Maternity exam 1

The nurse in the obstetric clinic received a telephone call from a bottle-feeding mother of a 3-day-old. The client states that her breasts are firm, red, and warm to the touch. Which of the following is the best action for the nurse to advise the client to perform? 1. Intermittently apply ice packs to her axillae and breasts. 2. Apply lanolin to her breasts and nipples every 3 hours. 3. Express milk from the breasts every 3 hours. 4. Ask the primary healthcare provider to order a milk suppressant.

1

The nurse is caring for a postpartum client who experienced a second-degree perineal laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time? 1. Apply an ice pack to the perineum. 2. Advise the woman to use a sitz bath after every voiding. 3. Advise the woman to sit on a pillow. 4. Teach the woman to insert nothing into her rectum.

1

The nurse notes each of the following findings in a 10-week gestation client. Which of the findings would enable the nurse to tell the client that she is positively pregnant? 1. Fetal heart rate via Doppler. 2. Positive pregnancy test. 3. Positive Chadwick sign. 4. Montgomery gland enlargements.

1

A client asks the nurse what was meant when the physician told her she had a positive Chadwick sign. Which of the following information about the finding would be appropriate for the nurse to convey at this time? 1. "It is a purplish stretch mark on your abdomen." 2. "It means that you are having heart palpitations." 3. "It is a bluish coloration of your cervix and vagina." 4. "It means the doctor heard abnormal sounds when you breathed in."

1, 3

An antenatal client is informing the nurse of her prenatal signs and symptoms. Which of the following findings would the nurse determine are presumptive signs of pregnancy? Select all that apply. 1. Amenorrhea. 2. Breast tenderness. 3. Quickening. 4. Frequent urination. 5. Uterine growth.

1,2,3,4

9.) A pregnant patient has a nonstress test performed. The results showed the baby had 4 fetal heart rate accelerations of at least 15 beats/min that lasted 15 seconds from start to finish in association with fetal movement during 20 minutes. The results of this would be documented as:* 1. Negative Contraction Stress Test 2. "Reactive" Nonstress Test 3. "Nonreactive" Nonstress Test 4. Positive Contraction Stress Tes

2

A 16-year-old, G1 P0000, is being seen at her 10-week gestation visit. She tells the nurse that she felt the baby move that morning. Which of the following responses by the nurse is appropriate? 1. "That is very exciting. The baby must be very healthy." 2. "Would you please describe what you felt for me?" 3. "That is impossible. The baby is not big enough yet." 4. "Would you please let me see if I can feel the baby?"

2

A breastfeeding client, G10 P6408, delivered 10 minutes ago. Which of the following assessments is most important for the nurse to perform at this time? 1. Pulse. 2. Fundus. 3. Bladder. 4. Breast.

2

A breastfeeding woman has been counseled on how to prevent engorgement. Which of the following actions by the mother shows that the teaching was effective? 1. She pumps her breasts after each feeding. 2. She feeds her baby every 2 to 3 hours. 3. She feeds her baby 10 minutes on each side. 4. She supplements each feeding with formula.

2

To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks? 1. Apply antibiotic ointment to the perineum daily. 2. Change the peripad at each voiding. 3. Void at least every two hours. 4. Spray the perineum with povidone-iodine after toileting.

2

The nurse monitors his or her postpartum clients carefully because which of the following physiological changes occurs during the early postpartum period? 1. Decreased urinary output. 2. Increased blood pressure. 3. Decreased blood volume. 4. Increased estrogen level.

3

Which of the following skin changes should the nurse highlight for a pregnant woman's healthcare practitioner? 1. Linea nigra. 2. Melasma. 3. Petechiae. 4. Spider nevi.

3

A G2 P2002 who is postpartum 6 hours from a spontaneous vaginal delivery is assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia rubra, and perineal sutures are intact. Which of the following actions should the nurse take at this time? 1. Do nothing. This is a normal fi nding. 2. Massage the woman's fundus. 3. Take the woman to the bathroom to void. 4. Notify the woman's primary healthcare provider.

4

A multigravid client is 22 weeks pregnant. Which of the following symptoms would the nurse expect the client to exhibit? 1. Nausea. 2. Dyspnea. 3. Urinary frequency. 4. Leg cramping.

4

The client has just given birth to a healthy, full-term infant. The client is Rho(D) negative and her baby is Rho(D) positive. Which intervention will take place to reduce the possibility of isoimmunization? A. Administering Rho(D) immune globulin to the baby, IM, within 72 hours B. Administering Rho(D) immune globulin to the mother, IM, within 72 hours C. Administering Rho(D) immune globulin to the mother, IM, at her 6-week visit D. Administering Rho(D) immune globulin to the mother, IM, within 3 months

B

A nurse is explaining to a client about monthly hormonal changes. Starting with day 1 of the menstrual cycle, please place the following four hormones in the chronological order in which they elevate during the menstrual cycle. 1. Follicle-stimulating hormone. 2. Luteinizing hormone. 3. Progesterone.

FSH, LH, progesterone

A woman's temperature has just risen 0.4°F and will remain elevated during the remainder of her cycle. She expects to menstruate in about 2 weeks. Which of the following hormones is responsible for the change? 1. Estrogen. 2. Progesterone. 3. Luteinizing hormone (LH). 4. Follicle-stimulating hormone (FSH).

Progesterone

A 20-year-old client states that the at-home pregnancy test that she took this morning was positive. Which of the following comments by the nurse is appropriate at this time? 1. "Congratulations, you and your family must be so happy." 2. "Have you told the baby's father yet?" 3. "How do you feel about the results?" 4. "Please tell me when your last menstrual period was."

3

A female client is scheduled for a hysterectomy. When discussing the preoperative preparation the nurse identifies that the client has inadequate understanding of the surgery. the nurse should: describe the surgery to the client notify the surgeon that the client needs more information proceed with implementing the preoperative plan explain to the client that she should have asked more questions

notify the surgeon that the client needs more information

Which of the following are included in the Nurse Practice Act? protect the public enforce the ethical standards of behavior determine liability insurance rates accredit schools of nursing define the scope of nursing practice

protect the public, define the scope of practice

A breastfeeding client, 7 weeks postpartum, complains to an obstetrician's triage nurse that when she and her husband had intercourse for the first time after the delivery, "I couldn't stand it. It was so painful. The doctor must have done something terrible to my vagina." Which of the following responses by the nurse is appropriate? 1. "After a delivery the vagina is always very tender. It should feel better the next time you have intercourse." 2. "Does your baby have thrush? If so, you should be assessed for a yeast infection in your vagina." 3. "Women who breastfeed often have vaginal dryness. A vaginal lubricant may remedy your discomfort." 4. "Sometimes the stitches of episiotomies heal too tight. Why don't you come in to be checked?"

3