NURS 2156 Practice Questions Test One (From Accompanying Study Guide)
A nurse is assessing an infant who has experienced asphyxia at birth. Which finding indicated that the resuscitation methods have been successful? (Chapter 23) A. Heart rate of 80 BPM B. Jitteriness C. Hypotonic D. Strong cry
D
A nurse is caring for a postpartum client who has been treated for deep vein thrombosis (DVT). Which order would the nurse question? (Chapter 22) A. Wear compression stockings B. Plan long rest periods throughout the day C. Take aspirin as needed D. Take an oral contraceptive every day
D
Two weeks after a vaginal birth, a client presents with a low-grade fever. The client also reports a loss of appetite and low energy levels. The health care provider suspects an infection of the episiotomy. What sign or symptom is MOST indicative of an episiotomy infection? (Chapter 22) A. Foul-smelling vaginal discharge B. Sudden onset of shortness of breath C. Pain in the lower leg D. Apprehension and diaphoresis
A
The nurse is caring for an Rh-negative nonimmunized client at 14 weeks gestation. What information would the nurse provide to the client? (Chapter 19) A. Obtain RhoGAM at 28 weeks gestation B. Consume a well-balanced, nutritional diet C. Avoid sexual activity until after 28 weeks D. Undergo periodic transvaginal ultrasounds
A
A nurse is caring for a pregnant client with sickle cell anemia. What should the nursing care for the client include? SELECT ALL THAT APPLY (Chapter 20) A. Teach the client meticulous hand washing B. Assess serum electrolyte levels of the client at each visit C. Instruct client to consume protein-rich foods D. Assess hydration status of the client at each visit E. Urge the client to drink 8 to 10 glasses of fluid daily
A, D, E
A client in her 7th week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of PPD? SELECT ALL THAT APPLY (Chapter 22) A. Inability to concentrate B. Loss of confidence C. Manifestations of mania D. Decreased interest in life E. Bizarre behavior
A,B,D
A client in her second trimester arrives at a health care facility for a follow-up visit. During the exam, the client reports constipation. Which instruction should the nurse offer to help alleviate the constipation? (Chapter 12) A. Ensure adequate hydration and bulk in the diet B. Avoid spicy or greasy food in meals C. Practice Kegel exercises D. Avoid lying down for 2 hours after meals
A
A client with preeclampsia is receiving magnesium sulfate to suppress or control seizures. Which nursing intervention should a nurse perform to determine effectiveness of therapy? (Chapter 19) A. Assess deep tendon reflexes B. Monitor intake and output C. Assess the client's mucous membrane D. Assess client's skin turgor
A
A client in her third month of pregnancy arrives at the health care facility for a regular follow-up visit. The client reports discomfort due to increased urinary frequency. Which instruction should the nurse offer the client to reduce her discomfort? (Chapter 12) A. Avoid consumption of caffeinated drinks B. Drunk fluids with meals rather than between meals C. Avoid an empty stomach at all times D. Munch on dry crackers and toast in the early morning
A
The nurse is caring for a pregnant client who is in her 30th week of gestation and has congenital heart disease. Which should the nurse recognize as a symptom of cardiac decompensation with this client? (Chapter 20) A. Swelling of the face B. Dry, rasping cough C. Slow, labored respiration D. Elevated temperature
A
A client who is in labor presents with shoulder dystocia of the fetus. Which is an important nursing intervention? (Chapter 21) A. Assist with positioning woman in squatting position B. Assess for reports of intense back pain in the first state of labor C. Anticipate possible use of forceps to rotate to anterior position at birth D. Assess for prolonged second stage of labor with arrest of descent
A
A pregnant client's last menstrual period was March 10. Using Naegele's Rule, the nurse estimates the date of birth to be: (Chapter 12) A. January 7 B. December 17 C. February 21 D. January 30
B
A nurse is caring for a pregnant adolescent client, who is in her first trimester, during a visit to the maternal child clinic. Which important area should the nurse address during assessment of this client? (Chapter 20) A. Sexual development of the client B. Whether sex was consensual C. Options for birth control in the future D. Knowledge of the child's development
D
A nurse is caring for a pregnant client who is human immunodeficiency virus (HIV) positive. What is a PRIORITY issue that the nurse should discuss with the client? (Chapter 20) A. The client's relationship with the spouse B. The amount of physical contact that should occur with the infant C. The client's plan for future pregnancies D. The client's need to avoid breast feeding
