Maternal Newborn Exam A

C. urinary output 20 mL/hr

a nurse is assessing a client who is at 35 wks of gestation and is receiving magnesium sulfate via continuous IV infusion for severe pre-eclampsia. which of the following finding should the nurse report to the provider? A. DTR 2+ B. BP 150/96 C. urinary output 20 mL/hr D. RR 16/min

B. uterine contractions

a nurse is assessing a client who is at 37 wks of gestations and has a suspected pelvic fracture due to blunt abdominal trauma. which of the following findings should the nurse expect? A. bradycardia B. uterine contractions C. seizures D. bradypnea

C. Rho(D) immune globulin

a nurse is caring for a client who had no prenatal care, is Rh-negative, and will undergo an external version at 38 weeks of gestation. which of the following medications should the nurse plan to administer prior to the version? A. prostaglandin gel B. magnesium sulfate C. Rho(D) immune globulin D. oxytocin

A. fetal distress C. vaginal bleeding D. cervical dilation great than 6 cm

a nurse is caring 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 great than 6 cm E. severe gestational hypertension

D. methylergonovine

a nurse is caring for a client who has a soft uterus and increased lochia flow. which of the following medications should the nurse plan to administer to promote uterine contractions? A. terbutaline B. nifedipine C. magnesium sulfate D. methylergonovine

A. fetal engagement

a nurse is caring for a client who has been in labor for 12 hr with intact membranes. the nurse performs a vaginal exam to ensure which of the following prior to the performance of the amniotomy? A. fetal engagement B. fetal lie C. fetal attitude D. fetal position

D. pelvic inflammatory disease (PID)

a nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. which of the following findings is a risk factor for an ectopic pregnancy? A. anemia B. frequent UTIs C. previous cesarean birth D. pelvic inflammatory disease (PID)

A. preeclampsia

a nurse is caring for a client who has disseminated intravascular coagulation (DIC). which of the following antepartum complications should the nurse understand is a risk factor for this condition? A. preeclampsia B. thrombophlebitis C. placenta previa D. hyperemesis gravidarum

A. Ceftriaxone

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

B. renal agenesis

a nurse is caring for a client who has oligohydramnios. which of the following fetal anomalies should the nurse expect? A. atrial septal defect B. renal agenesis C. spina bifida D. hydrocephalus

D. prolapsed umbilical cord

a nurse is caring for a client who is in labor. with the use of Leopold maneuvers, it is noted that the fetus is in a breech presentation. for which of the following possible complications should the nurse observe? A. precipitous labor B. premature ROM C. postmaturity syndrome D. prolapsed umbilical cord

B. lecithin/sphingomyelin (L/S) ratio

a nurse is caring for a client who is in preterm labor and is scheduled to undergo an amniocentesis. the nurse should evaluate which of the following tests to assess fetal lung maturity? A. alpha-fetoprotein (AFP) B. lecithin/sphingomyelin (L/S) ratio C. Kleihauer-Betke test D. indirect Coombs' test

D. a distended bladder reduced pelvic space needed for birth

a nurse is caring for a client who is in the first stage of labor and is encouraging the client to void every 2 hr. which of the following statements should the nurse make? A. a full bladder increases the risk for fetal trauma B. A full bladder increases the risk for bladder infections C. a distended bladder will be traumatized by frequent pelvic exams D. a distended bladder reduced pelvic space needed for birth

D. apply pressure to the client's sacral area during contractions

a nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain. which of the following actions should the nurse take? A. instruct the client to pant during contractions B. position the client supine with legs elevated C. encourage the client to soak in a warm baht D. apply pressure to the client's sacral area during contractions

B. blunt abdominal trauma C. cocaine use E. cigarette smoking

a nurse is providing 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

D. betamethasone

a nurse is 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

A. hypospadias C. family history of hemophilia E. epispadias

a nurse is reviewing contraindications for circumcision with a newly hired nurse. which of the following conditions are contraindicates? select all that apply A. hypospadias B. hydrocele C. family history of hemophilia D. hyperbilirubinemia E. epispadias

BUBBLE B = breasts U = uterus B = bowel B = bladder L = lochia E = episiotomy

What is a good acronym to help remember important steps to a focused postpartum assessment?

C. 110-160

What is a normal fetal heart? A. 70-90 B. 100-120 C. 110-160 D. 160-200

B. Magnesium Sulfate

What is the drug of choice for pre-eclampsia? A. Labetalol B. Magnesium Sulfate C. Cocaine

January 27

What is the due date? LMP: April 20

November 11

What is the due date? LMP: February 4

B. Vitamin K D. Erythromycin

What medications are given to ALL newborns within 1 hour of birth? Select all that apply A. Hepatitis B vaccine B. Vitamin K C. Vitamin D D. Erythromycin E. Iron

-Limit caffeine 200-300mg per day (may increase miscarriage or IUGR) -No alcohol -Avoid seafood high in mercury (swordfish, shark, tilefish, king mackerel) -OTC medications

What should be avoided during pregnancy?

A. Fetal heart rate B. Urine output C. Clonus D. Lung Sounds

What should be included in a pre-eclamptic assessment? SELECT ALL THAT APPLY A. Fetal heart rate B. Urine output C. Clonus D. Lung Sounds E. Blood sugar

Signs of true labor

-Ripening of cervix -bloody show -uterine contractions that radiate and do not go away with rest

Fertilization

-This can happen up to 24 hours after ovulation -also referred to as conception and impregnation -union of ovum and spermatozoon

Implantation

-contact between growing structure and uterine endometrium, approximately 8-10 days after fertilization -spotting and cramping can occur -referred as zygote from fertilization to this -hCG production begins

Spinnbarkeit test

-estrogen secretion caused cervical mucous to stretch into long strands, progesterone causes it to be thick and viscous -high levels of estrogen at ovulation = mucous is thin, watery, and stretchy; this test can be performed to assess cervical mucous

Return of mensuration and ovulation in Nonlactating moms (ovulation returns sooner)

-ovulation occurs 7-9 weeks after birth -menses resume by 12 weeks postpartum

Return of mensuration and ovulation in lactating moms

-serum prolactin levels remain elevated and suppress ovulation -first postpartum ovulation is approximately 6 months -mensuration won't return for 3 months or until after lactating

-Calories: 340 in the 2nd trimester, 452 in the 3rd -Protein -Folic acid (600 mcg) -Iron supplement (best absorbed between meals and when taken with vitamin C) -Calcium -increased fluid

What should be increased during pregnancy?

C. evaporation

a newborn was not dried completely after birth. this places the infant at risk for which of the following types of heat loss? A. conduction B. convection C. evaporation D. radiation

B. dark brown vaginal discharge

a nurse is assessing a client who is at 12 wks of gestation and has a hydatidiform mole. which of the following findings should the nurse expect? A. hypothermia B. dark brown vaginal discharge C. decreased urinary output D. fetal heart tones

-baseline FHR 110-160/min -2 accelerations (15x15) -moderate variability (changes in baseline by 6-25 bpm) -20 minutes -no decelerations if missing anyone of these five, then test is nonreactive

5 requirements for a reactive nonstress test

- G = 4 - T = 1 - P = 1 - A = 1 - L = 2

A client arrives for her first prenatal appointment and reports her LMC was July 2nd. Her history includes a vaginal delivery at 36 weeks gestation 5 years ago and a cesarean section delivery at 40 weeks of gestation 2 years ago. She also had an elective abortion at 17 weeks gestation 12 years ago. What is her GTPAL?

A. Void frequently E. It should go away in the second trimester, but will return in the third trimester

A client at 10 week's gestation tells the nurse that she has been bothered by episodes of frequent urination. What education should the nurse provide? Select all that apply A. Void frequently B. Increase fluid intake at night C. Decrease fluid intake during the day D. Call the provider, this is abnormal E. It should go away in the second trimester, but will return in the third trimester

A. Eat high fiber foods B. Drink plenty of water C. Use warm sitz baths D. Use topical ointments E. Hemorrhoids are normal in pregnancy

A client at 32 week's gestation tells the nurse that she has been bothered by her hemorrhoids. What education should the nurse provide? Select all that apply A. Eat high fiber foods B. Drink plenty of water C. Use warm sitz baths D. Use topical ointments E. Hemorrhoids are normal in pregnancy

A. Sit upright for 30 minutes after meals D. Eat small, frequent meals E. Eat crackers or dry toast before rising

A client at 7 week's gestation tells the nurse that she has been bothered by episodes of nausea throughout the day. Which interventions should the nurse recommend? Select all that apply A. Sit upright for 30 minutes after meals B. Take low-sodium antacids after meals C. Drink carbonated beverages with meals D. Eat small, frequent meals E. Eat crackers or dry toast before rising

B. Inform the patient this is normal in the third trimester

A client comes to her prenatal appointment at 39 weeks gestation. Her vital signs are: BP 112/67, RR 20, Temp 98.2, and O2 sat 99%. She complains of dyspnea over the past several days. What should the nurse do? A. Notify the provider immediately B. Inform the patient this is normal in the third trimester C. Apply 02 via nasal cannula D. Offer 8 oz of water to the client

