OB ATI Practice Questions

A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statements should the nurse include in the teaching? "Obtain informed consent prior to obtaining the specimen." "Collect at least 1 milliliter of urine for the test." "Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen." "Premature newborns may have false negative tests due to immature development of liver enzymes."

"Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen."

A nurse is providing teaching to a client who is 40 weeks gestation and has a new prescription for misoprostol. Which fo the following instructions should the nurse include in the teaching? "Remain in a side-lying position for 15 minutes after the medication is inserted." "You will need a full bladder prior to the insertion of the medication." "I can administer oxytocin 4 hours after the insertion of the medication." "An antacid will be given 20 minutes prior to the insertion of the medication."

"I can administer oxytocin 4 hours after the insertion of the medication."

A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching? "I will get injections of the medication once daily until my labor stops." "My blood sugar may be low while I'm on this medication." "I will have blood tests because my potassium might decrease." "My blood pressure may increase while I'm on this medication."

"I will have blood tests because my potassium might decrease."

A nurse is teaching a client who is Rh negative about Rh0 (D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching? "I will receive this medication if my baby is Rh-negative." "I will receive this medication when I am in labor." "I will need a second dose of this medication when my baby is 6 weeks old." "I will need this medication if I have an amniocentesis."

"I will need this medication if I have an amniocentesis."

A nurse is providing teaching for a client who gave birth 2 hr ago about the facility policy for newborn safety. Which of the following client statements indicates an understanding of the teaching? "My sibling will be able to carry my baby from the nursery to my room when they arrive." "The nurse will match my wrist band to my baby's crib card when they bring them to me." "The person who comes to take my baby's pictures will be wearing a photo identification badge." "My baby doesn't need to wear the electronic security bracelet when they're in my room."

"The person who comes to take my baby's pictures will be wearing a photo identification badge."

A nurse is preparing to administer azithromycin to a client who is at 16 weeks gestation and has a positive chlamydia culture. The prescription states "administer azithromycin 1 g orally now". Available is 250 mg tablets. How many tablets should the nurse administer?

4

A nurse is assessing a client who is at 35 weeks of gestation and has mild gestational HTN. What finding should the nurse identify as the priority? 480 mL urine output in 24 hrs 1+ protein in the urine +2 edema of the feet BP 144/92

480 mL urine output in 24 hrs

A nurse is preparing to administer magnesium sulfate 2 g/hr IV to a client who is in preterm labor. Available is 20 g magnesium sulfate in 500 mL of dextrose 5% in water. The nurse should set the IV infusion pump to deliver how many mL/hr?

50 mL

A nurse is teaching a client during the clients first prenatal visit. Which of the following instructions should the nurse include? A fetal stethoscope can first detect your baby's heart rate at 22 weeks After week 16 we can see if your baby is a boy or girl A Doppler device can detect your baby's heart rate at 12 weeks You will first feel the baby move at about 8 weeks

A Doppler device can detect your baby's heart rate at 12 weeks

A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first? A client who is at 11 weeks gestation and reports abdominal cramping A client who is 15 weeks gestation and reports tingling and numbness in the right hand A client who is 20 weeks gestation and reports constipation for the past 4 days A client who is 8 weeks gestation and reports having three bloody noses in the pat week

A client who is at 11 weeks gestation and reports abdominal cramping

A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority? A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL A client who is at 34 weeks gestation and reports epigastric pain A client who is at 28 weeks gestation and has a Hgb of 10.4 g/dL A client who is at 39 weeks gestation and reports urinary frequency and dysuria

A client who is at 34 weeks gestation and reports epigastric pain

A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider? A newborn who is 26 hr old and has erythema toxicum on their face A newborn who is 32 hr old and has not passed meconium stool A newborn who is 12 hr old and has pink tinged urine A newborn who is 18 hr old and has an axillary temperature of 37.7 C (99.9 F)

A newborn who is 18 hr old and has an axillary temperature of 37.7 C (99.9 F)

A nurse is providing teaching about nonpharmacological pain management to a client who is breastfeeding and has engorgement. The nurse should recommend the application of which of the following items? Cold cabbage leaves Purified lanolin cream A snug-fitting support bra Breast shells

Cold cabbage leaves

A nurse is caring for a newborn who is 48 hr old. Vital Signs Day 2, 0900: Heart rate 174/min Respiratory rate 88/min Temperature 36.1° C (97.0° F) Oxygen saturation 97% on room air​ Diagnostic Results Day 1, 0800: Newborn results Blood type: A+ Urine toxicology screen: positive marijuana Day 2, 0800: Newborn results Total bilirubin 10 mg/dL (1.0 to 12.0 mg/dL) Day 2, 0915: Blood glucose: 38 mg/dL (expected value greater than 40 to 45 gm/dL Nurses Notes Day 2, 0900: Newborn awake, alert, and crying. Loosely wrapped in one blanket. Mild tremors noted. Yellow discoloration of mucus membranes and sclera noted. Respirations 88/min, no retractions, grunting, or nasal flaring noted. Diaper changed for small amount of urine and transitional stool. Medical History Apgars: 7 at 1 min and 8 at 5 min of age Birth weight: 3,515 g (7 lb 12 oz) Maternal blood type: O+ Uncomplicated pregnancy. Maternal use of marijuana during

Condition- Cold stress Actions- Place newborn skin to skin on birthing parents chest, encourage birthing parent to breastfeed Monitor- Temperature, blood glucose level

A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which fo the following statements by the client indicates an understanding of the teaching? "I should increase my protein intake to 60 grams each day" "I should drink 2 liters of water each day" "I should increase my overall daily caloric intake by 300 calories" "I should take 600 micrograms of folic acid each day"

I should take 600 micrograms of folic acid each day

A nurse is teaching a client who has pre-gestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? "I will need to increase my insulin doses during the first trimester" "I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater" "I will continue taking my insulin if I experience nausea and vomiting" "I will ensure that my bedtime snack is high in refined sugar"

I will continue taking my insulin if I experience nausea and vomiting

A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching? "I will eat foods that taste good instead of balancing my meals" "I will avoid having a snack before I go to bed each night" "I will have a cup of hot tea with each meal" "I will eliminate products that contain dairy from my diet"

I will eat foods that taste good instead of balancing my meals

A nurse is providing teaching for a client about the physiological changes that occur during pregnancy. The client is at 10 weeks gestation and has a BMI within the expected range. Which of the following client statements indicates an understanding of the teaching? I will not gain more that 15-20 pounds during my pregnancy I will likely need to use alternative positions for sexual intercourse I'm glad I had a breast reduction years ago, so they will ot enlarge with my pregnancy I'm glad I have a light complexion and will not get any stretch marks

I will likely need to use alternative positions for sexual intercourse

A nurse is talking with a client at 20 weeks gestation who is scheduled for a sonogram. The client states "I am here to have my regular prenatal checkup, but I do not want any pictures taken of my baby." Which of the following responses should the nurse make?

