Maternity Final Test Review 1
A nurse is preparing for a neonate to be born. What nursing actions will be performed after the birth? Place the actions below in the correct order. 1. Place the neonate skin to skin 2. Dry the neonate 3. Assess vital signs 4. Obtain Apgar scores
1. Dry the neonate 2. Place neonate skin to skin 3. Obtain Apgar scores 4. Assess vital signs
A patient with preeclampsia is prescribed magnesium sulfate 6grams IV infusion now as a loading dose, followed by 5 grams/hr. The pharmacy prepared an infusion of 500 mL of LR with 100 grams of magnesium sulfate. If the patient receives the loading dose and 3 hours of the medication, how many mL of the infusion did the patient receive?
105 mL
Which of the following is indicated by the arrow in the picture? A. Cystocele B. Rectocele C. Vaginal prolapse D. Uterocele
A. Cystocele
The acronym PURPLE stands for what? Place in order: 1. Unexpected 2. Evening 3. Long lasting 4. Pain like face 5. Resists soothing 6. Peak of crying
1. Peak of crying 2. Unexpected 3. Resists soothing 4. Pain like face 5. long lasting 6. Evening
The nurse is teaching the parents of a newborn about period of purple crying. Which of the following soothing techniques should be included in the teaching? Select all that apply A. "Hold your baby close to you with skin to skin contact" B. "Walk and sing to your baby" C. "Give your baby a warm bath" D. "Check to see if your baby is hungry or tired, or needs changing" E. "Increase stimulation in baby's environment by providing brightly colored objects to look at"
A. "Hold your baby close to you with skin to skin contact" B. "Walk and sing to your baby" C. "Give your baby a warm bath" D. "Check to see if your baby is hungry or tired, or needs changing"
A nurse is providing emotional support to a patient who just experienced a stillbirth at 38 weeks gestation. Which statement would indicate a non-therapeutic response by the nurse when providing support to the patient? A. "I am sorry for your loss, but don't worry, you still have time to become pregnant again" B. "I am going to hand this image of a butterfly outside your door to maintain your privacy and comfort" C. "I am going to provide your family when mementos to take home" D."I am here to support you. Let's discuss any religious or cultural needs you may have"
A. "I am sorry for your loss, but don't worry, you still have time to become pregnant again"
The postpartum nurse is preparing to administer Rh(D) Immune Globulin (RhoGAM) to a post cesarean section patient on the mother baby unit. What statements made by the patient indicate an understanding of RhoGAM? Select all that apply A. "I need this because my blood type is negative and my baby is positive" B."I will avoid pregnancy for 4 weeks" C. "This medication will help protect my future babies" D. "I only need to get this once in my lifetime"
A. "I need this because my blood type is negative and my baby is positive" C. "This medication will help protect my future babies"
A woman in her late 40s reporting irregular menstrual cycles and asks the nurse if she still needs to use birth control. What is the best response by the nurse? A. "It is possible for a woman to become pregnant during perimenopause" B. "If you are experiencing hot flashes, you have reached menopause and you cannot get pregnant" C. "Until you have gone six months without a menstrual period, you can still get pregnant" D. "It is likely you would get pregnant now, and birth control is not safe to use at your age"
A. "It is possible for a woman to become pregnant during perimenopause"
The nurse is performing discharge teaching for a newly delivered first time mother and her infant on the 2nd postpartum day. Which statement by the mother indicates that teaching has been successful? A. "Taking site baths will help my perineum feel less sore each day" B. "If I develop heavy bleeding, I should take my temperature" C. " My bowel movements should resume in a week" D. "I will go back to the doctor in 4 days for my RhoGAM shot"
A. "Taking site baths will help my perineum feel less sore each day"
The mother baby educator is orienting a group of new nurses and discussing the hepatic system. The educator determines the group understands bilirubin production when choosing which statements are correct? Select all that apply A. "The neonate produces more bilirubin after birth due to an increase in RBC production" B. "Direct (conjugated) bilirubin is a water soluble substance" C. "Hyperbilirubin may occur from immature liver function" D. Indirect bilirubin can be excreted in the urine and stool E. Direct bilirubin is deposited in the body tissues and cross the blood brain barrier
A. "The neonate produces more bilirubin after birth due to an increase in RBC production" B. "Direct (conjugated) bilirubin is a water soluble substance" C. "Hyperbilirubin may occur from immature liver function"
A client was diagnosed with endometriosis and asks the nurse what this is. How should the nurse respond? A. "This is inflammation of abnormal endometrial tissue found outside the uterus" B. "This is an infection of the lining of the uterus" C. "This is excessive growth of cells in the uterus" D. "This is a collection of benign growths on the uterus"
A. "This is inflammation of abnormal endometrial tissue found outside the uterus"
A newborn appears large for its gestational age, while a lower score for neurological maturation is noted on the gestational exam. The nurse knows that which cause can best explain this outcome? A. Maternal analgesia B. Maternal diabetes C. Maternal hypertension D. Maternal preeclampsia
B. Maternal diabetes
The mother of a 10 year old girl asks the nurse when she should expect her daughter to have her first period. Which response by the nurse is correct? A. 2 to 2.5 years after the beginning of puberty B. About the time that the breasts begin to develop C. Any time between 13 to 14 years of age D. At the age the mother had menarche
A. 2 to 2.5 years after the beginning of puberty
During preconception counseling, the clinic nurse explains that the time period when the fetus is most vulnerable to the effects of teratogens occurs from which of the following gestational periods? A. 4-8 weeks of gestation B. 8-12 weeks of gestation C. 12-16 weeks of gestation D. 16-20 weeks of gestation
A. 4-8 weeks of gestation
A G3 P3003 woman gave birth 12 hours ago to a 4454 (9lbs 8 oz) infant. She experiences severe cramps with breastfeeding. The nurse knows that which of the following best describes this condition? A. Afterpains B. Uterine hypertonia C. Bladder hypertonia D. Rectus abdominis diastasis
A. Afterpains
The nurse uses the external electronic fetal heart monitor to evaluate fetal status. The fetal heart tracing shows accelerations. Accelerations in the fetal heart are: A. Associated with fetal well-being and oxygenation B. An indication of potential fetal intolerance to labor C. Never associated with the uterine contraction pattern D. A reason to notify the care provider
A. Associated with fetal well being and oxygenation
The nurse is caring for a patient with placenta previa. Which of the following assessments would indicate instability in the patient hospitalized for placenta previa? A. BP <90/60 mm/Hg, Pulse <60 BPM or > 120 BPM B. FHR moderate variability without accelerations C. Dark brown vaginal discharge when voiding D. Oral temperature of 99.9 degrees F
A. BP <90/60 mm/Hg, Pulse <60 BPM or > 120 BPM
The nurse is caring for a woman who is 30 weeks gestation and is having preterm labor. Which of the following medications does the nurse anticipate giving the patient to stimulate the lung maturity of the fetus? A. Betamethasone B. Terbutaline C. Nifedipine D. Magnesium Sulfate
A. Betamethasone
The nurse is caring for a 24 year old woman who is G-1 P-0000 at 40 weeks, 1 day gestation and in active labor. She has just received an epidural and now complains of an itchy feeling all over. Her vitals are as follows: HR 89, RR 13, BP 130/74, T 98.8 and O2 sat 96%. Which action should the nurse take first? A. Call the health care provider regarding the patient's pruritus to order an antipruritic medication B. Activate emergency response due to patient's pruritus and tachycardia postepidural placement C. Call the anesthesiologist regarding the patient's oxygen saturation level D. Take no further action regarding the patient's complaints, as they are normal after epidural placement
A. Call the health care provider regarding the patient's pruritus to order an antipruritic medication
The nurse notes the presence of diffuse edema on a newly born infant's head. Review of the birth record indicates that her mother experienced a prolonged labor and difficult childbirth. By the second day of life, the edema has disappeared. The nurse documents the following condition in the infant's chart. A. Caput succedaneum B. Cephalohematoma C. Subperiosteal hemorrhage D. Epstein pearls
A. Caput succedaneum
The nurse is monitoring the fetal heart rate (FHR) tracing and sees that her patient has a tracing with a baseline of 120, moderate variability, with absence of decelerations and accelerations. According to the National Institute of Child Health and Human Development tier systems, what category tracing does the patient fall into? A. Category I tracing B. Category II tracing C. Category III tracing D. Category IV tracing