A. Every 2 years B. If she has a 20% weight change C. After abdominal/pelvic surgery D. After pregnancy

A client should be re-fitted for a diaphragm: Select all that apply A. Every 2 years B. If she has a 20% weight change C. After abdominal/pelvic surgery D. After pregnancy

B. Cheese and broccoli

A client tells the nurse she has been having leg cramps. Which foods should the nurse encourage her to eat? A. Liver and raisons B. Cheese and broccoli C. Eggs and lean meats D. Whole-wheat breads and cereals

B. Returns to baseline after the end of the contraction

A late deceleration: A. Is caused from cord compression B. Returns to baseline after the end of the contraction C. Starts at the beginning of the contraction

C. 30-60

A normal respiratory rate for a newborn is: A. 15-20 B. 30-40 C. 30-60 D. 60-80

A. it is good to know that I won't have a tubal pregnancy in the future

A nurse in a clinic is caring for a client who is PO following a salpingectomy due to an ectopic pregnancy. which of the following statements by the client requires clarification? A. it is good to know that I won't have a tubal pregnancy in the future B. the doctor said that this surgery can affect my ability to get pregnant again C. I understand that one of my fallopian tubes had to be removed D. ovulation can still occur because my ovaries were not affected

A. weight fluctuations can occur C. you should increase your intake of calcium E. irregular vaginal spotting can occur

A nurse in a clinic is teaching a client about a new prescription for medroxyprogesterone. which of the following info should the nurse include in the teaching? select all that apply A. weight 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

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

A nurse in a health clinic is reviewing 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

C. shortness of breath

A nurse is instructing a client who is taking an oral conceptive 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

- G3 - T1 - P0 - A1 - L1

A pregnant client comes into the clinical for her first prenatal appointment. She has had one vaginal delivery at 38 weeks and 1 miscarriage at 6 weeks. What is the GTPAL?

A. The esophageal sphincter relaxes and allows acid to be regurgitated

A pregnant client in the third trimester tells the nurse that she is experiencing heartburn after every meal. Which explanation should the nurse provide regarding the cause of heartburn? A. The esophageal sphincter relaxes and allows acid to be regurgitated B. Gastric motility decreases, causing a burning sensation C. Gastric pH increases, causing acid to enter the esophagus D. The pyloric sphincter relaxes, allowing acid to enter the intestine

B. Blue hands and feet

Acrocyanosis is: A. Blue eyes B. Blue hands and feet C. Blue trunk D. Blue hair

B. Head compression

An early deceleration is caused from: A. Cord compression B. Head compression C. Placental insufficiency

A. Painless

Bleeding with a placenta previa is: A. Painless B. Painful

A. Miscarriage C. Ectopic pregnancy

Common causes of first trimester bleeding include: SELECT ALL THAT APPLY A. Miscarriage B. Cervical dilation C. Ectopic pregnancy D. Labor

B. Cervical insufficiency D. Molar pregnancy

Common causes of second trimester bleeding include: SELECT ALL THAT APPLY A. Labor B. Cervical insufficiency C. Ectopic pregnancy D. Molar pregnancy

-h/o thromboembolic disorders aka DVT -stroke -heart attack -coronary artery disease -gallbladder disease -cirrhosis or liver tumor -headache with focal neurologic findings -uncontrolled hypertension -diabetes mellitus with vascular involvement -breast or estrogen related cancers -pregnancy -lactating -less than 6 weeks postpartum -smoking (if 35 years of age or older)

Contraindications for combined oral contraceptives

A. History for DVT B. Uncontrolled HTN D. 2 weeks postpartum

Contraindications to combined oral contraceptives include: SELECT ALL THAT APPLY A. History for DVT B. Uncontrolled HTN C. History of emergent cesarean section 2 years ago D. 2 weeks postpartum E. Family history of diabetes

D. dark red vaginal bleeding

a nurse is assessing a client who is at 34 wks of gestation and has a mild placental abruption. which of the following finding should the nurse expect? A. increased platelet count B. fetal distress C. decreased urinary output D. dark red vaginal bleeding

True

Estrogen levels are high immediately before ovulation. True or False?

-24 hr: 2-6 mg/dL -48 hr: 6-7 mg/dL -3-5 days: 4-6 mg/dL

Expected bilirubin of a newborn at 24 hr, 48 hr, and 3-5 days old

greater than 40-45

Expected lab value for newborn glucose

C. 6 hours

How long should a client leave spermicide in after having intercourse? A. 2 hours B. 4 hours C. 6 hours D. 8 hours

1st trimester: 1-4.4 lbs total 2nd trimester: 1 lb per week 3rd trimester: 1 lb per week

How much weight is gained in the first, second, and third trimester?

C. -1 station

If a fetus is not engaged, is 1 cm above the iliac crest of the maternal spine, and ballotable, what would its station be? A. 0 station B. +1 station C. -1 station

True

If a non-stress test is NON-REACTIVE after 20 minutes we can perform interventions and monitor for another 20 minutes (most of the time). True or False?

B. Heart rate would increase

If the client is hemorrhaging what would happen to her vital signs? A. Blood pressure would increase B. Heart rate would increase C. O2 saturation would increase D. Temperature would increase

B. Stop the magnesium infusion

If you suspect magnesium toxicity what is the FIRST thing you should do? A. Administer calcium gluconate B. Stop the magnesium infusion C. Administer a fluid bolus

A. Hyper

In pre-eclampsia, reflexes are: A. Hyper B. Hypo C. Normal

A. Massage the uterus B. Administer oxytocin as ordered C. Increase IV fluids D. Call provider

Interventions for a postpartum hemorrhage include: SELECT ALL THAT APPLY A. Massage the uterus B. Administer oxytocin as ordered C. Increase IV fluids D. Call provider E. Check cervix

A. Apply pressure to the presenting part B. Place client in Trendelenburg position C. Prep for an emergency c/section E. Call for help

Interventions for a prolapsed cord include: SELECT ALL THAT APPLY A. Apply pressure to the presenting part B. Place client in Trendelenburg position C. Prep for an emergency c/section D. Apply pressure to the cord E. Call for help

A. Position changes B. Increase IV fluids C. Check cervix D. Notify provider E. Apply O2 to client

Interventions for variable and/or late decelerations include: Select all that apply A. Position changes B. Increase IV fluids C. Check cervix D. Notify provider E. Apply O2 to client

A. 480 mL of urine output in 24 hr

a nurse is assessing a client who is at 35 wks of gestation and has preeclampsia w/o severe features. which of the following finding should the nurse ID as the priority? A. 480 mL of urine output in 24 hr B. BP 144/92 C. +2 edema of the feet D. 1+ protein in the urine

A. Fetal growth

McDonald's Rule helps assess what? A. Fetal growth B. Maternal history C. STI status

C. If it occurs along with variable and/or late decels

Meconium-stained fluid is considered an ominous sign in labor if: A. It is present B. If the provider says so C. If it occurs along with variable and/or late decels

True

Medroxyprogesterone can cause osteoporosis: True or False?

-PKU diet 3 mo prior to pregnancy and throughout. -Low protein diet -avoid aspartame -blood levels of PKU monitored

Mom with PKU

B. Administer an IV fluid bolus

PRIOR to epidural insertion, the nurse should: A. Obtain informed consent B. Administer an IV fluid bolus C. Check the client's cervix D. Scream

-Fetal heart tones -visualization of fetus by ultrasound -fetal movement (felt by an experienced examiner)

Positive signs of pregnancy

-amenorrhea -fatigue -N/V -urinary frequency -breast changes -quickening -uterine enlargement

Presumptive signs of pregnancy

-abdominal enlargement -Hegar's sign -Chadwick's sign -Goodell's sign -Ballottement -Braxton Hick's contractions -positive pregnancy test -fetal outline

Probable signs of pregnancy

True

Progesterone levels remain high if a female becomes pregnant. True or False?

B. Reoccurring variable decelerations E. Meconium-stained fluid

Reasons for an amnioinfusion include: SELECT ALL THAT APPLY A. Maternal stress B. Reoccurring variable decelerations C. Prolonged labor D. Epidural anesthesia E. Meconium-stained fluid

-CBC, blood type, Rh factor, RPR, Hep B, HIV, Rubella, hCG -Pap smear, urinalysis -Prenatal vitamin, 600 mcg of folic acid (most PNVs have folic acid in them, but want to be sure before disregarding folic acid)

Routine labs and test for FIRST prenatal visit

-could offer CVS for genetic disorders -can doppler FHR at 12 weeks

Routine tests at 10-12 weeks of gestation

-Maternal Serum Fetal Alpha Protein (MSFAP) for genetic/chromosomal detection

Routine tests at 14-15 weeks of gestation

-ultrasound -could offer amniocentesis if serum tests were abnormal

Routine tests at 16-20 weeks of gestation

-Glucose screening/oral glucose challenge; 50g 1 hr, if fail then 100g 3 hr -Rhogam at 28 weeks for Rh negative moms

Routine tests at 24-28 weeks of gestation

-GBS swab

Routine tests at 35-37 weeks of gestation

-most providers will repeat prenatal labs (CBC, blood type, Rh factor, RPR, Hep B, HIV, Rubella)

Routine tests when admitted for labor

Kleihauer-Betke test (KB stain)

Test determines the amount of fetal blood in maternal circulation. If greater than 15 mL of fetal blood is detected, the mother should receive an increased dose of Rhogam.