I would like to hear more about why you do not want the sonogram, including any cultural reasons

A nurse is teaching a client who is at 24 weeks gestation regarding a 1-hr glucose tolerance test. Which of the following statements should the nurse include in the teaching? You will need to drink the glucose solution 2 hours prior to the test Limit your carbohydrate intake for 3 days prior to the test If this test is positive you will be scheduled for a 3-hour glucose tolerance test You will need to fast for 12 hours prior to the test

If this test is positive you will be scheduled for a 3-hour glucose tolerance test

A nurse is caring for a client who is 35 weeks gestation and has placenta previa. Which of the following actions should the nurse take? Perform a vaginal exam to determine cervical dilation every 2 hr Instruct the client to ambulate in the hallway once every 4 hr Administer betamethasone to the client via IM injection Initiate continuous fetal monitoring

Initiate continuous fetal monitoring

A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take? Apply oxygen to the client at 2 L/min via nasal cannula Wrap the visible cord tightly with sterile, dry gauze Insert two fingered gloves into the vaginal and apply upward pressure to the presenting part Place the client in the lithotomy position and apply fundal pressure

Insert two fingered gloves into the vaginal and apply upward pressure to the presenting part

A nurse is planning care for a client who is to undergo a nonstress test. which of the following actions should the nurse include in the plan of care? Maintain the client NPO throughout the procedure Place the client in supine position Instruct the client to massage the abdomen to stimulate fetal movement Instruct the client to press the provided button each time fetal movement is detected

Instruct the client to press the provided button each time fetal movement is detected

A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider? Acrocyanosis Transient strabismus Jaundice Caput succedaneum

Jaundice

A nurse is caring for a client who is pregnant and is at the end of their first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones? Just above the umbilicus Just above the symphysis pubis The right lower quadrant The left lower quadrant

Just above the symphysis pubis

A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental abruption. Which of the following laboratory tests should the nurse expect the provider to prescribe? Kleihauer-Betke test Progesterone serum level Lecithin/sphingomyelin (L/S) ratio Maternal alpha-fetoprotein (AFP)

Kleihauer-Betke test

A nurse is caring for a client who is to receive oxytocin to augment their labor. Which of the following findings contraindicates the intitiation of the oxytocin infusion and should be reported to the provider? Late decelerations Moderate variability of the FHR Cessation of uterine dilation Prolonged active phase of labor

Late decelerations

A nurse is observing a new guardian care for their crying newborn who is bottle feeding. Which of the following actions by the guardian should the nurse recognize as a positive parenting behaviour? Lays the newborn across their lap and gently sways Places the newborn in the crib in a prone position Offers the newborn a pacifier dipped in formula Prepares a bottle of formula mixed with rice cereal

Lays the newborn across their lap and gently sways

A nurse is caring for a client following an amniocentesis at 18 weeks gestation. Which of the following findings should the nurse report to the provider as a potential complication? Increased fetal movement Leakage of fluid from the vagina Upper abdominal discomfort Urinary frequency

Leakage of fluid from the vagina

A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has determined the fetal position as left occiput anterior. To which of the following areas of the client's abdomen should the nurse apply the ultrasound transducer to assess the point of maximum intensity of the fetal heart? Left upper quadrant Right upper quadrant Left lower quadrant Right lower quadrant

Left lower quadrant

A nurse in a knot and delivery unit is preparing to teach a Norway licensed nurse about intermittent auscultation of the fetal heart rate. Which of the following interventions should the nurse include? Count the fetal heart rate for 15 seconds after contractions Palpate and count the maternal radial pulse while listening to the fetal heart rate Place a listening device over the fetal chest to hear the fetal heart rate Percussion the maternal abdomen to verify the position of the fetus

Palpate and count the maternal radial pulse while listening to the fetal heart rate

A nurse is preparing to perform leopald maneuvers for a client. Identify the sequence the nurse should follow Identify the attitude of the head Palpate the fundus to identify the fetal part Determine the location of the fetal back Palpate for the fetal part presenting at the inlet

Palpate the fundus to identify the fetal part Determine the location fo the fetal back Palpate for the fetal part presenting at the inlet Identify the attitude of the head

A nurse in a provider's office is reviewing the medical record of a client who is in the first trimester of pregnancy. Which of the following findings should the nurse identify as a risk factor for the development of preeclampsia? Singleton pregnancy BMI of 20 Maternal age 32 years Pregestational diabetes mellitus

Pregestational diabetes mellitus

A nurse is creating a care plan for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care? Protect the client's head and feet from cold air Bathe the client within 12 hr following birth Ambulate the client within 24 hr following birth Offer the client a glass of cold milk with their first meal

Protect the client's head and feet from cold air

A nurse is reviewing the provider's prescription in the adolescent's medical chart. The nurse is reviewing the provider's prescriptions in the adolescent's medical chart. The nurse should first implement -scheduling follow up appointments -administering doxycycline -providing education on medications and -administering metronidazole -administering ceftriaxone -educating on condom use

Providing education on medications and administering ceftriaxone

A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following findings indicate that the client has progressed to preeclampsia with sever features? Blood pressure 152/98 mm Hg Elevated liver enzymes Epigastric pain with medication Pulmonary edema

Pulmonary edema

A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. WHich of the following actions should the nurse include in the plan? Feed the newborn 1 oz of water every 4 hr Apply lotion to the newborn's skin three times per day Remove all clothing from the newborn except the diaper Discontinue therapy if the newborn develops a rash

Remove all clothing from the newborn except the diaper

A nurse is caring for a client who has oligohydraminios. What fetal anomalies should the nurse expect? Renal agenesis Atrial septal defect Spina bifida Hydrocephalus

Renal agenesis

A nurse is assessing a client who is 36 weeks gestation. Which of the following findings should the nurse report to the provider? Report of visual disturbances Report of tingling in the fingers Report of urinary frequency Report of leg cramps

Report of visual disturbances

A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take? Administer penicillin G2.4 million unites IM to the client Instruct the client to schedule an annual pelvic examination Tell the client they will start medication for HIV immediately after delivery Report the clients condition to the local health department

Report the clients condition to the local health department

A nurse is assessing a client with gestational diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect? Reports blurred vision Diaphoresis Shallow respirations Reports increased urinary output

Reports increased urinary output

A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia? Hypertonia Increased feeding Hyperthermia Respiratory distress

Respiratory distress

A nurse is caring for a client who is 30 weeks gestation and has a prescription for magnesium sulfate to treat preterm labor. The nurse should notify the provider of which of the following adverse effects? Client reports nausea Urinary output of 40 mL/hr Respiratory rate 10/min Client reports feeling flushed

Respiratory rate 10/min

A nurse is teaching a client who is at 12 wks gestation and has HIV. What statement should the nurse include in the teaching? You will be in isolation after delivery Abstain from sexual intercourse throughout pregnancy Breastfeed your newborn to provide passive immunity You should continue to take zidovudine throughout the pregnancy

You should continue to take zidovudine throughout the pregnancy

A nurse is providing teaching about family planning to client who has a new prescription for a diaphragm. Which of the following statements should the nurse include in the treatment? You should replace the diaphragm every 5 years You should leave the diaphragm in place for at least 6 hours after intercourse You should use an oil-based product as a lubricant when inserting the diaphragm? You should insert the diaphragm when your bladder is full

You should leave the diaphragm in place for at least 6 hours after intercourse

A nurse is teaching a client who is 37 weeks gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include? "The test should take 10 to 15 minutes to complete" "You will lay in a supine position throughout the test" "You should not eat or drink for 2 hours before the test" "You should press the handheld button when you feel your baby move"