A. Category I tracing
A female patient is admitted to the hospital for a pelvic inflammatory disease (PID). Which organism does the nurse know is most likely to cause PID? A. Chlamydia trachomatis B. Candida albicans C. Escherichia coli D. Human papillomavirus
A. Chlamydia trachomatis
The clinic nurse encourages all pregnant women to increase their water intake to at least 8 to 10 glasses per day. The nurse explains that this will decrease the risk of which of the following? Select all that apply A. Constipation B. Bile Stasis C. Fatigue D. Urinary tract infections E. Chloasma
A. Constipation B. Bile Stasis C. Fatigue D. Urinary tract infections
A client who is having false labor most likely would have which of the following? Select all that apply. A. Contractions that do not intensify with walking B. An increase in the intensity and frequency of contractions C. Progressive cervical effacement and dilation D. Pain in the abdomen that does not radiate E. Contractions that lessen with rest and warm tub baths
A. Contractions that do not intensify with walking D. Pain in the abdomen that does not radiate E. Contractions that lessen with rest and warm tub baths
The perinatal nurse is caring for the client who has been missing her prenatal appointments. Which information is most important for the nurse to understand? A. Cultural practices can influence the pregnant woman's use of health care services B. The woman will not attend prenatal classes if they are only offered in English C. Prenatal vitamins are viewed as harmful in some cultures D. Confidence in healthcare providers and their recommendations is a shared belief across cultures
A. Cultural practices can influence the pregnant woman's use of health care services
A patient in the third trimester of pregnancy is instructed on how to perform daily fetal movement count. The nurse needs to inform the patient what to do if fetal movement is decreased. Which patient actions are appropriately recommended by the nurse? Select all that apply. A. Eat something B. Recount movements the next morning C. Arrange for a period of rest D. Focus on movement for 1 hour
A. Eat something C. Arrange for a period of rest D. Focus on movement for 1 hour
A 29 year old female is currently 9 weeks pregnant. She has no living children. Two years ago she had 2 miscarriages at 10 and 12 weeks gestation, and 9 months ago a miscarriage at 36 weeks gestation. What is her GTPAL? A. G=4, T=0, P=1, A=2, L=0 B. G=4, T=0, P=1, A=3, L=0 C. G=4, T=0, P=1, A=2, L=1 D. G=4, T=1, P=1, A=2, L=0
A. G=4, T=0, P=1, A=2, L=0
The nursing staff in a labor and delivery unit has noticed an increase in the number of patients experiencing placental abruption. The nurses begin to review demographics for the patients involved. Which risk factors will the nurses expect? Select all that apply A. Hypertensive disorders B. Maternal Age C. Cigarette smoking D. Methamphetamine Use E. Abdominal trauma
A. Hypertensive disorders B. Maternal Age C. Cigarette smoking D. Methamphetamine Use E. Abdominal trauma
Which of the following is an ethical dilemma unique to perinatal nursing? A. Innate conflict between maternal and fetal rights B. Intensive use of technology C. Shortage of healthcare resources D. Risk of violation of the principle of veracity
A. Innate conflict between maternal and fetal rights
The obstetric nurse is assessing the laboring patient for pain. Which of the following should the nurse identify in a pain assessment? Select all that apply A. Intensity of contractions B. Presence of pain in the back C. Frequency and duration of contractions D. Signs of anxiety E. Presence of FHR with intermittent auscultation
A. Intensity of contractions B. Presence of pain in the back C. Frequency and duration of contractions D. Signs of anxiety
The client says, "I will get some salmon and that kind of orange juice the next time I'm at the store". The nurse knows this meets the expected outcome for which identified problem on the concept map? A. Knowledge deficit related to diet and bone health B. Ineffective health promotion related to Lack of Education Regarding the Relationship of exercise to bone health C. Risk for fractures
A. Knowledge deficit related to diet and bone health
A 37-year-old G8 P7017 woman was admitted to the postpartum unit at 2 hours post birth. On admission to the unit, her fundus was at the umbilicus, midline, and firm, and her lochia was moderate rubra. An hour later, her fundus is midline and boggy, and the lochia is heavy with small clots. Based on this assessment data, the first nursing action is which of the following? A. Massage the fundus of the uterus B. Assist the woman to the bathroom and reassess the fundus C. Notify the physician or midwife D. Start IV oxytocin therapy as per standing order
A. Massage the fundus of the uterus
The nurse is caring for a gravid patient in labor who is 7 cm dilated and experiencing slow labor progress. Which factors can contribute to labor dystocia? Select all that apply A. Maternal exhaustion B. History of precipitous birth C. Hypertonic uterine dysfunction (tachysystole) D. Occiput anterior presentation E. Analgesia early in labor
A. Maternal exhaustion C. Hypertonic uterine dysfunction (tachysystole) E. Analgesia early in labor
A woman presents to the prenatal clinic at 30 weeks' gestation reporting dysuria, frequency, and urgency with urination. Appropriate nursing actions include which of the following? A. Obtain clean catch urine to assess for a possible urinary tract infection B. Reassure the woman that the signs are normal urinary changes in the third trimester C. Teach the woman to decrease fluid intake to manage these symptoms D. Perform a Leopold's maneuver to assess fetal position and station
A. Obtain clean catch urine to assess for a possible urinary tract infection
A woman who is G-1 P-0000 is having her first prenatal physical exam. Which of the following assessments should the nurse inform the patient that she will have that day? Select all that apply A. Pap Smear B. Mammogram C. Glucose tolerance test D. Complete blood count
A. Pap smear. D. Complete blood count
The nurse is assessing a female patient with polycystic ovarian syndrome (PCOS). Which of the following would be subjective assessment finding that would indicate hyperandrogegism associated with PCOS? A. Patient reports menstrual irregularities B. Oily skin with acne C. Hirsutism D. Male-pattern baldness
A. Patient reports menstrual irregularities
A patient is admitted to the birth setting in early labor. She is 3 cm dilated, -2 station, with intact membranes, and FHR of 150 bpm. Her membranes rupture spontaneously, and the FHR drops to 90 bpm with variable decelerations. What would the nurse's initial response be? A. Perform a vaginal exam B. Notify the physician C. Place the client in a left lateral position D. Administer oxygen at 2 L via nasal canula
A. Perform a vaginal exam
A patient who is in the third trimester of pregnancy is informed that she will need a cesarean hysterectomy and bladder reconstruction due to a placenta defect. Which medical condition does the nurse explain to the patient? A. Placenta accreta B. Placenta abruption C. Placenta inversion D. Placenta previa
A. Placenta accreta
Postpartum women are at a increased risk of thrombus formation immediately following birth due to an increased level of which of the following? A. Plasma fibrinogen B. Platelets C. White blood cells D. Eosinophils
A. Plasma fibrinogen
The prenatal clinic has received four phone calls. Which client should the nurse call back first? A. Pregnant woman at 28 weeks with history of asthma who is reporting difficulty breathing and shortness of breath B. Pregnant woman at 6 weeks with seizure disorder who is inquiring which foods are good folic acid sources for her C. Pregnant woman at 35 weeks with positive HBsAG who is wondering what treatment her baby will receive after birth D. Pregnant woman at 11 weeks with untreated hyperthyroidism who is describing the onset of vaginal bleeding
A. Pregnant woman at 28 weeks with history of asthma who is reporting difficulty breathing and shortness of breath
The physician has ordered intravenous oxytocin for induction for four gravitas. In which of the following situations should the nurse refuse to comply with the order? A. Primigravida with complete placenta previa B. Multigravida with extrinsic asthma C. Primigravida who is 38 years old D. Multigravida who is colonized with group B streptococci
A. Primigravida with complete placenta previa
An infant admitted to the newborn nursery has a blood glucose level of 55 mg/dL. Which of the following actions should the nurse perform at this time? A. Provide the baby with routine feedings B. Assess the baby's blood pressure C. Place the baby under the infant warmer D. Monitor the baby's urinary output
A. Provide the baby with routine feedings
Which of the following nursing actions are directed at promoting bonding? Select all that apply A. Providing opportunity for parents to hold their newborn as soon as possible following the birth B. Providing opportunities for the couple to talk about their birth experience and about becoming parents. C. Promoting rest and comfort by keeping the newborn in the nursery at night. D. Providing positive comments to parents regarding their interactions with their newborn.
