intense contractions c. Sudden leg cramps d. Bladder distention

Bladder distention

Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority nursing assessment? 1. Uterine tone 2. Blood pressure 3. Amount of lochia 4. Deep tendon reflexes

Blood pressure

What assessment should be taken immediately after the anesthesiologist administers an epidural block to a laboring woman? a. Bladder for distention b. Blood pressure c. Sensation in the lower extremities d. Intravenous fluid flow rate

Blood pressure

A woman who is 6 cm dilated has the urge to push. What will the nurse instruct the woman to do during the contraction? a. Use slow-paced breathing. b. Hold her breath and push. c. Blow in short breaths. d. Use rapid-paced breathing.

Blow in short breaths.

During the physical examination for the first prenatal visit, it is noted that Chadwick's sign is present. What is Chadwick's sign? a. Bluish or purplish discoloration of the vulva, vagina, and cervix b. Presence of early fetal movements c. Darkening of the areola and breast tenderness d. Palpation of the fetal outline

Bluish or purplish discoloration of the vulva, vagina, and cervix

A patient with gestational hypertension is exhibiting all of the signs below. What should the nurse report immediately? a. Diarrhea b. Urticaria c. Blurred vision d. Backache

Blurred vision

What would the nurse assess for in a preterm infant receiving an intravenous infusion containing calcium gluconate? a. Seizures b. Bradycardia c. Dysrhythmias d. Tetany

Bradycardia

A preterm infant has a yellow skin color and a rising bilirubin level. The nurse knows that this infant is at risk for what? a. Skin breakdown b. Renal failure c. Brain damage d. Heart failure

Brain damage

Which nursing assessment suggests that a postpartum woman has cystitis? A. Burning with every urination B. High fever accompanied by chills C. Fever with nausea and vomiting D. Voiding large amounts or urine

Burning with every urination

Parents of a newborn with a unilateral cleft lip are concerned about having the defect repaired. The nurse explains that a child with a cleft lip usually undergoes surgical repair at which time? a. Immediately after birth b. By 3 months of age c. After 12 months of age d. Varies in every case

By 3 months of age

The nurse is caring for a patient who is not certain if she is in true labor. How might the nurse attempt to stimulate cervical effacement and intensify contractions in the patient? a. By offering the patient warm fluids to drink b. By helping the patient to ambulate in the room c. By seating the patient upright in a straight-back chair d. By positioning the patient on her right side

By helping the patient to ambulate in the room

When a woman is admitted to the labor and delivery unit, she tells the nurse that she is anxious about delivery, the welfare of her infant, and how quickly she will recover. How can anxiety affect labor? a. By decreasing a woman's pain sensitivity b. By reducing blood flow to the uterus c. By increasing the ability to tolerate pain d. By enhancing maternal pushing through greater muscle tension

By reducing blood flow to the uterus

A laboring patient requests hot and cold applications be applied to her abdomen for pain control. How will this intervention act to control pain? a. By increasing endorphin production b. By facilitating effacement and dilation c. By producing increasing pain tolerance d. By stimulation of large nerve fibers

By stimulation of large nerve fibers

A pregnant patient asks the nurse when her infant's heart will begin to pump blood. What will the nurse reply? a. By the end of week 3 b. Beginning in week 8 c. By the end of week 16 d. Beginning in week 24

By the end of week 3

A nursing assisting with the care of a client who is receiving IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if magnesium sulfate toxicity is suspected? A. Nifedipine B. Pyridoxine C. Ferrous sulfate D. Calcium gluconate

Calcium gluconate

What drug will the nurse plan to have available for immediate IV administration whenever magnesium sulfate is administered to a maternity patient? a. Ergonovine maleate (Ergotrate) b. Oxytocin c. Calcium gluconate d. Hydralazine (Apresoline)

Calcium gluconate

The nurse assesses a positive Homans' sign when the patient's leg is flexed and foot sharply dorsiflexed. Where does the patient report that the pain is felt? a. Groin b. Achilles tendon c. Top of the foot d. Calf of the leg

Calf of the leg

A nurse is assisting with the care of a client in active labor. The nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform first? A. Place the client in the Trendelenburg position B. Apply finger pressure to the presenting part C. Administer oxygen at 10 L/min via a nonrebreather D. Call for assistance

Call for assistance

A 21-year-old college student has come to see the nurse practitioner for treatment of a vaginal infection. Physical assessment reveals inflammation of the vagina and vulva, and vaginal discharge has a cottage cheese appearance. With what are these findings consistent? a. Candidiasis b. Trichomoniasis c. Bacterial vaginosis d. Chlamydia

Candidiasis

The nurse is providing care to a child with Down syndrome. What body system has the highest risk of congenital anomaly in a child with Down syndrome? a. Reproductive system b. Genitourinary system c. Cardiovascular system d. Gastrointestinal system

Cardiovascular system

The nurse coaches the primigravida not to bear down until the cervix is completely dilated. What may premature bearing down cause? a. Increased use of oxygen b. Cervical laceration c. Uterine rupture d. Compression of the cord

Cervical laceration

Nursing the newborn promotes uterine involution because it A. uses maternal fat stores accumulated during pregnancy B. Stimulates additional secretion of colostrum C. Causes the pituitary to secrete oxytocin to contract the uterus D. Promotes maternal formation of antibodies

Causes the pituitary to secrete oxytocin to contract the uterus

A nurse is caring for a client who has gonorrhea. Which of the following medications should the nurse expect the provider will prescribe? A. Ceftriaxone B. Fluconazole C. Metronidazole D. Zidovudine

Ceftriaxone

While inspecting a newborn's head, the nurse identifies a swelling of the scalp that does not cross the suture line. How would the nurse refer to this finding when documenting? a. Molding b. Caput succedaneum c. Cephalohematoma d. Enlarged fontanelle

Cephalohematoma

The nurse is discussing cervical mucus changes with a woman who wishes to use natural family-planning methods. What information about cervical mucus at ovulation will the woman indicate to the nurse, demonstrating that learning has taken place? a. Cervical mucus enhances the motility of the sperm. b. Cervical mucus indicates endometrial readiness for implantation. c. Cervical mucus facilitates movement of the ovum through the fallopian tube. d. Cervical mucus provides vaginal lubrication during intercourse.

Cervical mucus enhances the motility of the sperm.

The parents of a newborn girl express concern about the infant's vaginal discharge, which appears to be bloody mucus. What does the nurse explain as the cause? a. Premature stimulation of the ovarian hormones by the pituitary system b. Cessation of female sex hormones transferred in utero from mother to infant c. The increased amount of circulating blood from the mother throughout pregnancy d. Trauma to the genitalia during the birth process

Cessation of female sex hormones transferred in utero from mother to infant

What would the nurse include when instructing parents about positioning their toddler who has just had a body spica cast applied? a. Prop the child upright with pillows for meals. b. Use the bar between the legs to turn the child. c. Put the child on her abdomen to sleep. d. Change the child's position frequently.

Change the child's position frequently

The nurse notes a pattern of variable decelerations on the electronic fetal monitor strip. The initial nursing response should be to: A. reassure the woman that the pattern is expected B. change the laboring woman's position C. increase the rate of the nonadditive IV fluid D. notify the health care provider of the abnormal pattern

Change the laboring woman's position.

Choose the correct patient teaching about the IUD. a. You should not use this contraception if you smoke or are older than age 35. b. Check for the strings weekly for the first 4 weeks, then monthly c. Do not use tampons when you have your menstrual period d. use another form of contraception for the first month after insertion

Check for the strings weekly for the first 4 weeks, then monthly

What should the nurse implement for security purposes when bringing the infant from the nursery to the mother? a. Ask, "Is this your band number?" b. Confirm room number of mother. c. Ask the mother to identify herself verbally. d. Check the band number of the infant with that of the mother.

Check the band number of the infant with that of the mother

One hour postdelivery the nurse notes the new mother has saturated three perineal pads. What is the most appropriate nursing action? a. Check the fundus for position and firmness. b. Report to the doctor immediately. c. Change the pads and chart the time. d. Time how long it takes to soak one pad.

Check the fundus for position and firmness.

The most appropriate way to identify mother and newborn when reuniting them is to A. Check the identification band numbers of each B. Ask the mother to clearly state her name C. Examine the mother's fingerprint and newborn's footprints D. Verify that the names on the crib card and band are identical

Check the identification band numbers of each

The nurse notes that a new mother has several bottles of partly consumed formula on her overbed table. Choose the most appropriate nursing action. A. Recommend that she prepare bottles that contain only what the baby is likely to drink B. Inform her that the bottles cannot be used because they have not been refrigerated C. Tell her she may combine the leftover formula for the baby's next feeding D. Check the room for other partially used bottles, then throw all of them in the trash

Check the room for other partially used bottles, then throw all of them in the trash

The nurse notes that the 4 hours postpartum client has cool, clammy skin and that she is restless and excessively thirst. The nurse immediately notifies the registered nurse and then performs which action? 1. Checks the vital signs 2. Begins fundal massage 3. Encourages ambulation 4. Encourages the client to drink fluids

Checks the vital signs

A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes ruptured spontaneously. What complication should the nurse closely assess for with this patient? a. Chorioamnionitis b. Hemorrhage c. Hypotension d. Amniotic fluid embolism

Chorioamnionitis

What is the embryonic membrane that contains fingerlike projections on its surface, which attach to the uterine wall? a. Amnion b. Yolk sac c. Chorion d. Decidua basalis

Chorion

The nurse tells a woman who is trying to conceive to check her cervical mucus for changes. What will she expect the characteristic of cervical mucus to be a few days before ovulation? a. Cloudy and tacky b. Scant and thick c. Thin and white d. Clear and slippery

Clear and slippery

What should the nursing mother be taught about breast care? A. Clean the breasts with plain water when washing B. Give one formula feeding daily to limit engorgement C. Do not wear a bra the first few days after birth D. Begins with the same breast at each feeding

Clean the breasts with plain water when washing

A woman who is 3 days postpartum comes to the emergency clinic because she is having pain and burning discomfort when she urinates. She denies that she has had any fever and states that her lochia is "light pink." The nurse should expect an initial order for A. bladder analgesics B. Intravenous antibiotics C. Culture of vaginal discharge D. Clean-catch urine specimen

Clean-catch urine specimen

What instruction should the nurse teach the postpartum woman about perineal self-care? a. Perform perineal self-care at least twice a day. b. Cleanse with warm water in a squeeze bottle from front to back. c. Remove perineal pads from the rectal area toward the vagina. d. Use cool water to decrease edema of the perineum.

Cleanse with warm water in a squeeze bottle from front to back.

The nurse is assigned to assist with caring for a client who is at risk for eclampsia. If the client who progresses from preeclampsia to eclampsia, the nurse should take which action first? 1. Administer oxygen by face mask 2. Clear and maintain an open airway. 3. Check the blood pressure and the fetal heart tones 4. Prepare for the administration of intravenous magnesium sulfate

Clear and maintain an open airway

What nursing care should be provided to a woman with a third-degree laceration immediately after delivery? a. Warm compresses to the perineum b. Cold pack to the perineum c. Warm sitz bath d. Elevation of hips to prevent edema

Cold pack to the perineum

While assisting with the measurement of fundal height, the client at 36 weeks' gestation states that she is feeling lightheaded. On the basis of the nurse's knowledge of pregnancy, the nurse determines that this most likely a result of which reason? 1. A full bladder 2. Emotional instability 3. Insufficient iron intake 4. Compression of the vena cava

Compression of the vena cava

While caring for a postpartum patient who had a vaginal delivery yesterday, the nurse assesses a firm uterine fundus and a trickle of bright blood. How does the nurse most likely feel and react to this finding? a. Concerned and reports a probable cervical laceration b. Attentive and massages the uterus to expel retained clots c. Distressed and reports a possible clotting disorder d. Satisfied with the normal early postpartum finding

Concerned and reports a probable cervical laceration

The nurse is the newborn nursery receives a telephone call to prepare for the admission of a neonate born at 43 weeks' gestation with Apgar scores of 1 and 4. When planning for the admission of this infant, which is the nurse's highest priority? 1. Turning on the apnea and cardiorespiratory monitor 2. Connecting the resuscitation bag to the oxygen outlet 3. Setting up the intravenous line with 5% dextrose in water 4. Setting the radiant warmer control temperature at 36.5 C (97.6 F)

Connecting the resuscitation bag to the oxygen outlet

A nursing student is assigned to a client in labor. The nurse instructor asks the student to describe fetal circulation. specifically the ductus venosus. The instructor determines that the student understands the structure of the ductus venosus if the student states which about the ductus venosus? 1. Connects the pulmonary artery to the aorta 2. Is an opening between the right and left atria 3. Connects the umbilical vein to the inferior vena cava 4. Connects the umbilical artery to the inferior vena cava

Connects the umbilical vein to the inferior vena cava

The nurse is counseling a lactating mother about diet. What would the nurse include with this information? a. Consume 500 more calories than her usual prepregnancy diet. b. Eat less meat and more fruits and vegetables. c. Drink 3 to 4 tall glasses of fluid daily. d. Eat 1000 more calories than her usual prepregnancy diet.

Consume 500 more calories than her usual prepregnancy diet.

How should the nurse respond to acrocyanosis in a 12 hour old newborn? A. Administer oxygen through a newborn-sized mask B. Apply heat with an incubator or radiant warmer C. Assess the pulse and respirations for abnormal rates D. Continue routine newborn nursing observations

Continue routine newborn nursing observations

Which nursing assessment finding should promptly reported to the physician or nurse-midwife? A. clear amniotic fluid containing white flecks B. Fetal heart rate of 145 bpm with variability C. vaginal discharge of mucus with dark blood D. Contraction intervals shorter than 2 minutes

Contraction intervals shorter than 2 minutes

The nurse explains to a patient in preterm labor that what may be ordered by the physician to accelerate fetal lung maturity? a. Prostaglandins b. Oxytocin c. Magnesium sulfate d. Corticosteroids

Corticosteroids

The nurse is caring for a pregnant woman receiving an intravenous infusion with magnesium sulfate. What is the highest priority nursing intervention? a. Count respirations and report a rate of less than 12 breaths/minute. b. Count respirations and report a rate of more than 20 breaths/minute. c. Check blood pressure and report a rate of less than 100/60 mm Hg. d. Monitor urinary output and report a rate of less than 100 mL/hr.

Count respirations and report a rate of less than 12 breaths/minute.

A nurse is assisting with the care of a newborn immediately following birth. Which of the following nursing interventions is the highest priority? A. Initiating breastfeeding B. Performing the initial bath C. Giving a vitamin K injection D. Covering the newborn's head with a cap

Covering the newborn's head with a cap

A nurse in a prenatal clinic is reinforcing education to a client who is at weeks of gestation. The client states, "I don't like milk." Which of the following foods should the nurse recommend as a good source of calcium? A. Dark green leafy vegetables B. Deep red or orange vegetables C. White breads and rice D. Meat, poultry, and fish

Dark green leafy vegetables

The nurse is going to use a bulb syringe to clear mucus from a newborn's nose and mouth. What is the nurse's first action? a. Place the tip in the nose and squeeze the bulb gently. b. Suction secretions from the nose before the mouth. c. Depress the bulb before inserting the syringe tip into the mouth. d. Insert the tip into the back of the mouth to reach mucus.

Depress the bulb before inserting the syringe tip into the mouth.

A primigravida's membranes rupture spontaneously. Which action should the nurse take first? 1. Determine the fetal heart rate 2. Prepare for immediate delivery 3. Monitor the contraction pattern 4. Note the amount, color, and odor of the amniotic fluid

Determine the fetal heart rate

The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. During admission, which action should the nurse take initially? 1. Estimate the fetal size 2. Check pelvic adequacy 3. Administer an analgesic 4. Determine the maternal and fetal vital signs

Determine the maternal and fetal vital signs

A woman seeking prenatal care relates a history of macrosomic infants, two stillbirths, and polyhydramnios with each pregnancy. What does the nurse recognize these factors highly suggest? a. Toxoplasmosis b. Abruptio placentae c. Hydatidiform mole d. Diabetes mellitus

Diabetes mellitus

A woman has had persistent lochia rubra for 2 weeks after her delivery and is experiencing pelvic discomfort. What does the nurse explain is the usual treatment for subinvolution? a. Uterine massage b. Oxytocin infusion c. Dilation and curettage d. Hysterectomy

Dilation and curettage

During an ultrasound, two amnions and two placentas are observed. What will be the most likely result of this pregnancy? a. Dizygotic twins b. Monozygotic twins c. Conjoined twins d. High-birth weight twins

Dizygotic twins

A nurse is assisting with the care for a client who is receiving nifedipine for prevention of preterm labor. The nurse should monitor the client for which of the following manifestations? A. blood-tinged sputum B. Dizziness C. Pallor D. Somnolence

Dizziness

The nurse compared the birth weight of a 3-day-old with her current weight and determined the infant had lost weight. What is the most appropriate intervention by the nurse? a. Do nothing because this is a normal occurrence. b. Report the discrepancy to the pediatrician immediately. c. Decrease the interval between the infant's feedings. d. Try feeding the infant a different type of formula.