You should press the handheld button when you feel your baby move

A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching? "You should take the medication within 72 hours following unprotected sexual intercourse" "You should avoid taking this medication if you are on an oral contraceptive" "If you don't start your period within 5 days of taking this medication, you will need a pregnancy test" "One dose of this medication will prevent you from becoming pregnant for 14 days after taking it"

You should take the medication within 72 hours following unprotected sexual intercourse

A nurse is providing teaching to a lien who has come to the family planning clinic requesting an intrauterine device (IUD). Which of the following pieces of information should the nurse provide to the client? If you lose weight you will need to have your IUD refitted An IUD provides protection from certain STIs Your risk for ectopic pregnancy increases with an IUD You shouldn't use an IUD if you want to have children later

Your risk for ectopic pregnancy increases with an IUD

A nurse is speaking with a client who is trying to make a decision about tubal ligation. The client asks, "What effects will this procedure have on my sex life?" Which of the following responses should the nurse make? "I think that is something you should discuss with your doctor." "This procedure should have no effect on your sexual performance or adequacy." "You'll be fine. I can't imagine you and your partner will have any problems with sexual function." "If this concerns you, perhaps you should reconsider and use another form of contraception."

"This procedure should have no effect on your sexual performance or adequacy."

A nurse is reviewing the provider's prescription in the adolescent's medical chart. The nurse has just reviewed discharge instructions with the adolescent. Which of the following indicates whether the adolescent understands the teaching or requires further education? 1 "I should continue taking all my medications even if I don't show any symptoms." 2 "If I continue to get this type of infection, it can affect my ability to have kids in the future." 3 "I should go to the emergency department if my urine turns dark." 4 "As long as I keep my IUD, I don't need to use condoms." 5 "I'm more likely to get a sunburn while taking these medications."

1- understanding 2- understanding 3- further need for education 4- further need for education 5- understanding

A nurse at a provider's office is caring for a client who is 28 years of age. History and Physical Gravida 3, Para 2, Abortion 1 Asthma (managed with levalbuterol inhaler as needed) Pelvic inflammatory disease (PID) Spontaneous vaginal delivery X 2 (hypertension with first pregnancy at 20 years of age) Voluntary termination of pregnancy (3rd pregnancy) Nurses' Notes Client presents to the office with concerns of late menses, abdominal pain, and scant dark red vaginal spotting. Client reports menstrual period is usually regular and is 2 weeks late. Last menstrual period: 2/20/XX. Client reports occasional dull abdominal pain and rates it as 2 on a 0 to 10 pain scale. Client is alert and oriented, appears anxious. Speech clear. Skin warm and dry to touch. Heart rate regular at 90/min. Respirations even and non-labored. Lungs slight inspiratory wheezes. Bowel sounds hyperactive in all four quadrants. Abdomen tender to t

Abdomen assessment Vaginal spotting Menstrual period

A nurse in the clinic is caring for a 16 year old adolescent. Which of the following findings should the nurse report to the provider? Abdominal assessment Vaginal discharge Heart Rate Temperature Dyspareunia Condom usage Vital Signs 1300:Blood pressure 118/72 mm Hg Heart rate 100/min Respiratory rate 20/min Temperature 38.3° C (101° F) Provider Prescriptions Standing prescriptions for clients who present with abdominal pain: Obtain laboratory tests: Urinalysis Cervical culture C-reactive protein Beta hCG History and Physical Adolescent is sexually active with two current partners. IUD in place Reports not using condoms during sexual activity. History of type 1 diabetes mellitus Nurses' Notes Admitted adolescent reporting "cramping in my stomach." Reports pain as a 4 on 0 to 10 pain scale and describes pain as constant and dull. Reports nausea and vomiting over past 24 hours. Reports painful urination and pain dur

Abdominal assessment Vaginal discharge Heart Rate Temperature Dyspareunia Condom usage

A nurse in a clinic is caring for a 16-year-old adolescent. Which of the following conditions should the nurse identify as being consistent withe the adolescents assessment findings of: Abdominal pain, greenish discharge, diabetes, pain on urination, absence of condom use Conditions: trichomoniasis, gonorrhea, candidiasis

Abdominal pain- gonorrhea Greenish discharge- trichomoniasis and gonorrhea Diabetes- candidiasis Pain on urination- trichomoniasis, gonorrhea, and candidiasis Absence of condom use- trichomoniasis and gonorrhea

A nurse is admitting a client who is in labor. The client admits recent cocaine use. For which of the following complications should the nurse assess? Abruptio placenta Placenta previa Preeclampsia Maternal bradycardia

Abruptio placenta

A nurse is caring for a client who is 3 days postpartum. Medical History Gravida 1, Para 1 38 weeks of gestation Forceps-assisted birth following failed vacuum-assisted attempt. 3rd degree laceration with a repair. Amniotic membranes ruptured for 18 hr prior to delivery. Pregnancy complicated by gestational diabetes and anemia. Vital Signs Temperature 38.3° C (101° F) Heart rate 104/min Respiratory rate 20/min Blood pressure 108/70 mm Hg Nurses' Notes Client states "I feel terrible today. I have this feeling of pain and pressure in my pelvis." Client reports general malaise and chills. Uterus firm at the umbilicus and tender to palpation. Moderate amount of dark foul-smelling lochia noted. Generalized perineal edema observed. Frequently voiding large amounts of urine. Client reports an abdominal pain level of 5 on a scale of 0 to 10. Diagnostic Results Hemoglobin 10 mg/dL (11 to 16 g/dL) Hematocrit 37% (33% to 4

Action to take-Obtain a culture of vaginal fluid using a sterile swab, plan to administer IV antibiotics Potential condition- endometriosis Parameter to monitor- temperature, lochia amount and odor

A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 minutes apart, each lasting 80 ton90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?

Active

A nurse is planning care for a client who has a prescription for oxytocin. Which of the following is a contraindication for the use of this medication? Prolonged rupture of membranes at 38 weeks gestation Intrauterine growth Post-term pregnancy Active genital herpes

Active genital herpes

A nurse is caring for a client who is Medical History Gravida 1, Para 0 41 weeks of gestation Induction of labor due to postdates Nurses' Notes 1400: Client received epidural anesthesia for reports of a pain level of 7 on a scale of 0 to 10 from uterine contractions. Contractions occurring every 4 to 5 min, lasting 60 seconds, palpate moderate. FHR: Baseline 135/min, average variability, accelerations present, no decelerations noted. Oxytocin infusing at 8 milliunit/min. Rate last increased by 2 milliunits/min at 1330. 1415: Client reports feeling light-headed. Contractions occurring every 4 to 5 min, lasting 60 seconds, palpate moderate FHR: Prolonged deceleration of fetal heart rate to 90/min, minimal variability. Vital Signs 1400: Temperature 37.1° C (98.8° F) Heart rate 72/min Respiratory rate 16/min Blood pressure 128/76 mm Hg Oxygen saturation 96% 1415: Heart rate 90/min Respiratory rate 20/min Blood pr

Administer a bolus of IV fluids. Reposition the client to their side. Apply oxygen at 10 to 12 L/min by nonrebreather mask. Elevate the client's legs.