A. Providing opportunity for parents to hold their newborn as soon as possible following the birth B. Providing opportunities for the couple to talk about their birth experience and about becoming parents. D. Providing positive comments to parents regarding their interactions with their newborn.
The nurse is advising parents of a full term neonate being discharged from the hospital regarding car seat safety. Which of the following should be included in the teaching plan? A. Put the car seat facing forward only after the baby reaches 20 pounds and is at least 1 year old. B. The infant care seat should be placed facing the rear seat in the front seat of the car C. A fist should fit between the straps of the seat and the baby's body D. A used car seat is a good alternative if a new one is not affordable
A. Put the car seat facing forward only after the baby reaches 20 pounds and is at least 1 year old.
The nurse is collecting health information from a patient who is early in the first trimester of pregnancy. Which topic is most important for the nurse to discuss with the patient after learning that the patient works for a commercial cleaning company? A. Risk related to exposure to environmental toxins B. Weight limit for lifting during the patient's pregnancy C. Importance of resting with feet up during the day D. Reasons for the patient to look for a safer job
A. Risk related to exposure to environmental toxins
The nurse describes infant feeding cues to a new mother. These feeding cues include which of the following? Select all that apply. A. Rooting B. Mouth movements C. Moving the hand to the mouth D. Yawning
A. Rooting B. Mouth movements C. Moving the hand to the mouth
Which of the following breath sounds are normal to hear in the neonate during the first few hours post birth? A. Scattered Crackles B. Wheezes C. Stridor D. Grunting
A. Scattered Crackles
The nurse is providing care to a postpartum patient after an emergency cesarean due to eclampsia. The patient received spinal anesthesia prior to delivery. Magnesium sulfate is infusing 2g/hr. Which assessment finding will cause the nurse to administer calcium gluconate to the patient via IV push? A. Serum magnesium sulfate level is 10 mg/dL B. Patella reflexes are rated at 2+ C. Respiratory rate is 18 breaths per minute D. Urinary output remains at 30 mL/hr
A. Serum magnesium sulfate level is 10 mg/dL
The Joint Commission Standard states that there should be a "time-out" during the final verification process before the start of any invasive or surgical procedure, such as a C-section. Which of the following should be accurately identified and clearly communicated during the "time-out"? Select all that apply A. Site B. Procedure C. Patient D. The day of the week E. The patient's room number
A. Site B. Procedure C. Patient
To identify the duration of a contraction, the nurse would do which of the following? A. Start timing from the beginning of one contraction to the completion of the same contraction. B. Time between the beginning of one contraction and the beginning of the next contraction. C. Palpate for the strength of the contraction at its peak. D. Time from the beginning of the contraction to the peak of the same contraction.
A. Start timing from the beginning of one contraction to the completion of the same contraction.
During labor, the nurse notes the presence of meconium stained fluid. What does the nurse prepare for at the time for delivery? A. Suctioning of the infant's mouth and trachea B. Administration of antibiotics to the mother C. Vigorous tactile stimulation of the infant D. Culturing of the placenta for pathology
A. Suctioning of the infant's mouth and trachea
Identify the hallmark of placenta previa that differentiates it from placenta abruption. A. Sudden onset of painless vaginal bleeding B. Board-like abdomen with severe pain C. Sudden onset of bright red vaginal bleeding D. Severe vaginal pain with bright red bleeding
A. Sudden onset of painless vaginal bleeding
A patient at 35 weeks gestation arrives at the prenatal clinic in physical distress. Assessment reveals hypotension, thready pulse, shallow respirations, pallor, cold and clammy skin, and anxiety. The nurse does not find evidence of vaginal bleeding but suspects placental abruption. For which reason does the nurse call for emergency transport to the hospital? Select all that apply A. The patient has the symptoms of hypovolemia B. The patient reports a recent bout with nausea and vomiting C. The absence of blood can indicate a concealed hemorrhage D. Both the patient and fetus are at risk of death from hypovolemic shock E. The patient states a sudden onset of severe symptoms
A. The patient has the symptoms of hypovolemia C. The absence of blood can indicate a concealed hemorrhage D. Both the patient and fetus are at risk of death from hypovolemic shock E. The patient states a sudden onset of severe symptoms
A gravida, G4P1203, fetal heart rate 150s, is 14 weeks pregnant, fundal height 2 cm above the symphysis. She denies experiencing quickening. Which of the following nursing conclusions made by the nurse is correct? A. The woman is experiencing a normal pregnancy B. The woman may be having difficulty accepting this pregnancy C. The woman must see a nutritionist as soon as possible D. The woman will likely miscarry the pregnancy
A. The woman is experiencing a normal pregnancy
The nurse is speaking with a pregnant patient who is asking what processes start labor. Which responses by the nurse are appropriate? Select all that apply A. There is more pressure on the cervix, which causes the start of contractions by releasing oxytocin B. Oxytocin stimulates uterine muscles to contract C. The uterus begins to contract due to a decrease in estrogen D. The placenta begins to age and deteriorate and this triggers the start of contractions E. The fetus releases a stress hormone, cortisol and this start contractions
A. There is more pressure on the cervix, which causes the start of contractions by releasing oxytocin B. Oxytocin stimulates uterine muscles to contract D. The placenta begins to age and deteriorate and this triggers the start of contractions E. The fetus releases a stress hormone, cortisol and this start contractions
The clinic nurse includes screening for domestic violence in the first prenatal visit for all patients. An appropriate question would be which the following? A. This is something that we ask everyone. Do you feel safe in your current living environment and relationships? B. This is something we ask everyone. Do you have any abuse in your life right now? C. Is your partner threatening or harming you in any way right now? D. I need to ask you, do you feel safe from abuse right now