True

The fetus has NOT experienced acidosis if the non-stress test is reactive. True or False?

C. 0-10 cm dilation

The first stage of labor is: A. Pushing B. Delivery of the placenta C. 0-10 cm dilation D. Recovery

C. 0-3 cm

The latent phase of labor (aka early phase) is: A. 8-10 cm B. 4-7 cm C. 0-3 cm

C. 10

The max APGAR score is: A. 6 B. 8 C. 10 D. 12

Vaccinate after delivery due to live vaccine

What if mom is rubella non-immune?

Appetite disorder; craving to eat nonfood substances such as dirt or red clay; this might diminish the amount of nutrients ingested.

What is PICA?

B. Count from the beginning of one contraction to the beginning of the next

To count the frequency of contractions you should: A. Count from the end of one contraction to the beginning of the next B. Count from the beginning of one contraction to the beginning of the next C. Count from the beginning of one contraction to the end of the same contraction

True

Variable decelerations must last at least 15 seconds and decrease by at least 15 beats. True or False?

It's Not My Time, But I = Indomethacin (NSAID); blocks production of prostaglandins N = Nifedipine (CA channel blocker); suppresses contractions M = Magnesium Sulfate (CNS depressant) relaxes smooth muscle and inhibits uterine activity T = Terbutaline (beta-adrenergic agonist); relaxes smooth muscle and inhibits uterine activity B = Betamethasone (steroid); enhances fetal lung maturity

What are the preterm labor meds, and the acronym to remember them?

Fetal death, development delays

What can syphilis cause in pregnancy?

Congenital anomalies

What can toxoplasmosis cause in pregnancy?

-Intrauterine growth restriction (IUGR) -Preterm labor (PTL)

What does cigarette smoking in pregnancy cause?

Pregnant 4 times, 2 term deliveries, 1 preterm delivery, 1 miscarriage/abortion, 3 living children

What does this mean? G4, T2, P1, A1, L3

2nd test to confirm syphilis. If positive, treat with PCN

What if VDRL/RPR is reactive?

Educate, avoid procedures that increase fetal exposure, treatment with antiviral

What if mom is HIV +?

Foraman ovale

What shunt is located between the left and right atrium and closes after birth?

Paten ductus arteriosus (PDA)

What shunt is located between the pulmonary artery and the aorta and closes after birth?

C. Eyebrow line

What's the appropriate landmark to obtain an accurate head circumference? A. Outer cantus of the eye B. Top of ear lobe C. Eyebrow line D. Tip of nose

C. Check the FHR

When a client's membranes rupture, the FIRST thing the nurse should do is: A. Mop the floor B. Scream C. Check the FHR D. Check the cervix

B. Fluid return

When administering an amnioinfusion, always monitor for: A. Insects B. Fluid return

B. 10-12 weeks gestation

When can you first obtain a fetal heart rate with a DOPPLER? A. 5-6 weeks gestation B. 10-12 weeks gestation C. 16-20 weeks gestation

D. Treat constipation when it occurs and continue drinking milk

When discussing dietary needs during pregnancy, a client tells the nurse that milk causes her to be constipated at times. What should the nurse teach the client? A. Substitute a variety of cheeses for the milk B. Replace fat-free or low-fat milk for whole milk C. Increase intake of prenatal supplements and omit the milk D. Treat constipation when it occurs and continue drinking milk

C. 14 days prior to the start of the next cycle

When does ovulation normally occur? A. At the cycles midpoint B. 14 days after the cycle begins C. 14 days prior to the start of the next cycle

35-37 weeks; vaginal/rectal swab; Treat with IV antibiotics IN labor

When is GBS screening done? How? What if positive?

24-28 weeks; 50g oral glucose challenge followed by blood draw 1 hr later; screens for gestational diabetes; if positive, then do a 100g 3 hr challenge; if that is positive then client need to change diet and exercise; if that is unsuccessful then insulin

When is glucose screening done? How? Screens for what? What if positive?

Increase

When ovulation occurs a client's temperature will slightly: Increase or Decrease?

A. 2nd stage of labor

When would you NOT want to give IV pain medicine? A. 2nd stage of labor B. Active phase of labor C. Recovery

B. Over the top of the fetal back

Where can you best obtain the fetal heart rate? A. Over the fetal buttocks B. Over the top of the fetal back C. Over the fetal heart

at the umbilicus

Where is the fundus located 1 hr postpartum

A. FHR baseline 110-160 B. Moderate variability C. 2 accelerations (15x15) D. No decelerations F. 20-minute time frame

Which of the following are qualifications for a REACTIVE non-stress test? Select all that apply A. FHR baseline 110-160 B. Moderate variability C. 2 accelerations (15x15) D. No decelerations E. At least 2 contractions F. 20-minute time frame

A. Absent reflexes B. Respirations <12/min D. Slurred speech

Which of the following are signs of magnesium toxicity? A. Absent reflexes B. Respirations <12/min C. Increased urine output D. Slurred speech E. Reactive non-stress test

B. It can decrease milk supply D. It can decrease the baby's growth

Why do we not want a breastfeeding mom to take a form of birth control that contains estrogen? SELECT ALL THAT APPLY A. She will become depressed B. It can decrease milk supply C. It can cause constipation D. It can decrease the baby's growth

Assess fetal lung development

Why would an amniocentesis be done in the 3rd trimester?

B. Decrease

With a prolapsed cord, the FHR will most likely: A. Increase B. Decrease C. Not change

D. true contractions

a client calls a provider's office and reports having contractions for 2 hr that increased with activity and did not decrease with rest and hydration. the client denies leaking of vaginal fluid but did notice blood when wiping after voiding. which of the following manifestations is the client experiencing? A. Braxton Hicks contractions B. ROM C. fetal descent D. true contractions

B. give the client time to express feelings

a client in the early postpartum period is very excited and talkative. they repeatedly tell the nurse every detail of the labor and birth. because the client will not stop talking, the nurse is having difficulty completing the postpartum assessments. which of the following actions should the nurse take? A. come back later when the client is more cooperative B. give the client time to express feelings C. tell the client they need to be quiet so the assessment can be completed D. redirect the client's focus so that they will become quiet

A. eat crackers or plain toast before getting out of bed

a client who is at 7 weeks of gestation is experiencing nausea and vomiting in the morning. which of the following info 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

B. it is normal to have these feelings during the first few months of pregnancy

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 a new life into the world D. I am going to make an appointment with the counselor for you to discuss these thoughts

B. decreased blood glucose

a nurse administers betamethasone to a client who is at 33 wks of gestation to stimulate fetal lung maturity. when planning care for the newborn, which of the following conditions should the nurse ID as an adverse effect of this medication? A. hyperthermia B. decreased blood glucose C. rapid pulse rate D. irritability

D. a urine test for the presence of human chorionic gonadotropin

a nurse at a prenatal clinic is caring for a client who suspects she may be pregnant and asks the nurse how the provider will confirm her pregnancy. the nurse should inform the client that which of the following lab test will be used to confirm her pregnancy? A. a blood test for the presence of estrogen B. a blood test for the amount of circulating progesterone C. a urine test for the presence of human chorionic somatomammotropin D. a urine test for the presence of human chorionic gonadotropin

C. hydatidiform mole

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 complications should the nurse suspect? A. hyperemesis gravidarum B. threatened abortion C. hydatidiform mole D. preterm labor

D. provide education about infant care when the parent is present

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 education about infant care when the parent is present

A. they are tablets administered vaginally

a nurse educator in the L&D unit is reviewing the use of chemical agents to promote cervical ripening with a group of newly licensed nurses. which of the following statements by a nurse indicates understanding of the teaching? A. they are tablets administered vaginally B. they act by absorbing fluid from tissues C. they promote dilation of the os D. they include an amniotomy

A. precipitous deliver C. inversion of the uterus E. retained placental fragments

a nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage. which of the following factors should be included in the teaching? select all the apply A. precipitous deliver B. obesity C. inversion of the uterus D. oligohydramnios E. retained placental fragments

B. a client whose partner has von Willebrand disease

a nurse in a clinic is caring for a group of female clients who are being evaluated for infertility. Which of the following clients should the nurse anticipate the provider will refer to a genetic counselor? A. a client whose sister has alopecia B. a client whose partner has von Willebrand disease C. a client who has an allergy to sulfa D. a client who had rubella 3 months ago

D. neural tube defects

a nurse in a clinic is teaching 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. macrocosmic fetus D. neural tube defects

D. you should collect urine from the first morning void

a nurse in a clinic receives a phone call from a client who would like to be tested in the clinic to confirm pregnancy. which of the following info should the nurse provide the client? A. you should wait until 4 weeks after conception to be tested B. you should be off any medications for 24 hours prior to the test C. you should be NPO for at least 8 hours prior to the test D. you should collect urine from the first morning void

A. client has delivered one newborn at term B. client has experienced no preterm labor D. client has had two prior pregnancies E. client has one living child

a nurse in a prenantal 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 the information? Select all that apply A. client has delivered one newborn at term B. client has experienced no preterm labor C. client had been through active labor D. client has had two prior pregnancies E. client has one living child