A nurse is caring for a client who is 26 weeks gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client's head to one side, which of the following actions should the nurse take immediately after the seizure? Monitor the FHR Assess uterine activity Administer oxygen via a nonrebreather mask Start a bolus of IV fluids

Administer oxygen via a nonrebreather mask

A nurse is caring for a newborn who is 72 hr old. Medical History Newborn delivered by repeat cesarean birth at 40 weeks of gestation. Birth weight 3,515 g (7 lb 12 oz) Apgar scores 8 at 1 min and 9 at 5 min Maternal history of methadone use during pregnancy. Vital Signs 0700: Heart rate 156/min Respiratory rate 68/min Temperature 37.7° C (99.9° F) Oxygen saturation 97% on room air 1100: Heart rate 174/min Respiratory rate 84/min Temperature 38.2° C (100.8° F) Oxygen saturation 98% on room air Physical Examination 1100: Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously on pacifier but breastfeeds poorly. Increased muscle tone with moderate to severe tremors when disturbed. Hyperactive Moro reflex noted. Mottled skin noted on extremities. Frequent sneezing. Several loose stools today. Diagnostic Results Maternal urine toxicology screen: positive for opiates (negative) The nurse is plann

Administer scheduled doses of oral morphine. Maintain a low-stimulus environment. Initiate neonatal abstinence syndrome (NAS) scoring.

Diagnostic Results​ Lecithin/sphingomyelin (L/S) ratio 1.4:1 (greater than 2:1) Phosphatidylglycerol (PG) negative (positive) ABO-Rh B-negative Medication Administration Record​ Terbutaline 0.25 mg SQ every hr PRN contractions Rho​(D) immune globulin 300 mcg IM once Nalbuphine 10 mg IV every 3 hr PRN pain Progress Report 1655: Amniocentesis completed, tocotransducer and external fetal monitor applied 1700: Fetal heart rate 130/min with moderate variability Uterine contractions occurring every 5 to 8 min lasting 30 to 60 seconds duration Uterine contractions palpated at 1+ intensity Client reports uterine contraction pain of 2 on a scale of 0 to 10 A nurse is reviewing the medical record at 1800 for a client who is 34 weeks gestation. Based on the chart findings and documentation, the nursing care plan should include which of the following actions? Administer terbutaline Discuss possible genetic anomalies with

Administer terbutaline

A nurse is preparing to administer routine medications to a newborn following birth. Which of the following actions should the nurse take? Administer vitamin K subcutaneously Administer erythromycin eye ointment within 12 hours Administer erythromycin eye ointment from the outer canthus toward the inner canthus Administer vitamin K in the newborns thigh

Administer vitamin K in the newborns thigh

A nurse is planning discharge for a client who is 3 days postpartum. Which of the following nonpharmacological interventions should the nurse include in the plan of care for lactation suppression? Place warm, moist packs on the breasts Apply cabbage leaves to the breasts Wear a loose-fitting bra Put green tea bags on the breasts

Apply cabbage leaves to the breasts

While caring for a client who is in active labor, a nurse notes late decelerations on the fetal monitor.which of the following actions should the nurse take? Administer methyl-prostaglandin IM Encourage the client to use the shower Place the client in a supine position Apply oxygen at 10L/min via nonrebreather face mask

Apply oxygen at 10L/min via no rebreather face mask

A nurse is caring for a patient whose last menstrual period (LMP) began on July 8. Using Naegele's rule, what is the clients estimated date of birth (EDB)? October 1 April 1 October 15 April 15

April 15

A nurse is caring for a newborn Medical History 1000: Apgars: 8 at 1 min and 9 at 5 min Birth weight: Weight: 4,423 g (9 lb 12 oz) Gestational age: 41 weeks Vacuum-assisted birth for large for gestational age term newborn Vital Signs 1030: Temperature 37.1° C (98.8° F) Axillary Heart rate 128/min Respiration rate 52/min Nurses' Notes 1100: Newborn held skin-to-skin with client who is breastfeeding for 1 hr and breastfed vigorously for 30 minutes. Large ecchymotic caput succedaneum noted on occiput with molding of the skull. Anterior fontanel level and soft. Respirations shallow and irregular. Crepitus palpated over left clavicle. Skin color consistent with infant's genetic background. Acrocyanosis noted. Active and moves all extremities except for left arm. Limited spontaneous movement of the left arm noted. Wrist unflexed. Left arm remains at side during Moro reflex. Palmar grasp reflex equal bilaterally Fo

Arm movement- clavicle fracture, Erb-Duchenne Palmar grasp reflex- Erb-Duchenne Moro reflex- clavicle fracture, Erb-Duchenne Crepitus- clavicle fracture Birth history- clavicle fracture, Erb-Duchenne Wrist flexion- Erb-Duchenne

A nurse is caring for a client in the third trimester of pregnancy who is scheduled to undergo a non-stress test. Which of the following actions should the nurse take prior to the test? Ask the client to drink a glass of orange juice Prepare the client for a vaginal exam Request a serum hemoglobin level Obtain a clean-catch specimen

Ask the client to drink a glass of orange juice

A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform? Reassess the client in 2 hr Administer simethicone Assist the client to empty their bladder Instruct the client to lie on their right side

Assist the client to empty their bladder

A nurse is caring for a client who is at 32 weeks gestation and is experiencing preterm labor. What meds should the nurse plan to administer? Misoprolol Betamethasone Poractant alfa Methylergonovine

Betamethasone

A nurse is admitting a client to the labor and delivery unit when the client states, "my water just broke". Which of the following interventions is the nurse's priority? Perform nitrazine testing Assess the fluid Check cervical dilation Begin FHR monitoring

Begin FHR monitoring

A nurse is caring for a client who is 36 weeks gestation and has a postive contraction stress test. The nurse should plan to prepare which of the following diagnostic tests? Biophysical profile Amniocentesis Cordocentesis Kleihauer-Betke test

Biophysical profile

A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client? Percutaneous umbilical blood sampling Amnioinfusion Biophysical profile Chronic villus sampling

Biophysical profile

A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider? Blood pressure 105/64 mmHg Heart rate 98/min Urine output 280 mL within 8 hr Urine negative for ketones

Blood pressure 105/64 mmHg

A nurse is providing teaching to a client who is at 8 wks gestation about manifestations to report to the provider during pregnancy. What info should the nurse include in the teaching? Nausea upon awakening Blurred or double vision Increase in white vaginal discharge Leg cramps when sleeping

Blurred or double vision

A nurse is assessing a client who has preeclampsia with severe features. Which of the following manifestations should the nurse expect? 2+ deep tendon reflexes Hypotension Polyuria Blurred vision

Blurred vision

A nurse is assessing a newborn who is 12 hr old. Which of the following findings should the nurse report to the provider? Subconjunctival hemorrhages Petechia on the trunk and face Central cyanosis Respiratory rate of 40/min