D
A nurse is caring for a pregnant client with heart disease in a labor unit. Which intervention is MOST important in the first 48 hours postpartum? (Chapter 20) A. Limiting sodium intake B. Inspecting the extremities for edema C. Ensuring that the client consumes a high fiber diet D. Assessing for cardiac decompensation
D
Upon assessment, the nurse notes a postpartum client has increased vaginal bleeding. The client had a forceps birth which resulted in lacerations 4 hours ago. What should the nurse do NEXT? (Chapter 22) A. Assess for uterine contractions B. Change the client's peripad C. Obtain the client's vital signs D. Have the client void
A
What important instruction should the nurse give a pregnant client with tuberculosis? (Chapter 20) A. Maintain adequate hydration B. Avoid direct sunlight C. Avoid red meat D. Wear light cotton clothes
A
A pregnant client is brought to the health care facility with signs of premature rupture of membranes (PROM). Which conditions and complications are associated with PROM? SELECT ALL THAT APPLY (Chapter 19) A. Prolapsed cord B. Abruptio placenta C. Spontaneous abortion D. Placenta previa E. Preterm labor
A, B, E
The nurse is caring for a pregnant client who indicates that she is fond of meat, works with children, and has a pet cat. Which instructions should the nurse give this client to prevent toxoplasmosis? SELECT ALL THAT APPLY (Chapter 20) A. Eat meat cooked to 160 degrees B. Avoid cleaning the cat's litter box C. Keep the cat outdoors at all times D. Avoid contact with children when they have a cold E. Avoid outdoor activities such as gardening
A, B, E
A nurse is assessing a client with postpartum hemorrhage; the client is presently on IV oxytocin. Which interventions should the nurse perform to evaluate the efficacy of the drug treatment? SELECT ALL THAT APPLY (Chapter 22) A. Assess client's uterine tone B. Monitor client's vital signs C. Assess client's skin turgor D. Get a pad count E. Assess deep tendon reflexes
A,B,D
Which maternal factors should the nurse consider contributory to a newborn being large for gestational age? SELECT ALL THAT APPLY (Chapter 23) A. Diabetes mellitus B. Postdates gestation C. Alcohol use D. Prepregnancy obesity E. Renal infection
A,B,D
The nurse is caring for a client in the early stages of labor. What maternal history factors will alert the nurse to plan for the possibility of a small for gestational age (SGA) newborn? SELECT ALL THAT APPLY (Chapter 23) A. Maternal smoking during pregnancy B. Hypotension upon admission C. Asthma exacerbations during pregnancy D. Drug abuse E. Pregnancy weight gain of 25 lb
A,C,D
A nurse is caring for an infant born with an elevated bilirubin level. When planning the infant's care, what interventions will assist in reducing the bilirubin level? SELECT ALL THAT APPLY (Chapter 23) A. Increase the infant's hydration B. Stop breast feeding until jaundice resolves C. Offer early feedings D. Administer vitamin supplements E. Initiate phototherapy
A,C,E
A client is seeking advice for his pregnant wife, who is experiencing mild elevations in blood pressure. In which position should a nurse recumbent a client rest? (Chapter 19) A. Supine positon B. Lateral recumbent position C. Left lying lateral position D. Head of bed slightly elevated
B
A nurse caring for a pregnant client suspected substance abuse during pregnancy What is the PRIORITY nursing intervention for this client? (Chapter 20) A. Determine how long the client has been using drugs B. Obtain a urine specimen for a drug screening C. Determine if the client has emotional support D. Provide education material on cessation of substance abuse
B
A nurse is caring for a client in her second trimester of pregnancy. During a regular follow-up visit, the client reports varicosities of the legs. Which instruction should the nurse provide to help the client alleviate varicosities of the legs? (Chapter 12) A. Avoid sitting in one position for too long B. Refrain from crossing legs when sitting for long periods C. Apply heating pads on the extremities D. Refrain from wearing any kind of stockings
B
A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform FIRST? (Chapter 22) A. Administration of prescribed NSAIDs B. Administration of platelet transfusions as ordered C. Avoiding administration of oxytocics D. Continual form massage of the uterus
B
What is the role of the nurse during the preconception counseling of a pregnant client with chronic hypertension? (Chapter 20) A. Stressing the avoidance of dairy products B. Pressing the positive benefits of a healthy lifestyle C. Stressing the increased use of vitamin D supplements D. Stressing regular walks and exercise