Do nothing because this is a normal occurrence.

The pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner and should tell the client to perform which measure? 1. Dorsiflex the client's foot while flexing the knee. 2. Plantarflex the client's foot while flexing the knee 3. Dorsiflex the client's foot while extending the knee 4. Plantarflex the client's foot while extending the knee

Dorsiflex the client's foot while extending the knee

A woman is prescribed to take alendronate (Fosamax) for osteoporosis postmenopause. What information will the nurse provide when educating this patient on alendronate (Fosamax)? a. Drink 8 oz. of water following dosage. b. Lay down for 30 minutes after taking. c. This medication has no known side effects. d. Avoid weight-bearing exercises.

Drink 8 oz. of water following dosage.

Which teaching by the nurse is appropriate for the new mother who has cystitis? A. Eat several servings of whole grains and meats each day B. Remain in bed except for going to the bathroom C. Drink about 3 liters of noncaffeinated beverages daily D. Take a stool softener to reduce added pain of constipation

Drink about 3 liters of noncaffeinated beverages daily

The nurse is reinforcing instructions to a pregnant client regarding measures to prevent heartburn. The nurse should instruct the client to take which best measure? 1. Eliminate between-meal snacks 2. Drink decaffeinated coffee and tea 3. Lie down for 30 minutes after eating 4. Substitute salt in cooking for other spices

Drink decaffeinated coffee and tea

The best way to maintain the newborn's temperature immediately after birth is to A. Dry the newborn thoroughly, including the hair B. Give the newborn a bath using warm water C. Feed 1 to 2 ounces of warmed formula D. Limit the length of time that parents hold the newborn

Dry the newborn thoroughly, including the hair

The nurse is caring for an infant born at 42 weeks. What would the physical assessment reveal? a. Dry, peeling skin b. Minimal hair on the head c. Short, rough nails d. Abundant lanugo on the body

Dry, peeling skin

After birth, the nurse prevents hypothermia as a result of evaporation in the newborn by performing which action? 1. Warming the crib pad 2. Closing the doors of the room 3. Drying the baby with a warm blanket 4. Turning on the overhead radiant warmer

Drying the baby with a warm blanket

What contraction duration and interval does the nurse recognize could result in fetal compromise? a. Duration shorter than 30 seconds, interval longer than 75 seconds b. Duration shorter than 90 seconds, interval longer than 120 seconds c. Duration longer than 90 seconds, interval shorter than 60 seconds d. Duration longer than 60 seconds, interval shorter than 90 seconds

Duration longer than 90 seconds, interval shorter than 60 seconds

A woman diagnosed with endometriosis reports "painful intercourse." What is the appropriate medical term for the nurse to document when describing this symptom? a. Dyspnea b. Dysmenorrhea c. Dyspareunia d. Dysrhythmia

Dyspareunia

A woman diagnosed with endometriosis reports painful intercourse. What is the appropriate medical term for the nurse to document when describing this symptom? a. Dyspnea b. Dysmenorrhea c. Dyspareunia d. Dysrhythmia

Dyspareunia

A client who is at 7 weeks of gestation is experiencing nausea and vomiting in the morning. Which of the following information should the nurse include? A. Eat crackers or plain toast before getting out of bed B. Awaken during the night to eat a snack C. Skip breakfast and eat lunch after nausea has subsided D. Eat a large evening meal

Eat crackers or plain toast before getting out of bed

When the nurse tells a pregnant woman that she needs 1200 mg of calcium daily during pregnancy, the woman responds, "I don't like milk." What dietary adjustments could the nurse recommend? a. Increase intake of organ meats. b. Eat more green leafy vegetables. c. Choose more fresh fruits, particularly citrus fruits. d. Include molasses and whole-grain breads in the diet.

Eat more green leafy vegetables.

A nurse in the emergency department is caring for a client who reports abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding. The client states, "I missed one menstrual cycle and cannot be pregnant because I have an intrauterine device." The nurse should suspect which of the following? A. Missed abortion B. Ectopic pregnancy C. Severe preeclampsia D. Hydatidiform mole

Ectopic pregnancy

Choose the most appropriate intervention to prevent deep venous thrombosis in a woman who is 1 day postcesarean birth. A. Encourage her to walk several times each day B. Provide her with increased fluids that she enjoys C. Take her temperature to identify an elevation D. Instruct her to stay in bed most of the day

Encourage her to walk several times each day

What nursing intervention during labor can increase space in the woman's pelvis? a. Promote adequate fluid intake b. Position her on the left side c. Assist her to take a shower d. Encourage regular urination

Encourage regular urination

The nurse is preparing a pregnant patient for an abdominal ultrasound at 8 weeks' gestation. What intervention will the nurse implement before this diagnostic test? a. Instruct the patient to take nothing by mouth after midnight the night before the test. b. Initiate an IV. c. Encourage the patient to drink 1 to 2 quarts of water before the test. d. Instruct the patient to remove all jewelry.

Encourage the patient to drink 1 to 2 quarts of water before the test.

What would the nurse guide a labor coach to do to comfort a woman tensing her muscles with contractions? a. Offer warm liquids to the patient. b. Encourage the patient to pant. c. Engage the patient in conversation. d. Assist the patient to the knee-chest position.

Encourage the patient to pant.

Five days after a spontaneous vaginal delivery, a woman comes to the emergency room because she has a fever and persistent cramping. What does the nurse recognize as the possible cause of these signs and symptoms? a. Dehydration b. Hypovolemic shock c. Endometritis d. Cystitis

Endometritis

What chemical substance(s) produced in the body acts as a natural pain reliever? a. Endorphins b. Morphine c. Codeine d. Atropine

Endorphins

Which foods are highest in iron? A. Citrus fruits, apricots, tomatoes B. Sweet potatoes, corn, dried beans C. Enriched bread, dark green leafy vegetables D. Milk, cheeses, legumes

Enriched bread, dark green leafy vegetables

A nurse is collecting data from a newborn and observes small pearly white nodules on the roof of the newborn's mouth. This finding is a characteristic of which of the following conditions? A. Mongolian spots B. Milia spots C. Erythema toxicum D. Epstein's pearls

Epstein's pearls

A nurse is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. Which of the following medications should the nurse anticipate administering? A. Ofloxacin B. Nystatin C. Erythromycin D. Ceftriaxone

Erythromycin

After birth, the nurse quickly dries and wraps the newborn in a blanket. How does this action prevent heat loss? a. Conduction b. Radiation c. Evaporation d. Convection

Evaporation

How often will the nurse caring for a preterm infant in an incubator record the temperature of the infant and the incubator? a. Every hour b. Every 2 hours c. Every 4 hours d. Every 8 hours

Every 2 hours

A woman calls her health care provider to schedule prenatal visits in an uncomplicated pregnancy. How frequently will the nurse assist the patient to schedule these appointments? a. Every 3 weeks until the 6th month, then every 2 weeks until delivery b. Every 4 weeks until the 7th month, after which appointments will become more frequent c. Monthly until the 8th month d. Every 2 to 3 weeks for the entire pregnancy

Every 4 weeks until the 7th month, after which appointments will become more frequent

A new mother asks why her 2-day-old baby's skin appears slightly yellow. Which is the best nursing response to explain the cause of this skin color? A. Small blood vessels are broken during labor, releasing waste products into the blood B. The baby's digestive tract is immature and cannot yet excrete bilirubin effectively C. Skin color changes slightly during the first few weeks until the permanent color is evident D. Excess blood cells are being broken down rapidly because the baby is now breathing air

Excess blood cells are being broken down rapidly because the baby is now breathing air

A woman comes to the clinic for her 6 week postpartum check after having her first babt. She says to the nurse, "I don't what's wrong with me. "I'm exhausted all the time and yet I can't seem to sleep when I have the chance." The nurse should A. Reassure her that the demands of being a mother can seem overwhelming, especially, especially with her first baby. B. Ask her if her partner, family members, or firends can help her with care of the baby and her home so she can rest C. Explain that women lose more blood at birth than they expect, and a slight anemia often leads to theses symptoms D. Find a quiet place to talk with her about feelings related to her new role as a mother

Explain that women lose more blood at birth than they expect, and a slight anemia often leads to theses symptoms

What marks the end of the third stage of labor? a. Full cervical dilation b. Expulsion of the placenta and membranes c. Birth of the infant d. Engagement of the head

Expulsion of the placenta and membranes

What will the nurse's instructions for a new mother to care for the infant's umbilical cord include? a. Keeping the area covered with a sterile dressing b. Dressing the stump with antibiotic ointment at every diaper change c. Fastening the diaper low to allow for air circulation d. Giving the newborn a daily tub bath until the cord falls off

Fastening the diaper low to allow for air circulation

Why is the postterm neonate at risk for cold stress? a. Inadequate vernix caseosa b. Hypoxia from a deteriorated placenta c. Polycythemia d. Fat stores have been used in utero for nourishment

Fat stores have been used in utero for nourishment

An 18-month-old child had a surgical repair of a cleft palate and is now allowed to eat a regular diet. What nursing action is the most appropriate? a. Feed solid foods with the spoon at the side of the mouth. b. Puree foods and offer them through a straw. c. Place small bites of food in the mouth with a tongue blade. d. Offer small, frequent meals of finger foods.

Feed solid foods with the spoon at the side of the mouth.

Choose the contraceptive method from those listed that provides the best protection against sexually transmitted infections. a. Female condoms b. Hormone injection c. Intrauterine device d. Oral contraceptives

Female condoms

A woman had a vaginal delivery two days ago and is preparing for discharge. What will the nurse plan to teach the woman to report to help prevent postpartum complications? a. Fever b. Change in lochia from red to white c. Contractions d. Fatigue and irritability

Fever

Regarding PKU testing, the nurse should teach parents that A. A negative test indicates that their baby will not have brain damage B. Follow-up testing should be done during one of the early clinic visits C. The test must be done before the newborn nurses or has any formula D. A special diet started with solid foods will prevent disability

Follow-up testing should be done during one of the early clinic visits

Which assessments are expected 24 hours after birth? A. Scant amount of lochia alba on the perineal pad B. Fundus firm and in the midline of the abdomen C. Breast distended and hard with flat nipples D. Bradycardia

Fundus firm and in the midline of the abdomen

The nurse is collecting data from a client who is pregnant with twins. The client has a healthy 5 year old child ho was delivered at 38 weeks, and she tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse should document which as the GTPAL for this client? 1. G=3, T=2, P=0, A=0, L=1 2. G-2, T=1, P=0, A=0, L=1 3. G=1, T=1, P=1, A=0, L=1 4. G=2, T=0, P=0, A=0, L=1

G-2, T=1, P=0, A=0, L=1

The nurse observes that a preterm infant has a pulse rate of 96 and a pulse oximetry reading of 89%. The FIRST action of the nurse should be A. Go and call the health care provider B. Gently rub the infant's back and suction the nose C. Call a code D. continue observation and documentation as this is normal

Gently rub the infant's back and suction the nose

The apnea monitor indicates that a preterm infant is having an apneic episode. What is the most appropriate nursing action in this situation? a. Administer oxygen via a nasal cannula. b. Gently rub the infant's feet or back. c. Ventilate with an Ambu bag. d. Perform nasopharyngeal suctioning.

Gently rub the infant's feet or back.

What term describes the age of a neonate that is based on the actual time in utero? a. Maturational age b. Gestational age c. Neurological age d. Chronological age

Gestational age

Choose the best method during the admission process to help relieve general anxiety for a woman who has not attended prepared childbirth classes and who is having her first baby: A. Assure her that she will be given pain medication any time she needs it B. Determine her reasons for not attending the classes offered in the hospital C. Haver her take deep breaths to relax all muscles before doing any admission assessments D. Give simple explanations about her environment and what to expect during labor

Give simple explanations about her environment and what to expect during labor.

The nurse explains that the softening of the cervix and vagina is a probable sign of pregnancy. What is the appropriate term for this sign? a. Chadwick's b. Hegar's c. McDonald's d. Goodell's

Goodell's

The nurse is collecting data from a client who is pregnant with triplets. The client also has a 3 year old child who was born at 39 weeks' gestation. The nurse should document which gravida and para status on this client? 1. Gravida 1, para 1 2. Gravida 2, para 1 3. Gravida 2, para 2 4. Gravida 3, para 2

Gravida 2, para 1

A woman who is 7 weeks pregnant tells the nurse that this is not her first pregnancy. She has a 2-year-old son and had one previous spontaneous abortion. How would the nurse document the patient's obstetric history using the TPALM system? a. Gravida 2, para 20120 b. Gravida 3, para 10011 c. Gravida 3, para 10110 d. Gravida 2, para 11110

Gravida 3, para 10110

Which woman is most likely to have afterpains? A. Gravida 1, para 1, 6.5 lb (2951 g) newborn B. Gravida 3, para 1, 7 lb (3178 g) newborn C. Gravida 1, para 1, twins weighing 3.5 lb (1589 g) and 4.5 lb (2043 g) D. Gravida 4, para 4, 9.5 lb (4313 g) newborn

Gravida 4, para 4, 9.5 lb (4313 g) newborn

Several hours after delivery, the nurse finds a woman crying. The woman says repeatedly, "My baby is beautiful, but I was planning on a vaginal delivery. Instead I needed an emergency C-section." What is the most appropriate nursing diagnosis? a. Anxiety related to the development of postpartum complications b. Ineffective individual coping related to unfamiliarity with procedures c. Risk for ineffective parenting related to emergency cesarean section d. Grieving related to loss of expected birth experience

Grieving related to loss of expected birth experience

A pregnant woman is experiencing nausea in the early morning. What recommendations would the nurse offer to alleviate this symptom? a. Eat three well-balanced meals per day and limit snacks. b. Drink a full glass of fluid at the beginning of each meal. c. Have crackers handy at the bedside, and eat a few before getting out of bed. d. Eat a bland diet and avoid concentrated sweets.

Have crackers handy at the bedside, and eat a few before getting out of bed.

A woman is 8 hours postpartum after a spontaneous vaginal birth. Her admission hemoglobin was 9.5 g/dL, and her estimated blood loss during the birth was 1000 mL. She asks the nurse if she can walk to the bathroom. The best nursing response is to A. Remind her that she should catch her urine in a "hat" to be measured B. Have her sit briefly on the side of the bed before helping her to the bathroom C. Encourage her to urinate every 2 hours to decrease the risk of excess bleeding D. Tell her to return to bed promptly after she finishes using the bathroom

Have her sit briefly on the side of the bed before helping her to the bathroom

Which assessment of the newborn should be reported? a. Head circumference is 5 cm greater than the chest circumference. b. Hands and feet are warm with a blue color. c. Temperature is 36.6° C (97.8° F). d. Head has a longer than normal shape to it.

Head circumference is 5 cm greater than the chest circumference.

What side effect would the nurse instruct a woman to look for when starting hormone replacement therapy (HRT)? a. Fatigue b. Headache c. Weight loss d. Amenorrhea

Headache

What is the most appropriate nursing action to take when a laboring woman hyperventilates? a. Help her breathe into her cupped hands. b. Place her flat on her back. c. Initiate oxygen at 2 liters via mask. d. Notify the doctor.

Help her breathe into her cupped hands

Two hours after a vaginal birth with an epidural anesthesia, the nurse determines that the woman's bladder is full. The most appropriate initial nursing action is to: A. help her walk to the bathroom if movement and sensation have returned B. ask her how full her bladder feels before allowing her to walk to the bathroom C. insert an indwelling catheter until the woman is at least 8 hours postpartum D. take no action unless the woman says her full bladder makes her uncomfortable

Help her walk to the bathroom if movement and sensation have returned.

Two hours after a woman's uncomplicated vaginal birth requiring no anesthesia, the nurse notes that her uterus is firm, two fingerwidths above her umbilicus, and deviated slightly to her right side. The most appropriate nursing action at this time is to A. Assess for shock or hemorrhage B. Massage her uterus continuously C. Insert an indwelling catheter D. Help her walk to the bathroom to urinate

Help her walk to the bathroom to urinate

The nurse is assessing a newborn. Which sign would indicate hypoglycemia? a. Increased nasal mucus b. Increased temperature c. Active muscle movements d. High-pitched cry

High-pitched cry

After a prolonged labor, a woman vaginally delivered a 10-pound, 3-ounce infant boy. What complication should the nurse be alert for in the immediate postpartum period? a. Cervical laceration b. Hematoma c. Endometritis d. Retained placental fragments

Hematoma

When obtaining a prenatal history on a pregnant patient the nurse notes a family history of sickle cell disease. Given this information, what lab test can the nurse anticipate the physician will order? a. Endovaginal ultrasound b. Pap test c. Complete blood count d. Hemoglobin electrophoresis

Hemoglobin electrophoresis

A 48-year-old woman tells the nurse, "I missed my period last month. Am I in menopause?" The nurse knows that at which point is a woman considered to be menopausal? a. Her periods have stopped for 1 year. b. Her periods have been irregular and light for 12 months. c. She has symptoms of vasomotor instability. d. She experiences symptoms of decreased estrogen, such as dyspareunia.