Central cyanosis

A nurse is caring for a newborn who is 70 hr old. Which of the following findings should the nurse report to the provider? Select all that apply Respiratory findings Temperature Oxygen saturation Central nervous system findings Gastrointestinal findings Medical History Newborn delivered by repeat cesarean birth at 40 weeks of gestation. Birth weight 3,515 g (7 lb 12 oz) Apgar scores 8 at 1 min and 9 at 5 min Maternal history of methadone use during pregnancy. Vital Signs 0700: Heart rate 156/min Respiratory rate 58/min Temperature 37.2° C (98.9° F) Oxygen saturation 98% on room air 1100: Heart rate 160/min Respiratory rate 60/min Temperature 37.3° C (99.2° F) Oxygen saturation 96% on room air Physical Examination 1100: Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously on pacifier but breastfeeds poorly. Respirations unlabored. Lungs sound clear on auscultation. Increased muscle tone

Central nervous system findings Gastrointestinal findings

A nurse is caring for a client who is at 39 weeks gestation and shows manifestations of labor. Which of the following findings will alert the nurse that the client is in true labor? Contractions felt in the upper abdomen A small amount of bloody discharge Contractions occurring every 2 to 10 min Changes in cervical dilation or effacement

Changes in cervical dilation or effacement

A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain? Decreased heart rate Chin quivering Pinpoint pupils Slowed respirations

Chin quivering

A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client history should the nurse recognize as a contraindication to oral contraceptives? select all that apply Cholecystitis Hypertension Human papillomavirus Migraine headaches Anxiety disorder

Cholecystitis Hypertension Migraine headaches

A nurse is caring for a client who is in the latent phase of labor and is receiving oxytocin via continuous IV infusion. The nurse notes that the client is having contractions every 2 min which last 100-110 seconds that the fetal heart rate is reassuring. What action should the nurse take? Decrease the dose of oxytocin by half Administer oxygen via nonrebreather mask Decrease the infusion rate of the maintenance IV fluid Administer terbutaline 0.25mg subq

Decrease the dose of oxytocin by half

A nurse is providing teaching about the selection of commercial formula to the guardian of the newborn. Which of the following should the nurse include? Soy-based formula is recommended to decrease colic A,ion acid formula is recommended to increase the newborns protein intake Cows milk based formula is recommended for healthy newborns Low iron formula is recommended to prevent excess iron intake

Cows milk formula is recommended for healthy newborns

A nurse is assessing a client who is at 12 weeks gestation and has a hydatidiform mole. Which of the following findings should the nurse expect? Hypothermia Dark brown vaginal discharge Decreased urinary output Fetal heart tones

Dark brown urinary discharge

A nurse is assessing a client who is at 12 wks gestation and has hydatidiform mole. What findings should the nurse expect? Hypothermia Dark brown vaginal discharge Fetal heart tones Decreased urinary output

Dark brown vaginal discharge

A nurse is assessing a client at 34 weeks gestation who has a mild placental abruption. Which of the following findings should the nurse expect? Increased platelet count Fetal distress Decreased urinary output Dark red vaginal bleeding

Dark red vaginal bleeding

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

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

A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect? Decreased platelet count Increased erythrocyte sedimentation rate (ESR) Decreased megakaryocytes Increased WBC

Decreased platelet count

A nurse is assessing a client who is 26 weeks gestation and has mild preeclampsia. Which of the following findings should the nurse report to the provider? Platelet count 97,000 mm^3 Deep tendon reflexes 4+ Urine protein 1+ BUN 22 mg/dL

Deep tendon reflexes 4+

A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment? Discuss contraceptive options with the client and their partner Repeat information to ensure client understanding Listen to the client and their partner as they reflect upon the birth experience Demonstrate to the client how to perform a newborn bath

Demonstrate to the client how to perform a newborn bath

A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication? Depression Polyuria Hypotension Urticaria

Depression

A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first? Determine respiratory function Increase IV fluid rate Access emergency medications from cart Collect a maternal blood sample

Determine respiratory function

A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take prior to leaving the newborn with their parent? Ensure that the parent's identification band number matches the newborn's identification band number Ask the parent to verify their name and date of birth Check the newborn's security tag number to ensure it matches the newborn's medical record Match the newborn's date and time of birth to the information in the parents medical record

Ensure that the parent's identification band number matches the newborn's identification band number

A nurse is caring for a client who is in labor. Client resting in bed with external fetal monitor in place. Reports discomfort from contractions as a 4 on a scale of 0 to 10. Client doing slow paced breathing during contractions. Client reports blurred vision and a frontal headache rated at a 6 on a scale of 0 to 10. Deep tendon reflexes 3+. Negative for clonus. Contractions: every 6 to 8 min, lasting 45 to 60 seconds, palpate mild/moderate. Uterus soft between contractions. Fetal heart rate: Baseline 135/min, moderate variability, accelerations present, no decelerations noted. Oxytocin infusion rate at 4 milliunits/minute. Magnesium sulfate at 2 g/hr with Lactated Ringer's at 50 mL/hr infusing via peripheral IV. 1130: Client sleepy. Reports pain of a 6 on a scale of 0 to 10 due to uterine contractions. Denies headache or visual disturbances. Deep tendon reflexes are absent. Contractions: occurring every 4 t

Discontinue the magnesium infusion, administer calcium gluconate, and apply oxygen at 10L by nonrebreather mask

The nurse is reviewing laboratory results in the adolescent's medical record. The nurse suspects the adolescent is experiencing pelvic inflammatory disease and is planning care. Which of the following prescriptions should the nurse expect the provider to prescribe (2)? Doxycycline Imiquimod Fluconazole Ceftriaxone Acyclovir

Doxycycline and ceftriaxone

A nurse is teaching a client who is 35 weeks gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include? Shortness of breat when climbing stairs Swelling of feet and ankles at the end of the day Headache that is unrelieved by analgesia Braxtion hicks contractions

Headache that is unrelieved by analgesia

A nurse at a provider's office is caring for a client who is 28 years of age. Gravida 3, Para 2, Abortion 1Asthma (managed with levalbuterol inhaler as needed)Pelvic inflammatory disease (PID)Spontaneous vaginal delivery X 2 (hypertension with first pregnancy at 20 years of age)Voluntary termination of pregnancy (3rd pregnancy) Client presents to the office with concerns of late menses, abdominal pain, and scant dark red vaginal spotting. Client reports menstrual period is usually regular and is 2 weeks late. Last menstrual period: 2/20/XX. Client reports occasional dull abdominal pain and rates it as 2 on a 0 to 10 pain scale. Client is alert and oriented, appears anxious. Speech clear. Skin warm and dry to touch. Heart rate regular at 90/min. Respirations even and non-labored. Lungs slight inspiratory wheezes. Bowel sounds hyperactive in all four quadrants. Abdomen tender to touch right lower quadrant. Perineal pad

Ectopic pregnancy as evidence by right lower quadrant tenderness

A nurse is caring for a newborn. Medical History 1600: Apgar score 9 at 1 min and 9 at 5 min Birth weight 4,706 g (10 lb 6 oz) Gestational age 40 weeks Difficult vaginal birth with shoulder dystocia. Nurses' Notes 1700: Newborn is active and moves all extremities except for right arm. No spontaneous movement of the right arm noted. Right arm remains at side during Moro reflex. Physical Examination 1830: Absent Moro reflex noted in right arm. Right shoulder and arm are internally rotated and adducted. Elbow extended. Forearm pronated with wrist and fingers flexed. Diagnosis: Brachial plexus injury resulting in Erb-Duchenne (Erb's palsy) paralysis. Which of the following actions should the nurse plan to implement? Educate the parents to begin range of motion exercises on the affected arm after 1 week. Assess for grasp reflex in the affected extremity. Immobilize the arm across the abdomen by pinning the newborn's slee

Educate the parents to begin range of motion exercises on the affected arm after 1 week. Assess for grasp reflex in the affected extremity. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt.