B
A nurse is caring for a client who has had an intrauterine fetal death with prolonged retention of the fetus. For which signs and symptoms should the nurse watch to assess for an increased risk of disseminated intravascular coagulation? SELECT ALL THAT APPLY (Chapter 22) A. Hypertension B. Bleeding gums C. Tachycardia D. Acute renal failure E. Lochia less than usual
B,C,D
A nurse is caring for a postpartum client who has a history of thrombosis during a pregnancy and is at high risk of developing a pulmonary embolism. For which sign or symptom should the nurse monitor the client to prevent the occurrence of a PE? (Chapter 22) A. Sudden change in mental status B. Difficulty in breathing C. Calf swelling D. Sudden chest pain
C
Which intervention should a nurse implement to promote thermal regulation in a preterm newborn? (Chapter 23) A. Assess the newborn's temperature every 8 hours until stable B. Set the temperature of the radiant warmer at a fixed level C. Observe for clinical signs of cold stress such as a weak cry D. Check the blood pressure of the infant every 2 hours
C
A pregnant client has been diagnosed with gestational diabetes. Which are risk factors for developing gestational diabetes? SELECT ALL THAT APPLY (Chapter 20) A. Maternal age less than 18 years B. Genitourinary tract abnormalities C. Obesity D. Hypertension E. Previous large for gestational age (LGA) infant
C,D,E
The nurse would monitor clients with which conditions for fetal demise? SELECT ALL THAT APPLY (Chapter 21) A. hydraminos B. Multifetal gestation C. Prolonged pregnancy D. Malpresentation E. Hypertension
C,E
The nurse is performing a newborn assessment and the infant's lab work reveals a heelstick Hct of 66. What is the BEST response to this finding? (Chapter 23) A. The infant is suffering from polycythemia and needs a partial exchange transfusion to prevent complications B. This is a normal lab value and no intervention is needed C. A capillary hematocrit needs to be rechecked in 8 hours to see if it increases or decreases D. The hematocrit needs to be repeated as a venous stick to see what the central hematocrit is
D
The nurse is required to assess a pregnant client who is reporting vaginal bleeding. Which nursing action is the PRIORITY? (Chapter 19) A. Monitoring uterine contractility B. Assessing signs of shock C. Determining the amount of funneling D. Assessing the amount and color of the bleeding
D
A client in the third trimester of pregnancy has to travel long distance by car. The client is anxious about the effect the travel may have on her pregnancy. Which instruction should the nurse provide to promote easy and safe travel for the client? (Chapter 12) A. Activate the air bag in the car B. Use a lap belt that crosses over the uterus C. Apply a padded shoulder strap properly D. Always wear a three-point seat belt
D
A client is admitted to the health care facility. The fetus has a gestational age of 42 weeks and is suspected to have cephalopelvic disproportion. What should the nurse do NEXT? (Chapter 21) A. Place the client in lithotomy position for birth B. Administer oxytocin intravenously at 4 mU/min C. Perform artificial rupture of membranes D. Prepare the client for cesarean birth
D
A client is experiencing shoulder dystocia during birth. The nurse would place PRIORITY on performing which assessment post delivery? (Chapter 21) A. Extensive lacerations B. Monitor for a cardiac abnormality C. Assess for cleft palate D. Brachial plexus assessment (Moro)
D
Which symptom would MOST accurately indicate that a newborn has experienced meconium aspiration during the birth process? (Chapter 23) A. Bluish skin discoloration B. Listlessness or lethargy C. Stained umbilical cord and skin D. Meconium-stained fluids followed by tachypnea
D
Which postoperative intervention should a nurse perform when caring for a client who has undergone a cesarean birth? (Chapter 21) A. Assess uterine tone to determine fundal firmness B. Delay breast feeding the newborn for a day C. Ensure the client does not cough or breathe deeply D. Avoid early ambulation to prevent respiratory problems
A
A nurse is caring for a client with CVD who has just delivered. What nursing interventions should the nurse perform when caring for this client? SELECT ALL THAT APPLY (Chapter 20) A. Assess for shortness of breath B. Assess for a moist cough C. Assess for edema and note any pitting D. Auscultate heart sounds for abnormalities E. Monitor the client's hemoglobin and hematocrit
A, C, D