Her periods have stopped for 1 year.

The nurse is educating a woman diagnosed with premenstrual dysphoric disorder (PMDD). What is the best type of diet for the nurse to recommend? a. High protein, low fat b. High carbohydrate, high fiber c. Low calorie, low fat d. Low carbohydrate, high protein

High carbohydrate, high fiber

A nurse is preparing to collect data about the reflects of a newborn. In checking for the Moro reflex, the nurse should perform which of the following? A. Hold t he newborn vertically under arms and allow one foot to touch table. B. Stimulate the pads of the newborn's hands with stroking or massage C. Stimulate the soles of the newborn's feet on the outer lateral surface of each foot D. Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward

Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward

A woman missed her menstrual period 1 week ago and has come to the doctor's office for a pregnancy test. Which placental hormone is measured in pregnancy tests? a. Progesterone b. Estrogen c. Human chorionic gonadotropin d. Human placental lactogen

Human chorionic gonadotropin

A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea; vomiting; and scant, prune-colored discharge. The client has experienced no weight loss and has a fundal height larger than expected. Which of the following complication should the nurse suspect? A. Hyperemesis gravidarum B. Threatened abortion C. Hydatidiform mole D. Preterm labor

Hydatidiform mole

What occurrence results from obstruction within the ventricles of the brain or inadequate reabsorption of cerebrospinal fluid? a. Meningitis b. Meningocele c. Spina bifida occulta d. Hydrocephalus

Hydrocephalus

A pregnant patient tells the nurse that she has been nauseated and vomiting. How will the nurse explain that hyperemesis gravidarum is distinguished from morning sickness? a. Hyperemesis gravidarum usually lasts for the duration of the pregnancy. b. Hyperemesis gravidarum causes dehydration and electrolyte imbalances. c. Sensitivity to smells is usually the cause of vomiting in hyperemesis gravidarum. d. The woman with hyperemesis gravidarum will have persistent vomiting without weight loss.

Hyperemesis gravidarum causes dehydration and electrolyte imbalances.

Methylergonovine (Methergine) should be avoided if the woman has A. Uterine agony B. Retained placenta C. Hypertension D. Endometritis

Hypertension

Several hours into labor, a woman complains of dizziness, numbness, and tingling of her hands and mouth. What does the nurse recognize these symptoms signify? a. Hypertension b. Anxiety c. Anoxia d. Hyperventilation

Hyperventilation

The nurse caring for an infant born at 36 weeks of gestation assesses tremors and a weak cry. The nurse is aware that these symptoms indicate what? a. Respiratory distress syndrome b. Hypoglycemia c. Necrotizing enterocolitis d. Renal failure

Hypoglycemia

The nurse is caring for a macrosomic newborn of a diabetic patient. What complications will the nurse assess for in the newborn? a. Meconium ileus b. Diarrhea c. Hypoglycemia d. Muscle tremors

Hypoglycemia

The nurse is caring for a macrosomic newborn whose mother has diabetes. What should the nurse assess for with this neonate? a. Hypoglycemia b. Erythroblastosis fetalis c. Intracranial hemorrhage d. Pancreatic failure

Hypoglycemia

After several hours of labor, a nursing assessment reveals that a woman's cervix is 5 cm dilated, but contractions are becoming shorter and less frequent. What is this labor pattern considered? a. Normal b. Hypotonic c. Hypertonic d. False

Hypotonic

A pregnant woman states, "My husband hopes I will give him a boy because we have three girls." What will the nurse explain to this woman? a. The sex chromosome of the fertilized ovum determines the gender of the child. b. When the sperm and ovum are united, there is a 75% chance the child will be a girl. c. When the pH of the female reproductive tract is acidic, the child will be a girl. d. If a sperm carrying a Y chromosome fertilizes an ovum, then a boy is produced

If a sperm carrying a Y chromosome fertilizes an ovum, then a boy is produced.

Postpartum bipolar disorder is characterized by A. Periods of letdown feelings but general enjoyment of life B. Impaired reality characterized by europhia alternating with depression C. Alternate periods of overeating and lack of interest in food and drink D. Prolonged feelinds of worthlessness or guilt

Impaired reality characterized by europhia alternating with depression

The nurse observes that the infant's anterior fontanelle is bulging after placement of a ventriculoperitoneal shunt. How should the nurse position this infant? a. Prone, with the head of the bed elevated b. Supine, with the head flat c. Side-lying on the operative side d. In a semi-Fowler's position

In a semi-Fowler's position

The nurse explains that the birth weight of monozygotic twins is frequently below average. What is the most likely cause? a. Inadequate space in the uterus b. Inadequate blood supply c. Inadequate maternal health d. Inadequate placental nutrition

Inadequate placental nutrition

In the week before her menstrual period, a woman experiences irritability, anxiety, and difficulty concentrating. What remedy might the nurse suggest to relieve these symptoms? a. Drink tea or hot chocolate before going to bed. b. Take a daily folic acid and vitamin C supplement. c. Include complex carbohydrates and fiber in the diet. d. Avoid exercise when symptoms occur.

Include complex carbohydrates and fiber in the diet. *recommended for premenstrual dysmorphic disorder (PMDD)

At her regular gynecological examination, a woman tells the nurse that she is concerned about osteoporosis. What suggestion can the nurse make to this patient? a. Take a vitamin E supplement daily. b. Do isometric exercises that can be practiced every day. c. Include more dairy products and green, leafy vegetables in her diet. d. Try to limit her intake of caffeine

Include more dairy products and green, leafy vegetables in her diet. *rich in calcium

A woman is 9 weeks pregnant and experiencing heavy bleeding and cramping. She reports passing some tissue. Cervical dilation is noted on examination. What is the most likely cause of these symptoms? a. Inevitable abortion b. Incomplete abortion c. Complete abortion d. Missed abortion

Incomplete abortion

The nurse is caring for a patient who is threatening preterm labor and has been given glucocorticoids. What is the purpose of glucocorticoid administration? a. Prevent infection. b. Increase fetal lung maturity. c. Increase blood flow from placenta. d. Relax the cervix.

Increase fetal lung maturity

What sign(s) of infection should the nurse assess for after an amniotomy? a. Oral temperature of 37° C (99.8° F) b. Increase of fetal heart rate (FHR) from 160 to 174 beats/minute c. Flecks of vernix in the amniotic fluid d. Low back pain

Increase of fetal heart rate (FHR) from 160 to 174 beats/minute

What is the best nursing action to implement when late decelerations occur? a. Reposition the patient to supine. b. Decrease flow of intravenous (IV) fluids. c. Increase oxygen to 10 L/minute. d. Prepare to increase oxytocin drip.

Increase oxygen to 10 L/minute.

Which sign or symptom normally occurs shortly before labor begins? A. An urge to push or bear down B. Increased clear vaginal discharge C. Moderate amount of vaginal bleeding D. Sudden weight gain of 3-5 pounds

Increased clear vaginal discharge

What symptoms of cold stress might the nurse recognize in a preterm infant? a. Tremors and weak cry b. Plasma glucose level below 40 mg/dL c. Warm skin with low core temperature d. Increased respiratory rate and periods of apnea

Increased respiratory rate and periods of apnea

The nurse should learn to evaluate labor progress by methods other than vaginal examination, primarily because vaginal examination: A. worsens the mother's discomfort B. Increases the risk for infection C. reduces fetal heart rate variability D. delays normal progression of labor

Increases the risk for infection.

Which statement indicates the parents understand when to contact the pediatrician or nurse practitioner? a. Infant refuses a feeding b. Infant has an axillary temperature of 97° F c. Infant has three pasty, yellow-brown stools in 24 hours d. Infant's diaper is not wet after 8 hours

Infant's diaper is not wet after 8 hours

Colostrum's greatest benefit to the infant is prevention of A. Constipation B. Weight loss C. Hemorrhage D. Infection

Infection

A newborn has a small laceration on the forehead when delivered by cesarean. Brief finger pressure in the operating room stopped the bleeding and the health care provider does not need to suture the laceration. The nurse should primarily observe for what other complication related to the baby's laceration? A. Anemia, possibly manifested by pallor and tachycardia B. Hypothermia due to delay of placement in a warmer C. Excessive erythrocyte destruction and early jaundice D. Infection limited to the site or possible generalized

Infection limited to the site or possible generalized

Infections in the newborn require prompt intervention because: A. they spread more quickly B. Infections that are relatively harmless to an adult can be fatal to the newborn C. the portals of entry and exit are more numerous D. the newborn has few defenses against infection

Infections that are relatively harmless to an adult can be fatal to the newborn

A pregnant woman is attending her second prenatal visit. Prenatal lab work indicates she is not immune to the rubella virus. What is the most appropriate nursing intervention? a. Provide the rubella vaccine as ordered by the physician immediately. b. Inform the woman she should receive the vaccine in the hospital after delivery. c. Hold all immunizations until 1 month postpartum. d. Encourage the patient to decide whether or not to get the rubella vaccine prenatally.

Inform the woman she should receive the vaccine in the hospital after delivery.

The nurse notes that a woman's contractions during oxytocin induction of labor are every 2 minutes; the contractions last 95 seconds, and the uterus remains tense between contractions. What action is expected based on these assessments? a. No action is expected; the contractions are normal. b. The rate of oxytocin administration will be increased slightly c. Pain medication or an epidural block will be offered d. Infusion of oxytocin will be stopped

Infusion of oxytocin will be stopped

Why does the woman taking oral hypoglycemic agents to control diabetes mellitus need to take insulin during pregnancy? a. Insulin can cross the placental barrier to the fetus. b. Insulin does not cross the placental barrier to the fetus. c. Oral agents do not cross the placenta. d. Oral agents are not sufficient to meet maternal insulin needs.

Insulin does not cross the placental barrier to the fetus.

The nurse is preparing to administer beractant to a premature infant who has respiratory distress syndrome. The nurse plan to administer the medication by which route? 1. Intradermal 2. Intratracheal 3. Subcutaneous 4. Intramuscular

Intratracheal

A woman has an emergency cesarean delivery after the umbilical cord was found to be prolapsed. She repeatedly asks similar questions about what happened at birth. The nurse's interpretation of the woman's behavior is that she: a. Cannot accept that she did not have the type of delivery she planned b. Is trying to understand her experience and move on with postpartum adaptation c. Thinks the staff is not telling her the truth about what happened at birth d. Is confused about events because the effects of the general anesthetic are persisting

Is trying to understand her experience and move on with postpartum adaptation

Fetal descent during labor is measured in relation to the mother's: A. Posterior perineum B. Sacral promontory C. Ischial spines D. Uterine fundus

Ischial spines

A nurse is teaching a childbirth preparation class. The group is discussing individual expression of labor pain. What statement is accurate about a patient's expression of pain? a. It reduces the patient's perception of pain. b. It is intensified by the vertex position of the fetus. c. It is influenced by culture. d. It can be completely controlled by nonpharmacological techniques.

It is influenced by culture.

A woman in the transition phase of labor requests a narcotic analgesic medication for pain relief. What should the nurse explain regarding giving a narcotic analgesic medication at this stage of labor? a. It can cause medication given at later stages to be ineffective. b. It will have no complications for the mother or infant. c. It may result in respiratory depression to the newborn. d. It will speed up labor and increase pain.

It may result in respiratory depression to the newborn.

The nurse is planning to teach a woman about perimenopause. What would the nurse include regarding lowered estrogen level? a. It prevents osteoporosis. b. It decreases vaginal lubrication. c. It raises the level of low-density lipoproteins. d. It raises the level of high-density lipoproteins.

It raises the level of low-density lipoproteins. *with lowered levels of estrogen, LDLs increase, causing an increase in the incidence of heart attacks and strokes

The nurse is reinforcing teaching to a pregnant woman about the physiological effects and hormonal changes that occur during pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which purpose of estrogen? 1. It maintains the uterine lining for implantation. 2. It stimulates the metabolism of glucose and converts glucose to fat 3. It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation 4. It prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed.

It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation

A nurse is caring for a client who is pregnant and states that their last menstrual period was April 1st. Which of the following is the client's estimated date of delivery? A. January 8 B. January 15 C. February 8 D. February 15

January 8

The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her las menstrual period (LMP) was October 20, 2019. Using Nagele's rule, the nurse determines the estimated date of birth is which date? 1. July 12, 2020 2. July 27, 2020 3. August 12, 2020 4. August 27, 2020

July 27, 2020

A nurse is reinforcing discharge teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following instructions should the nurse include? A. Use a condom with sexual intercourse B. Avoid bubble bath solution when take a tub bath C. Wipe from the back to the front when performing perineal hygiene D. Keep a daily record of fetal kick counts

Keep a daily record of fetal kick counts

When admitted to the nurse, a baby's initial temperature is 35.8 C (96.6 F). Choose the most appropriate nursing response for this assessment. A. Chart the expected temperature and continue doing other admission assessments and measurements B. Keep the baby in a radiant warmer during admission and recheck the temperature in 30 minutes C. Remove blankets and sources of added heat from the baby D. Recheck the temperature in 30 minutes to verify accuracy

Keep the baby in a radiant warmer during admission and recheck the temperature in 30 minutes

The nurse is assisting with caring for a postpartum client who is experiencing uterine hemorrhage. When planning to meet the psychosocial needs of the client, the nurse should plan which action? 1. Maintain strict bed rest 2. Monitor the vital signs every 2 weeks 3. Perform firm fundal massage every 2 hours 4. Keep the client and her family members informed of her progress

Keep the client and her family members informed of her progress

The nurse is assigned to assist with caring for a client who has admitted to the labor unit. The client is 9 cm dilated and is experiencing precipitous labor. Which is the priority nursing action? 1. Prepare for an oxytocin infusion 2. Keep the client for epidural anesthesia 3. Prepare the client for epidural anesthesia 4. Encourage the client to start pushing with the contraction

Keep the client for epidural anesthesia

Phototherapy is instituted for an infant. What is the most appropriate nursing action for the infant having phototherapy? a. Cover the infant's head with a hat. b. Dress the infant lightly in a T-shirt. c. Keep the infant's eyes covered. d. Reposition the infant at least every 4 to 8 hours.

Keep the infant's eyes covered.

A nurse is reinforcing teaching with a group of new parents about proper techniques for bottle feeding. Which of the following instructions should the nurse provide? A. Burp the newborn at the end of the feeding B. Hold the newborn close in a supine position C. Keep the nipple full of formula throughout the feeding D. Refrigerate any unused formula

Keep the nipple full of formula throughout the feeding

Choose the abbreviation that describes the fetus in a breech presentation. A. LSA B. LOA C. ROA D. FHR

LSA *Left Sacrum Anterior

A woman is 7 cm dilated, and her contractions are 3 minutes apart. When she begins cursing at her birthing coach and the nurse, what does the nurse assess as the most likely explanation for the woman's change in behavior? a. Labor has progressed to the transition phase. b. She lacked adequate preparation for the labor experience. c. The woman would benefit from a different form of analgesia. d. The contractions have increased from mild to moderate intensity.

Labor has progressed to the transition phase.

A woman who is 25 weeks pregnant asks the nurse what her fetus looks like. What does the nurse explain is one physical characteristic present in a 25-week-old fetus? a. Lanugo covering the body b. Constant motion c. Skin that is pink and smooth d. Eyes that are closed

Lanugo covering the body

When assessing a neonate born at 38 weeks of gestation, the nurse records his weight as 8 pounds, 10 ounces. What will the nurse consider this newborn? a. Term b. Small for gestational age c. Large for gestational age d. Late preterm

Large for gestational age *Term infants over 4000 g (8.8 lb) may be classified as large for gestational age (LGA). For the preterm infant this is less than 38 weeks, for the term infant it is 38 to 42 weeks, and for the postterm infant it is beyond 42 weeks. A late preterm infant, also known as a near-term infant, is born between 34 and 36 weeks.

The nurse should observe the woman who received epidural opioid narcotics for: A. late respiratory depression B. nausea and vomiting C. unstable blood pressure D. persistent headache

Late respiratory depression.

What information will the nurse provide when educating a woman about the correct use of a diaphragm? a. Use of a spermicidal cream or jelly is not recommended. b. Leave in place for at least 6 hours after intercourse. c. Remove immediately after intercourse for douching. d. It is effective for up to 48 hours if positioned properly.

Leave in place for at least 6 hours after intercourse.

What nursing action will the nurse implement after feeding an infant with hydrocephalus? a. Position the infant sitting upright in an infant seat. b. Place the infant over the shoulder to burp. c. Leave the infant in a side-lying position. d. Stimulate the infant by rubbing its feet.

Leave the infant in a side-lying position.