A. This is something that we ask everyone. Do you feel safe in your current living environment and relationships?
The nurse is conducting a staff education session about preeclampsia and eclampsia complications. Which statements by the nurse are accurate about HELLP syndrome? Select all that apply A. This syndrome destroys red blood cells B. This syndrome impacts the amount of platelets C. This syndrome decreases a patient's white blood cell count D. This syndrome decreases a patient's blood urea nitrogen (BUN) E. This syndrome increases liver enzymes
A. This syndrome destroys red blood cells B. This syndrome impacts the amount of platelets E. This syndrome increases liver enzymes
A new mother is planning to bottle feed her infant and wants help with suppressing lactation. What should the nurse suggest to help this new mother? Select all that apply A. Wear a supportive bra 24 hours a day B. Apply cold cabbage leaves to the breast tissue C. Apply warm compress every 4 to 6 hours D. Massage lotion on the breasts 3 times a day E. Avoid all nipple stimulation for 7 to 10 days
A. Wear a supportive bra 24 hours a day B. Apply cold cabbage leaves to the breast tissue E. Avoid all nipple stimulation for 7 to 10 days
A mother has a child who is 4 years of age, and she is expecting another child. The mother expresses concern to the nurse about how the older sibling will receive the newborn. Which intervention by the mother does the nurse discourage? A. " I plan to let him hear the baby's heartbeat at the next prenatal visit" B. "I think that I will just bring the new baby home as a surprise" C. "I have enrolled him in a sibling preparation class at the hospital" D. "I let him pick out a gift for the baby, and have one for him from the baby"
B. "I think that I will just bring the new baby home as a surprise"
The grandmother of a new infant approaches the nurse in the hallway and questions why the infant is staying in the mother's room. What is the appropriate nursing response? A. "This is how we do it" B. "Rooming-in with the infant facilitates bonding" C. "I cannot discuss the infant with you" D. "Only bottle fed infants spend time in the nursery now"
B. "Rooming-in with the infant facilitates bonding"
A patient is concerned because her 2-hour-old newborn is sleeping skin to skin and will not breastfeed. Which is the best response by the nurse to correctly explain this behavior? A. "The medication you received in labor is affecting the baby's ability to stay awake" B. "This is normal response after birth and may last two to four hours" C. "The baby could be sleepy because of a low glucose level. Try to wake the baby up and breastfeed" D. "We can give the baby a bath to wake the baby up"
B. "This is normal response after birth and may last two to four hours"
During a discharge education, the nurse notes the postpartum patient starting to fall asleep. What is the appropriate nursing response to the patient? A. "you will need to stay awake to learn this important information" B. "You should rest and I will come back later to review this information" C. "you will not be able to go home until tomorrow, since you are having trouble staying awake still" D. "You can nap and I will just review this information with your partner"
B. "You should rest and I will come back later to review this information"
A nurse assesses a term newborn for respiratory functioning. The nurse knows that which of the following conditions are normal for newborns? Select all that apply. A. A respiratory rate of 60 to 80 breaths per minute B. A breathing pattern that is often shallow, diaphragmatic, and irregular C. Periodic episodes of apnea that last 30 seconds D. The neonate's lung sounds may sound moist during early auscultation
B. A breathing pattern that is often shallow, diaphragmatic, and irregular D. The neonate's lung sounds may sound moist during early auscultation
A 25 year old woman gave birth to her second child 6 hours ago. She informs the nurse that she is bleeding more than her previous birth experience. The nurse's initial action is which of the following? A. Explain that this is normal for second time moms B. Asses the location and firmness of the fundus C. Change her pad and return in 1 hour and reassess D. Give her 10 units of oxytocin as per standing order
B. Asses the location and firmness of the fundus
A female client has been prescribed oral metronidazole (Flagyl) for the treatment of bacterial vaginosis. What is essential for the nurse to teach the woman? A. Male sexual partners should also be treated B. Avoid alcohol while taking this medication C. Take the medication until the symptoms resolve D. The medication can also treat candidiasis
B. Avoid alcohol while taking this medication
A certified nursing assistant (CNA) is working with a registered nurse (RN) in the neonatal nursery. Which of the following actions would be appropriate for the nurse to delegate to the CNA? A. Admit a newly delivered baby to the nursery B. Bathe and weigh a 3 hour old baby C. Provide discharge teaching to the mother of a 4 day old baby D. Interpret a bilirubin level reported by the laboratory
B. Bathe and weigh a 3 hour old baby
Which of the following medications administered to the pregnant patient experiencing preterm labor requires close monitoring of the patient's blood glucose levels? A. Nifedipine B. Betamethasone C. Magnesium sulfate D. Indomethacin
B. Betamethasone
The primary care nurse is reviewing records for female clients coming in today. Which clients are at higher risk of developing osteoporosis? Select all that apply. A. 48 year old woman with a BMI of 32 B. Caucasian woman who smokes C. 60 year old woman wit autoimmune disease who frequently takes corticosteroids D. African american Womacks with normal Vitamin D level E. Asian small boned woman who drinks 3 alcoholic beverages a day
B. Caucasian woman who smokes C. 60 year old woman wit autoimmune disease who frequently takes corticosteroids E. Asian small boned woman who drinks 3 alcoholic beverages a day
A patient asks the function of the amniotic fluid. The nurse explains that the amniotic fluid helps the fetus to maintain a normal body temperature. Which of the following does the nurse include in the teaching? A. Facilitates asymmetrical growth of the fetal limbs B. Cushions the fetus from mechanical injury C. Promotes development of muscle tone D. Promotes adherence of fetal lung tissue
B. Cushions the fetus from mechanical injury
The nurse is providing care for a patient at 30 weeks gestation. Which topic related to patient concern or discomfort is most important for the nurse to address? A. Increased breast enlargement B. Dizziness when lying supine C. Dependent edema and varicosities D. Hyperpigmentation on the face
B. Dizziness when lying supine
Which of the following sites is priority for the nurse to assess when caring for a breastfeeding client, G8 P5035, who is 1 hour post delivery? A. Nipples B. Fundus C. Lungs D. Rectum
B. Fundus