A pregnancy client has come to a health care provider for her first prenatal visit. The nurse needs to document useful information about the past health history. What are goals of the nurse in the history-taking process? SELECT ALL THAT APPLY (Chapter 12) A. To prepare a plan of care that suits the client's lifestyle B. To develop a trusting relationship with the client C. To prepare a plan of care for pregnancy D. To assess the client's partner's sexual health E. To urge the client to achieve an optimal body weight
A,B,C
A full-term client is being assessed for induction of labor. Her Bishop score is less than 6. Which order would the nurse anticipate? (Chapter 21) A. Insertion of a Foley bulb into the endocervical canal B. Prepare the client for a cesarean birth C. Administer oxytocin intravenously at 10 mU/min D. Artificial rupture of membranes
A
A nurse is assessing a term newborn and finds the blood glucose level is 23 mg/dL. The newborn has a weak cry, is irritable, and exhibits bradycardia. What intervention is MOST appropriate? (Chapter 23) A. Administer dextrose intravenously B. Monitor the infant's hematocrit levels closely C. Administer PO glucose water immediately D. Place the infant on a radiant warmer
A
A nurse is assessing the following antenatal clients. Which client is at highest risk for having a multiple gestation? (Chapter 21) A. The 41 year old client who conceived by in vitro fertilization B. The 38 year old client whose spouse is a triplet C. The 19 year old client diagnosed with polycystic ovarian syndrome D. The 27 year old client who delivered twins two years ago
A
A nurse is caring for a client at 38 weeks gestation who is diagnosed with chorioamnionitis. On which intervention should the nurse place PRIORITY? (Chapter 21) A. Administer oxygen B. Monitor WBC count C. Assess temperature D. Assess amniotic fluid
A
A nurse is caring for a client undergoing treatment for ectopic pregnancy. Which symptom is observed in a client if rupture or hemorrhaging occurs before the ectopic pregnancy is successfully treated? (Chapter 19) A. Phrenic nerve irritation B. Painless bright red vaginal bleeding C. Fetal distress D. Tetanic contrations
A
A nurse is caring for a client who is scheduled to undergo an amnioinfusion. The nurse would question this order if which is noted upon client assessment? (Chapter 21) A. Uterine hypertonicity B. Active genital herpes infection C. Blood pressure of 130/88 D. Decreased urine output
A
A nurse is caring for a newborn with fetal alcohol spectrum disorder. What characteristic of the FASD should the nurse assess for in the newborn? (Chapter 20) A. Small head circumference B. Decreased blood glucose level C. Abnormal breathing pattern D. Wide eyes
A
A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's PRIORITY for this client? (Chapter 22) A. Check the lochia B. Assess the temperature C. Monitor the pain level D. Assess the fundal height
A
A nurse is caring for a pregnant client in her second trimester of pregnancy. The nurse educated the client to look for which danger sign of pregnancy needing immediate attention by the physician? (Chapter 12) A. Vaginal bleeding B. Painful urination C. Severe, persistent vomiting D. Lower abdominal and shoulder pain
A
A nurse is caring for an antenatal mother diagnosed with umbilical cord prolapse. For which should the nurse monitor the fetus? (Chapter 21) A. Fetal hypoxia B. Preeclampsia C. Coagulation defects D. Placental pathology
A
A nurse is caring for an infant born with polycythemia. Which intervention is MOST appropriate when caring for this infant? (Chapter 23) A. focus on decreasing blood viscosity by increasing fluid volume B. Check blood glucose within 2 hours of birth by reagent test strip C. Repeat screening every 2 to 3 hours or before feeds D. Focus on monitoring and maintaining blood glucose levels
A
A nurse is caring for an infant. A serum blood sugar of 40 was noted at birth. What care should the nurse provide to this newborn? (Chapter 23) A. Begin early feedings either by the breast or the bottle B. Give dextrose intravenously before oral feedings C. Place infant on radiant warmer immediately D. Focus on decreasing blood viscosity by introducing feedings
A
A pregnant client wishes to know if sexual intercourse would be safe during her pregnancy. Which should the nurse confirm before educating the client regarding sexual behavior during pregnancy? (Chapter 12) A. client does not have incompetent cervix B. Client does not have anxieties and worries C. Client does not have anemia D. Client does not experience facial and hand edema
A