C. this is due to the weight of the uterus on the vena cava

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

D. a weight gain of about 25-35 lb is good

a nurse in a prenatal clinic is caring for a client who is within the recommended guideline for weight. the client asks the nurse how much weight is safe for her to gain during pregnancy. which of the following responses should the nurse make? A. your provider can discuss an appropriate amount of weight gain with you B. a weight gain of about 14 lb each trimester is suggested C. if you eat nutritious foods when you feel hungry, the amount of weight gain is insignificant D. a weight gain of about 25-35 lb is good

B. 3.6 kg (8 lb) weight gain and is in the first trimester 1-4.4 lb during the first trimester 1 lb per week for the last two trimesters 25-35 lb is the recommended weight gain for a single pregnancy

a nurse in a prenatal clinic is 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 is 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

A. dark green leafy vegetables

a nurse in a prenatal clinic is providing education to a client who is at 8 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

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

a nurse in an OB clinic is teaching 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

A. instruct the client about vena cava syndrome and measures to prevent it

a nurse in an antepartum clinic answers a phone call form a client who is at 37 wks of gestation and reports, "I became very dizzy while lying in bed this morning, but the feeling went away when I turned on my side." which of the following actions should the nurse take? A. instruct the client about vena cava syndrome and measures to prevent it B. arrange for the client to come to the clinic for an assessment C. check the client's chart for gestational diabetes D. schedule a nonstress test for the client

A. joint pain B. malaise C. rash E. tender lymph nodes

a nurse in an antepartum clinic is assessing 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

A. occupation B. menstrual history C. childhood infectious diseases

a nurse in an infertility clinic is providing care to clients who have been unable to conceive for 18 months. Which of the following data should the nurse assess? select all that apply A. occupation B. menstrual history C. childhood infectious diseases D. history of falls E. recent blood transfusions

B. ectopic pregnancy

a nurse in the ER 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 IUD." the nurse should suspect which of the following? A. missed abortion B. ectopic pregnancy C. severe preeclampsia D. hydatidiform mole

D. position the neonate skin-to-skin on the client's chest

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

D. I can conceive any time I want after 10 days

a nurse is administering a rubella immunization to a client who is 2 days postpartum. which of the following statements indicates to the nurse the client needs further instruction? A. I can continue to breastfeed B. I will still need to have my provider perform a rubella titer check with my next pregnancy C. I cannot receive the rubella immunization during my pregnancy D. I can conceive any time I want after 10 days

A. respirations less than 12/min B. urinary output less than 25 mL/hr D. decreased LOC

a nurse is administering magnesium sulfate IV for seizure prophylaxis to a client who has severe preeclampsia. which of the following indicates 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 relfexes D. decreased LOC E. flushing and sweating

B. obtain blood samples for baseline lab values

a nurse is admitting a client who is in labor and experiencing moderate bright red vaginal bleeding. which of the following actions should the nurse take? A. perform a vaginal exam to determine cervical dilation B. obtain blood samples for baseline lab values C. place a spiral electrode on the fetal presenting part D. prepare the client for a transvaginal u/s

A. vacuum extractor C. forceps E. internal fetal monitoring

a nurse is admitting a client who is in labor and has HIV. which of the following interventions should the nurse ID as contraindicated for this client? select all that apply A. vacuum extractor B. oxytocin infusion C. forceps D. cesarean birth E. internal fetal monitoring

C. continue routine monitoring

a nurse is assessing a 12-hr old newborn and notes a RR of 44/min with shallow respirations and periods of apnea lasting up to 10 sec. which of the following actions should the nurse take? A. perform chest percussion B. Place the newborn in a prone position C. continue routine monitoring D. request a prescription for supplemental O2

C. place the naked newborn on the mother's bare chest and cover both with a blanket

a nurse is assessing a 4 hr old newborn who is to breastfeed and notes hands and feet that are cool and slightly blue. which of the following actions should the nurse take? A. apply an oxygen hood over the newborn's head and neck B. check the newborn's temp using a temporal thermometer C. place the naked newborn on the mother's bare chest and cover both with a blanket D. give the newborn glucose water between feedings

C. ask the client when she last voided

a nurse is assessing a client on the first postpartum day. findings include fundus firm and one fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temp 99.2 F, and HR 52/min. which of the following actions should the nurse take? A. report the VS to the provider B. massage the fundus C. ask the client when she last voided D. administer an oxytocic agent

B. concerns about lack of income to pay bills C. anxiety about assuming a new role as a parent D. rapid decline in estrogen and progesterone E. feeling of inadequacy with the new role as a parent

a nurse is assessing a client who has postpartum depression. the nurse should expect which of the following manifestations? select all that apply A. paranoia that their infant will be harmed B. concerns about lack of income to pay bills C. anxiety about assuming a new role as a parent D. rapid decline in estrogen and progesterone E. feeling of inadequacy with the new role as a parent

B. assist the client to empty her bladder

a nurse is assessing a client who is 14 hr postpartum and has a third-degree perineal laceration. the client's temp is 100 F, and her fundus is firm and slightly deviated to the right. the client reports a gush of blood when she ambulates and no BM since delivery. which of the following actions should the nurse take? A. notify the provider about the elevated temp B. assist the client to empty her bladder C. administer a Bisacodyl suppository D. massage the client's fundus

C. a slow trickle of bright vaginal bleeding and a firm fundus

a nurse is assessing a client who is postpartum following a vacuum-assisted birth. for which of the following finding should the nurse monitor to ID a cervical laceration? A. continuous lochia flow and a flaccid uterus B. report of increasing pain and pressure in the perineal area C. a slow trickle of bright vaginal bleeding and a firm fundus D. a gush of rubra lochia when the nurse massages the uterus

B. urinary output 40 mL in 2 hr

a nurse is assessing a client who is receiving magnesium sulfate as treatment for preeclampsia. which of the following clinical findings is the nurse's priority? A. RR 16/min B. urinary output 40 mL in 2 hr C. Reflexes +2 D. FHR 158/min

A. jaundice of the sclera

a nurse is assessing a newborn 1 hr after birth. which of the following assessment finding should the nurse report to the provider? A. jaundice of the sclera B. RR of 50/min C. acrocyanosis D. blood glucose 60 mg/dL

B. obtain a stat prescription for a bilirubin level

a nurse is assessing a newborn who is 12 hr old and notes mild jaundice of the face and trunk. which of the following actions should the nurse take? A. administer phytonadione IM B. obtain a stat prescription for a bilirubin level C. obtain a bagged urine specimen D. perform a gestational age assessment

B. urinary retention

a nurse is assessing a postpartum client for fundal height, location, and consistency. The fundus is noted to be displaced laterally to the right, and there is uterine atony. the nurse should ID which of the following conditions as the cause of the uterine atony? A. poor involution B. urinary retention C. hemorrhage D. infection

D. postpartum blues

a nurse is assessing 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

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

a nurse is assessing the reflexes of a newborn. in checking for the Moro reflex, the nurse should perform which of the following? A. hold the newborn vertically under arms and all one foot to touch the 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

B. blood pools in the vagina when you are lying in bed

a nurse is assisting a client who is 4 hr postpartum to get out of bed for the first time. the client becomes frightened when she has a gush of dark red blood from her vagina. which of the following statements should the nurse make? A. you might have retained placental fragments in your uterus B. blood pools in the vagina when you are lying in bed C. you might have a damaged blood vessel D. the amount of blood flow will increase during the first few days after giving birth

A. lanugo C. weak grasp reflex D. translucent skin

a nurse is called to the birthing room to assist with the assessment of a newborn who was born at 32 wks 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. plump face

C. the vaginal are will budge as the baby's head appears

a nurse is caring for a client and partner during the second stage of labor. the client's partner asks the nurse to explain how to know when crowning occurs. which of the following responses should the nurse make? A. the placenta will protrude from the vagina B. your partner will report a decrease in the intensity of contractions C. the vaginal are will budge as the baby's head appears D. your partner will report less rectal pressure

C. it is needed to counteract hypotension

a nurse is caring for a client following the administration of an epidural block and is preparing to administer an IV fluid bolus. the client's partner asks about the purpose of the IV fluids. which of the following statements should the nurse make? A. it is needed to promote increased urine output B. it is needed to counteract respiratory depression C. it is needed to counteract hypotension D. it is needed to prevent oligohydramnios

A. First stage, latent phase

a nurse is caring for a client having contractions every 8 min that are 30-40 sec in duration. the clients cervix is 2 cm dilated, 50% effaced, and the fetus is at -2 station with a FHR around 140/min. which of the following stages and phases of labor is this client experiencing? A. First stage, latent phase B. First stage, active phase C. First stage, transition phase D. second stage of labor

B. apply pressure to the presenting part with the fingers

a nurse is caring for a client in active labor. when last examined 2 hr ago, the client's cervix was 3 cm dilated, 100% effaced, membranes intact, and the fetus was at a -2 station. the client suddenly states, "my water broke." The monitor reveals a FHR of 80 to 85/min and the nurse performs a vaginal exam, noticing clear fluid and a pulsing loop of umbilical cord in the client's vagina. which of the following actions should the nurse perform first? A. place the client in the Trendelenburg position B. apply pressure to the presenting part with the fingers C. administer O2 at 10L/min via a face mask D. initiate IV fluids

