OB Final exam 101-165

A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse? "Mongolian spots can be found on the skin of many newborns." "A caput succedaneum occurs due to compression of blood vessels." "This is a cephalhematoma, which can occur spontaneously." "This is erythema toxicum, which is a transient condition."

"A caput succedaneum occurs due to compression of blood vessels."

A nurse is reinforcing teaching about newborn care with a postpartum client. Which of the following statements by the client indicates a need for further teaching? "I will use mild soap." "I will use a basin during bathing." "Baby powder will help prevent a diaper rash." "I will test the water on my wrist for temperature before bathing."

"Baby powder will help prevent a diaper rash."

A nurse is providing education to a client during the first prenatal visit. Which of the following statements by the client should indicate to the nurse a need for clarification? "I should drink about 2 liters of fluid each day." "I should not drink alcoholic beverages during my pregnancy." "I can have a moderate amount of caffeine daily." "I should increase my calcium intake to 1,500 milligrams per day"

"I should increase my calcium intake to 1,500 milligrams per day"

A nurse is caring for a client who is 16 -hr postpartum and states "My baby has been breathing funny, fast and slow, off and on." Which of the following responses should the nurse provide? "Most new mothers feel somewhat anxious about things like this." "There's nothing for you to worry about. Newborns often breathe this way." "Why do you think there is something wrong with that?" "Let's sit here together and observe your baby while you feed him."

"Let's sit here together and observe your baby while you feed him."

A nurse is providing teaching about phenylketonuria (PKU) testing to the parent of a newborn. Which of the following statements by the parent indicates a need for additional teaching? "My baby will be placed under special lights if the test result is positive." "My baby needs to be on formula or breast milk before the test can be done." "This test checks for a genetic disorder that can be managed by diet." "Sometimes the test is repeated in the doctor's office at the baby's 2-week check-up."

"My baby will be placed under special lights if the test result is positive."

A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide? "There is an increased risk of introducing infection." "This could initiate preterm labor." "This could result in profound bleeding." "There is an increased risk of rupture of the membranes."

"This could result in profound bleeding."

A nurse is completing discharge instructions for a new mother and her 2-day-old newborn. The mother asks, "How will I know if my baby gets enough breast milk?" Which of the following responses should the nurse make? "Your baby should have a wake cycle of 30 to 60 minutes after each feeding." "Your baby should wet 6 to 8 diapers per day." "Your baby should burp after each feeding." "Your baby should sleep at least 6 hours between feedings."

"Your baby should wet 6 to 8 diapers per day."

A nurse in a prenatal clinic is teaching a group of clients about nutrition requirements during lactation. Which of the following statements should the nurse make? "Calcium intake should be at least 2,000 mg per day." "Zinc intake should be at least 12 mg per day." "The recommended intake of folic acid remains the same as for pregnant women." "The recommended intake of iron increases."

"Zinc intake should be at least 12 mg per day."

A nurse in a prenatal clinic is caring for a client who is pregnant and asks the nurse for her estimated date of birth (EDB). The client's last menstrual period began on July 27. What is the client's EDB? (State the date in MMDD. For example, July 27 is 0727)

0504 Using Nägele's rule, the nurse subtracts three months from the date of the last menstrual period, then adds 7 days. July minus 3 months equals April. There are 30 days in April, so 27 + 7 = May 4. The client's EDB is May 4, which would be written as 0504 in the MMDD format.

A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 min after delivery. He has a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning. The nurse should document what Apgar score for this infant?

8 Apgar scoring is an assessment of five areas of newborn well-being: respiratory effort, heart rate, muscle tone, reflex irritability, and color. This newborn scores 2 each for heart rate, muscle tone, and reflex irritability. The weak cry and acrocyanosis of the hands and feet score 1 each, for a total of 8.

A nurse is caring for a client during a nonstress test (NST). At the end of a 30-min period of observation, the nurse notes the following findings: The fetal heart rate baseline is 120/min with minimal variability and no accelerations. There are two decelerations of 15 /min in the fetal heart rate during a period of fetal movement, each lasting 20 seconds. Which of the following interpretations of these findings should the nurse make? A negative test A nonreactive test A positive test A reactive test

A nonreactive test

A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.) Administer magnesium sulfate IV. Provide a dark, quiet environment. Assess respiratory status every 4 hr. Evaluate neurologic status every 8 hr. Ensure that calcium gluconate is readily available.

Administer magnesium sulfate IV. Provide a dark, quiet environment. Ensure that calcium gluconate is readily available.

A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following? The client is carrying more than one fetus. There is an elevated level of alpha-fetoprotein (AFP) in the amniotic fluid. An excessive amount of amniotic fluid is present. The fetus is likely to have a congenital anomaly, be growth restricted, or demonstrate fetal distress during labor.

An excessive amount of amniotic fluid is present.

A nurse is caring for a client who is considering several methods of contraception. Which of the following methods of contraception should the nurse identify as being most reliable? A male condom An intrauterine device (IUD) An oral contraceptive A diaphragm with spermicide

An intrauterine device (IUD)

A nurse is caring for a client who presents to a labor and delivery unit experiencing rapidly progressing labor. Which of the following is the priority action for the nurse to take? Cut the umbilical cord. Apply perineal pressure to the emerging fetal head. Prevent the perineum from tearing. Promote delivery of the placenta.

Apply perineal pressure to the emerging fetal head.

A nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure? Monitor the client's temperature. Assess the fetal heart rate. Assess the odor of the amniotic fluid. Provide clean, dry underpads.

Assess the fetal heart rate.