During the assessment of a laboring client the nurse learns that the client has cardiovascular disease (CV). Which assessment would be the PRIORITY for the newborn? (Chapter 20) A. Respiratory function B. Heart rate C. Temperature D. Urine output
A
The nurse is caring for a 2 day old newborn whose mother was diagnosed with cytomegalovirus during the first trimester. On which health care provider order should the nurse place the PRIORITY? (Chapter 20) A. Perform a hearing screen test B. Obtain a urine specimen C. Monitor growth and development D. Assess pulse rate
A
The nurse is caring for a client experiencing a prolonged second stage of labor. The nurse would place PRIORITY on preparing the client for which intervention? (Chapter 21) A. A forceps and vacuum assisted birth B. A precipitous birth C. Artificial rupture of membranes D. A cesarean section
A
When caring for a client with premature rupture of membranes (PROM), the nurse observes an increase in the client's pulse. What should the nurse do NEXT? (Chapter 19) A. Assess the client's temperature B. Monitor the client for preterm labor C. Assess for cord compression D. Monitor the fetus for respiratory repression
A
When caring for a preterm infant, what intervention will BEST address the sensorimotor needs of the infant? (Chapter 23) A. Rocking and massaging B. Swaddling and positioning C. Using minimal amount of tape D. Using distraction through objects
A
Which safety precautions should a nurse take to prevent infection in a newborn? SELECT ALL THAT APPLY (Chapter 23) A. Avoid coming to work when ill B. Cover jewelry when washing hands C. Use sterile gloves for an invasive procedure D. Avoid using disposable equipment E. Initiate universal precautions when caring for the infant
A,C,E
A pregnant client has come to a health care facility for a physical examination. Which assessments should a nurse perform when going a physical examination of the head and neck? SELECT ALL THAT APPLY (Chapter 12) A. Previous injuries and sequelae B. Eye movements C. Levels of estrogen D. Limitations in range of motion E. Thyroid gland enlargement
A,D,E
A nurse is caring for a client who is experiencing acute onset dyspnea and hypotension. The physician suspects the client has an amniotic fluid embolism. What other signs or symptoms would alert the nurse to the presence of this condition in the client? SELECT ALL THAT APPLY (Chapter 21) A. Cyanosis B. Arrhythmia C. Hyperglycemia D. Hematuria E. Pulmonary edema
A,E
A nurse is caring for a pregnant client with asthma. Which intervention would the nurse perform FIRST? (Chapter 20) A. Monitoring temperature frequently B. Assessing oxygen saturation C. Monitoring frequency of headache D. Assessing for feeling nauseated
B
A nurse is caring for a pregnant client. The initial interview reveals that the client is accustomed to drinking coffee at regular intervals. For which increased risk should the nurse make the client aware? (Chapter 20) A. Heart disease B. Anemia C. Rickets D. Scurvy
B
A nurse is caring for a preterm infant. Which intervention will prepare the newborn's gastrointestinal tract to better tolerate feedings when initiated? (Chapter 23) A. Administer vitamin D supplements B. Administer 0.5 mL/kg/hr of breast milk enterally C. Administer iron supplements D. Administer dextrose intravenously
B
A nurse is documenting a dietary plan for a pregnant client with PREgestational diabetes. What instructions should the nurse include in the dietary plan for this client? (Chapter 20) A. Include more dairy products in the diet B. Include complex carbohydrates in the diet C. Eat only 2 meals per day D. Eat at least 1 egg per day
B
A nurse is monitoring a client with PROM who is in labor and observes meconium in the amniotic fluid. What does this indicate? (Chapter 19) A. Cord compression B. Fetal distress related to hypoxia C. Infection D. Central nervous system involvement
B
A postpartum client who was discharged home returns to the primary health care facility after 2 weeks with reports of fever and pain in the breast. The client is diagnosed with mastitis. What education should the nurse give to the client for managing and preventing mastitis? (Chapter 22) A. Discontinue breastfeeding to allow time for healing B. Perform hand washing before and after breast feeding C. Avoid hot or cold compresses on the breast D. Discourage manual compression of breast for expressing milk
B
The nurse is caring for a client after experiencing a placental abruption. Which finding is the PRIORITY to report to the healthcare provider? (Chapter 21) A. Hematocrit of 36% B. 45 mL urine output in 2 hours C. Hemoglobin of 13 g/dL D. Platelet count of 150,000 mm3
B