A patient is confirmed to be pregnant. Obestetric history includes two sets of twins born at 30 and 32 weeks gestation, respectively, a singleton birth born at 39 weeks gestation and two pregnancies lost in the first trimester. In which way will the nurse define the patient's obstetrical history? A. G4, T3, P2, A2, L3 B. G6, T1, P2, A2, L5 C. G5, T1, P2, A2, L5 D. G6, T4, P0, A4, L3
B. G6, T1, P2, A2, L5
A laboring patient has received an order for epidural anesthesia. In order to prevent the most common complication associated with this procedure, what would the nurse expect to do? A. Observe fetal heart rate variability B. Hydrate the vascular system with 500-1000 mL of intravenous fluids C. Place the client in the semi-fowler's position D. Teach the client appropriate breathing techniques
B. Hydrate the vascular system with 500-1000 mL of intravenous fluids
A woman at 10 weeks' gestation is diagnosed with gestational trophoblastic disease (Hydatifrom mole). Which of the following findings would the nurse expect to see? A. Platelet count of 550,000/mm3 B. Hyperemesis gravidarum C. White blood cell count 17,000/mm3 D. Macular papular rash
B. Hyperemesis gravidarum
Which of the following would be a priority for the nurse when caring for a pregnant woman who has recently emigrated from another country? A. Help her develop a realistic, detailed birth plan B. Identify her support system C. Teach her about expected emotional changes of pregnancy D. Refer her to a doula for labor support
B. Identify her support system
A nurse is caring for a patient 6 hours post vaginal delivery of a term neonate. She notes a white blood cell count of 20,000/mm3. What is the priority nursing intervention for this patient? A. Notify the physician or midwife B. Interpret as a normal finding C. Administer tylenol 1,000 mg PO D. Order a repeat CBC for the next morning
B. Interpret as a normal finding
A G2, P1011 patient experienced a precipitous birth 90 minutes ago. Her infant is 4200 grams ( 9lbs 1 oz) and a repair of a second degree laceration was needed following the birth. As part of the nursing assessment, the nurse discovers that the patient's uterus is midline and boggy. Furthermore, it is noted that the patient's vaginal bleeding has increased. The nurse's most appropriate first action is to do which of the following? A. Assess vital signs including blood pressure and pulse B. Massage the uterine fundus with continual lower segment support C. Measure and document each perineal pad changed in order to assess blood loss. D. Ensure appropriate listing for a perineal repair if it is needed
B. Massage the uterine fundus with continual lower segment support
A nurse initiates measures to maintain thermoregulation in a newborn. Which statement best describes why neonates are at higher risk for thermoregulatory problems? A. Neonates have a smaller body surface area B. Neonates have decreased subcutaneous fat C. Neonates are able to shiver and increase heat production D. Neonates have a lower metabolic rate
B. Neonates have decreased subcutaneous fat
The clinic nurse reviews the complete blood count results for a 30 year old woman who is now 33 weeks' gestation. The woman's hemoglobin value is 11.2 g/dL, and her hematocrit is 38%. The clinic nurse interprets these findings as which of the following? A. Normal adult values B. Normal pregnancy values for the third trimester C. Increased adult values D. Increased values for 33 weeks' gestation
B. Normal pregnancy values for the third trimester
A female client with a history of breast cancer reports hot flashes and night sweats. Which treatment option would the nurse question if included in her plan of care? A. Low-dose antidepressants B. Oral Estrogen C. Avoid alcohol, hot beverages, and spicy foods D. Biofeedback
B. Oral Estrogen
The nurse understand that which is the primary reason that women stop breast-feeding before the eighth week? A. Engorgement B. Painful nipples C. Mastitis D. Thrush
B. Painful nipples
A 15 year old female patient with a history of menarche at age 12 reports that she has not had menses for the last three months. Which contributing conditions should the nurse be aware of in order to anticipate laboratory or diagnostic imaging orders? Select all that apply. A. Congenital absence of the vagina or uterus B. Pregnancy C. Eating Disorder D. Thyroid dysfunction
B. Pregnancy C. Eating Disorder D. Thyroid dysfunction
The image shows a priority nursing action for which obstetrical emergency? A. Placenta previa B. Prolapsed umbilical cord C. Shoulder dystocia D. Face presentation
B. Prolapsed umbilical cord
A woman confides in the nurse that she practices pica. Which of the following alternatives would be appropriate for the nurse to suggest to the woman? A. Replace laundry starch with salt B. Replace ice with frozen fruit juice C. Replace soap with cream cheese D. Replace soil with uncooked pie crust
B. Replace ice with frozen fruit juice
The blood of a pregnant client was initially assessed at 10 weeks' gestation and reassessed at 38 weeks' gestation. Which of the following results would the nurse expect to see? A. Rise in hematocrit from 34% to 38% B. Rise in white blood cells from 5,000 cells/mm3 to 15,000 cells/mm3 C. Rise in potassium from 3.9 mEq/L to 5.2 mEq/L D. Rise in sodium from 137 mEq/L to 150 mEq/L
B. Rise in white blood cells from 5,000 cells/mm3 to 15,000 cells/mm3
The nurse is reviewing a client's prenatal lab results and notes the white blood cell (WBC) count as 15,000 mm3. How would the nurse interpret that finding? A. The client has an active infection B. This is a normal increase due to pregnancy C. The client is immunosuppressed D. This is a normal decrease due to pregnancy
B. This is a normal increase due to pregnancy
A nurse is going to teach the postpartum about newborn bathing, diapering, and swaddling. Which of the following indicates that the nurse incorporated teaching/learning principles in the teaching plans? Select all that apply. A. Asked family members to leave B. Turned off the TV C. Close the door of the room D. Administered analgesics before teaching session E. Provide teaching while the infant was sleeping
B. Turned off the TV C. Close the door of the room D. Administered analgesics before teaching session E. Provide teaching while the infant was sleeping
The nurse knows that when performing postpartum uterine palpation, support for the lower uterine segment is critical, as without it, there is an increased risk of which of the following? A. Uterine edema B. Uterine inversion C. Incorrect measurement D. Intensifying the patient's level of pain
B. Uterine inversion
The nurse teaches the postpartum woman about warning signs regarding development of postpartum infection. Signs and symptoms that merit assessment by the health care provider include the development of a fever and which of the following? A. Breast engorgement B. Uterine tenderness C. Diarrhea D. Emotional lability
B. Uterine tenderness
Four minutes after the birth of a baby, there is a sudden gush of blood from the mother's vagina, and about 8 inches of umbilical cord slides out. What action should the nurse take first? A. Place the client in McRoberts position. B.Watch for the emergence of the placenta. C. Prepare for the delivery of an undiagnosed twin. D.Place the client in a supine position.