A nurse in the antepartum clinic is assessing a clients adaptation to pregnancy. The client states they are "happy one minute and crying the next". The nurse should interpret the client's statement as an indication of which of the following? Emotional liability Focusing phase Cognitive restructuring Couvade syndrome

Emotional liability

A nurse at a provider's office is caring for a client who is 28 years of age. Day 3, 0900: Schedule client for laparoscopic right salpingostomy within 24 hr. Client was given information about ectopic pregnancy. Client to notify provider or go to the emergency room if excessive bleeding, severe sharp abdominal pain, lightheadedness, or dizziness occur. Client to return to office in 2 days for repeat quantitative β-hCG. Transvaginal ultrasound: No intrauterine pregnancy. Pelvic ultrasound: Right Fallopian tube- ampulla contains products of conception. Quantitative β-hCG 15,000 IU/L (negative) Blood type B negative The nurse is preparing the client for surgery. Which of the following actions should the nurse take? Select all that apply. Ensure the client is NPO prior to surgery. Administer Rho(D) immune globulin prior to surgery. Prepare to administer AB positive blood products if needed. Insert an 18-gauge periphera

Ensure the client is NPO prior to surgery Insert an 18-gauge peripheral IV prior to surgery Obtain a complete blood count Verify a consent form is signed by the client

A nurse is caring for a client who is at 22 weeks gestation and reports concern about blotchy hyperpigmentation on their forehead. Which of the following actions should the nurse take? Tell the client to follow up with a dermatologist Explain to the client this is an expected occurrence Instruct the client to increase their intake of vitamin D Inform the client they might have an allergy to their skin care products

Explain to the client this is an expected occurrence

A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect? Deep tendon reflexes 4+ Fundal height 14 cm Blood pressure 142/94 mm Hg FHR 152/min

FHR 152/min

A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? Select all that apply Flaccid uterus Cervical laceration Excessive vaginal bleeding Increased afterbirth cramping Increased maternal temperature

Flaccid uterus Excessive vaginal bleeding

A nurse is caring for a client who is at 10 weeks gestation. Which of the following findings should the nurse report to the provider? Frequent vomiting with weight loss 3lb in 1 week Reports of mood swings Nosebleeds occurring approximately 3x a week Increased vaginal discharge

Frequent vomiting with weight loss 3lb in 1 week

Graphic Record​​ Blood pressure 130/78 mm HgRespiratory rate 20/minHeart rate 90/min Diagnostic Results​​ Hemoglobin 12 g/dL (11 to 16 g/dL)Hematocrit 34% (33% to 47%)1-hr glucose tolerance test 120 mg/dL (less than 180-190 mg/dL) Progress Notes​Fundal height 30 cmGood fetal movementNot experiencing headache, dizziness, blurred vision, or vaginal bleedingFetal heart rate 110/min A nurse is an antepartum clinic is providing care for a client who is at 26 weeks gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider? 1-hr glucose tolerance test Hematocrit Fundal height measurement Fetal heart rate

Fundal height measurement

A nurse is planning care for a client who is at 35 weeks gestation. Which of the following lab tests should the nurse obtain? Rubella tiger Blood type Group B streptococcus b-hemolytic 1-hour glucose tolerance test

Group B streptococcus b-hemolytic

A nurse is caring for a client who has preeclampsia and is recieving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take? Restrict hourly fluid intake to 150 mL/hr Have calcium gluconate readily available Assess deep tendon reflexes every 6 hr Monitor intake and output every 4 hr

Have calcium gluconate readily available

A nurse at a provider's office is caring for a client who is 28 years of age. Temperature 37.2° C (98.9° F) Heart rate 104/min Respirations 18/min Blood pressure 116/70 mm Hg Oxygen saturation 97% room air Blood human chorionic gonadotropin (hCG) 50 IU/L (less than 5 IU/L) Quantitative beta human chorionic gonadotropin (β-hCG) 20,000 IU/L (negative) Progesterone 4 ng/dL (1st trimester 725 to 4400 ng/dL) Hgb 10 g/dL (11 to 16 g/dL) Hct 31% (33 to 47%) Platelets 152,000/mm3​ (150,000 to 300,000/mm3) Complete the following sentence by using the list of options. The nurse should first address the client's - bowel sounds -lung sounds -heart rate followed by the client's -hemoglobin level -anxiety -vaginal spotting

Heart rate Vaginal spotting

A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? Select all that apply Heart rate 154/min Axillary temperature 36° C (96.8° F) Respiratory rate 58/min Length 43 cm (16.9 in) Weight 2,600 g (5 lb 12 oz)

Heart rate 154/min Respiratory rate 58/min Weight 2,600 g (5 lb 12 oz)

A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect of this medication? Hypertension Hypothermia Constipation Muscle weakness

Hypertension

A nurse is teaching a client about breast feeding. Which of the following client teaching statements indicates an understanding of the teaching? I should consume about 700 extra calories a day while breastfeeding I will introduce bottle feeding of pumped breast milk when my baby is 2 weeks I may notice increased cramping when I am feeding my baby I will place my baby in a strict feeding schedule to help establish a good feeding pattern

I may notice increased cramping when I am feeding my baby

A nurse is caring for a newborn. For each assessment finding, specify if the finding is consistent with hypoglycemia, hyperbilirubinemia, or sepsis. Each finding may support more than one disease process. Lethargy Ecchymotic caput succedaneum Yellow sclera and oral mucosa Decreased temperature Respiratory distress Poor feeding Vital Signs 8 hr of age: Temperature: 37.1° C (98.8° F) Axillary Pulse rate: 132/min Respiratory rate: 52/min 36 hr of age: Temperature: 36.1° C (97° F) Axillary Pulse rate: 160/min Respiratory rate: 78/min Nurses' Notes​ 8 hr of age: Newborn is awake, alert, and active. Oral mucosa pink. Respirations easy and unlabored. Extremities flexed. Good muscle tone. Breastfed vigorously x 2 for 30-40 minutes. Fontanel level and soft. Large ecchymotic caput succedaneum noted on posterior scalp. Voided. Passed meconium stool. 36 hr of age: Infant lethargic with hypotonia. Yellow discoloration

Lethargy- hypoglycemia, sepsis Ecchymotic caput succedaneum- hyperbilirubinemia Yellow sclera and oral mucosa- hyperbilirubinemia, sepsis Decreased temperature- hypoglycemia, sepsis Respiratory distress- hypoglycemia, sepsis Poor feeding- hypoglycemia, hyperbilirubinemia, sepsis

A nurse is caring for a client who is recieving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take? Administer aspirin for pain Maintain the client on bed rest Massage the affected leg every 12 hr Apply cold compresses to the affected calf

Maintain the client on bedrest

A. nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the following actions is the nurse's priority? Check the client's capillary refill Massage the client's fundus Insert an indwelling urinary catheter for the client Prepare the client for a blood transfusion