Which assessment finding would BEST validate a problem in a small for gestational age (SGA) newborn secondary to meconium in the amniotic fluid? (Chapter 23) A. Total bilirubin level of 15 B. Respiratory rate of 60-70 per minute C. Heart rate of 162 beats per minute D. Hematocrit of 44%
B
Which nursing intervention should the nurse perform when assessing fetal well-being through abdominal ultrasonography in a client? (Chapter 12) A. inform the client that she may feel hot initially B. Instruct the client to refrain from emptying her bladder C. Instruct the client to report the occurrence of fever D. Obtain and record vital signs of the client
B
A nurse is monitoring a client with spontaneous abortion who has been prescribed misoprostol. Which symptoms are common adverse effects associated with misoprostol? SELECT ALL THAT APPLY (Chapter 19) A. Constipation B. Dyspepsia C. Headache D. Hypotension E. Tachycardia
B,D,E
The nurse is required to assess a client for HELLP syndrome. Which are the signs and symptoms of this condition? SELECT ALL THAT APPLY (Chapter 19) A. Blood pressure higher than 160/110 B. Epigastric pain C. Oliguria D. Upper right quadrant pain E. hyperbilirubinemia
B,D,E (FYI: other symptoms include dependent edema, nausea, malaise)
A 28 year old client who has just conceived arrives at a health care facility for her first prenatal visit to undergo a physical examination. Which intervention should the nurse perform to prepare the client for the physical examination? (Chapter 12) A. Ensure that the client is laying down B. Ensure that the client's family is present C. Instruct the client to empty her bladder D. Instruct the client to keep taking deep breaths
C
A client in her third trimester of pregnancy wishes to use the method of feeding formula to her baby. What instruction should the nurse provide? (Chapter 12) A. Mix one scoop of power with an ounce of water B. Feed the infant every 8 hours C. Serve the formula at room temperature D. refrigerate any leftover formula
C
A nurse is caring for a client who delivered vaginally 2 hours ago. What postpartum complication can the nurse assess within the first few hours following birth? (Chapter 22) A. Postpartum infection B. Postpartum blues C. Postpartum hemorrhage D. Postpartum depression
C
A nurse is caring for a client who has been diagnosed with precipitous labor. For which potential fetal complication should the nurse monitor? (Chapter 21) A. Facial nerve injury B. Cephalohematoma C. Intracranial hemorrhage D. Facial lacerations
C
A nurse is caring for a client who has just undergone birth. What is the BEST method for the nurse to assess this client for postpartum hemorrhage? (Chapter 22) A. By assessing skin turgor B. By assessing blood pressure C. By frequently assessing uterine involution D. By monitoring hCG titers
C
A nurse is caring for a postpartum client. What instruction should the nurse provide to the client as precautionary measures to prevent thromboembolitic complications? (Chapter 22) A. Avoid performing any deep breathing exercises B. Try to relax with pillows under knees C. Avoid sitting in one position for long periods of time D. Refrain from elevating legs above heart level
C
A nurse is caring for a pregnant client with eclamptic seizure. What is a characteristic of eclampsia? (Chapter 19) A. Muscle rigidity followed by facial twitching B. Respirations are rapid during the seizure C. Coma occurs after the seizure D. Respiration falls after the seizure
C
A nurse is caring for a pregnant client with gestational diabetes. Which meal should the nurse recommend for this client? (Chapter 20) A. Baked chicken, green beans, and chocolate cake B. Pizza, corn, and orange slices C. Baked turkey, brown rice, and strawberries D. Steak, baked potato with butter, and ice cream
C
A nuse has been assigned to assess a pregnant client for abruptio placenta. For which classic manifestation of this condition should the nurse assess? (Chapter 19) A. Painless bright bed vaginal bleeding B. Increased fetal movement C. "Knife-like" abdominal pain with vaginal bleeding D. Generalized vasospasm
C
A pregnant client has come to a clinic for a pelvic examination. What assessments should a nurse perform when examining external genitalia? (Chapter 12) A. Cervix is smooth, long, thick, and closed B. Bluish coloration of the cervix and vaginal mucosa C. Any infection due to hematomas, varicosities, and inflammation D. Hemorrhoids, masses, prolapse, and lesions
C
A pregnant client with hyperemesis gravidarum needs advice on how to minimize nausea and vomiting. Which instruction should the nurse give this client? (Chapter 19) A. Lie down or recline for at least 2 hours after eating B. Avoid dry crackers, toast, and soda C. Eat small, frequent meals throughout the day D. Decrease intake of carbonated beverages