B. Watch for the emergence of the placenta.
A nurse is caring for a full term pregnant client undergoing an induction with oxytocin. Upon assessment, the nurse determines that the fetus is in distress and identifies a Category III fetal rate pattern. The nurse will complete interventions in which order? A. Administer O2 via non-rebreather mask at 10 L/min B.Discontinue oxytocin C. Notify the provider D. Change maternal position to left lateral position E. Assess emotional response and provide reassurance
B.Discontinue oxytocin D.Change maternal position to left lateral position A.Administer O2 via non-rebreather mask at 10L/min C.Notify the provider E. Assess emotional response and provide reassurance
A postpartum woman, who gave birth 12 hours ago, is breastfeeding her baby. She tells her nurse that she is concerned that her baby is not getting enough food since her milk has not come in. The best response for this patient is which of the following? A. "I understand your concern, but your baby will be okay until your milk comes in" B. "Your baby seems content, so you should not worry about him getting enough to eat" C. "Milk normally comes in around the third day. Prior to that, your baby is getting colostrum which is high in protein and immunoglobulins which are important for your baby's health" D."You can bottle feed until your milk comes in"
C. "Milk normally comes in around the third day. Prior to that, your baby is getting colostrum which is high in protein and immunoglobulins which are important for your baby's health"
A woman with type 1 diabetes presents for her first prenatal appointment. Which anticipatory guidance would the nurse provide the patient? A. "Insulin needs will most likely decrease over the course of pregnancy" B. "The risk of diabetic ketoacidosis (DKA) is highest in the first trimester" C. "Watch for signs and symptoms of preterm labor" D. "If your fasting blood glucose is under 95, you don't need to check it again"
C. "Watch for signs and symptoms of preterm labor"
The nurse has received an shift change report on the four following mother- baby couplets. Based on the provided information, which couplet should the nurse first assess? A. A 25 year old G2 P1011 woman who is 36 hours post-birth and is having difficulty breastfeeding her baby girl. Her fundus is firm at the umbilicus, and lochia is moderate to scant B. A 16 year old G1P1001 who will be discharged in the afternoon. It was reported that she refers to her baby as "it" and that she requested to have her baby stay in the nursery so she could sleep C. A 32 year old G5 P5005 woman who delivered a 4500 gram (9lbs 14 oz) baby boy 2 hours ago after a 20 hour labor that was augmented. It was reported that her fundus is 2 cm above umbilicus with moderate lochia D. A 28 year old who gave birth to a 3800 gram (8lb 6oz) who has been given morphine for postoperative pain management. Her vital signs are B/P: 115/75, P: 80, R: 18, T: 98.2 F
C. A 32 year old G5 P5005 woman who delivered a 4500 gram (9lbs 14 oz) baby boy 2 hours ago after a 20 hour labor that was augmented. It was reported that her fundus is 2 cm above umbilicus with moderate lochia
The nurse completes an initial newborn examination on an infant at 90 minutes of age. The baby was born at 40 weeks gestation with no birth trauma. The nurse's findings include the following parameters: Heart rate: 136 beats per minute Respiratory Rate: 54 breaths per minute Temperature: 98.2 Degrees F Length: 49.5 cm (19.5 in) Weight: 3500 gm (7lbs 9oz) The nurse documents the presence of a heart murmur, absence of bowel sounds, symmetry of ears and eyes, no grunting or nasal flaring, and full range of movement of all extremities. Which assessment would warrant further investigation and require immediate consultation with the baby's health care provider? A. Respiratory Rate B. Presence of heart murmur C. Absent bowel sounds D. Weight
C. Absent bowel sounds
The nurse sees this fetal heart rate change on the FHR monitor. The nurse recognizes this as which of the following? A. A late deceleration caused by decreased maternal fetal exchange B. An early deceleration caused by umbilical cord occlusion C. An early deceleration cause by an increased intracranial pressure due to head compression D. A late deceleration caused by compression of the umbilical cord
C. An early deceleration cause by an increased intracranial pressure due to head compression
A nurse is preparing a woman in early labor for an urgent cesarean birth related to breech presentation. Select the best nursing action for reducing the couple's anxiety levels. A. Explain the reason for the need for a cesarean section B. Inform parents that their baby is in distress C. Ask the couple to share their concerns D. Reassure the couple that both the woman and baby are in no danger
C. Ask the couple to share their concerns
A labor patient is ambulating in the hall. Her vaginal exam 1 hour ago indicated she was 4 cm dilated, 70% effaced, and at -1 station. She tells the nurse that she has fluid running down her leg. Which of the following is the priority nursing intervention. A. Assess the color, odor, and amount of fluid B. Assist your patient to the bathroom C. Assess the fetal heart rate D. Call the care provider
C. Assess the fetal heart rate
It is noted that the amniotic fluid of a 42 week gestation baby, born 30 seconds ago, is thick and green. Which of the following actions by the nurse is critical at this time? A. Perform a gavage feeding immediately B. Assess the brachial pulse C. Assist a physician with intubation D. Stimulate the baby to cry
C. Assist a physician with intubation
The nurse is caring for a woman, G2 P1001, 40 weeks gestation, in labor. The following assessments have been recorded on the patient: 10/20/18 @ 1200- Cervix 4 cm, 80% effaced, -3 station, FHR 124 with moderate variability 10/20/2018 @ 1700- Cervix 6 cm, 90% effaced, -3 station, FHR 120 with minimal variability 10/21/2108 @1000- Cervix 8 cm, 100% effaced, -3 station, FHR 124 with absent variability Based on these assessments, which of the following should the nurse conclude? A. Descent is progressing well B. Woman is carrying a small for gestational age fetus C. Baby is potentially acidotic D. Woman should begin to push with the next contraction
C. Baby is potentially acidotic
A nurse is providing discharge teaching to the parents of a 2 day old neonate. Which of the following information should be included in the discharge teaching on umbilical cord care? A. Cleanse the cord twice a day with hydrogen peroxide B. Remove the cord with sterile tweezers if the cord does not fall off by 10 days of age C. Call the doctor if greenish discharge appears D. Cover the cord with sterile dressing until it falls off
C. Call the doctor if greenish discharge appears
The nurse is caring for a patient admitted to labor and delivery at 32 weeks' gestation and diagnosed with preterm labor. The patient is currently receiving magnesium sulfate, 2gm per hour. Upon initial assessment, the nurse notes that the patient has a respiratory rate of 8 with absent deep tendon reflexes. Which of the following nursing interventions will the nurse perform first? A. Elevate the head of the bed B. Notify the MD C. Discontinue magnesium sulfate D. Draw a serum magnesium level
C. Discontinue magnesium sulfate
To prevent heat loss from evaporation immediately after delivery, what is the most important nursing intervention? A. Place the neonate on a chemical mattress. B. Keep the neonate's head covered with a hat C. Dry the neonate gently and replace the wet linen D. Place the neonate in a double walled incubator
C. Dry the neonate gently and replace the wet linen
The postpartum patient is concerned about mastitis because she experienced it with her last baby. Preventive measures the nurse can teach include which of the following? A. Wearing a tight fitting bra B. Limiting breastfeedings C. Frequent breastfeedings D. Restricting fluid intake
C. Frequent breastfeedings
A nurse is performing an assessment on a pregnant woman during a prenatal cyst. Which of the following findings would lead the nurse to report to the obstetrician that the patient may be experiencing intrauterine growth restriction (IUGR)? A. Leopold's maneuvers: hard round object in the fundus, flat object on left of uterus, small parts on right of uterus, soft round object above the symphysis B. Weight gain: 6-pound increase over 4 week period C. Fundal height measurement: 22 cm at 26 weeks' gestation D. Alpha-fetoprotein assessment: level is one half normal, accompanied by complaints of severe nausea and vomiting