A. lengthening of the umbilical cord D. appearance of dark blood from the vagina E. fundus firm upon palpation

a nurse is caring for a client in the third stage of labor. which of the following findings indicate placental separation? select all that apply A. lengthening of the umbilical cord B. swift gush of clear amniotic fluid C. softening of the lower uterine segment D. appearance of dark blood from the vagina E. fundus firm upon palpation

A. palpable fetal movement

a nurse is caring for a client who believes she may be pregnant. which of the following finding should the nurse ID as a positive sign of pregnancy? A. palpable fetal movement B. Chadwick's sign C. positive pregnancy test D. amenorrhea

B. menorrhagia

a nurse is caring for a client who desires and IUD for contraception. which of the following findings is a contraindication for the use of this device? A. HTN B. menorrhagia C. h/o multiple gestations D. h/o thromboembolic disease

B. ask the client if they have thoughts of harming themselves or their infant

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

B. urine ketones present

a nurse is caring for a client who has suspected hyperemesis gravidarum and is reviewing the client's lab reports. which of the following findings is a manifestation of this condition? A. Hgb 12.2 B. urine ketones present C. alanine aminotransferase 20 D. blood glucose 114

A. demonstrates apathy when the newborn cries C. views the newborn's behavior as uncooperative during diaper changing

a nurse is caring for a client who is 1 day postpartum. the nurse is assessing for maternal adaption and parent-infant bonding. which of the following behaviors by the client indicated a need for the nurse to intervene? select all that apply A. demonstrates apathy when the newborn cries B. touch the newborn and maintains close physical proximity C. views the newborn's behavior as uncooperative during diaper changing D. ID's and related newborn's characteristics to those of family members E. interprets the newborn's behavior as meaningful and a way of expressing needs

B. your son is showing an adverse sibling response

a nurse is caring for a client who is 2 days postpartum. the client states, "my 4 year old son was toilet trained and now he is frequently wetting himself." which of the following statements should the nurse provide 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. you son may need counseling D. you should try sending your son to preschool to resolve the behavior

B. massage the fundus

a nurse is caring for a client who is 2 hr postpartum. the nurse notes the client's perineal pad has a large amount of lochia rubra with several clots. which of the following actions should the nurse take first? A. check for a full bladder B. massage the fundus C. measure VS D. administer carboprost IM

B. check the FHR

a nurse is caring for a client who is 40 weeks of gestation and reports having large gush of fluid from the vagina while walking from the bathroom. which of the following actions should the nurse take first? A. examine the amniotic fluid for meconium B. check the FHR C. dry the client and make them comfortable D. apply a tocotransducer

A. oligohydramnios C. fetal cord compression

a nurse is caring for a client who is 42 weeks of gestation and is having an u/s. for which of the following conditions should the nurse plan for an amnioinfusion? select all that apply A. oligohydramnios B. hydraminos C. fetal cord compression D. hydration E. fetal immaturity

A. diabetes B. multifetal pregnancy D. gestational trophoblastic disease

a nurse is caring for a client who is at 14 weeks of gestation and has hyperemesis gravidarum. the nurse should ID 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

use a 20-gauge needle, and administer the med using the Z-track method

a nurse is caring for a client who is at 16 wks of gestation and has severe iron-deficiency anemia. the provider prescribes an injection of iron dextran IM. which of the following methods should the nurse use to administer the med? A. use a 20-gauge needle, and administer the med using the Z-track method B. use a 22-gauge needle, and administer the med deep into the thigh C. use a 25-gauge needle, and administer the med into the deltoid muscle D. use a 18-gauge needle, and administer the med into the rectus femoris muscle

B. you should walk for at least 30 minutes every day

a nurse is caring for a client who is at 26 wks of gestation and reports constipation. which of the following responses by the nurse is appropriate? A. you should drink 1 ounce of mineral oil every morning B. you should walk for at least 30 minutes every day C. you should eat at least 3 ounces of red meat per day D. you should stop taking your prenatal vitamin

A. betamethasone

a nurse is caring for a client who is at 32 weeks of gestation and has a placenta previa. the nurse notes that the clients is actively bleeding. which of the following medication should the nurse expect the provider will prescribe? A. betamethasone B. indomethacin C. nifedipine D. methylergonovine

A. betamethasone

a nurse is caring for a client who is at 32 weeks of gestation and is experiencing preterm labor. which of the following meds should the nurse plan to administer? A. betamethasone B. misoprostol C. methylgonovine D. poractant alfa

D. my heart feels as if it is racing

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

C. nonreactive nonstress test

a nurse is caring for a client who is at 36 wks of gestation and has preeclampsia. which of the following findings should the nurse ID as the priority? A. 1+ proteinuria B. BP 140/98 C. nonreactive nonstress test D. fundal height 33 cm

A. use vibroacoustic stimulation on the client's abdomen for 3 seconds

a nurse is caring for a client who is at 37 wks of gestation and is undergoing a nonstress test. the FHR is 130/min without accelerations for the past 10 min. which of the following actions should the nurse take? A. use vibroacoustic stimulation on the client's abdomen for 3 seconds B. report the nonstress test results to the provider immediately C. request a prescription for an internal fetal scalp electrode D. auscultate the FHR with a doppler transducer

A. auscultate for fetal heart rate

a nurse is caring for a client who is at 38 wks of gestation and reports no fetal movement for 24 hr. which of the following actions should the nurse take? A. auscultate for fetal heart rate B. have the client drink orange juice C. reassure the client that a term fetus is less active D. palate the uterus for fetal movement

D. check the cervix prior to analgesic administration

a nurse is caring for a client who is at 39 wks gestation and is in active labor. which of the following actions should the nurse include in the plan of care? A. keep four side rails up while the client is in bed B. monitor FHR every hour C. insert an indwelling catheter D. check the cervix prior to analgesic administration

A. uteroplacental insufficiency

a nurse is caring for a client who is at 39 wks of gestation and is in the active phase of labor. the nurse observes late decelerations in the FHR. which of the following findings should the nurse ID as the cause of late decels? A. uteroplacental insufficiency B. fetal head compression C. fetal ventricular septal defect D. umbilical cord compression

A. encourage use of patterned breathing techniques C. administer opioid analgesic medication D. suggest application of cold

a nurse is caring for a client who is at 40 weeks of gestation and experiencing contractions every 3-5 min and becoming stronger. a vaginal exam 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 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

C. meconium aspiration

a nurse is caring for a client who is at 42 weeks of gestation and in active labor. which of the following findings is the fetus at risk for developing? A. intrauterine growth restriction B. hyperglycemia C. meconium aspiration D. polyhydramnios

D. your baby's skin will have a leathery appearance

a nurse is caring for a client who is at 42 wks of 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 body 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

D. report of severe shoulder pain

a nurse is caring 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 U/S indicating a fetus in the uterus C. blood progesterone greater than the expected reference range D. report of severe shoulder pain

C. prepare equipment needed for newborn resuscitation

a nurse is caring for a client who is in active labor and has meconium staining of the amniotic fluid. the nurse notes a reassuring FHR tracing from the external fetal monitor. which of the following actions should the nurse take? A. prepare the client for an u/s B. prepare the client for an emergency C-section C. prepare equipment needed for newborn resuscitation D. perform endotracheal suction as soon as the fetal head is delivered

A. hands and knees

a nurse is caring for a client who is in active labor and reports severe back pain. during assessment, the fetus is noted to be in the occiput posterior position. which of the following maternal positions should the nurse suggest to the client to facilitate normal labor progress? A. hands and knees B. lithotomy C. Trendelenburg D. supine with a rolled towel under one hip

C. transition phase

a nurse is caring 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

A. moderate variability B. FHR accelerations D. Normal baseline FHR

a nurse is caring for a client who is in active labor. the cervix is dilated to 5 cm, and the membranes are intact. based on the use of external electronic fetal monitoring, the nurse notes a FHR of 115 to 125/min with occasional increase up to 150 to 155/min that last for 25 seconds and have moderate variability. There is no slowing of the FHR from the baseline. this client is exhibiting manifestations of which of the following? A. moderate variability B. FHR accelerations C. FHR decelerations D. Normal baseline FHR E. Fetal tachycardia

B. sacral counterpressure

a nurse is caring for a client who is in active labor. the client reports low-back pain. the nurse suspect that this pain is related to a persistent occiput posterior fetal position. which of the following nonpharmacological nursing interventions should the nurse recommend to the client? A. abdominal effleurage B. sacral counterpressure C. showering if not contraindicated D. back rub and massage

B. reduced fetal oxygen supply

a nurse is caring for a client who is in labor and experiencing incomplete uterine relaxation between hypertonic contractions. the nurse should ID that this contraction pattern increases the risk for which of the following? A. prolonged labor B. reduced fetal oxygen supply C. delayed cervical dilation D. increased maternal stress

C. hypotension

a nurse is caring for a client who is in labor and has an epidural for pain relief. which of the following is a complication from the epidural block? A. N/V B. tachycardia C. hypotension D. respiratory depression

A. assist the client into the left-lateral position

a nurse is 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 to 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