C
The nurse is caring for a pregnant client with fallopian tube rupture. Which intervention is the PRIORITY for this client? (Chapter 19) A. Monitor the client's beta-hCG level B. Monitor the mass with transvaginal ultrasound C. Monitor the client's vital signs and bleeding D. Monitor the fetal heart rate
C
What assessment by the nurse will BEST monitor the nutrition and fluid balance of the post-term newborn? (Chapter 23) A. Measure weight once every 2 to 3 days B. Assess for increased muscle tone C. Assess for decrease in urinary output D. Monitor for drop in temperature, indicative of dehydration
C
Which should the nurse identify as a risk associated with anemia during pregnancy? (Chapter 20) A. Newborn with heart problems B. Fetal asphyxia C. Preterm birth D. Newborn with an enlarged liver
C
A client with full term pregnancy who is not in active labor has been ordered oxytocin intravenously. The nurse would notify the healthcare provider is which is noted? (Chapter 21) A. Dysfunctional labor pattern B. Posterm status C. Prolonged ruptured membranes D. Overdistended uterus
D
A nurse caring for a client in labor has asked her to perform Lamaze breathing techniques to avoid pain. Which should the nurse keep in mind to promote effective Lamaze-method breathing? (Chapter 12) A. Ensure deep abdominopelvic breathing B. Ensure abdominal breathing during contractions C. Ensure client's concentration on pleasurable sensations D. Remain quiet during client's period of imagery
D
A nurse finds that a client is bleeding excessively after a vaginal birth. Which assessment finding would indicate retained placental fragments as a cause of bleeding? (Chapter 22) A. Soft and boggy uterus that deviates from the midline B. Firm uterus with trickle of bright red blood in perineum C. Firm uterus with a steady stream of bright red blood D. Large uterus with painless, dark-red blood mixed with clots
D
A nurse is assessing a pregnant client with preeclampsia for suspected dependent edema. Which description of dependent edema is MOST accurate? (Chapter 19) A. Dependent edema leaves a small depression or pit after finger pressure is applied to a swollen area B. Dependent edema occurs only in clients on bed rest C. Dependent edema can be measured when pressure is applied D. Dependent edema may be seen in the sacral area if a client is on bed rest
D
A nurse is assessing pregnant clients for the risk of placenta previa. Which of the following clients faces the greatest risk for this condition? (Chapter 19) A. A 23 year old multigravida client B. A client with a history of alcohol abuse C. A client with a structurally defective cervix D. A client who had a myomectomy to remove fibroids
D
A nurse is caring for a 38 year old overweight client 24 post cesarean birth. The client is reporting calf tenderness. What should the nurse do FIRST? (Chapter 22) A. Assess the client's respiratory rate B. Determine the severity of the pain C. Administer an anticoagulant D. Have the client rest with the extremity elevated
D
A nurse is caring for a 45 year old pregnant client with a cardiac disorder, who has been instructed by her physician to follow Class 1 functional activity recommendations. The nurse correctly instructs the client to follow which limitations? (Chapter 20) A. "You will need to be on bedrest for the remainder of your pregnancy" B. "It is important for you to rest after any physical activity in order to prevent any cardiac complications" C. "It will be beneficial if you plan rest periods throughout your day" D. "You do not need to limit your physical activity unless you experience any problems such as fatigue, chest pain, or shortness of breath"
D
A nurse is caring for a client with hyperemesis gravidarum. Which nursing action is the PRIORITY for this client? (Chapter 19) A. Administer total parental nutrition B. Administer an antiemetic C. Set up for a percutanetous endoscopic gastrostomy D. Administer IV NS with vitamins and electrolytes
D
A pregnant client in her 12th week of gestation has come to a health care center for a physical examination of her abdomen. Where should the nurse palpate for the fundus in this client? (Chapter 12) A. At the umbilicus B. Below the ensiform cartilage C. Midway between the symphysis pubis and umbilicus D. At the symphysis pubis
D
The nurse is caring for a pregnant client with severe preeclampsia. Which nursing interventions should a nurse perform to institute and maintain seizure precautions in this client? (Chapter 19) A. Provide a well-lit room B. Keep head of bed slightly elevated C. Place the client in supine position D. Keep the suction equipment readily available
D