C. Fundal height measurement: 22 cm at 26 weeks' gestation
A female client presents to acute care reporting genital blisters that are very painful. She also reports muscle aches and malaise. Which condition does the nurse anticipate the client will be treated for? A. Influenza B. Syphilis C. Genital herpes D. Condyloma
C. Genital herpes
The nurse is assessing a newborn who is 20 hours old. Which of the following findings should the nurse report to the health care provider? A. Intermittent strabismus B. Startling C. Grunting D. Vaginal Bleeding
C. Grunting
The nurse is assessing a preterm neonate immediately after delivery. Which assessment finding indicates respiratory distress? Select all that apply. A. Cyanosis of hands and feet B. Low body temperature C. Grunting on exhalation D. Intercostal retraction E. Slow capillary refill
C. Grunting on exhalation D. Intercostal retraction
A client in the gynecology clinic asks the nurse about the word "menorrhagia", which the client saw written in their medical record. What is the correct definition of menorrhagia? A. Painful menstruation B. Bleeding between periods C. Heavy menstrual bleeding D. No menstruation in three months
C. Heavy menstrual bleeding
Which of the following is a medical indication for a cesarean birth? Select all that apply A. Maternal blood pressure of 130/90 B. Cervical dilation of 1.5 cm per hour during the active phase of labor C. Late deceleration of the fetal heart rate with minimal variability D. Arrest of fetal descent
C. Late deceleration of the fetal heart rate with minimal variability D. Arrest of fetal descent
The nurse is analyzing the above fetal heart rate pattern. The nurse knows that this pattern is which of the following? A. Moderate variability B. Early decelerations C. Late decelerations D. Accelerations
C. Late decelerations
Which of these medications is commonly used to control postpartum bleeding related to uterine atony? A. Magnesium sulfate B. Phytonadione C. Oxytocin D. Warfarin
C. Oxytocin
The nursing is caring for a 31 year old female patient who is pregnant at 37 weeks and 5 days gestation. The patient is having contractions every 3 minutes and was found to have a platypelloid pelvis upon examination. The fetus has an estimated fetal weight of 7lbs and is in the LOA position. This patient is laboring on the birth ball, and her mother in law is helping her labor. The nurse is concerned about the five Ps and their effect on the patient's labor. Which P is the nurse most likely concerned about based on the patient's history? A. Passenger B. Position C. Passage D.Psyche
C. Passage
The postpartum nurse is caring for a patient who gave birth to a full term twins earlier today. The nurse will know to assess for symptoms of which of the following? A. Increased Blood pressure B. Hypoglycemia C. Postpartum hemorrhage D. Postpartum infection
C. Postpartum hemorrhage
A woman who is 12 weeks postpartum presents with the following behaviors: -she reports severe mood swings and hearing voices -she believes her infant is going to die -she has to be reminded to shower and put on clean clothes -she feels she is unable to care for her baby These behaviors are associated with which of the following? A. Postpartum blues B. Postpartum depression C. Postpartum psychosis D. Maladaptive mother-infant attachment
C. Postpartum psychosis
A woman at 32 weeks' gestation is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will identify which of the following as a positive patient care outcome? A. Rise in serum creatine B. Drop in serum protein C. Resolution of thrombocytopenia D. Resolution of polycythemia
C. Resolution of thrombocytopenia
A pregnant teen is being treated for a sexually transmitted infections. Which STI can cause neonatal blindness and death? A. Chlamydia B. Gonorrhea C. Syphilis D. HIV
C. Syphilis
Four babies have just ben admitted into the neonatal nursery. Which of the babies should the nurse assess first? A. The baby with respirations 52, oxygen saturation 94% B. The baby with Apgar 9/9, weight 2690 grams C. The baby with temperature 96.3 degrees F, length 17 in D. The baby with glucose 60 mg/dL, Heart rate 132
C. The baby with temperature 96.3 degrees F, length 17 in
The nurse in a prenatal clinic is reviewing the files of four patients schedules for visits. Which patient does the nurse identify as having the highest risk pregnancy? A. The patient who is 16 years of age just diagnosed with gestational diabetes B. The patient with preexisting hypertension who is currently pregnant with twins C. The patient who is 37 years of age, obese, and experiencing pregnancy induced hypertension D. The patient who is 28 years of age who delivered a premature neonate 3 years prior
C. The patient who is 37 years of age, obese, and experiencing pregnancy induced hypertension
Which of the following patients does the nurse anticipate requiring a RhoGam injection? A. The patient who is blood type O+, G3, P2002 and her partner is O- B. The patient who is blood type AB+, G1 P0000 and her partner is O+ C. The patient who is blood type O-, G4 P1111 and her partner AB+ D. The patient who is blood type B+, G2 P0101 and her partner is O-
C. The patient who is blood type O-, G4 P1111 and her partner AB+
The nurse is preparing to offer discharge instructions to a postpartum patient. What does the nurse do to prepare for the education session? A. Ask the partner to leave the room B. Turn off all the lights in the room C. Turn off the TV in the room D. Open the door and curtain to the hallway
C. Turn off the TV in the room
The nurse is caring for a 12 hour old neonate and incorporating measures to prevent heat loss through conduction. What is the priority nursing action? A. Drying the infant after the first bath B. Placing the infant away from the window C. Warming the stethoscope prior to assessment D. Moving the crib away from air conditioner vent
C. Warming the stethoscope prior to assessment
During a prenatal intake a client admits to smoking marijuana daily. The nurse's only option, while functioning as an advocate is to do which of the following? A. Report her substance abuse to the police B.Have the patient committed to a substance abuse center C. Encourage the client to stop and provide information for recovery D. Report the client to the public health department
C.Encourage the client to stop and provide information for recovery
The nurse is teaching a 16 year old girl about the human papillomavirus (HPV) vaccine. Which statement by the teen indicates more teaching is needed? A. "The vaccine will help prevent cervical cancer" B. "The vaccine will help prevent genital warts" C. "I will need to get three doses of the vaccine" D. "I don't need to have a Pap test if I am fully vaccinated"
D. "I don't need to have a Pap test if I am fully vaccinated"
A client requests to keep the placenta following delivery. How would the nurse respond to this request? A. "We do not allow that in this hospital. It is against all regulations" B. "Can you tell me what you plan to do with the placenta? We only allow if you plan to bury the placenta" C. "Why would you want to take that home? It will begin to smell and can attract insects" D. "I understand that this is very important to you, and I will see what I can do to honor this request"
D. "I understand that this is very important to you, and I will see what I can do to honor this request"
A 42 year old female patients scheduled to have a hysterectomy with bilateral sapling-oophorectomy. The nurse is reviewing pre-op instructions with her. Which statement by the patient indicates the need for further teaching? A. "I will not be able to become pregnant again" B. "The surgery will put me in menopause" C. "I will no longer menstruate" D. "I will lose my uterus, but I'll still have my ovaries"
D. "I will lose my uterus, but I'll still have my ovaries"
A woman at 28 weeks' gestation is asked to keep a fetal activity record and to bring the results with her to her next clinic visit. One week later, she calls the clinic and anxiously tells the nurse that she has not felt the baby move for more than 30 minutes. Which of the following would be the nurse's most appropriate initial comment? A. "You need to come to the clinic right away for further evaluation." B. "Have you been smoking?" C. "When did you eat last?" D. "Your baby might be asleep."