Parents express concern about the milia on the face and nose of their infant. What is the nurse's most helpful response when instructing the parents? a. Contact a pediatric dermatologist for topical medication. b. Squeeze out the white material after cleansing the face. c. Wash the infant's face with a mild astringent several times a day. d. Leave the milia alone; it will disappear spontaneously. No treatment is needed.

Leave the milia alone; it will disappear spontaneously. No treatment is needed.

A nurse is assisting with the car of a client who is in preterm labor and is scheduled to undergo an amniocentesis. The nurse should review which of the following tests to check fetal lung maturity? A. Alpha-fetoprotein (AFP) B. Lecithin/sphingomyelin (L/S) ratio C. Kleihauer-Betke test D. Indirect Coombs' test

Lecithin/sphingomyelin (L/S) ratio

The nurse is preparing a teaching plan for a woman receiving a subarachnoid block before delivery. What nursing action will be included in this plan to prevent the associated side effect of this type of anesthesia? a. Restrict oral fluids. b. Keep legs flexed. c. Walk with assistance as soon as possible. d. Lie flat for several hours.

Lie flat for several hours.

The client is in her second trimester of pregnancy. She complains of frequent low back pain and ankle edema at the end of the day. The nurse should recommend which measure to help relieve both discomforts? 1. Lie on the left side with the feet dorsiflexed. 2. Soak the feet in hot water after performing 10 pelvic tilt exercises. 3. Lie on the right side with the feet elevated on a pillow and a heating pad on the back 4. Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle.

Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle.

What organ does the ductus venosus shunt blood away from in fetal circulation? a. Liver b. Heart c. Lungs d. Kidneys

Liver

The nurse is caring for an infant born at 35 weeks of gestation. What physical characteristic might the nurse expect this infant to exhibit? a. Thin, long extremities b. Large genitals for its size c. Minimal vernix caseosa d. Loose, transparent skin

Loose, transparent skin

What complication is more likely for a newborn of a diabetic mother within the first few hours after birth? A, intracranial hemorrhage B. hyperactive reflexes C. Excessive urination D. Low blood glucose levels

Low blood glucose levels

The nurse is assigned to assist with caring for a neonate born to a mother who is human immunodeficiency virus (HIV)-positive. The nurse understands that which should be included in the plan of care? 1. Monitoring the neonate's vital signs routinely 2. Maintaining standard precautions at all times while caring for the neonate 3. Instructing breastfeeding mothers regarding the treatment of their nipples with an antifungal cream 4. Initiating a referral to evaluate for blindness, deafness, learning, or behavioral problems in the neonate

Maintaining standard precautions at all times while caring for the neonate

The term infant may be placed in skin-to-skin contact with the mother immediately after birth primarily for the purpose of: A. breastfeeding while the baby is alert B. maintaining the infant's temperature C. promoting early parent-infant attachment D. stimulating expulsion of the placenta

Maintaining the infants temperature.

At her 6-week postpartum checkup, a woman mentions to the nurse that she cannot sleep and is not eating. She feels guilty because sometimes she believes her infant is dead. What does the nurse recognize as the cause of this woman's symptoms? a. Bipolar disorder b. Major depression c. Postpartum blues d. Postpartum depression

Major depression

The nurse who encourages the gate control theory of pain control would advise a woman in labor and her partner to use which nonpharmacological method of pain management? a. Slow abdominal breathing b. Guided relaxation c. Listening to music d. Massage

Massage

A mother phones the postpartum unit 4 days after birth. She says her baby cannot suck well on her nipples because her breasts are full and engorged. What should the nurse recommend? A. Apply ice packs just before allowing the newborn to nurse B. Feed formula for the next two feedings to reduce pain and congestion C. Massage the breasts and express a small amount of milk before nursing D. Reduce daily liquid intake to 1 quart for a few days

Massage the breasts and express a small amount of milk before nursing

A mother is breastfeeding her newborn baby and experiences breast engorgement. The nurse should encourage the mother to which to provide relief of the engorgement? 1. Breastfeed only during the daytime hours 2. Apply cold compresses to the breast before feeding 3. Avoid the use of a bra while the breasts are engorged 4. Massage the breasts before feeding to stimulate let-down

Massage the breasts before feeding to stimulate let-down

After delivery, the nurse's assessment reveals a soft, boggy uterus located above the level of the umbilicus. What is the most appropriate nursing intervention? a. Notify the physician. b. Massage the fundus. c. Initiate measures that encourage voiding. d. Position the patient flat.

Massage the fundus.

A nurse is assisting in the care of a client who is in active labor. The nurse notes tachycardia on the external fetal monitor tracing. Which of the following conditions should the nurse identify as a potential cause of the heart rate? A. Maternal fever B. Fetal heart failure C. Maternal hypoglycemia D. Fetal head compression

Maternal fever

The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. The nurse would assess for which adverse effect? a. Maternal tachycardia b. Maternal hypertension c. Fetal bradycardia d. Fetal hypokalemia

Maternal tachycardia

A woman reports that her last normal menstrual period began on August 5, 2013. What is this woman's expected delivery date using Nägele's rule? a. April 30, 2014 b. May 5, 2014 c. May 12, 2014 d. May 26, 2014

May 12, 2014 *To determine the expected date of delivery, count backward 3 months from the first day of the last menstrual period, then add 7 days and change the year if necessary

A nurse is contributing to the plan of care for a client who is postpartum and has thrombophlebitis. Which of the following nursing interventions should the nurse recommend? A. Apply cold compresses to the affected extremity B. Massage the affected extremity C. Allow the client to ambulate D. Measure leg circumferences

Measure leg circumferences

The nurse teaches a woman who is 8 weeks pregnant about how rubella can affect the developing fetus. What can result from maternal rubella during pregnancy? a. Facial abnormalities b. Mental retardation c. Liver failure d. Limb deformities

Mental retardation

Which of the following is most appropriately used for pain relief during labor when the cervix is dilated less than 4 cm? A. naloxone (Narcan) via IM route B. Meperidine (Demerol) via IM route C. Promethazine (Phenergan) via epidural route D. Fentanyl (Sublimaze) via epidural route

Meperidine (Demerol) via IM route

A breastfeeding mother reports that she has cramping after every time she feeds her baby. The nurse informs her that these are afterpains, intermittent uterine contractions similar to menstrual cramps. What is the best physician-ordered pharmacological nursing intervention? A. Narcotic B. Mild analgesic C. Anesthetic D. Tocolytic

Mild analgesic

During the latent phase of labor, the nurse should expect the woman's behavior to be: A. sleepy, except during contractions B. mildly anxious, coping with contractions C. quiet, concentrating on each contraction D. frustrated, losing control with contractions

Mildly anxious, coping with contractions.

A nurse is checking the fundus of a client who is 2 days postpartum and observes the perineal pad for lochia. The pad is saturated approximately 12 cm with lochia that is bright red and contains small clots. Which of the following findings should the nurse document in the client's medical record? A. Moderate lochia rubra B. Excessive lochia serosa C. Light lochia rubra D. Scant lochia serosa

Moderate lochia rubra

When assessing labor contractions, the nurse notes that the contracting uterus can be slightly indented with fingertips when contractions are at their peak. Contraction intensity should be recorded as: A. mild B. moderate C. firm D. latent

Moderate.

Parents of a newborn are worried about dark areas over the sacrum of the newborn. What does the nurse explain this transitory skin discoloration is called? a. Epstein's pearls b. Milia c. Stork bites d. Mongolian spots

Mongolian spots

What nursing action is appropriate to prevent possible retinopathy in a preterm infant requiring oxygen therapy? a. Monitor arterial oxygen levels with a pulse oximeter. b. Position the head slightly lower than the body. c. Administer low concentrations of oxygen. d. Keep the infant's eyes covered at all times.

Monitor arterial oxygen levels with a pulse oximeter.

Which reflex shows the baby's reaction to sudden movement by drawing up the legs, extending the arms, then folding the arms across the chest with the fingers open? A. Dancing B. Moro C. Rooting D. Grasp

Moro

A woman asks about resumption of her menstrual cycle after childbirth. What should the nurse respond? a. A woman will not ovulate in the absence of menstrual flow. b. Most nonlactating women resume menstruation about 2 months postpartum. c. Generally, a woman does not ovulate in the first few cycles after childbirth. d. The return of menstruation is delayed when a woman does not breastfeed.

Most nonlactating women resume menstruation about 2 months postpartum.

What part of the fetal body derives from the mesoderm? a. Nails b. Oil glands c. Muscles d. Lining of the bladder

Muscles

A mother asks the nurse, "Do you think my baby recognized my voice?" The nurse should consider which correct information when responding? a. Voice recognition is delayed because the ears are not well developed at birth. b. Infants respond to voice by increasing movements and sucking. c. Infants initially respond to low-pitched voices. d. Neonates can distinguish a mother's voice from other sounds in the first days of life.

Neonates can distinguish a mother's voice from other sounds in the first days of life

A nurse in a clinic is reinforcing teaching with a client of childbearing age about recommended folic acid supplements. Which of the following defects can occur in the fetus or neonate as a result of folic acid deficiency? A. Iron deficiency anemia B. Poor bone formation C. Macrosomic fetus D. Neural tube defects

Neural tube defects

The nurse encourages adequate intake of folic acid for women of childbearing age before and during pregnancy. What is folic acid thought to decrease the incidence of in fetal development? a. Structural heart defects b. Craniofacial deformities c. Limb deformities d. Neural tube defects

Neural tube defects

When preparing to teach a class about prenatal development, the nurse would include information about folic acid supplementation. What is folic acid known to prevent? a. Congenital heart defects b. Neural tube defects c. Mental retardation d. Premature birth

Neural tube defects

A pregnant woman's membranes ruptured prematurely at 34 weeks. She will be discharged to her home for the next few weeks. What would the nurse planning discharge instruction teach the woman to do? a. Report any increase in fetal activity. b. Notify her obstetrician if she has a temperature above 37.8° C (100° F). c. Massage her breasts to promote uterine relaxation. d. Rest in a side-lying Trendelenburg's position with hips elevated.

Notify her obstetrician if she has a temperature above 37.8° C (100° F).

During a strenuous labor, the woman asks for some pain remedy for the sudden pain between her scapulae that seems to occur with every breath she takes. What is the best nursing action? a. Give the pain remedy. b. Notify the charge nurse immediately. c. Turn the patient to her back and flex her knees. d. Suggest that the coach give her a back rub.

Notify the charge nurse immediately

The nurse is caring for a child who has had a ventriculoperitoneal shunt (VP) for hydrocephalus and observes an increasing abdominal girth. What is the most appropriate response? a. Elevate the child's head. b. Check bowel sounds. c. Record retention of feeding. d. Notify the charge nurse of possible malabsorption.

Notify the charge nurse of possible malabsorption.

The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on exertion. What action should the nurse implement based on these symptoms? a. Notify the charge nurse of a possible upper respiratory infection. b. Notify the physician of a possible pulmonary embolism. c. Document expected postpartum mucous membrane congestion. d. Medicate with antipyretic remedy for elevated temperature.

Notify the physician of a possible pulmonary embolism.

A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings which is the priority nursing action? 1. Monitor the maternal vital signs 2. Notify the registered nurse (RN) immediately 3. Continue monitoring labor and the fetal heart rate 4. Encourage relaxation and breathing techniques between contractions

Notify the registered nurse (RN) immediately

The nurse is caring for a postpartum client. At 4 hours postpartum, the client's temperature is 102 F (38.9 C). Which is the appropriate nursing action? 1. Apply cool packs to the abdomen 2. Continue to monitor the temperature 3. Remove the blanket from the client's bed 4. Notify the registered nurse (RN), who will then contact the primary health care provider (PHCP)

Notify the registered nurse (RN), who will then contact the primary health care provider (PHCP)

The most effective way to identify adequate maternal oxygenation after epidural administration of a narcotic for cesarean birth is to: A. take the blood pressure regularly B. observe for cyanosis or restlessness C. maintain a side-lying position D. observe pulse oximeter readings

Observe pulse oximeter readings.

The primary means of identifying hemorrhage after vaginal birth is to: A. Assess vital signs frequently B. observe the uterine fundus and lochia C. keep an ice pack on the perineum D. have the woman urinate every 2 hours

Observe the uterine fundus and lochia.

which is the priority for nursing care during the second stage of labor? A. Observe the woman's perineum B. Encourage pushing with contractions C. Evaluate labor coping skills D. Administer ordered analgesia

Observe the woman's perineum.

A pulsating structure is felt during a vaginal examination of a woman in labor. How would the nurse position the woman to prevent compression of a prolapsed cord? a. On her right side with knees flexed b. On her left side with a pillow placed between her legs c. On her back with her head lower than the rest of her body d. Supine with her legs elevated and bent at the knee

On her back with her head lower than the rest of her body

The nurse is caring for a prenatal patient diagnosed with a placenta previa. What is the best position for this patient? a. Flat on her back with knees flexed to help prevent hemorrhage b. On her side to prevent supine hypotension c. In the semi-Fowler's position to prevent supine hypotension d. In the knee-chest position to reduce pressure on the placenta

On her side to prevent supine hypotension

When bathing an infant, what sign does the nurse recognize as a sign of developmental hip dysplasia? a. Hypotonicity of the leg muscles b. One leg is shorter than the other c. Broadening and flattening of the buttocks d. Two skinfolds on the back of each thigh

One leg is shorter than the other

The nurse is reviewing fetal circulation with a pregnant patient and explains that blood circulates through the placenta to the fetus. What vessel(s) carry blood to the fetus? a. One umbilical vein b. Two umbilical veins c. One umbilical artery d. Two umbilical arteries

One umbilical vein

The nurse reviews the procedure for breast self-examination (BSE) with a 25-year-old woman who has a family history of breast cancer. When reviewing the procedure, when will the nurse indicate as the best time for a woman to perform a breast self-examination? a. A few days before her period b. During her menstrual period c. On the last day of menstrual flow d. One week after the beginning of her period

One week after the beginning of her period

What will the nurse expect when assessing the anterior fontanelle of a healthy, full-term newborn? a. Depressed and sunken b. Triangular shaped c. Smaller than the posterior fontanelle d. Open and diamond shaped

Open and diamond shaped

A nurse is reviewing a new prescription for iron supplements with a client who is at 8 weeks of gestation and has iron deficiency anemia. Which of the following beverages should the nurse reinforce the client to take the iron supplements with? A. Ice water B. Low-fat or whole milk C. Tea or coffee D. Orange juice

Orange juice

What is the most common site for fertilization? a. Lower segment of the uterus b. Outer third of the fallopian tube near the ovary c. Upper portion of the uterus d. Area of the fallopian tube farthest from the ovary

Outer third of the fallopian tube near the ovary

A nurse is assisting with the care of a newborn who is preterm and has respiratory distress syndrome. Which of the following should the nurse monitor to evaluate the newborn's condition following administration of synthetic surfactant? A. Oxygen saturation B. Body temperature C. Serum bilirubin D. Heart rate

Oxygen saturation

Massage and putting the infant to the breast of a postpartum patient have been ineffective in controlling a boggy uterus. What will the nurse anticipate might be ordered by the physician? a. Ritodrine b. Magnesium sulfate c. Oxytocin d. Bromocriptine

Oxytocin

An 18-year-old primigravida is 4 cm dilated and her contractions are 5 minutes apart. She received little prenatal care and had no childbirth preparation. She is crying loudly and shouting, "Please give me something for the pain. I can't take the pain!" What is the priority nursing diagnosis? a. Pain related to uterine contractions b. Knowledge deficit related to the birth experience c. Ineffective coping related to inadequate preparation for labor d. Risk for injury related to lack of prenatal care

Pain related to uterine contractions

In the recovery room, the nurse checks the newly delivered woman's fundus following a cesarean section. How would the nurse proceed with this assessment? a. Palpate from the midline to the side of the body. b. Palpate from the symphysis to the umbilicus. c. Palpate from the side of the uterus to the midline. d. Massage the abdomen in a circular motion.

Palpate from the side of the uterus to the midline.

A nurse is assisting with performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie? A. Apply palms of both hands to sides of uterus. B. Palpate the fundus of the uterus C. Grasp lower uterine segment between thumb and fingers D. Stand facing client's feet with fingertips outlining cephalic prominence

Palpate the fundus of the uterus

The nurse is caring for a woman of Middle Eastern descent on the first postpartum day. Education is provided regarding instruction on use of a sitz bath. What documentation best indicates that the woman has understood the provided instruction? a. Patient correctly performed return demonstration. b. Patient indicated understanding by nodding head with instruction. c. Patient verbalizes "I understand." d. Family member indicates patient understands procedure.

Patient correctly performed return demonstration.

A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to 5 cm with membranes intact. What action by the physician will the nurse anticipate? a. Perform an amniotomy. b. Initiate tocolytic drugs. c. Order a sedative for the patient. d. Plan to do an emergency cesarean section.

Perform an amniotomy.

Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication , the nurse contacts the primary health care provider (PHCP) who prescribed the medication if which condition is documented in the client's medical history? 1. Hypotension 2. Hypothyroidism 3. Diabetes Mellitus 4. Peripheral vascular disease

Peripheral vascular disease

Choose the finding that suggests infection after birth A. Poorly relieved perineal pain 4 hours postpartum B. Oral temperature of 37.7 C (100 F) 18 hours postpartum C. White blood cell count of 21,000/dL at 1 day postpartum D. Persistent and severe cramping 3 days postpartum

Persistent and severe cramping 3 days postpartum

The nurse caring for a client with abruptio placentae is monitoring the client for signs of disseminated intravascular coagulopathy (DIC). The nurse should suspect DIC if which is observed? 1. Rapid clotting times 2. Pain and swelling of the calf of one leg 3. Laboratory values that indicate increased platelets 4. Petechiae, oozing from injection sites, and hematuria

Petechiae, oozing from injection sites, and hematuria

One day after discharge, the postpartum patient calls the clinic complaining of a reddened area on her lower leg, temperature elevation of 37° C (99.8° F), rust-colored lochia, and sore breasts. What does the nurse suspect from these symptoms? a. Phlebitis b. Puerperal infection c. Late postpartum hemorrhage d. Mastitis

Phlebitis

When teaching a woman following vaginal birth 24 hours ago, the nurse should tell her to report A. Pink vaginal drainage followed by red drainage B. Menstrual-like odor of vaginal discharge C. Uterine cramping when the newborn nurses D. Excretion of large quantities of dilute urine

Pink vaginal drainage followed by red drainage

Which is the best nursing measure to increase the woman's perineal comfort during the first hour after vaginal birth with a midline episiotomy? A. Help her take a warm sitz bath B. Give her an oral analgesic drug C. Apply topical anesthetic ointment D. Place an ice pack on the area

Place an ice pack on the area

How should the nurse intervene to relieve perineal bruising and edema following delivery? a. Place an ice pack on the area for 12 hours. b. Place a warm pack on the perineal area for 24 hours. c. Administer aspirin to relieve inflammation. d. Change the perineal pad frequently.

Place an ice pack on the area for 12 hours.

A nurse is providing prenatal education. The nurse will explain that pregnancy affects glucose metabolism in what way? a. Placental hormones increase the resistance of cells to insulin. b. Insulin cells cannot meet the body's demands as the woman's weight increases. c. There is a decreased production of insulin during pregnancy. d. The speed of insulin breakdown is decreased during pregnancy.

Placental hormones increase the resistance of cells to insulin.

A newborn was just admitted to the neonatal intensive care unit with a meningomyelocele. What is the priority preoperative nursing care of this newborn? a. Keep the sac dry. b. Diaper snugly. c. Position prone in an incubator. d. Move from side to side every hour.

Position prone in an incubator.

A nurse in the delivery room is planning to promote parent-infant bonding for a client who just delivered. Which of the following is the priority action by the nurse? A. Encourage the parents to touch and explore the neonate's features B. Limit noise and interruption in the delivery room C. Place the neonate at the client's breast D. Position the neonate skin-to-skin on the client's chest.

Position the neonate skin-to-skin on the client's chest.

A new mother has decided not to breastfeed her newborn. What information will the nurse include when planning to teach the mother about formula feeding? a. Positioning the bottle so that the nipple is full of formula during the entire feeding b. Heating the infant formula in a microwave c. Burping the infant after 4 ounces and again when the bottle is empty d. Propping a bottle for a feeding

Positioning the bottle so that the nipple is full of formula during the entire feeding

A nurse is assisting with the care of a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown. Which of the following conditions are associated with these manifestations? A. Postpartum fatigue B. Postpartum psychosis C. Letting-go phase D. Postpartum blues

Postpartum blues

The nurse is assisting with planning care for a postpartum woman who has small vulvar hematomas. To assist with reducing the swelling, the nurse should perform which action? 1. Check vital signs every 4 hours 2. Measure the fundal height every 4 hours 3. Prepare a heat pack for application to the area 4. Prepare an ice pack for application to the area

Prepare an ice pack for application to the area

The client received an epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client's systolic blood pressure (BP) dropped by 20 points, the diastolic BP dropped 10 points, and her pulse is 120 beats per minute. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. Based on this diagnosis, the nurse should plan which action? 1. Reassure the client 2. Apply perineal pressure 3. Monitor fundal height 4. Prepare the client for surgery

Prepare the client for surgery

The nurse administers erythromycin ointment (0.5%) to the newborn's eyes and the mother asks the nurse why this is done. The nurse should give which response to the client? 1. Prevents cataracts in the neonate born to a woman who is susceptible to rubella 2. Protects neonate's eyes from possible infections acquired while hospitalized. 3. Minimizes the spread of microorganisms to the neonate from invasive procedures during labor 4. Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection

Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection

A woman asks the nurse, "How do oral contraceptives prevent pregnancy?" What will the nurse explain about the combination of estrogen and progesterone in oral contraceptives? a. Makes cervical mucus hostile to sperm b. Prevents ovulation c. Prohibits implantation of the egg d. Acts as a barrier by destroying sperm

Prevents ovulation

Which hormone is responsible for converting the endometrium into decidual cells for implantation? a. Estrogen b. Human chorionic gonadotropin c. Human placental lactogen d. Progesterone

Progesterone

What is the hormone responsible for the production of breast milk? A. Prolactin B. Oxytocin C. Endorphin D. Progestin

Prolactin

What does the nurse explain is used to soften the cervix with a "cervical ripening" agent? a. Prostaglandin gel insertion b. Intravenous oxytocin c. Warm saline douches d. Nipple stimulation

Prostaglandin gel insertion

A pregnant woman asks if she should take prepared childbirth classes. The best response of the nurse is to tell her that classes will: A. allow her to avoid pain medications during labor B. be required if her partner wants to be with her C. provide methods to help her cope with labor D. reduce the likelihood that complications will occur

Provide methods to help her cope with labor.

A nurse concludes that the parent of a newborn is not showing positive indications of parent-infant bonding. The parent appears very anxious and nervous when asked to bring the newborn to the other parent. Which of the following actions should the nurse use to promote parent-infant bonding? A. Hand the parent the newborn, and suggest that they change the diaper. B. Ask the parent why they are so anxious and nervous. C. Tell the parent that they will grow accustomed to the newborn. D. Provide reinforcement about infant care when the parent is present

Provide reinforcement about infant care when the parent is present

The client asks the nurse about the purpose of the placenta. The nurse plans to respond to the client knowing which about the placenta? 1. Cushions and protects the fetus 2. Maintains the body temperature of the fetus 3. Surrounds the fetus and allows for fetal movement 4. Provides an exchange of nutrients and waste products between the mother and the fetus

Provides an exchange of nutrients and waste products between the mother and the fetus

A woman had a forceps-assisted birth 2 hours ago. Baseline vital signs were T 37.1 C (98.8 F), P 78, R 20, BP 118/70. Which assessment suggests possible development of hypovolemic shock in this woman? A. Firm fundus, slightly right of midline B. Pulse 100, respirations 24 C. Respirations 22, blood pressure 114/76 D. Light lochia rubra with small clots

Pulse 100, respirations 24

What is the function of contractions during the second stage of labor? a. Align the infant into the proper position for delivery b. Dilate and efface the cervix c. Push the infant out of the mother's body d. Separate the placenta from the uterine wall

Push the infant out of the mother's body

One hour after vaginal birth, the nurse notes that a woman has a flat purple area, about 2 cm by 3 cm, on her perineum. What is the most the appropriate nursing action at this time? A. Assist her to take a warm sitz bath B. Apply pressure with a tightly applied pad C. Reapply a chemical cold pack on the area D. Notify the health care provider of the observation

Reapply a chemical cold pack on the area

In a routine prenatal visit, the nurse examining a patient who is 37 weeks pregnant notices that the fetal heart rate (FHR) has dropped to 120 beats/minute from a rate of 160 beats/minute earlier in the pregnancy. What is the nurse's first action? a. Ask if the patient has taken a sedative. b. Notify the physician. c. Turn the patient to her right side. d. Record the rate as a normal finding.

Record the rate as a normal finding

The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth state of labor. Which lochia characteristic should the nurse expect to note? 1. Red 2. Pink 3. White 4. Serosanguineous

Red

The patient remarks that she has heard some foods will enhance brain development of the fetus. The nurse replies that foods high in docosahexaenoic acid-omega 3 fatty acid (DHA) are thought to enhance brain development. What food can the nurse recommend? a. Fried fish b. Olive oil c. Red meat d. Leafy green vegetables

Red meat

When checking range of motion of a newborn, what sign suggests developmental hip dysplpasia? A. Reduced thigh abduction B. full abduction and adduction C. equal gluteal creases in the back D. limited flexion of one knee

Reduced thigh abduction

An advantage of an epidural block is that it: A. reduces pain for both labor and birth B. has no fetal or maternal risks C. supports normal blood pressure D. enhances the woman's urge to push

Reduces pain for both labor and birth.

What is the Dick-Read method of childbirth preparation based on? a. Mild sedation throughout labor b. Relaxation techniques c. Skin stimulation d. Deep massage

Relaxation techniques

At a prenatal visit, a primigravida asks the nurse how she will know her labor has started. The nurse knows that what indicates the beginning of true labor? a. Contractions that are relieved by walking b. Discomfort in the abdomen and groin c. A decrease in vaginal discharge d. Regular contractions becoming more frequent and intense

Regular contractions becoming more frequent and intense

What complication can result from untreated respiratory distress in the newborn? a. Esophageal atresia b. Gastric dilation c. Cold stress d. Reopening of the foramen ovale

Reopening of the foramen ovale

A nurse is assisting with the care for a client who is experiencing a ruptured ectopic pregnancy. Which of the following findings is expected with this condition? A. No alteration in menses B. Transvaginal ultrasound indicating a fetus in the uterus C. Blood progesterone greater than the expected reference range D. Report of severe shoulder pain

Report of severe shoulder pain

While caring for a laboring woman, the nurse notices a pattern of variable decelerations in fetal heart rate with uterine contractions. What is the nurse's initial action? a. Stop the oxytocin infusion. b. Increase the intravenous flow rate. c. Reposition the woman on her side. d. Start oxygen via nasal cannula.

Reposition the woman on her side.

A nurse instructs a woman's labor coach to comfort her by firmly pressing on her lower back. What is this technique? a. Sacral pressure b. Distraction c. Effleurage d. Conscious relaxation

Sacral pressure

Parents of a 2-month-old infant with Down syndrome are attending a well visit at the pediatric clinic. What should they be instructed to provide special attention to in regard to the generalized hypotonicity of the child? a. Preventing hyperthermia b. Respiratory care c. Prevention of diarrhea d. Incontinence care

Respiratory care

When assessing a preterm infant, the nurse observes nasal flaring, sternal retractions, and expiratory grunting. What do these findings indicate? a. Respiratory distress syndrome b. Postmaturity syndrome c. Apneic episode d. Cold stress

Respiratory distress syndrome

Which lochia characteristic should the nurse teach the woman to report? A. Change from red to pink-brown to white B. Cessation of flow by 4 weeks postpartum C. Return of red flow at 12 days postpartum D. Presence of a menstrual-like odor

Return of red flow at 12 days postpartum

A primigravida in her first trimester is Rh negative. What will this woman receive to prevent anti-Rh antibodies from forming? a. Rh immune globulin during labor b. Intrauterine transfusions with O-negative blood c. Rh immune globulin at 28 weeks and within 72 hours after the birth of an Rh-positive infant d. Rh immune globulin now and again in the last trimester

Rh immune globulin at 28 weeks and within 72 hours after the birth of an Rh-positive infant

What situation would concern the nurse about the presence of Rh incompatibility? a. Rh-negative mother, Rh-positive fetus b. Rh-positive mother, Rh-negative fetus c. Rh-negative mother, Rh-negative fetus d. Rh-positive mother, Rh-positive fetus

Rh-negative mother, Rh-positive fetus

Choose the situation that describes appropriate administration of RHo (D) immune globulin (RhoGAM): A. Rh-negative newborn, Rh-negative mother, given IV to the newborn within 12 hours of birth B. Rh-positive newborn, Rh-negative mother, given IV to the mother within 1 week of birth C. Rh-positive newborn, Rh-negative mother, given IM to the mother within 72 hours of birth D. Rh-negative newborn, Rh-positive mother, given IM to the mother within 72 hours of birth

Rh-positive newborn, Rh-negative mother, given IM to the mother within 72 hours of birth

The nurse formulates a nursing diagnosis for a woman in the fourth stage of labor. What is the most appropriate nursing diagnosis? a. Pain related to increasing frequency and intensity of contractions. b. Fear related to the probable need for cesarean delivery. c. Dysuria related to prolonged labor and decreased intake. d. Risk for injury related to hemorrhage.

Risk for injury related to hemorrhage.

What type of lochia will the nurse assess initially after delivery? a. Serosa b. Rubra c. Alba d. Vaginalis

Rubra

When the placenta is delivered with the fetal side presenting the mechanism is called: A. Duncan B. Lamaze C. VBAC D. Schultze

Schultze (shiny)

The best position for the woman who has postpartum endometritis is A. Semi-Fowler's B. Side-lying C. Supine D. Prone

Semi-Fowler's

When caring for the laboring patient, the nurse determines that the fetus is located in the right occiput posterior (ROA). What will the nurse anticipate? a. Urinary retention b. Severe lower back pain c. A shorter labor process d. Nausea

Severe lower back pain

The nurse is caring for an Rh-negative mother on the labor and birth unit. What scenario indicates this patient will require RhoGAM administration? a. She has had one Rh-negative child and is pregnant with an Rh-negative child. b. She has had an Rh-positive infant and is pregnant with an Rh-positive fetus. c. She has had an O-negative child and is pregnant with a B-negative child. d. She is a primipara with an O-negative child.

She has had an Rh-positive infant and is pregnant with an Rh-positive fetus.

A woman phones the birth center and says," I think my water broke and my baby is due, but I'm not having any contractions." The most appropriate nursing response is to tell her that: A. labor should begin within a few hours at most B. urine leakage may be confused with ruptured membranes C. She should come to the birth center for evaluation D. there is no concern unless the fluid is bloody

She should come to the birth center for evaluation.

A woman is 5 days postpartum and breastfeeding. She telephones the nurse at the clinic and says that her breasts feel very heavy and one of them is tender. She says the newborn nurses "fair." The nurse should tell the woman that A. Her symptoms should go away when when the newborn begins the nursing better B. Breastfeeding should be stopped until the pain goes away C. A cold pack between should reduce the pain D. She should come to the clinic for evalutation of her symptoms

She should come to the clinic for evalutation of her symptoms

A nurse is instructing a client who is taking an oral contraceptive about manifestations to report to the provider. Which of the following manifestations should the nurse include? A. Reduced menstrual flow B. Breast tenderness C. Shortness of breath D. Increased appetite

Shortness of breath

What symptom assessed in the newborn shortly after delivery should be reported? a. Cyanosis of the hands and feet b. Irregular heart rate c. Mucus draining from the nose d. Sternal or chest retractions

Sternal or chest retractions

The nurse is caring for a client who is in labor. The nurse rechecks the client's blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position? 1. Squatting 2. Side-lying 3. Tailor sitting 4. Semi-Fowler's

Side-lying

A woman is having a difficult labor because the fetus is presenting in the right occipital position (ROP). What position will the nurse promote to encourage fetal rotation and pain relief? a. Prone with legs supported and give her a back massage b. Supine with legs bent at the knee c. Standing with support d. Sitting up and leaning forward on the overbed table

Sitting up and leaning forward on the overbed table

The newborn of a woman who receives narcotic analgesics during labor should be observed primarily for: A. Convulsions B. slow respirations C. excess activity D. Constipation

Slow respirations.

Which postpartum patient assessment requires immediate nursing interventions? A. Excretion of large amount of urine on first postpartum day B. Soft uterine fundus, to right of the midline, 2 hours after birth C. Nipple intact but reddened on the first postpartum day D. Perineal are edematous with minor tenderness and slight bruising

Soft uterine fundus, to right of the midline, 2 hours after birth

A nurse is reinforcing discharge instructions for a client. At 4 weeks postpartum, the client should contact the provider for which of the following client findings? A. Scant, nonodorous white vaginal discharge B. Uterine cramping during breastfeeding C. Sore nipple with cracks and fissures D. Decreased response with sexual activity

Sore nipple with cracks and fissures

The nurse is instructing a man considering a vasectomy. What instruction will the nurse provide to address the postoperative time period? a. Intercourse should be delayed for 6 weeks. b. Sperm will still be ejaculated for a month. c. Erections will be difficult to maintain. d. Monthly sperm counts for a year will be necessary.

Sperm will still be ejaculated for a month.

The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. The panicked woman begs the nurse, "Please give me something." What is the most appropriate pain-relief intervention for a woman in precipitate labor? a. Get an order for an intravenous narcotic. b. Notify the anesthesiologist for an epidural block. c. Stay and breathe with her during contractions. d. Tell her to bear with it because she is close to delivery.