C. vertex

a nurse is caring for a client who is in labor. a vaginal exam reveals the following info: 2cm, 50%, +1, ROA. based on this info which of the following fetal positions should the nurse document in the medical record? A. transverse B. breech C. vertex D. mentum

D. we need to observe your baby more closely

a nurse is caring for a client who is in labor. the client questions the application of an internal fetal scalp monitor. which of the following responses should the nurse make? A. don't worry. your baby is fine B. you will need to ask your provider C. your provider feel it would be best D. we need to observe your baby more closely

A. gonorrhea B. chlamydia C. HIV D. Group B streptococcus beta-hemolytic

a nurse is caring for a client who is in labor. the nurse should ID 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

C. decrease the dose of oxytocin by half

a nurse is caring for a client who is in the latent phase of labor and is receiving oxytocin via continuous infusion. the nurse notes that the client is haivng contractions every 2 minutes which last 100 to 110 seconds and that the FHR is reassuring. which of the following actions should the nurse take? A. decrease the infusion rate of the maintenance IV fluid B. administer oxygen via nonrebreather mask C. decrease the dose of oxytocin by half D. administer terbutaline 0.25 mg subQ

A. pudendal

a nurse is caring for a client who is in the second stage of labor. the client's labor has been progressing, and a vaginal delivery is expected in 20 min. the provider is preparing to administer lidocaine for pain relief and perform an episiotomy. the nurse should know that which of the following types of regional anesthetic block is to be administered? A. pudendal B. epidural C. spinal D. paracervical

B. prepare for an impeding delivery

a nurse is caring for a client who is in the transition phase of labor and reports that they need to have a BM with the peak of contractions. which of the following actions should the nurse make? A. assist the client to the bathroom B. prepare for an impeding delivery C. prepare to remove a fecal impaction D. encourage the client to take deep, cleansing breaths

A. increasing pulse and decreasing blood pressure

a nurse is caring for a client who is postpartum. the nurse should ID which of the following findings as an early indicator of hypovolemia caused by hemorrhage? A. increasing pulse and decreasing blood pressure B. dizziness and increasing RR C. cool, clammy skin, and pale mucous membranes D. altered mental status and LOC

A. decreased fetal movement B. intrauterine growth restriction (IUGR) C. post maturity

a nurse is caring for 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. post maturity D. placenta previa E. amniotic fluid emboli

A. vaginal bleeding

a nurse is caring for a client who is pregnant and reviewing manifestations of complications the client should promptly report to the provider. which of the following complications should the nurse include? A. vaginal bleeding B. swelling of the ankles C. heartburn after eating D. lightheadedness when lying on back

A. January 8

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

D. it awakens a sleeping fetus

a nurse is caring for 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

D. calcium gluconate

a nurse is caring for 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

B. dizziness

a nurse is caring 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

B. duration of 90 to 120 seconds

a nurse is caring for a client who is receiving oxytocin for induction of labor and has an intrauterine pressure catheter (IUPC) placed to monitor uterine contractions. For which of the following contraction patterns should the nurse d/c the infusion of oxytocin? A. frequency of every 2 min B. duration of 90 to 120 seconds C. intensity of 60 to 90 mm Hg D. resting tone of 15 mm Hg

A. perform continuous FHR monitoring

a nurse is caring for a client who is receiving oxytocin for induction of labor. which of the following actions should the nurse take? A. perform continuous FHR monitoring B. measure maternal temp every hr C. evaluate maternal contraction pattern every hr D. check BP every 5 min

D. place an oxygen mask over the nose and mouth

a nurse is caring for a client who is using patterned breathing during labor. the client reports numbness and tingling of the fingers. which of the following actions should the nurse take? A. administer oxygen via nasal cannula at 2 L/min B. apply a warm blanket C. assist the client to a side-lying position D. place an oxygen mask over the nose and mouth

A. assist the client to ambulate in the hallway

a nurse is caring for a client who reports intestinal gas pain following a C-section. which of the following actions should the nurse take? A. assist the client to ambulate in the hallway B. instruct the client to splint the incision with a pillow C. have the client drink fluids through a straw D. encourage the client to drink carbonated beverages

A. UTI B. multifetal pregnancy D. diabetes mellitus E. uterine abnormalities

a nurse is caring 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. UTI B. multifetal pregnancy C. oligohydramnios D. diabetes mellitus E. uterine abnormalities

D. April 15

a nurse is caring for a client whose LMP was July 8. using Nagele's rule the nurse should ID the client's EDD as which of the following? A. October 1 B. April 1 C. October 15 D. April 15

A. turn the client onto her left side

a nurse is caring for a client whose membranes have ruptures and is in active labor. the fetal monitor tracing reveals late decelerations. which of the following actions should the nurse take first? A. turn the client onto her left side B. palpate the client's uterus C. administer oxygen to the client D. increase the client's IV fluids

C. apnea for 10-second periods D. obligatory nose breathing

a nurse is completing an assessment. which of the following data 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

C. the male is the easiest to assess, and the provider will usually begin there

a nurse is caring for a couple who is being evaluated for infertility. Which of the following statements by the nurse indicated understanding of the infertility assessment process? A. you will need to see a genetic counselor as part of the assessment B. it is usually the female who is having trouble, so the male doesn't have to be involved C. the male is the easiest to assess, and the provider will usually begin there D. think about adopting first because there are many babies that need good homes

B. erythromycin ophthalmic ointment

a nurse is caring for a newborn directly after birth. which of the following meds should the nurse administer to the newborn within 1-2 hr of delivery? A. naloxone B. erythromycin ophthalmic ointment C. poractant alpha D. rotavirus immunization

D. covering the newborn's head with a cap

a nurse is caring for 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

B. place the newborn directly on the client's chest

a nurse is caring for a newborn immediately following delivery. which of the following actions should the nurse take first? A. perform a detailed physical assessment B. place the newborn directly on the client's chest C. give the newborn vitamin K IM D. administer erythromycin ophthalmic ointment

C. apply petroleum gauze to the site

a nurse is caring for a newborn immediatley following a circumcision using a Gomco procedure. which of the following actions should the nurse implement? A. apply Gelfoam powder to the site B. place the newborn in the prone position C. apply petroleum gauze to the site D. avoid changing the diaper until the first voiding

D. exaggerated reflexes

a nurse is caring for a newborn who has neonatal abstinence syndrome. which of the following clinical finding should the nurse expect? A. extended periods of sleep B. poor muscle tone C. RR 50/min D. exaggerated reflexes

B. position the naked newborn on the parent's bare chest

a nurse is caring for a newborn who is premature in the neonatal intensive care unit. which of the following actions should the nurse take to promote development? A. rapidly advance oral feedings B. position the naked newborn on the parent's bare chest C. provide frequent periods of visual and auditory stimulation D. discourage the use of pacifiers

A. oxygen saturation

a nurse is caring for 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

B. appropriate for gestational age

a nurse is caring for a newborn who was born at 38 weeks of gestations, weighs 3,200 g, and is in the 60th percentile for weight. based on the weight and gestational age, the nurse should classify this neonate as which of the following? A. low birth weight B. appropriate for gestational age C. small for gestational age D. large for gestational age

A. respiratory depression

a nurse is caring for a newborn whose mother received magnesium sulfate to treat preterm labor. which of the following clinical manifestations in the newborn indicates toxicity due to the magnesium sulfate therapy? A. respiratory depression B. hypothermia C. hypoglycemia D. jaundice

B. attempts to place their hand in their mouth

a nurse is caring for a newborn. which of the following actions by the newborn indicates readiness to feed? A. spits up clear mucus B. attempts to place their hand in their mouth C. turns the head toward sounds D. lies quietly with their eyes open

A. magnesium sulfate infusion B. distended bladder D. prolonged labor

a nurse is caring for a postpartum client 8 hr after delivery. which of the following factors places the client at risk for uterine atony? select all that apply A. magnesium sulfate infusion B. distended bladder C. oxytocin infusion D. prolonged labor E. small for gestational age newborn

A. fatigue B. insomnia D. flat affect

a nurse is caring for a postpartum client who delivered their third infant 2 days ago. which of the following manifestations could indicate postpartum depression? select all that apply A. fatigue B. insomnia C. euphoria D. flat affect E. delusions

B. retinopathy

a nurse is caring for a preterm newborn who is receiving O2 therapy. which of the following findings should the nurse ID as a potential complication from the O2 therapy? A. atelectasis B. retinopathy C. interstitial emphysema D. necrotizing enterocolitis

C. sunken fontanels

a nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy. which of the following is the priority finding in the newborn? A. conjunctivitis B. bronze skin discoloration C. sunken fontanels D. maculopapular skin rash

C. fundal consistency

a nurse is caring for client who is to receive continuous IV infusion of oxytocin following a vaginal birth. which of the following findings should the nurse monitor to evaluate the effectiveness of the medication? A. urinary output B. blood pressure C. fundal consistency D. pulse rate

A. a newborn who is large for gestational age

a nurse is caring for four newborns. which of the following newborns is at greatest risk for hypoglycemia? A. a newborn who is large for gestational age B. a newborn who has an Rh incompatibility C. a newborn who has pathologic jaundice D. a newborn who has fetal alcohol syndrome

D. Epstein's pearls

a nurse is completing a newborn assessment 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