Massage the client's fundus

A nurse is caring for a client who has a soft uterus and increased lochial flow. Which of the following medications should the nurse plan to administer to promote uterine contractions? Terbutaline Nifedipine Magnesium sulfate Methylergonovine

Methylergonovine

A nurse is assessing a newborn who was born at 26 weeks gestation using the New Ballard Score. Which of the following findings should the nurse expect? Minimal arm recoil Popliteal angle of 90 degrees Creases over the entire foot sole Raised areolas with 3 to 4 mm buds

Minimal arm recoil

A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure? Check the client's temperature Observe for uterine contractions Adminiter Rh0 (D) immune globulin Monitor the FHR

Monitor the FHR

A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following interventions should the nurse include in the plan? Monitor the clients blood pressure every hour Restrict the total hourly intake to 200 mL Monitor the FHR continuously Administer protamine sulfate for manifestations of toxicity

Monitor the FHR continuously

A nurse is planning care for a client who is in labor and requesting an epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care? Place the client in a supine position for 30 min following the first dose of anesthetic solution Administer 1,000 mL of dextrose 5% in water prior to the first dose of anesthetic solution Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution Ensure te client has been NPO 4 hr prior to the placement of the epidural and the first dos of anesthetic solution

Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution

A nurse is teaching a client who had a vacuum assisted vaginal delivery. Which of the following statements should the nurse identify as an indication that the client understands the information? My baby's head will be cone shaped for about 2 months My doctor performed this procedure because I didn't dilate past 6 centimetres The doctor performed this procedure because my hemoglobin was low My baby has a higher risk of developing jaundice

My baby has a higher risk of developing jaundice

A nurse is caring for a client who believes she may be pregnant. What finding should the nurse identify as a positive sign of pregnancy? Palpable fetal movement Amenorrhea Chadwick's sign Positive pregnancy test

Palpable fetal movement

A nurse is providing education about family bonding to guardians who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7 y/o child in accepting the new family member? Allow the sibling to hold the newborn during a bath Make sure the sibling kisses the newborn each night Obtain a gift from the newborn to present to the sibling Switch the sibling's room with the nursery

Obtain a gift from the newborn to present to the sibling

A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for a fetal assessment using electronic fetal monitoring? Oligohydramnios Hyperemesis gravidarum Leukorrhea Periodic tingling of the fingers

Oligohydramnios

The nurse is reviewing laboratory results in the adolescent's medical record. The nurse is reviewing the adolesencts medical record. Which of the following conditions is the client most likely developing? - Pelvic inflammatory disease - Ectopic pregnancy - Pyelonephritis as evidence by - Beta hCG level - Urinalysis - C-reactive protein Vital Signs 1300: Blood pressure 118/72 mm Hg Heart rate 100/min Respiratory rate 20/min Temperature 38.3° C (101° F) Provider Prescriptions Standing prescriptions for clients who present with abdominal pain: Obtain laboratory tests: Urinalysis Cervical culture C-reactive protein Beta hCG History and Physical Adolescent is sexually active with two current partners. IUD in place Reports not using condoms during sexual activity. History of type 1 diabetes mellitus Nurses' Notes Admitted adolescent reporting "cramping in my stomach." Reports pain as a 4 on 0 to 10 pain scale and descr

Pelvic inflammatory disease as evidence by C-reactive protein

A nurse is caring for a client who is 38 weeks gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? Determine progression of dilation and effacement Perform leopold maneuvers Complete a sterile speculum exam Prepare a nitrazine paper test

Perform leopald maneuvers

A nurse is caring for a client who is 38 weeks gestation and is receiving an oxytocin IV for labor augmentation. The nurse notes variable decelerations on the FHR tracing. Which of the following actions should the nurse take first? Place the client in a side-lying position Discontinue the oxytocin infusion Apply oxygen to the client via face mask Check for umbilical cord prolapse

Place the client in a side lying position

A nurse is preparing to collect a blood specimen from a newborn via heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn? Apply a cool pack for 10 min to the heel prior to the puncture Request a prescription for IM analgesic Use a manual lance blade to pierce the skin Place the newborn skin to skin on the caregiver's chest

Place the newborn skin to skin on the caregiver's chest

A nurse is providing discharge teaching to the guardian of a newborn about car seat safety. Which of the following instructions should the nurse make? Place the shoulder harness in the slots above the newborn's shoulders Place the retainer clip at the level of the newborn's armpits Place the newborn at a 60° angle in the car seat Place the newborn in a blanket before securing them in the car seat

Place the retainer clip at the level of the newborn's armpits

A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take? Administer antiviral medication Schedule an ultrasound Administer Haemophilus influenzae type b vaccine Schedule an indirect Coombs test

Schedule an ultrasound

A nurse is calculating a clients expected date of birth using Naegele's rule. The client tells the nurse that their last menstraul cycle started on November 27th. Which of the following dates is the client's expected birth? September 3rd September 20th August 3rd August 20th

September 3rd

A nurse is teaching a postpartum client about steps the nurse will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make? "The nurse will carry your baby in their arms to the nursery for scheduled procedures" "We will document the relationship of visitors in your medical record" "It's okay for your baby to sleep in the bed with you while in the hospital" "Staff members who take care of your baby will be wearing a photo identification badge"

Staff members who take care of your baby will be wearing a photo identification badge

A nurse is teaching a new caregiver how to use a bulb syringe to suction their newborn's secretions. Which of the following instructions should the nurse take? Insert the syringe tip before compressing the bulb Suction each of the nares before suctioning the mouth Insert the tip of the syringe into the center of the newborn's mouth Stop suctioning when the newborn's cry sounds clear

Stop suctioning when the newborn's cry sounds clear

A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires interventions by the nurse? Acrocyanosis of the extremities Murmur at the left sternal border Substernal chest retractions while sleeping Positive Babinski reflex

Substernal chest retractions while sleeping

A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider? Substernal retractions Acrocyanosis Overlapping suture lines Head circumference 33 cm (13 in)

Substernal retractions

A nurse is assessing a client who is 30 weeks gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider? Swelling of the face Varicose veins in the calves Nonpitting 1+ ankle edema Hyperpigmentation of the cheeks

Swelling of the face

A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority? O2 saturation Temperature Blood pressure Urinary output

Temperature

A nurse at a provider's office is caring for a client who is 28 years of age. A nurse is evaluating the client following surgery. Which of the following findings indicate that the client is experiencing a potential complication of surgery that requires immediate follow-up? Click to highlight the findings below. Drowsy but easy to arouse. Temperature 35.3° C (95.5° F) Heart rate 60/min Respirations 16/min Blood pressure 90/60 mm Hg Oxygen saturation 94% (oxygen @2 L/min via nasal cannula) Rates pain as 1 on a 0 to 10 pain scale. Skin cool and moist to touch. Heart rate regular. Pedal pulse +1 bilateral. Lungs clear bilateral. Respirations even non labored. Abdomen soft non-distended. Bowel sounds hypoactive in all four quadrants. 2X2 gauze with a clear transparent dressing intact to right lower and upper abdominal quadrant.