Stay and breathe with her during contractions.

The nurse observes the patient bearing down with contractions and crying out, "The baby is coming!" What is the best nursing intervention? a. Find the physician. b. Stay with the woman and use the call bell to get help. c. Send the woman's partner to locate a registered nurse. d. Assist with deep breathing to slow the labor process.

Stay with the woman and use the call bell to get help.

A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce labor and begins to have contractions every 90 seconds. What is the nurse's initial action? a. Stop the oxytocin infusion. b. Continue the infusion and report the findings to the physician. c. Turn her on her left side and reassess the contractions. d. Administer oxygen by mask.

Stop the oxytocin infusion.

The nurse is advising parents about feeding their infant with phenylketonuria. What formula and/or diet should the nurse suggest? a. Lifelong high-protein diet b. A formula that is low in the amino acid leucine c. A soy-based formula d. Substitute Lofenalac for some protein foods

Substitute Lofenalac for some protein foods

The nurse assesses a pregnant woman for pregnancy-induced hypertension. What is the first sign of fluid retention suggestive of this complication? a. Abdominal enlargement b. Facial swelling c. Sudden weight gain d. Swelling of the feet and ankles

Sudden weight gain

A nurse is assisting with the care of an infant who has a high bilirubin level and is receiving phototherapy. Which of the following findings is the priority for the nurse to report to the charge nurse? A. Conjunctivitis B. Bronze skin discoloration C. Sunken fontanels D. Maculopapular skin rash

Sunken fontanels

Which maternal position should be avoided during labor? A. Sitting B. Walking C. Side-lying D. Supine

Supine

A woman who is 37 weeks pregnant reports feeling dizzy when lying on her back. What does the nurse explain as the most likely cause of this symptom? a. Supine hypotension syndrome b. Gestational diabetes c. Pregnancy-induced hypertension d. Malnutrition

Supine hypotension syndrome

The client who is being prepared for a cesarean delivery is brought to the delivery room. To maintain the optimal perfusion of oxygenated blood to the fetus, the nurse should place the client in which position? 1. Prone position 2. Semi-Fowler's 3. Trendelenburg's position 4. Supine position with a wedge under the right hip

Supine position with a wedge under the right hip

The nurse is caring for an infant with hydrocephalus. What nursing action is most important for this nurse to implement? a. Align the limbs. b. Support the head. c. Keep the head lower than the hip. d. Check intake and output.

Support the head.

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. The nurse would do which of the following to help the woman process what has happened? 1. Support the mother in her reaction to the newborn 2. Encourage the mother to breastfeed soon after birth 3. Tell the mother that it is important to hold the newborn 4. Document a complete account of the mother's reaction in the birth record

Support the mother in her reaction to the newborn

What deficiency causes a preterm infant respiratory distress syndrome? a. Protein b. Estrogen c. Hyaline d. Surfactant

Surfactant

What is the first sign of hypovolemic shock from postpartum hemorrhage? a. Cold, clammy skin b. Tachycardia c. Hypotension d. Decreased urinary output

Tachycardia

The nurse should monitor for which signs associated with respiratory distress syndrome (RDS) in a preterm newborn? 1. Tachypnea and retractions 2. Acrocyanosis and grunting 3. Hypotension and bradycardia 4. The presence of a barrel chest with acrocyanosis

Tachypnea and retractions

The patient who is 28 weeks pregnant shows a 10-pound weight gain from 2 weeks ago. What is the nurse's initial action? a. Assess food intake. b. Weigh the patient again. c. Take the blood pressure. d. Notify the physician.

Take the blood pressure.

A woman is being observed in the hospital because her membranes ruptured at 30 weeks gestation. While providing morning care, the nursing student notices that the draining fluid has a strong odor. The priority nursing action is to: a. Caution the woman to remain in bed until her physician visits b. Ask the woman if she is having any more contractions than usual c. Take the woman's temperature; report it and the fluid odor to the RN d. Help to prepare the woman for an immediate cesarean delivery

Take the woman's temperature; report it and the fluid odor to the RN

On the second postpartum day, a mother bathed her newborn for the first time. She tells the nurse, "I don't think I did it right." What postpartum psychological stage is this woman most likely in based on this comment? a. Taking in b. Taking hold c. Letting go d. Settling down

Taking hold

Which statement made by the nurse would teach an adolescent using tampons how to prevent toxic shock syndrome (TSS)? a. Super-absorbency tampons are effective for overnight absorption. b. Tampons should be changed at least every 4 hours. c. Gloves should be worn when changing tampons. d. TSS can be prevented by using a pad for the first 2 days of menstrual flow.

Tampons should be changed at least every 4 hours.

A woman is using prepared childbirth breathing techniques and complains of dizziness and tingling. The nurse should: A. have her breathe more rapidly with contractions B. ask her if she feels an urge to push or bear down C. tell her to exhale slowly into her cupped hands D. reassure her that these sensations are normal

Tell her to exhale slowly into her cupped hands.

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

Tell the client that these are common and they may occur throughout the pregnancy

What symptom reported by a pregnant patient would lead the nurse to suspect pyelonephritis? a. Frequency and urgency of urination b. Nausea and weight loss c. Burning sensation when voiding d. Tenderness in the flank area

Tenderness in the flank area

When the newborn's crib was moved suddenly, the nurse noticed that his legs flexed and arms fanned out, and then both came back toward the midline. How would the nurse interpret this behavior? a. The Moro reflex b. The grasp reflex c. An abnormality of the musculoskeletal system d. A neurological abnormality

The Moro reflex

The client is undergoing an amniocentesis at 16 weeks' gestation to detect the presence of biochemical or chromosomal abnormalities. Which instructions should the nurse reinforce to the client? 1. The bladder must be full during the examination. 2. The bladder must be empty during the examination 3. She should not eat or drink anything 4 to 6 hours during the examination. 4. She will given Rho(D) immune globulin because she is Rh positive

The bladder must be full during the examination.

After episiotomy and the delivery of a newborn, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it is firm. Which determination should the nurse make? 1. This is a normal expectation after episiotomy 2. The mother should be allowed bathroom privileges only 3. The bright red bleeding is abnormal and should be reported 4. The perineal assessment should be performed more frequently

The bright red bleeding is abnormal and should be reported

The nurse is monitoring a client with mild gestational hypertension (GH). Which data indicate that GH is a concern? 1. Urinary output has increased 2. There is no evidence of proteinuria 3. The client complains of a headache and blurred vision 4. The blood pressure reading has returned to the prenatal baseline

The client complains of a headache and blurred vision

Why is the relaxation phase between contractions important? a. The laboring woman needs to rest. b. The uterine muscles fatigue without relaxation. c. The contractions can interfere with fetal oxygenation. d. The infant progresses toward delivery at these times.

The contractions can interfere with fetal oxygenation.

A new mother is distressed and tearful about the elevated dome over her infant's posterior fontanelle. The nurse responds, "This condition will resolve itself in a few days." What is the cause? a. Prolonged pressure against the partially dilated cervix b. Small leak of fluid through the posterior fontanelle c. Pressure of the forceps during delivery d. The effect of the vacuum extractor

The effect of the vacuum extractor

How should the nurse interpret the abbreviation ROP? A. The fetal sacrum is in the mother's right posterior pelvis B. The fetal pelvis is in the mother's right occipital pelvis C. The fetal occiput is in the mother's right posterior pelvis D. The right fetal occiput is in the mother's posterior pelvis

The fetal occiput is in the mother's right posterior pelvis

A student nurse questions the instructor regarding what alteration should be made for the assessment of the fundus of a new postoperative cesarean section patient. What is the best response? a. The fundus is not assessed until the second postoperative day. b. The fundus is assessed by "walking" fingers from the side of the uterus to the midline. c. The fundus is assessed only if large clots appear in lochia. d. The fundus is assessed only once every shift.

The fundus is assessed by "walking" fingers from the side of the uterus to the midline.

A pregnant woman comes to the clinic stating that she has been exposed to hepatitis B. She is afraid that her infant will also contract hepatitis B. What will the nurse explain to this woman? a. The infant will be given a single dose of hepatitis immune globulin after birth. b. The infant will be able to use the antibodies from the immunizations given to the patient before delivery. c. The infant will not have hepatitis B because the virus does not pass through the placental barrier. d. The infant will be immune to hepatitis B because of the mother's infection.

The infant will be given a single dose of hepatitis immune globulin after birth

What is the rationale for placing a preterm infant born at 34 weeks of gestation in an incubator? a. The infant has a small body surface-to-weight ratio. b. Heat increases the flow of oxygen to the extremities. c. The infant's temperature control mechanism is immature. d. Heat within the incubator facilitates drainage of mucus.

The infant's temperature control mechanism is immature.

Leopold's maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure. Which information should the nurse provide to the client about Leopold's maneuvers? 1. The maneuvers measure the height of the maternal fundus 2. The maneuvers determine the "lie" and "attitude" of the fetus. 3. The maneuvers are a systematic method for palpating the fetus through the maternal back. 4. The maneuvers are a systematic method for palpating the fetus through the maternal abdominal wall

The maneuvers are a systematic method for palpating the fetus through the maternal abdominal wall

At 1 and 5 minutes of life, a newborn's Apgar score is 9. What does the nurse understand that a score of 9 indicates? a. The newborn will require resuscitation. b. The newborn may have physical disabilities. c. The newborn will have above average intelligence. d. The newborn is in stable condition.

The newborn is in stable condition.

Which is an abnormal clinical assessment for a Latino boy at 1 week of age? Birth weight was 3733 g (8 pounds, 5 ounces); vital signs at a hospital discharge time were: T 36.8 C (98.4 F) (axillary); P 142; R 40. There were no complications during pregnancy. A. The newborn weighs 3318 g (7 pounds, 5 ounces) B. The apical pulse is 130 bpm and slightly irregular C. The newborn has bluish areas on the lower back D. The newborn has tiny, white, raised papules on the nose

The newborn weighs 3318 g (7 pounds, 5 ounces)

The nurse is assisting with caring for a client with abruptio Placentae. While caring for the client, the nurse notes that the client begins to develop signs of shock. The nurse should take which action first? 1. Monitor the urinary output 2. Monitor the maternal pulse 3. Turn the client onto her side 4. Monitor the maternal blood pressure

Turn the client onto her side

The nurse is planning to reinforce instructions about cord care to a newborn mother. The nurse should plan to tell the mother which about cord care? 1. Alcohol is the only agent used to clean the cord 2. It takes 21 days for the cord to dry up and fall off 3. Cord care is done only at birth to control the bleeding 4. The process of keeping the cord clean and dry will decrease bacterial growth

The process of keeping the cord clean and dry will decrease bacterial growth

The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. Which description should the nurse give to the client? 1. The inverted uterus returning to normal 2. The gradual reversal of the uterine muscle into the abdominal cavity 3. The descent of the uterus into the pelvic cavity, which occurs at a rate of 2 cm/day 4. The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day

The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day

A postpartum woman is not immune to rubella. What will the nurse expect? a. The rubella virus vaccine should be administered before discharge. b. The woman should receive the rubella virus vaccine at her 6-week postpartum checkup. c. The woman should be instructed not to get pregnant until she receives the rubella vaccine. d. No intervention is indicated at this time because the woman is not at risk for rubella.

The rubella virus vaccine should be administered before discharge.

What does the nurse note when measuring the frequency of a laboring woman's contractions? a. How long the patient states the contractions last b. The time between the end of one contraction and the beginning of the next c. The time between the beginning and the end of one contraction d. The time between the beginning of one contraction and the beginning of the next

The time between the beginning of one contraction and the beginning of the next

What is the nurse primarily concerned about maintaining in the initial care of the newborn? a. Fluid intake b. Feeding schedule c. Thermoregulation d. Parental bonding

Thermoregulation

The nurse is caring for a woman in the first stage of labor. What will the nurse remind the patient about contractions during this stage of labor? a. They get the infant positioned for delivery. b. They push the infant into the vagina. c. They dilate and efface the cervix. d. They get the mother prepared for true labor.

They dilate and efface the cervix.

A patient who received an epidural block asks why her blood pressure is taken so often. What is the nurse's best response to explain the frequent blood pressure assessments? a. They ensure that unsafe levels of hypertension do not occur. b. They help assess for the need for further pain relief. c. They monitor the progress of labor. d. They ensure adequate placental perfusion.

They ensure adequate placental perfusion.

The school nurse is counseling a group of adolescent girls. What does the nurse explain about sperm ejaculated near the cervix? a. They are destroyed by the acidic pH of the vagina. b. They survive up to 5 days and can cause pregnancy. c. They lose their motility in about 12 hours after intercourse. d. They are usually pushed out of the vagina by the muscular action of the vaginal wall.

They survive up to 5 days and can cause pregnancy.

What is the least amount of sensation that one perceives as pain? a. Tolerance b. Threshold c. Level d. Abatement

Threshold

The nurse is caring for a pregnant woman diagnosed with preeclampsia. What will the nurse explain is the objective of magnesium sulfate therapy for this patient? a. To prevent convulsions b. To promote diaphoresis c. To increase reflex irritability d. To act as a saline cathartic

To prevent convulsions

Parents of a preterm infant come to the NICU every day to see their infant, who is being gavage fed. What will the nurse teaching about stimulating the infant tell the parents? a. To bring in colorful pictures and toys to place in the incubator b. That stimulating the infant during feedings increases intake c. To stroke the infant during feeding to increase intake d. Not to disturb the infant between feedings

To stroke the infant during feeding to increase intake

The mother of a 4-day-old calls the pediatrician's office because she is concerned about her infant's skin. Which finding needs to be reported promptly to the child's pediatrician? a. The hands and feet feel cooler than the rest of the body. b. Skin is peeling on several parts of the infant's body. c. There is a small pink patch on the left eyelid and one on the neck. d. Today, the infant's skin has a yellowish tinge.

Today, the infant's skin has a yellowish tinge.

An ultrasound on a woman who is 32 weeks pregnant reveals the placenta implanted over the entire cervical os. What does the nurse understand best describes this condition? a. Low-lying placenta b. Marginal placenta previa c. Partial placenta previa d. Total placenta previa

Total placenta previa

The labor phase when the woman often feels anxious, restless, and seems to lose control is: A. latent B. active C. transition D. placental

Transition

A nurse is assisting with the care for a client who is in active labor, irritable, and reports the urge to have a bowel movement. The client vomits and states, "I've had enough. I can't do this anymore." Which of the following stages of labor is the client experiencing? A. Second stage B. Fourth Stage C. Transition phase D. Latent Phase

Transition phase

The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse should tell the client that fetal circulation consists of which components? 1. Two umbilical veins and one umbilical artery 2. Two umbilical arteries and one umbilical vein 3. Arteries that carry oxygenated blood to the fetus 4. Veins that carry deoxygenated blood to the fetus

Two umbilical arteries and one umbilical vein

Where is the usual location for implantation of the zygote? a. Upper section of the posterior uterine wall b. Lower portion of the uterus near the cervical os c. Inner third of the fallopian tube near the uterus d. Lateral aspect of the uterine wall

Upper section of the posterior uterine wall

A nurse is caring for a client who has suspected hyperemesis gravidarum and is reviewing the client's laboratory reports. Which of the following findings is a manifestation of this condition? A. Hgb 12.2 g/dL B. Urine ketones present C. Alanine aminotransferase 20 IU/L D. Blood glucose 114 mg/dL

Urine ketones present

The nurse gives a postpartum woman a rubella immunization. Which is the most important patient teaching related to this immunization? A. Neomycin can be used for rash or elevated temperature B. Use a reliable birth control method for 3 months C. Immunization now gives the baby immunity through breast milk D. Increased urination is a common side effect of the immunization

Use a reliable birth control method for 3 months

What is the nurse's best action when a Spanish-speaking patient requires postpartum discharge teaching, but no one on the hospital staff speaks Spanish fluently? A. Have a family member help interpret discharge instructions. B. Try to relay the information using an English to Spanish dictionary. C. Provide instructions in writing with illustrations. D. Use an impartial interpreter to assist with discharge instructions.

Use an impartial interpreter to assist with discharge instructions.

The nurse is caring for a patient diagnosed with hypotonic labor dysfunction. What will the nurse expect when caring for this patient? a. Elevated uterine resting tone b. Painful and poorly coordinated contractions c. Implementation of fluid restriction d. Use of frequent position changes

Use of frequent position changes

Although the nurse has massaged the uterus every 15 minutes, it remains flaccid, and the patient continues to pass large clots. What does the nurse recognize these signs indicate? a. Uterine atony b. Uterine dystocia c. Uterine hypoplasia d. Uterine dysfunction

Uterine atony

A pregnant woman, gravida 2, para 1, tells the nurse she desires a VBAC (vaginal birth after cesarean section) with this pregnancy. What is the primary concern regarding complications for this patient during labor and birth? a. Eclampsia b. Placental abruption c. Congestive heart failure d. Uterine rupture

Uterine rupture

The woman having a vaginal birth after cesarean (VBAC) should be observed during labor, particularly for signs of A. labor progression B. Uterine rupture C. perineal pressure D. excessive anxiety

Uterine rupture.