B. infection

a nurse is completing an admission assessment for a client who is 39 weeks of gestation and reports fluid leaking from the vagina for 2 days. which of the following conditions is the client at risk for developing? A. cord prolapse B. infection C. postpartum hemorrhage D. hydraminos

B. I need a second vaccination at my postpartum visit

a nurse is completing postpartum d/c 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 of the teaching? 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-positive D. I will be tested in 3 months to see if I have developed immunity

A. apply cold compresses between feedings

a nurse is conducting a home visit for a client who is 1 wk postpartum and breastfeeding. the client reports breast engorgement. which of the following recommendations should the nurse make? A. apply cold compresses between feedings B. take a warm shower right after feedings C. apply breast milk to the nipples and allow them to air dry D. use the various infant positions for feedings

A. maternal meds

a nurse is discussing apgar scoring with a newly licensed nurse. The nurse should include that which of the following factors affect the apgar score? A. maternal meds B. sex of the newborn C. use of internal fetal monitoring during labor D. maternal age

C. I should replace my diaphragm every 2 years

a nurse is discussing diaphragm use with a client. which of the following statements by the client indicates an understanding of the teaching? A. I should clean my diaphragm with alcohol each time I use it B. I should leave the diaphragm in place 4 hours after intercourse C. I should replace my diaphragm every 2 years D. I should use a vaginal lubricant to insert my diaphragm

D. an epidural given too early can prolong labor

a nurse is discussing epidural anesthesia with a client who is receiving oxytocin for induction of labor. which of the following statement should the nurse make? A. an epidural given too early during labor can cause maternal hypertension B. an epidural given too early during labor will not be effective in active labor C. an epidural given too early can cause fetal depression D. an epidural given too early can prolong labor

A. epidural anesthesia B. urinary bladder catheterization C. frequent pelvic exams D. history of UTIs

a nurse is discussing risk factors for UTIs 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 catheterization C. frequent pelvic exams D. history of UTIs E. vaginal birth

D. when latched on, the infant's nose, cheek, and chin are touch the breast

a nurse is giving instructions to a parent about how to breastfeed their newborn. which of the following actions by the parent indicates understanding of the teaching? A. the parent places a few drops of water on their nipple before feeding B. the parent gently removes their nipple from the infant's mouth to break the suction. C. when they are ready to breastfeed, the parent gently strokes the newborn's neck with a finger D. when latched on, the infant's nose, cheek, and chin are touch the breast

B. palpate the fundus of the uterus

a nurse is performing Leopold maneuvers on a client who is in labor. which of the following techniques should the nurse use to ID the fetal lie? A. apply palms of both hands to the side of the uterus B. palpate the fundus of the uterus C. grasp lower uterine segment between thumb and fingers D. stand facing the client's feet with fingertips outlining cephalic prominence

A. moderate lochia rubra scant = less than 2.5 cm light = 2.5-10 cm moderate = more than 10 cm heavy = one pad saturated within 2 hr excessive blood loss = one pat saturated in 15 min or less/ or pooling of blood under buttocks

a nurse is performing a fundal assessment for 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? A. moderate lochia rubra B. excessive lochia serosa C. light lochia rubra D. scant lochia serosa

D. active genital herpes

a nurse is planning care for a client who has a prescription for oxytocin. which of the following is a contraindication for the use of this med? A. prolonged ROM at 38 wks of gestation B. intrauterine growth restriction C. postterm pregnancy D. active genital herpes

C. monitor the client's weight weekly

a nurse is planning care for a client who is postpartum and has cardiac disease. for which of the following prescriptions should the nurse seek clarification? A. monitor the client's intake and output B. initiate a high-fiber diet for the client C. monitor the client's weight weekly D. initiate bedrest with the head of the bed elevated

D. measure leg circumferences

a nurse is planning care for a client who is postpartum and has thrombophlebitis. which of the following nursing interventions should the nurse include in the plan of care? A. apply cold compresses to the affected extremity B. massage the affected extremity C. allow the client to ambulate D. measure leg circumferences

D. defer vaginal examinations

a nurse is planning care for a newly admitted client who reports, "I am in labor and I have been having vaginal bleeding for 2 weeks." Which of the following should the nurse include in the plan of care? A. inspect the introitus for a prolapsed cord B. perform a test to ID the ferning pattern C. monitor station of the presenting part D. defer vaginal examinations

A. it assist with blood clotting

a nurse is preparing to administer a vitamin K injection to a newborn. which of the following responses should the nurse make to the newborn's parent regarding why this medication is given? A. it assist with blood clotting B. it promotes maturation of the bowel C. it is a preventative vaccine D. it provides immunity

A. IV narcotics administered to the mother during labor

a nurse is preparing to administer naloxone to a newborn. which of the following conditions can require administration of this medication? A. IV narcotics administered to the mother during labor B. maternal drug use C. hyaline membrane disease D. meconium aspiration

C. erythromycin

a nurse is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. which of the following meds should the nurse anticipate administering? A. ofloxacin B. nystatin C. erythromycin D. ceftriaxone

B. a client who does not wash their hands between perineal care and breastfeeding

a nurse is providing care to four clients on the postpartum unit. which of the following clients is at greatest risk for developing a postpartum infection? A. a client who has an episiotomy that is erythematous and has extended into a third-degree laceration B. a client who does not wash their hands between perineal care and breastfeeding C. a client who is not breastfeeding and is using measures to suppress lactation D. a client who has a caesarean incision that is well-approximated with no drainage

C. sore nipple with cracks and fissures

a nurse is providing d/c instructions for a client. at 4 wks postpartum, the client should contact the provider for which of the following 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

C. Kegel exercises

a nurse is providing d/c instructions to a postpartum client following a caesarean birth. the client reports leaking urine every time they sneeze or cough. which of the following interventions should the nurse suggest? A. sit-ups B. pelvic tilt exercises C. Kegel exercises D. abdominal crunches

A. wear a supportive bra continuously for the first 72 hours

a nurse is providing d/c teaching for a nonlactating client. which of the following instructions should the nurse include in the teaching? A. wear a supportive bra continuously for the first 72 hours B. pump your breast every 4 hours to relieve discomfort C. use breast shells throughout the day to decrease milk supply D. apply warm compresses until milk suppression occurs

A. do not become pregnant for at least 1 year

a nurse is providing d/c teaching to a client following the removal of a hydatidiform mole. which of the following statements should the nurse include in the teaching? A. do not become pregnant for at least 1 year B. seek genetic counseling for yourself and your partner prior to getting pregnant again C. you have an hCG level drawn in 6 wks D. have your BP checked weekly for the next month

C. I will clean the penis with each diaper change

a nurse is providing d/c 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

A. use a perineal squeeze bottle to cleanse the perineum C. apply a topical anesthetic cream or spray to the perineum E. apply cold or ice packs to the perineum

a nurse is providing education to a client who is 2 hr postpartum and has perineal laceration. which of the following info 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

D. blurred or double vision

a nurse is providing teaching to a client who is at 8 wks of gestation about manifestations to report to the provider. which of the following info should the nurse include in the teaching? A. nausea upon awakening B. leg cramps when sleeping C. increase in white vaginal discharge D. blurred or double vision

D. it is normal for my baby to sometimes feed every hour for several hours in a row

a nurse is providing teaching to a client who is planning to breastfeed her newborn. which of the following statements by the client indicates an understanding of the teaching? A. I must drink milk every day in order to assure good quality breast milk B. drinking lots of fluids will increase my breast milk production C. after the first few weeks, my nipples will toughen up and breastfeeding won't hurt anymore D. it is normal for my baby to sometimes feed every hour for several hours in a row

B. place ice packs on your breasts

a nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. which of the following instructions should the nurse include in the teaching? A. stand under a hot shower with your breast exposed B. place ice packs on your breasts C. wear a lose-fitting, comfortable bra D. Limit fluid intake to 1 L a day

D. encourage nonnutritive sucking for pain relief

a nurse is providing teaching to the parents of a newborn about how to care for his circumcision at home. which of the following instructions should the nurse include in the teaching? A. apply the diaper tightly over the circumcision area B. remove the yellow exudate with each diaper change C. use prepackaged commercial wipes to clean the circumcision site D. encourage nonnutritive sucking for pain relief

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

a nurse is reviewing a new prescription for 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

D. orange juice

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 instruct the client to take the iron supplements with? A. ice water B. low-fat or whole milk C. tea or coffee D. orange juice

D. cradle

a nurse is reviewing breastfeeding positions with a parent of a newborn. which of the following positions should the nurse discuss? A. over-the-shoulder B. supine C. chin-supported D. cradle

C. back seat, rear-facing

a nurse is reviewing car seat safety with the parents of a newborn. which of the following instructions should the nurse include in the teaching regarding car seat position? A. front seat, rear-facing B. front-seat, forward facing C. back seat, rear-facing D. back seat, forward-facing

D. keep the diaper folded below the cord

a nurse is reviewing care of the umbilical cord with the parent of ta newborn. which of the following instructions should the nurse include in the teaching? A. cover the cord with a small gauze B. trickle clean water over the cord with each diaper change C. apply hydrogen peroxide to the cord twice a day D. keep the diaper folded below the cord