D. "Your baby might be asleep"
Each of the following pregnant women is scheduled for a 14 week antepartal visit. In planning care, the nurse would give priority teaching on amniotic fluid alpha-fetoprotein (AFP) screening in which client? A. 28 year old with history of rheumatic heart disease B. 18 year old with exposure to HIV C. 20 year old with history of preterm labor D. 35 year old with a child with spina bifida
D. 35 year old with a child with spina bifida
On day four following the birth of an average size baby, the nurse would expect the fundus to be at: A. 1 cm below umbilicus B. 2 cm below umbilicus C. 3 cm below umbilicus D. 4 cm below umbilicus
D. 4 cm below umbilicus
The following four babies are in the neonatal nursery. Which of the babies should be seen by the neonatologist as soon as possible? A. 1 day old, heart rate 170, crying B. 2 day old, Temp 98.9 degrees F, slightly jaundice C. 3 day old breastfeeding q2 hr, rooting D. 4 day old respiratory rate 70, dusky coloring
D. 4 day old respiratory rate 70, dusky coloring
The nurse receives a call from the partner of a client in labor. The partner asks when they should come to the hospital. During which part of labor would a pregnant client be told to come to the hospital? A. Transition phase B. Fourth stage C. Second Stage D. Active Phase
D. Active Phase
A pregnant patient who is currently receiving 2 gm/hr of magnesium sulfate has decreased deep tendon reflexes. Identify the priority nursing assessment to ensure patient safety. A. Assess uterine contractions continuously B. Assess fetal heart rate continuously C. Assess urinary output D. Assess respiratory rate
D. Assess respiratory rate
The postpartum homecare nurse is assessing a new mother, and finds her temperature to be 101.6°F. What is the most important nursing action? A. Ask the mother how often and how well the baby is nursing. B. Determine the frequency of the mother's voiding and stooling. C. Verify how many hours of sleep she is getting per day. D. Assess the odor and color of the lochia and perineum.
D. Assess the odor and color of the lochia and perineum.
A patient in the third trimester of pregnancy reports having heartburn nearly everyday. Which recommendations does the nurse make to alleviate the problem? Select all that apply A. Consume three moderate sized meals daily B. Sip clear, carbonated beverages when eating C. Assume a low Fowler position after meals D. Avoid eating 3 hours prior to bedtime E. Avoid consuming spicy, fatty, or fried food
D. Avoid eating 3 hours prior to bedtime E. Avoid consuming spicy, fatty, or fried food
A client calls the nurse to her room and states, "The baby is really sleepy and hasn't been feeding well." The nurse notes the infant is jittery. What additional assessment should the nurse perform? A. LATCH score B. Urine output C. Weight D. Blood Glucose
D. Blood Glucose
The nurse is performing an assessment on a neonate. What does the nurse document for the assessment data in the image below? A. Molding B. Cephalhematoma C. Subdural Hematoma D. Caput Succedaneum
D. Caput Succedaneum
Following a vaginal exam on a client in labor, the nurse documents the client to be 8 cm, 80%, +1. Which do these terms represent? A. Cervical effacement, fetal station, cervical dilation B. Cervical effacement, dilation, fetal station C. Fetal station, cervical dilation, cervical effacement D. Cervical dilation, effacement, fetal station
D. Cervical dilation, effacement, fetal station
A 37 year old woman who is 17 weeks pregnant has had an amniocentesis. Before discharge, the nurse teaches the woman to call her doctor if she experiences which of the following side effects? A. Pain at the puncture site B. Macular rash on the abdomen C.Decrease in urinary output D. Cramping of the uterus
D. Cramping of the uterus
The nurse is performing an assessment on a 1-day old neonate and notes a red rash with papule around the chest and abdomen. What is the priority action of the nurse? A. Obtain a culture B. Notify the physician C. Take the neonate's vital signs and place the infant on isolation D. Document the findings.
D. Document the findings
The nurse is teaching a postmenopausal woman about osteoporosis prevention and calcium intake. The client states she is lactose intolerant. Which calcium rich food should the nurse recommend for this client? A. Plain low fat yogurt B. Lean red meat C. Cooked Shrimp D. Green leafy vegetables
D. Green leafy vegetables
Which of the following is the primary complications of amniocentesis? A. Damage to fetal organs B. Puncture of the umbilical cord C. Maternal pain D. Infection
D. Infection
A patient who is pregnant asks the nurse when her baby is due to be born. The patient reports her last menstrual period (LMP) date as April 14th. Using Naegele's Rule, the nurse will set the estimated date of delivery (EDD) as what date? A. July 21 B. January 7 C. July 14 D. January 21
D. January 21
During an intrapartum vaginal examination the nurse assess the umbilical cord. In which positions should the patient be placed at this time? A. Supine B. Side lying C. Lithotomy D. Knee-Chest
D. Knee-Chest
A type 1 diabetic patient has repeatedly experienced elevated serum glucose levels throughout her pregnancy. Which of the following complications of pregnancy would the nurse expect to see? A. Postpartum hemorrhage B. Neonatal hyperglycemia C. Postpartum Oliguria D. Neonatal macrosomia
D. Neonatal macrosomia
A client is having contractions that last 20-30 seconds and that are occurring every 8-20 minutes. The client is requesting something to help relieve the discomfort of contractions. What should the nurse suggest? A. That a mild analgesic be administered B. An epidural C. A local analgesic block D. Nonpharmacologic methods of pain relief
D. Nonpharmacologic methods of pain relief
A nurse is caring for a woman 10 hours post-cesarean birth. She received a dose of intrathecal (spinal administration) morphine at the time of birth. Which of the following assessment data would require immediate intervention? A. Itching of the palms and feet B. Nausea C. Urinary output of 300 mL in the past 4 hours D. Respiratory rate of 10 breaths/minute
D. Respiratory rate of 10 breaths/minute
During a postpartum examination of a client who delivered an 3600 grams (8lbs0oz) newborn 6 hours ago, the following assessments findings are noted: fundus firm and at the umbilicus, and moderate lochia ruby with a steady trickle of blood from the vagina. What is the assessment finding that would necessitate follow-up? A. Firm fundus B. Fundus at the umbilical level C. Moderate lochia rubra D. Steady trickle of blood
D. Steady trickle of blood
A patient had a cesarean birth 3 days ago. She has tenderness, localized heat, and redness of the left leg. She is afebrile. As a result of these symptoms, what would the nurse anticipate would be the next course of action? A. That the patient would be encouraged to ambulate freely B. That the client would be given aspirin 650 mg by mouth C. That the client would be given methergine IM D. That the client would be placed on bed rest
D. That the client would be placed on bed rest
The nurse is completing a home visit on a family with a 1-month-old infant. During this visit, the nurse is completing a safety assessment. Which finding by the nurse would require further intervention? A. The baby sleeps in a crib right next to the parent's bed B. The baby was found to be swaddled in a light blanket. C. The baby was offered a pacifier at nap time. D. The baby had a strong smell of cigarette smoke.
D. The baby had a strong smell of cigarette smoke.
The nurse is caring for two laboring women. Which of the patients should be monitored most carefully for signs of placental abruption? A. The patient with placental previa B. The patient whose vaginal is colonized with group B streptococci C. The patient who is hepatitis B surface antigen positive D. The patient with eclampsia
D. The patient with eclampsia
The patient delivered her first child vaginally 7 hours ago. She has voided once since delivery. She has an IV of lactated ringers solution running at 100 mL/hr. Her fundus is firm and to the right of midline. What is the best nursing action? A. To massage the fundus vigorously B. To assess the client's pain level C. To increase the rate of the IV D. To assist the client to the bathroom
D. To assist the client to the bathroom
The clinic nurse sees a postpartum patient and her infant in the clinic for their 2 week follow up visit. The patient appears to be tired, her clothes and hair appear unwashed, and she does not make eye contact with her infant. She is carrying her so in the infant carrier and when asked to put him on the examining table, she holds him away from her body. The clinic nurse's most appropriate question to ask would be which of the following? A. "What has happened to you?" B." Do you have help at home?" C. "Is there anything wrong with your son?" D." Would you tell me about the first few days at home?"
D." Would you tell me about the first few days at home?"