A woman had a 16 hour labor that ended with the cesarean birth of a 4313 g (9.5 lb) newborn. Her membranes were ruptured for 24 hours and oxytocin augmentation of labor was attempted before the cesarean birth. She has an IV infusion of Ringers' lactate and an indwelling catheter. For which complication should the nurse be most observant during the immediate recovery-room period? A. Uterine atony B. Endometritis C. Uterine subinvolution D. Urinary tract infection

Uterine subinvolution

The nurse is assigned to assist with caring for a client with abruptio placentae who is experiencing vaginal bleeding. The nurse collects data from the client, knowing that abruptio placentae is accompanied by which additional finding? 1. Soft abdomen on palpation 2. Uterine tenderness on palpation 3. No complaints of abdominal pain 4. Lack of uterine irritability or tetanic contractions

Uterine tenderness on palpation

Which woman is at greatest risk for bleeding from a vaginal wall laceration? A. Vaginal birth assisted with vacuum extractor B. First newborn who weighs 3632 g (8 lb) C. History of uterine atony with previous birth D. Oxytocin (Pitocin) used to induce labor

Vaginal birth assisted with vacuum extractor

A nurse is reinforcing teaching with a client who is pregnant about manifestations of complications to promptly report to the provider. Which of the following complications should the nurse reinforce to the client? A. Vaginal bleeding B. Swelling of the ankles C. Heartburn after eating D. Lightheadedness when lying on back

Vaginal bleeding

What symptom presented by a pregnant women is indicative of abruptio placentae? a. Painless vaginal bleeding b. Uterine irritability with contractions c. Vaginal bleeding and back pain d. Premature rupture of membranes

Vaginal bleeding and back pain

The priority nursing observation during the fourth stage of labor is for: A. vaginal bleeding B. perineal bleeding C. uterine infection D. parent-infant bonding

Vaginal bleeding.

After the examination is completed, the patient asks the nurse why Chadwick's sign occurs during pregnancy. What would the nurse explain as the cause of Chadwick's sign? a. Enlargement of the uterus b. Progesterone action on the breasts c. Increasing activity of the fetus d. Vascular congestion in the pelvic area

Vascular congestion in the pelvic area

Vaginal examination reveals the presenting part is the infant's head, which is well flexed on the chest. What is this presentation? a. Vertex b. Military c. Brow d. Face

Vertex

The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly complains of chest pain and dyspnea. The nurse should initially check which item? 1. Vital signs 2. Fundal height 3. Presence of calf pain 4. Level of consciousness (LOC)

Vital signs

A woman is prescribed Coumadin (warfarin) to treat deep vein thrombosis. What will the nurse instruct this woman is the antidote for warfarin overdose? a. Vitamin A b. Vitamin B c. Vitamin E d. Vitamin K

Vitamin K

A woman in labor will receive general anesthesia prior to cesarean section. The nurse reminds the patient that food and fluids need to be restricted for several hours prior to delivery. What will this prevent? a. Nausea and vomiting b. Vomiting and aspiration c. Abdominal cramping d. Intestinal obstruction

Vomiting and aspiration

A woman who is 24 weeks pregnant is placed on an intravenous infusion of magnesium sulfate. What side effect should the nurse inform the patient that she might experience? a. Nausea and vomiting b. Headache c. Warm flush d. Urinary frequency

Warm flush

What action does the nurse implement to protect newborns from infection while in the nursery? a. Keep the newborn dressed warmly. b. Adjust room temperature between 23.8° C (75° F) and 26.6° C (80° F). c. Wash hands before touching each infant. d. Wear a disposable gown when giving infant care.

Wash hands before touching each infant

Why does a 4-day-old infant born at 33 weeks of gestation possibly need to be fed by gavage during the first few days of life? a. Weak or absent sucking or swallowing reflex b. Inability to digest food properly c. Refusal to take formula by mouth d. Need for a larger quantity of formula at each feeding

Weak or absent sucking or swallowing reflex

A new mother states her preference to formula feed her newborn. What will the nurse planning discharge instructions tell her to help suppress lactation and promote comfort? a. Wear a well-fitting bra continuously for several days. b. Stand in a warm shower, letting the water spray over the breasts. c. Express small amounts of milk from the breasts several times a day. d. Massage the breasts when they ache

Wear a well-fitting bra continuously for several days.

What would the nurse expect to find when assessing the fundus of the uterus immediately after delivery? a. Well-contracted with its upper border at or just below the umbilicus b. Well-contracted with its upper border three or four fingerbreadths above the umbilicus c. Relaxed with its upper border level with the umbilicus d. Relaxed with its upper border two or three fingerbreadths below the umbilicus

Well-contracted with its upper border at or just below the umbilicus

The nurse is collecting data from a pregnant client when the client asks the nurse about the purpose of the fallopian tubes. Which is the accurate response the nurse should make? 1. the organ of copulation 2. Where the fetus develops 3. Where fertilization occurs 4. The organ that secretes estrogen and progesterone

Where fertilization occurs

Immediately after an epidural block is begun, the woman may be positioned: A. flat on her back, with no pillow B. upright with her legs over the side of the bed C. with a small roll under her right hip D. in a head-dependent position for block initiation

With a small roll under her right hip.

An infant receives surfactant via endotracheal (ET) tube at birth for symptoms of respiratory distress syndrome (RDS). When will the nurse anticipate seeing improvement of lung function? a. Immediately b. Within 3 days c. 1 to 2 weeks d. At least 1 month

Within 3 days

The nurse is caring for a newborn who is being breastfed. What will the nurse expect the stool color to be 2 days after birth? a. Yellow b. Brown c. Greenish brown d. Black and tarry

Yellow

Which woman should NOT take oral contraceptives? a. a woman who has multiple sexual partners b. a 38 year old woman who smokes a pack of cigarettes daily c. a 19 year old woman who is formula feeding her 2 month old baby d. a woman who is being discharged after a spontaneous abortion

a 38 year old woman who smokes a pack of cigarettes daily

The nurse must particularly observe for signs and symptoms of uterine rupture if the laboring woman just admitted at 8cm has a. a hypotonic labor pattern b. estimated fetal weight of 3500 g c. prematurely ruptured membranes d. a prior cesarean birth

a prior cesarean birth

To relieve or reduce symptoms of premenstrual dysphoric disorder, what should the nurse recommend that the woman do? a. avoid simple sugars and caffeine consumption b. use oral contraceptive medication c. avoid physical exercise d. limit water intake to 1000 mL/day

avoid simple sugars and caffeine consumption

A bleeding laceration is typically manifested by a. a soft uterus that is difficulty to locate b. low pulse rate and a firm uterus c. bright red bleeding and a firm uterus d. profuse dark red bleeding and large clots

bright red bleeding and a firm uterus

A priority of postoperative nursing care for a 9 month infant who has palate repair is A. referral to a parent support group B. adequate nutrition C. keeping an intravenous line open D. continuous sedation

adequate nutrition

A sign that should make the nurse suspect hydrocephalus in the newborn is A. inability to sleep between feedings B. a patch of hair on the lower back C. axillary temperature of 37.8 C (100 F) D. an enlarged fontanelle or cranial sutures

an enlarged fontanelle or cranial sutures

The nursing intervention most likely to make the woman with a perineal laceration more comfortable during the first 2 hours after birth is a. warm-water soaks b. a small dressing c. an ice pack d. antibacterial ointment

an ice pack

A woman who is at 32 weeks gestation telephones the nurse in a labor unit and says that her baby seems to be "pushing down" much of the time and that she has a constant backache. Choose the most appropriate nursing response. a. ask her to have someone bring her to the labor unit for further assessment b. reassure her that pressure and backache are common during late pregnancy c. tell her she should rest with her feet elevated several times each day d. encourage her to promote bladder emptying by increasing her fluid intake

ask her to have someone bring her to the labor unit for further assessment

Of these options for cesarean birth, the most important nursing care during the post-anesthesia recovery is to a. provide analgesia b. assess the fundus c. position for comfort d. encourage urination

assess the fundus

Gestational age is best determined by A. weight of the infant at birth B. stability of the blood glucose level C. the age at which the infant reaches developmental milestones D. assessment of physical and neurologic characteristics

assessment of physical and neurologic characteristics

Thirty minutes after birth, the nurse assesses the woman's uterine fundus. It is firm, above her umbilicus, and deviated to the right side. The appropriate nursing action is to: A. massage the uterus B. assist her to urinate C. provide mild analgesia D. restrict oral intake

assist her to urinate

To determine the frequency of uterine contractions, the nurse should note the time from the: A. beginning to end of the same contraction B. end of one contraction to the beginning of the next contraction C. beginning of one contraction to the beginning of the next contraction D. contraction's peak until the contraction begins to relax

beginning of one contraction to the beginning of the next contraction

When assessing the duration of labor contractions by palpation, the nurse should time from the : A. beginning of one contraction to the end of the same contraction B. end of one contraction to the beginning of the next C. beginning of one contraction to the beginning of the next D. peak of one contraction to the end of the contraction

beginning of one contraction to the end of the same contraction.

A characteristic sign of necrotizing enterocolitis (NEC) in the newborn is A. blood diarrhea B. necrosis of the abdomen C. projectile vomiting D. high fever

bloody diarrhea

The ideal feeding for most preterm newborns is A. glucose water until the risk for necrotizing enterocolitis diminishes B. breast milk given by suckling, bottle, or gavage C. special commercial formula for preterm babies D. total parenteral nutrition to meet all of the infant's nutritional needs

breast milk given by suckling, bottle, or gavage

External version is most likely to be done in which of these situations? a. early labor with frank breech presentation b. breech presentation with placenta previa c. twins in cephalic and breech presentations d. breech presentation at 38 weeks

breech presentation at 38 weeks

which drug category can not be used at in pregnancy?

category x

The long-term risk of an infection with the human papillomavirus (HPV) is for a. cervical cancer b. ectopic pregnancy c. endometriosis d. nerve damage

cervical cancer

What is the priority nursing action following amniotomy? a. turn the woman on her side b. check the fetal heart rate c. assess the color of the fluid d. change the underpad

check the fetal heart rate

After a vaginal birth complicated by shoulder dystocia, the nurse should particularly assess the newborn for a. molding of the head b. flexed positioning c. clavicle fracture d. abnormal temperature

clavicle fracture

When the fetus is in a cephalic presentation, the amniotic fluid is expected to be: A. cloudy B. clear C. green D. yellow

clear

yellowish color. 1st milk

colostrum

A woman who is pregnant with her first child phones an intrapartum facility and says her "water broke." The nurse should tell her to: A. wait until she has contractions every 5 minutes for 1 hout B. take her temperature every 4 hours and come to the facility if it is 38°C (100.4°F) C. come to the facility promptly, but safely D. Call an ambulance to bring her to the facility

come to the facility promptly, but safely

The correct way to suction a baby's mouth with a bulb syringe is to A. compress the bulb, place the tip in the side of the mouth, then release the bulb B. place the tip in the side of the mouth, compress the bulb, then release the bulb C. compress the bulb, place the tip in the center of the mouth, then release the bulb D. place the tip in the center of the mouth, compress the bulb, then release the bulb

compress the bulb, place the tip in the side of the mouth, then release the bulb

A woman in active labor has contractions every 3 minutes lasting 60 seconds. and her uterus relaxes between contractions. The electronic fetal monitor shows the FHR reaching 90 beats/min for periods lasting 20 seconds during a uterine contraction. The appropriate priority nursing actions is to A. continue to monitor closely B. administer oxygen by mask at 10 L/min C. notify the health care provider D. prepare for a cesarean section

continue to monitor closely

After amniotomy, which observation should be reported immediately? a. clear fluid draining on the under pad b. maternal temperature of 37.2 C (99.0 F) c. fetal heart rate of 95 bpm d. moderate contractions every 3 minutes

fetal heart rate of 95 bpm

Amniotic fluid usually turns a pH swab or paper: A. yellow B. green C. dark blue D. purple

dark blue

Which is true about nitrous oxide when used for pain management during labor? A. Decreases nausea and vomiting B. Decreases the mother's awareness of pain C. Is injected into an intravenous line D. Causes severe fetal distress

decreases the mother's awareness of pain

A Pavlik harness is often used to correct A. clubfoot B. juvenile arthritis C. developmental hip dysplasia D. fracture femur

developmental hip dysplasia

Choose the correct patient teaching about the drug alendronate (Fosamax). a. Take food or milk within 30 minutes of the medication b. wash the nose out with saline 30 minutes after using the spray c. do not lie down for at least 30 minutes after taking the drug d. take calcium supplements at the same time as the medication

do not lie down for at least 30 minutes after taking the drug

A woman in labor states she wants to have epidural analgesia. When can this method of analgesia best be given? A. anytime during labor B. during the transition phase of labor C. during the first stage of labor D. during the third stage of labor

during the first stage of labor

The thinning of the cervix during labor is called: A. dilation B. effacement C. station D. presentation

effacement

A postpartum mother who is breastfeeding has developed mastitis. She states that she does not think it is good for her infant to drink milk from her infected breast. The best response from the nurse would be to a. instruct her to nurse the infant from only the unaffected breast until the infection clears up b. suggest that she discontinue breastfeeding and start the infant on formula c. encourage breastfeeding the infant to prevent engorgement d. apply a tight breast binder to the infected breast until the infection subsides

encourage breastfeeding the infant to prevent engorgement

Parent-newborn bonding for a newborn with a meningomyelocele prior to repair can be enhanced by A. encouraging the parents to talk and touch the baby B. having the parents change the baby's diaper C. encouraging the parents to hold the baby near their skin D. helping a parent give the baby an admission bath

encouraging the parents to hold the baby near their skin

endometriosis

endometrial tissue located outside the uterus 1. can cause pain, pressure, and inflammation 2. more constant than spasmodic 3. can cause dyspareunia (painful sexual intercourse 4. treated with danazol and gonadotropin-releasing hormone (GnRH) via nasal spray 5. Lupron given via IM is also effective

Diuresis in the early postpartum period indicates A. urinary tract infection B. retention of body fluids C. excretion of excess fluid D. edema near the urinary meatus

excretion of excess fluid

Choose the correct teaching for relief of symptoms associated with premenstrual dysphoric disorder. a. eat chocolate candies several times a day to reduce fluid retention and weight gain b. reduce fluid intake during the first half of the menstrual cycle c. plan the most stressful activities during the last half of the menstrual cycle d. exercise individually or with others several times each week

exercise individually or with others several times each week

A nursing measure that can improve stress incontinence is to:

explain how and when to perform the Kegel exercises

1st milk. watery. quenches thirst

foremilk

The nurse must handle the preterm infant gently because capillaries are A. not developed in all areas of the brain B. likely to develop microscopic clots C. sensitive to high levels of clotting factors D. fragile and prone to bleeding spontaneously

fragile and prone to bleeding spontaneously

During the postpartum period the white blood cell (leukocyte) count is normally a. higher than normal b. lower than normal c. unchanged d. unimportant

higher than normal

The alarm on an apnea monitor for a preterm infant sounds. The infant is asleep, the skin color is pink, and the heart rate is 130-135 bpm. The most appropriate initial nursing response is to A. contact the health care provider for orders B. gently rub the infant's back C. give oxygen with an Ambu bag D. suction the infant with a bulb syringe

gently rub the infant's back

Which nursing assessment best suggests respiratory distress syndrome? A. Apical heart rate 144/min; bluish hands and feet B. grunting, respiratory rate of 65/min, nasal flaring C. protruding abdomen, irregular respirations D. weak movements, lies with extended posture

grunting, respiratory rate of 65/min, nasal flaring

Expected advice for the woman with PKU who is considering pregnancy is to eat a daily diet that A. contains additional high-fiber foods B. contains adequate dairy products C. provides added amounts of leucine D. has low quantities of phenylalanine

has low quantities of phenylalanine

The nurse is teaching a woman, age 25, about breast self-examination (BSE). The correct teaching is that BSE a. detects malignancy more often than professional examinations b. allows her to delay the need for mammography until she is 50 years old c. helps her learn the normal characteristics of her own breasts d. is more accurate than a yearly mammogram

helps her learn the normal characteristics of her own breasts

The most serious potential problem if a woman's bladder is distended in the early postpartum period is A. Infection B. Discomfort C. Vomiting D. Hemorrhage

hemorrhage

later milk. higher fat. satisfies hunger

hindmilk

An infant is born at 43 weeks' gestation. The nurse should monitor the infant for common problems, such as (select all that apply) A. respiratory distress caused by immature lungs B. increased weight gain resulting from increased glucose availability C. hypoglycemia resulting from reduced glucose reserves D. presence of increased amounts of lanugo

hypoglycemia resulting from reduced glucose reserves

A woman-gravida 4, para 3-has been 5 cm dilated for 2 hours. Her contractions are every 7 minutes, 30 seconds duration, and mild. The FHR is 135-145/minute. She is relatively comfortable. This woman is most likely experiencing: a. hypotonic labor dysfunction b. hypertonic labor dysfunction c. occiput posterior fetal position d. fetal shoulder dystocia

hypotonic labor dysfunction

The nurse outlines the process of ova being mixed with sperm and then the resulting embryos being returned to the mothers uterus. This process of infertility treatment is ____________ ______________ _________________.