C. I will drink large amounts of fluids to flush the bacteria from my urinary tract E. I will take Tylenol for any discomfort

a nurse is reviewing d/c teaching with a client who has a UTI. which of the following statements by the client indicates understanding of the teaching? select all that apply A. I will perform perineal care and apply a perineal pad in a back-to-front direction B. I will drink grape juice to make my urine more acidic C. I will drink large amounts of fluids to flush the bacteria from my urinary tract D. I will go back to breastfeeding after I have finished taking the antibiotic E. I will take Tylenol for any discomfort

D. keep a daily record of fetal kick counts

a nurse is reviewing d/c teaching with a client who has premature rupture of membranes at 26 weeks of gestation. which of the following instructions should the nurse include in the teaching? A. use a condom with sexual intercourse B. avoid bubble bath solution when taking a tub bath C. wipe from the back to front when performing perineal hygiene D. keep a daily record of fetal kick counts

B. fetal breathing movement C. fetal tone E. amniotic fluid volume

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

C. place used bottles in the dishwasher D. check the nipple for appropriate flow of formula E. use tap water to dilute concentrated formula

a nurse is reviewing formula preparation with parents who place to bottle-feed their newborn. which of the following info should the nurse include in the teaching? select all that apply A. use a disinfectant wipe to clean the lid of the formula can B. store prepared formula in the refrigerator for up to 72 hours C. place used bottles in the dishwasher D. check the nipple for appropriate flow of formula E. use tap water to dilute concentrated formula

C. instruct the client to obtain a rubella immunization after deliver

a nurse is reviewing lab results for a client who is at 37 wks of gestation. the nurse notes that the client is rubella non-immune, positive for GBS, and has a blood type of O-. which of the following actions should the nurse take? A. administer a dose of Rho(D) immune globulin B. request a prescription for an antibiotic until delivery C. instruct the client to obtain a rubella immunization after deliver D. inform the client that she will need to delver via C-section

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

a nurse is 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

D. relaxation between uterine contractions

a nurse is reviewing the electronic monitor tracing of a client who is in active labor. a fetus receives more oxygen when which of the following appears on the tracing? A. peak of the uterine contraction B. moderate variability C. FHR accelerations D. relaxation between uterine contractions

B. Goodell's sign C. Ballottement D. Chadwick's sign

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

A. perform a vaginal exam

a nurse is reviewing the medical record of a client who is at 33 wks of gestation and has placenta previa and bleeding. which of the following prescriptions should the nurse clarify with the provider? A. perform a vaginal exam B. perform continuous external fetal monitoring C. insert a large-bore IV catheter D. obtain a blood sample for lab testing

D. fetal gastrointestinal anomaly

a nurse is reviewing the medical record of a client who is at 39 wks of gestation and has polyhydramnios. which of the following finding should the nurse expect? A. fundal height of 34 cm B. total pregnancy weight gain of 8 lb C. gestation hypertension D. fetal gastrointestinal anomaly

C. match the parent's ID band with the newborn's band

a nurse is taking a newborn to a parent following a circumcision. which of the following actions should the nurse take for security purposes? A. ask the parent to state their full name B. look at the name on the newborn's bassinet C. match the parent's ID band with the newborn's band D. compare name on the bassinet and room number

C. apgar scoring is a rapid assessment of the newborn's transition to extrauterine life

a nurse is teaching Apgar scoring to a newly licensed nurse. Which of the following into should the nurse include? A. apgar scoring predict future neurologic outcomes B. apgar scoring assesses the gestational age level of the newborn C. apgar scoring is a rapid assessment of the newborn's transition to extrauterine life D. apgar scoring should be done at 30 minutes following birth

C. I should press the button on the handheld marker when my baby moves

a nurse is teaching a client about a nonstress test. which of the following statements by the client indicated an understanding of the teaching? A. I know not to eat anything after midnight B. I will have medication given to me to cause contractions C. I should press the button on the handheld marker when my baby moves D. I will have to stimulate my breast to cause contractions

B. irregular vaginal bleeding C. weight gain D. nausea

a nurse is teaching 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

B. it can detect abnormal fetal heart tones early D. it allows for accurate reading with maternal movements E. it can measure uterine contraction intensity

a nurse is teaching 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 reading with maternal movements E. it can measure uterine contraction intensity

A. you will have a cesarean birth prior to the onset of labor

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

B. feeling of warmth

a nurse is teaching a client who has pre-eclampsia and is to receive magnesium sulfate via continuous IV infusion about expected adverse effects. which of the following adverse effects should the nurse include in the teaching? A. elevated BP B. feeling of warmth C. hyperactivity D. generalized pruritus

B. you will need to have a full bladder during the u/s

a nurse is teaching a client who is at 10 wks of gestation about abdominal u/s in the first trimester. which of the following info should the nurse include in the teaching A. you will have a nonstress test prior to the u/s B. you will need to have a full bladder during the u/s C. the u/s will determine the length of your cervix D. you will experience uterine cramping during the u/s

A. swelling of the face

a nurse is teaching a client who is at 12 wks of gestation about manifestations of potential complications that she should report to the provider. which of the following info should the nurse include? A. swelling of the face B. urinary frequency C. white vaginal discharge D. intermittent nausea

D. you should continue to take zidovudine throughout pregnancy

a nurse is teaching a client who is at 12 wks of gestation and has HIV. which of the following statements should the nurse include in the teaching? A. breastfeed your newborn to provide passive immunity B. abstain from sexual intercourse throughout pregnancy C. you will be in isolation after delivery D. you should continue to take zidovudine throughout pregnancy

C. I should go to the hospital if I think I may be in labor

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

C. vaginal bleeding

a nurse is teaching a client who is at 30 wks of gestation about warning signs of complications she should report to the provider. which of the following finding should the nurse include in the teaching? A. mild constipation B. nasal congestions C. vaginal bleeding D. 10 fetal movements per hour

A. breast tenderness B. urinary frequency C. epistaxis

a nurse is teaching 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

B. the fibroid can increase the risk for postpartum hemorrhage

a nurse is teaching a client who is at 8 wks of gestation and has a uterine fibroid about potential effects of the fibroid during pregnancy. which of the following info should the nurse include in the teaching? A. the fibroid will shrink during the pregnancy B. the fibroid can increase the risk for postpartum hemorrhage C. you will receive an injection of medroxyprogesterone acetate to shrink the fibroid D. you will have to undergo a C-section because of the fibroid

C. completely empty each breast at each feeding or use a pump

a nurse is teaching 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

C. you should empty your bladder prior to the procedure

a nurse is teaching a client who is pregnant about the amniocentesis procedure. which of the following statements should the nurse include in the teaching? 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

C. perform the pelvic rock exercises every day D. use proper body mechanics

a nurse is teaching 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 exercises every day D. use proper body mechanics E. avoid constrictive clothing

C. keep the nipple full of formula throughout the feeding

a nurse is teaching 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

B. the newborn will have a continuous high-pitched cry

a nurse is teaching a newly licensed nurse about neonatal abstinence syndrome. which of the following statements by the newly licensed nurse indicate 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 2-3 hours after a feeding D. the newborn will have mild tremors when disturbed

A. this is more commonly seen in newborns who have dark skin

a nurse is teaching a newly licensed nurse how to bathe a newborn and observes a bluish brown marking across the newborn's back. the nurse should include which of the following info in the teaching? 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

D. a client should avoid consuming undercooked meat while pregnant

a nurse manager is reviewing ways to prevent a TORCH infection during pregnancy with a group of newly licensed nurses. which of the following statements by a nurse indicates understanding of the teaching? A. obtain an immunization against rubella early in pregnancy B. seek prophylactic treatment if 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. calf tenderness to palpation C. elevated temperature D. area of warmth

a nurse on the postpartum unit is assessing a client who is being admitted with suspected DVT. which of the following clinical findings should the nurse expect? select all that apply A. calf tenderness to palpation B. mottling of the affected extremity C. elevated temperature D. area of warmth E. report of nausea

B. a client who had premature ROM and prolonged labor

a nurse on the postpartum unit is caring for four clients. which of the following clients should the nurse recognize as the greatest risk for developing a postpartum infection? A. a client who experienced precipitous labor less than 3 hr in duration B. a client who had premature ROM and prolonged labor C. a client who delivered a large for gestational age infant D. a client who had a boggy uterus that was not well-contracted

B. contractions that last for 60 seconds each with a 3 min rest between contractions

a nurse receives report on a client who is in labor and is experiencing contractions 4 min apart. which of the following patterns should the nurse expect on the fetal monitoring tracing? A. contractions that last for 60 seconds each with a 4 min rest between contractions B. contractions that last for 60 seconds each with a 3 min rest between contractions C. a contraction that last 4 min followed by a period of relaxation D. contractions that last 45 seconds each with a 3 min rest between contractions

Lochia serosa

brownish red or pink vaginal drainage from days 3-10

Lochia rubra

dark red vaginal drainage for 1-3 days

C. a normal postural discharge of lochia

during ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. on assessment, 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 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

Bishop score

used to determine maternal readiness for labor by evaluation whether the cervix is favorable; want the score to be higher; 39 weeks gestation should have a score of 8 or highter

Lochia alba

yellowish white vaginal discharge after day 10 to 8 weeks