Temperature 35.3° C (95.5° F) Blood pressure 90/60 mm Hg Oxygen saturation 94% (oxygen @2 L/min via nasal cannula) Skin cool and moist to touch Pedal pulse +1 bilateral

A nurse is caring for a client who is pregnant. Medical History 0900: Gravida 2 Para 1 31 weeks of gestation Allergies: NKDA Vital Signs 0900: Temperature 38.3° C (101° F) Pulse rate 89/min Respiratory rate 20/min Blood pressure 128/70 mm Hg Oxygen saturation 98% Nurses' Notes 0900: Client reports, ''I've been cramping and have had low back pain since yesterday. It burns when I urinate.'' Client is placed on electronic fetal monitor. Fundal height palpated above the umbilicus. 0930: Fetal heart rate baseline 150/min, moderate variability, spontaneous accelerations present, no decelerations noted. Uterine contractions occurring every 2 minutes, lasting 40-60 seconds, palpate mild to moderate intensity. Vaginal examination reveals cervix is 2 cm dilated and 80% effaced. Which of the following findings should the nurse report to the provider? Click to highlight the findings that require immediate follow-up. Vita

Temperature 38.3° C (101° F) Client reports, "I've been cramping and have had low back pain since yesterday. It burns when I urinate." Uterine contractions occurring every 2 minutes, lasting 40-60 seconds, palpate mild to moderate intensity. Vaginal examination reveals cervix is 2 cm dilated and 80% effaced.

A nurse is planning care for a newborn who is receiving phototherapy. Which of the following interventions should the nurse include in the plan of care? Apply lotion to the skin during phototherapy Supplement feedings with oral glucose water Cover the nares with an opaque mask Turn and reposition the newborn every 2 hours during phototherapy

Turn and reposition the newborn every 2 hours during phototherapy

A nurse is caring for a client who is experiencing preterm labor at 29 weeks gestation and has a prescription for betamethasone. Which of the following statements should the nurse make about the indication for medication administration? This medication will stop your labor This medication stimulates fetal lung maturity This medication will decrease your risk for uterine infections This medication will increase your baby's weight

This medication stimulates fetal lung maturity

A nurse is caring for a client who is 36 weeks gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound? To estimate the fetal weight To locate a pocket of fluid To determine multiparity To prescreen for fetal anomalies

To locate a pocket of fluid

A nurse at a provider's office is caring for a client who is 28 years of age. The nurse is collaborating with another nurse about the client's plan of care. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. Transvaginal ultrasound Meperidine IM Repeat quantitative β-hCG level Methotrexate IM Blood typing

Transvaginal ultrasound- indicated Meperidine IM- contraindicated Repeat quantitative β-hCG level- anticipated Methotrexate IM- anticipated Blood typing- anticipated

A nurse is proviing discharge teaching to a client who is postpartum. For which of the following manifestations should the nurse instruct the client to monitor and report to the provider? Persistent abdominal striae Temperature 37.8 C (100F) Unilateral breast pain Brownish-red discharge on day 5

Unilateral breast pain

A nurse at a prenatal clinic is caring for a client who suspects she may be pregnant and asks the nurse how the provider will confirm her pregnancy. The nurse should inform the client that what lab test will be used to confirm her pregnancy? Urine test for presence of HCG Urine test for the presence of HCS Blood test for presence of estrogend Blood test for the amount of circulating progesterone

Urine test for presence of HCG

A nurse is assessing a client who is at 37 wks gestation and has a suspected pelvic fracture due to blunt abd trauma. What findings should the nurse expect? Uterine contractions Bradycardia Seizures Bradypnea

Uterine contractions

A nurse is caring for a client who is pregnant in an antepartum clinic. Vital Signs 0900: Temperature 36.6° C (97.9° F) Heart rate 88/min Respiratory rate 18/min Blood pressure 130/70 mm Hg Oxygen saturation 97% on room air 1000: Heart rate 76/min Respiratory rate 20/min Blood pressure 138/68 mm Hg Oxygen saturation 98% on room air Medical History 0900: Gravida 3, Para 2 32 weeks of gestation Client reports cramping and lower back pain that started this morning. Client denies leaking fluid. Nurses' Notes 0900: Client placed on electronic fetal monitor. Client reports pain as 4 on a scale of 0 to 10. 1000: FHR assessment 150/min. Average variability. No decelerations. Spontaneous accelerations noted. ​Uterine contractions occurring every 2 min, lasting 40 to 60 seconds in duration. Palpate as moderate intensity. Vaginal examination performed. Cervix is 2 cm dilated and 50% effaced. Which of the following findings

Uterine contractions Gestational age Vaginal examination

A nurse is caring for a newborn who was transferred to the nursery 30min after birth because of mild respiratory distress. Which of the following actions should the nurse take first? Confirm the newborn's Apgar score Verify the newborn's identification Administer vitamin K to the newborn Determine obstetrical risk factors

Verify the newborn's identification

A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI? Large for gestational age Hyperglycemia Bradypnea Vomiting

Vomiting

A nurse is caring for a client who is in labor. The nurse questions the application of an internal fetal scalp monitor. Which of the following responses should the nurse provide? Don't worry. Your baby is fine You will need to ask your provider about the monitor Your provider feels this step would be best We need to observe your baby more closely

We need to observe your baby more closely

A nurse is teaching a prenatal class for a group of antepartum clients. Which of the following pieces of information should the nurse include about hepatitis B immunization? The first dose should be administered at 3 months of age Your baby will receive this immunization subcutaneous,y, which means under the skin We will need your consent prior to administering the vaccine Your baby will receive this vaccine in a series of 5 doses

We will need your consent prior to administering the vaccine

A nurse on an antepartum unit is caring for a client. Nurses' Notes 0900: Client reports a small amount of bright red blood in their underwear upon awakening. Client denies contractions or abdominal pain. External fetal monitor applied. 0930: Client passed large amount of bright red blood from vagina. Denies pain. Uterine tone soft and nontender to palpation. Contraction pattern: no contractions noted. Fetal heart rate pattern: Fetal heart rate baseline 135/min. Moderate variability. No decelerations noted. Vital Signs 0900: Temperature 36.2°C (97.2° F) Pulse rate 78/min Respiratory rate 20/min Blood pressure 112/64 mm Hg Fetal heart rate 132/min 0930: Pulse rate 82/min Blood pressure 116/60 mm Hg Fetal heart rate 160/min Medical History G4P3 30 weeks gestation Previous pregnancies delivered via cesarean section Which of the following nursing actions should the nurse plan to take? For each potential nursing action

Weigh perineal pads- indicated Assess cervical dilation- contraindicated Insert a large bore intravenous catheter- indicated Administer methotrexate- contraindicated

A nurse is assessing a client who is 38 weeks gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider? Blood pressure 136/88 mm Hg Report of insomnia Weight gain of 2.2 kg (4.8 lb) Report of Braxton Hicks contractions

Weight gain of 2.2 kg (4.8 lb)

A nurse is demonstrating to a client how to bathe their newborn. In which order should the nurse perform the following actions? Clean the newborn's diaper area Wash the newborn's neck by lifting the chin Wipe the newborn's eyes from the inner canthus outward Cleanse the skin around the newborn's umbilical cord stump Wash the newborns legs and feet

Wipe the newborn's eyes from the inner canthus outward Wash the newborn's neck by lifting the chin Cleanse the skin around the newborn's umbilical cord stump Wash the newborns legs and feet Clean the newborn's diaper area