in vitro fertilization

Vital sign changes when a newborn has increased intracranial pressure include A. increased blood pressure and pulse, hyperventilation B. decreased blood pressure, pulse, and respiration C. decreased blood pressure and respirations, increased pulse D. increased blood pressure, decreased pulse and respirations

increased blood pressure, decreased pulse and respirations

The nurse explains that the drug clomiphene (Clomid) is used in infertility treatment because it a. induces ovulation b. reduces endometriosis c. promotes implantation of a fertilized ovum d. inhibits excess prolactin

induces ovulation *it also may increase sperm production, although this is an unlabeled use

Excessive anxiety and fear during labor may result in a(n): A. ineffective labor pattern B. abnormal fetal presentation or position C. release of oxytocin from the pituitary gland D. rapid labor and uncontrolled birth

ineffective labor pattern

A mother gives birth to a preterm infant at 30 weeks gestation. When visiting the baby in the intensive care unit, she seems interested in the baby, but sits and watches everything the nurse does for her baby. Which is the most appropriate nursing intervention to promote mother-infant attachment? A. invite her to provide simple care to her infant B. Reassure her that she can hold the baby soon C. stress the importance of frequent visits to the nursery D. demonstrate the skills she will need for home care

invite her to provide simple care to her infant

The nurse should teach parents to avoid using baby powder because it A. irritates the newborn's respiratory tract B. may cause allergies in the newborn C. is difficult to remove during a bath D. dries the skin of the axillae and groin

irritates the newborn's respiratory tract

When teaching a mother how to nurse her baby, how should you explain the baby's rooting reflex? The rooting reflex A. shows equality of function on each side of the mouth B. helps the baby keep mucus or milk from being inhaled during breathing C. suggests that the baby is full as he or she turns away from the breast D. is the baby's way of seeking her nipple to obtain milk when hungry

is the baby's way of seeking her nipple to obtain milk when hungry

A 2 week old newborn will be fitted with a Pavlik harness as treatment for developmental hip dysplasia. The mother asks the nurse about the harness and how it will help her baby. To reinforce the healthcare provider's explanation, the nurse should teach the mother that A. keeping the hip bone within the hip socket helps the socket become deeper B. the infant cannot have surgery for the condition until he is at least 8 weeks old C. the longer leg gradually becomes shorter to equalize the leg lengths before walking D. time spent in a cast is reduced if the baby is treated with a harness for a few weeks

keeping the hip bone within the hip socket helps the socket become deeper

When bathing an infant, the nurse observes the hips for dislocation. What observation may indicate developmental hip dysplasia? A. toes turned inward B. limitation of abduction of legs C. asymmetry of epicanthal folds D. shortening of patella

limitation of abduction of legs

Early identification of galactosemia is required to prevent A. depletion of specific amino acids B. liver damage, cataracts, and mental retardation C. protein deposits in the adrenal glands and kidneys D. limitation of normal growth in height

liver damage, cataracts, and mental retardation

A laboring woman suddenly begins to make grunting sounds and bearing down a strong contraction. The njrse should initially: A. leave the room to find an experienced nurse to assess the woman B. look at her perineum for increased bloody show or perineal bulging C. ash her if she needs pain medication D. tell her that these are common sensations in late labor

look at her perineum for increased bloody show or perineal bulging

The child with PKU must be on a diet that is A. low in fatty acids to promote intellectual development B. high in soluble fiber to reduce constipation C. low in phenylalanine to limit buildup of the protein D. fluid-restricted to reduce the wastes delivered to the kidneys

low in phenylalanine to limit buildup of the protein

The advantage of radiant warmers in the care of preterm infants is that they A. cannot cause excessive body temperature B. maintain warmth with easy caregiver access C. reduce drying and cracking of the skin D. improve balance of fluids and electrolytes

maintain warmth with easy caregiver access

If the nurse finds that a new mother's uterus is soft, the appropriate initial action is to A. Insert an indwelling catheter B. Massage the uterus until it is firm C. Check the woman's vital signs D. Increase the rate of the IV fluid

massage the uterus until it is firm

A woman has ruptured membranes at 31 weeks gestation. Which nursing observation should be promptly reported? a. FHR: accelerations present; average rate of 145 bpm b. small quantity of clear, nonirritating vaginal discharge c. spontaneous fetal movement with uterine palpation d. maternal vital signs: T 38.2 C(100.7 F), P 102, R 20

maternal vital signs: T 38.2 C(100.7 F), P 102, R 20

bluish color later milk

mature milk

A key nursing intervention to prevent retinopathy of prematurity is to A. provide feedings as early as possible after birth B. perform care to avoid moving the infant more than necessary C. eliminate potential sources of infection from the environment D. monitor the infant's blood oxygen levels

monitor the infant's blood oxygen levels

During normal labor, contractions characteristically become: A. more frequent and of shorter duration B. more frequent and of longer duration C. less frequent and of shorter duration D. less frequent and of longer duration

more frequent and of longer duration

The nurse should suspect intracranial hemorrhage in a newborn if A. the fontanelle is of normal size, but depressed B. muscle tone has become poor since birth C. the newborn seems to be hungry much of the time D. both pupils are small and react to light when checked

muscle tone has become poor since birth

At her 2 week postpartum checkup, the woman's uterus should be A. two fingerwidths above the umbilicus B. two fingerwidths below the umbilicus C. just above the symphysis pubib D. no longer palpable through the abdomen

no longer palpable through the abdomen

A baseline fetal heart rate of 125 bpm during labor should be interpreted as: A. normal for a term fetus B. Abnormal if the fetus is preterm C. High normal when in labor D. A slow baseline

normal for term fetus

Appropriate care related to a new plaster cast for correction of clubfoot in the newborn is to A. keep the newborn snugly wrapped until the cast is dry to prevent hypothermia B. sprinkle powder into the dry cast to reduce irritation at the edges of the cast C. position with the feet lower than the level of the heart until the cast is dry D. observe the toes for pallor, cyanosis, reduced capillary refill, or cold temperature

observe the toes for pallor, cyanosis, reduced capillary refill, or cold temperature

Parents should be taught that the safest position for their term newborn in the crib is A. with the head elevated B. side-lying with head down C. on either the back or side D. prone with head elevated

on either the back or side

Choose the correct teaching about BSE technique. a. use the palms of the hand to press the breast tissue firmly against the ribs b. palpate each breast systematically, using the pads of the fingers c. palpate the underarm area only if the breasts are very large or sagging d. squeeze the breast tissue between the thumb and index finger

palpate each breast systematically, using the pads of the fingers

Which is the most typical labor characteristic when the fetus is in an occiput posterior position? a. labor duration shorter than 3 hours b. persistent back discomfort c. rapid fetal descent d. mild contraction strength

persistent back discomfort

Appropriate patient teaching following vasectomy is to a. apply heat to the operative area for 20 minutes at a time b. abstain from intercourse for at least 6 weeks after the surgery c. limit frequency of sexual intercourse for the first month d. place an ice pack on the operative area to reduce discomfort

place an ice pack on the operative area to reduce discomfort

Which nursing measure is appropriate for a 2 week old newborn who has a new cleft lip repair? A. position on the abdomen or side B. place in a car seat after each feeding C. provide a premature-sized pacifier D. limit visitors to immediate family

place in a car seat after each feeding

Expected treatment for hydrocephalus is A. placement of a shunt B. incision and draining C. oral liquid diuretics D. intravenous analgesics

placement of a shunt

A small area of a 6-day-old term infant's abdominal skin remains distorted when pinched gently. This assessment suggests: A. poor hydration B. postbirth edema C. excessive intake of breast milk or formula D. inadequate vernix during the prenatal period

poor hydration

When caring for a woman following a vehicle accident at 36 weeks of pregnancy, the fetal assessment should be for a. undetected trauma b. poor oxygenation c. intrauterine infection d. precipitous birth

poor oxygenation

A blood patch may be done to relieve: A. low blood pressure B. respiratory depression C. postspinal headache D. prolonged numbness

postspinal headache

an infants amniotic fluid was meconium stained. During the admission assessment the nurse notes that the infant is crying vigorously her skin is peeling and she has a long thin appearance, these facts suggest that this infant is probably? a. preterm b. postterm c. in respiratory distress d. large for her gestational age

postterm

Which is the most appropriate nursing care for the woman having hypertonic labor? a. encourage walking in the hallway to improve contractions and enhance labor b. promote rest and provide general comfort measures c. reassure her that this problem will go away when active labor begins d. omit oral fluids and increase the rate of intravenous fluid

promote rest and provide general comfort measures

Before surgical repair, the usual position of a newborn with a meningomyelocele is A. side-lying with the head slightly below the level of the heart B. prone, maintaining abduction with a pad between the legs C. supine with the crib flat to stabilize blood pressure D. supine with the legs widely abducted and thighs flexed

prone, maintaining abduction with a pad between the legs

The earliest finding in postpartum hypovolemic shock is usually a. low blood pressure b. rapid pulse rate c. pale skin color d. soft uterus

rapid pulse rate

"Hot flashes" are probably caused by a. anxiety about growing older and one's mortality b. shifts in a woman's fluid and electrolyte balance c. instability of the blood pressure d. reduced estrogen secretion

reduced estrogen secretion

Meconium aspiration syndrome may be prevented by A. stimulating the newborn to breathe as soon as delivery is complete B. reducing meconium in amniotic fluid before birth by amnioinfusion C. intubating the newborn immediately after birth for ventilation D. promoting adequate newborn oxygenation with an apnea monitor

reducing meconium in amniotic fluid before birth by amnioinfusion

A preterm infant is subject to hypothermia because the A. muscle activity is large related to the calories consumed B. relatively large body surface area allows heat to escape C. sweat glands are overactive, allowing evaporative cooling D. fats stores insulate the infant from radiant heater warmth

relatively large body surface area allows heat to escape

The first nursing action if a visibly prolapsed umbilical cord occurs is to a. call the health care provider b. palpate the cord for a pulse c. apply the internal fetal monitor d. relieve pressure on the cord

relieve pressure on the cord

The newborn with Down Syndrome is at increased risk for developing A. urinary tract infections B. respiratory infections C. kidney infections D. meningitis

respiratory infections

A first time mother reports that she is experiencing difficulty breastfeeding her newborn. Which neonatal reflex would the nurse teach the mother to elicit to facilitate breastfeeding? A. sucking B. rooting C. grasping D. tonic neck

rooting

a friend asks you what she can do because she is troubled by repeated "yeast" infections. As a nurse, your best advice to her is to a. keep over-the-counter medications on hand so she can begin treatment immediately b. see her medical care giver if she has another infection to identify possible causes c. increase her intake of fluids to include at least eight glasses of water each day d. avoid sexual intercourse for 1 month to see if that reduces the infections

see her medical care giver if she has another infection to identify possible causes

A friend tells you that she is "having periods again." She thought she had her last menstrual period 2 years ago. As a nurse, you should advise her that she a. is probably having reactivation of estrogens that are causing the bleeding b. should see a health care provider promptly because this is not an expected occurrence c. should use a contraceptive if she does not want to become pregnant d. probably has an infection of her vagina or cervix that should be treated

should see a health care provider promptly because this is not an expected occurrence

Appropriate nursing care for parents immediately after the birth of a baby who has characteristics typical of Down syndrome should include A. reassuring them that future babies are unlikely to have this problem B. keeping the newborn in the nursery until a definitive diagnosis is made C. spending time with them so they can best verbalize their concerns D. teaching them about lifelong nutritional care the baby will need

spending time with them so they can best verbalize their concerns

When intra-abdominal pressure increases from laughing, sneezing, or coughing in a woman with a cystocele, __________ ___________ results

stress incontinence

The let-down reflex is stimulated by A. Massage of the uterus B. Suckling of the baby C. Increased fluid intake D. Breast engorgement

suckling of the baby

Which physical characteristic should make the nurse an infant's gestational age may be preterm? A. Square window sign assessed at 0 degrees B. small amount of lanugo and vernix present C. labia major cover labia minora of the female D. superficial scalp and abdominal veins easily seen

superficial scalp and abdominal veins easily seen

Choose the most appropriate teaching for the woman who is prescribed multiphasic oral contraceptive pills. a. the menstrual period begins when the first week of pills is completed b. cigarette smoking should be limited to no more than 20 per day c. limit intake of foods that are high in iron or calcium d. take the pills at the same time of day and in order

take the pills at the same time of day and in order

An infant is brought to the newborn nursery. The gestation stated on the chart is 39 weeks. The nurse doing the initial assessment notes that the infant has peeling skin and long, thin appearance. What is the probable reason for the infant's appearance? A. the mother did not get adequate nutrients throughout pregnancy B. intrauterine infection depleted subcutaneous fat stores C. the actual gestational age may be greater than 42 weeks D. reduced production of glucose before birth caused weight loss

the actual gestational age may be greater than 42 weeks

Visually, babies prefer A. geometric objects B. soft or pastel colors C. the human face D. stationary objects

the human face

Eight hours postpartum the woman states she prefers the nurse take care of the newborn. The woman talks in detail about her birthing experience on the phone and to anyone who enters her room. She complains of being hungry, thirsty, and sleepy and is unable to focus on the newborn care teaching offered to her. The nurse would interpret this behavior as A. inability to bond with the newborn B. development of postpartum psychosis C. inability to assume the parenting role D. the normal taking in-phase of the puerperium

the normal taking in-phase of the puerperium

Why might a newborn of a diabetic mother be small for gestation age? A. the placenta did not receive adequate perfusion during pregnancy B. the fetus had episodes of hypoglycemia when the mother took insulin C. the fetal pancreas does not make insulin if the mother takes insulin D. the mother's diabetes causes small areas of bleeding in the placenta

the placenta did not receive adequate perfusion during pregnancy

A newborn looks at her mother and remains quiet when the mother sings to her in soft, high-pitched tones. This is an example of A. a sign of impaired hearing B. the quiet alert state of reactivity C. a need for reduced stimulation D. limited ability to respond to adults

the quiet alert state of reactivity

When teaching a woman the cervical mucus method to identify ovulation, the nurse teaches her that the normal character of the mucus near ovulation is a. thin and slippery b. yellowish with a distinct odor c. cloudy and sticky d. thick, sticky, and clear

thin and slippery

The mother of a newly born infant reports to the nurse that her infant has had a black, tarry stool. The nurse would tell her that A. this is most likely caused by blood the infant may have swallowed during the birth process B. the health care provider will be promptly notified C. the infant will be given nothing by mouth (remain NPO) until a stool culture is taken D. this is a normal stool in newborn infants

this is a normal stool in newborn infants

When teaching about the use of tampons, the nurse should emphasize replacing them at least every 4 hours to prevent a. pelvic inflammatory disease b. vasomotor symptoms c. STIs d. toxic shock syndrome

toxic shock syndrome

7-10 days after birth. in between milk

transitional milk

A 17 year old girl comes to the emergency department complaining of severe pain in her left lower quadrant. When an ovarian cyst is suspected, the nurse explains that the diagnosis is confirmed by a. laparotomy b. oophorectomy c. transvaginal ultrasound d. hysteroscopy

transvaginal ultrasound

Other than abstinence, the best way to prevent sexually transmitted infection with the human immunodeficiency virus is a. douching within 30 minutes of sexual intercourse b. avoiding intercourse during midcycle c. use of a condom for all episodes of sexual intercourse d. taking prophylactic antibiotics after unprotected intercourse

use of a condom for all episodes of sexual intercourse

Parents of a newborn delivered with low forceps ask about small bruises on each side of the baby's head. The nurse should tell the parents that the bruises a. will be reported to the health care provider b. usually disappear in a few days c. may indicate brain damage d. occur in all vertex births

usually disappear in a few days

Some preterm infant are fed by gavage because of A. confinement to the incubator B. overdeveloped gag and cough reflexes C. refusal of formula D. weak sucking and swallowing reflexes

weak sucking and swallowing reflexes

The earliest time when sexual intercourse can usually be resumed after birth is A. at 2 weeks postpartum B. when a laceration heals C. when lochia alba is present D. after the 6 week check

when a laceration heals

New parents should be taught to clean their baby's ears by: A. moistening a cotton-tipped applicator with water and rotating it in the ear B. gently instilling a small amount of warm water into the ear with a bulb syringe C. applying baby oil to a rolled piece of cotton and inserting it into the ear D. wiping the outside with a cotton ball that is moistened with water

wiping the outside with a cotton ball that is moistened with water