A nurse is assessing a newborn who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect? Absent plantar reflexes Lengthened thigh on the affected side Inwardly turned foot on the affected side Asymmetric thigh folds

Asymmetric thigh folds

A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding? Caput succedaneum Cephalhematoma Molding Pilonidal dimple

Cephalhematoma

A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor? Cervical dilation Report of pain above the umbilicus Brownish vaginal discharge Amniotic fluid in the vaginal vault

Cervical dilation

A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care? Keep four side rails up while the client is in bed. Check the cervix prior to analgesic administration Monitor the fetal heart rate (FHR) every hour. Insert an indwelling urinary catheter.

Check the cervix prior to analgesic administration

A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn? Clear the respiratory tract. Dry the infant off and cover the head. Stimulate the infant to cry. Cut the umbilical cord.

Clear the respiratory tract.

A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor. Which of the following assessment findings should the nurse report to the provider first? Expulsion of a blood-tinged mucous plug Continuous contraction lasting 2 min Pressure on the perineum causing the client to bear down Expulsion of clear fluid from the vagina

Continuous contraction lasting 2 min

A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply.) Cracked, peeling skin Positive Moro reflex Short, soft fingernails Abundant lanugo Vernix in the folds and creases

Cracked, peeling skin Positive Moro reflex

A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take? Discontinue the medication infusion. Prepare for an emergency cesarean birth. Assess maternal blood glucose. Place the client in Trendelenburg position.

Discontinue the medication infusion.

A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention? Decreased urge to void Increased urine output Displaced fundus from the midline Fundal height below the umbilicus

Displaced fundus from the midline

A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications? Anaphylactoid syndrome of pregnancy Disseminated intravascular coagulation Preeclampsia Puerperal infection

Disseminated intravascular coagulation

A nurse is caring for a client who had a vaginal delivery 2 hr ago. Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.) Document fundal height. Massage a firm fundus. Observe the lochia during palpation of fundus. Determine whether the fundus is midline. Administer methylergonovine maleate if uterus is boggy.

Document fundal height. Observe the lochia during palpation of fundus. Determine whether the fundus is midline. Administer methylergonovine maleate if uterus is boggy

A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action? Administer vitamin K. Dry the skin. Administer eye prophylaxis. Place an identification bracelet.

Dry the skin.

A nurse is assessing a newborn who was born at 42.5 weeks of gestation. Which of the following findings should the nurse expect? Copious vernix Scant scalp hair Increased subcutaneous fat Dry, cracked skin

Dry, cracked skin

A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn? Placing the newborn on a warm surface Preventing air drafts Drying the newborn's skin thoroughly Maintaining ambient room temperature at 24° C (75° F)

Drying the newborn's skin thoroughly

A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider? Headaches Nervousness Tremors Dyspnea

Dyspnea

A nurse is caring for a client who is 7 days postpartum and calls the clinic to report pain and redness of her left calf. Besides seeing her provider, which of the following interventions should the nurse suggest? Flex her knee while resting. Massage the area. Elevate her leg. Apply cold compresses.

Elevate her leg.

A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder? Increased urine output Vaginal discharge Elevated blood pressure Joint pain

Elevated blood pressure

A nurse is caring for a client who has a positive pregnancy test. The nurse is teaching the client about common discomforts in the first trimester of pregnancy as well as warning signs of potential danger. The nurse should instruct the client to call the clinic if she experiences which of the following manifestations? Leukorrhea Urinary frequency Nausea and vomiting Facial edema

Facial edema

A nurse is caring for a client who is to undergo a biophysical profile. The client asks the nurse what is being evaluated during this test. Which of the following should the nurse include? (Select all that apply.) Fetal breathing Fetal motion Fetal neck translucency Amniotic fluid volume Fetal gender

Fetal breathing Fetal motion Amniotic fluid volume

A nurse is planning care for a client who is 2 hours postpartum following a cesarean birth. The client has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care? Apply warm, moist heat to the client's lower extremities. Massage the client's posterior lower legs. Place pillows under the client's knees when resting in bed. Have the client ambulate.

Have the client ambulate.

A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication? Orthostatic hypotension Fundus palpable at the umbilicus Urine output of 3,000 mL in 12 hr Heart rate 110/min

Heart rate 110/min

A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following should the infant receive? Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine monthly for 6 months Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth Hepatitis B vaccine at 24 hr followed by hepatitis B immune globulin every 12 hr for 3 days

Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth

A nurse in a clinic is assessing a client who is at 8 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse expect? (Select all that apply.) History of migraines Nulliparous Twin gestations History of gestational hypertension Oligohydramnios

History of migraines Nulliparous Twin gestations

A nurse is preparing to administer an injection of Rho (D) immunoglobulin. The nurse should understand that the purpose of this injection is to prevent which of the following newborn complications? Hydrops fetalis Hypobilirubinemia Biliary atresia Transient clotting difficulties

Hydrops fetalis

A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2 diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the most likely cause of the respiratory distress is which of the following? Hyperinsulinemia Increased deposits of fat in the chest and shoulder area Brachial plexus injury Increased blood viscosity

Hyperinsulinemia

A nurse is admitting a client who has a diagnosis of preterm labor. The nurse anticipates a prescription by the provider for which of the following medications? (Select all that apply.) Prostaglandin E2 Indomethacin Magnesium sulfate Methylergonovine Oxytocin

Indomethacin Magnesium sulfate

A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first? Cover the cord with a sterile, moist saline dressing. Prepare the client for an immediate birth. Place the client in knee-chest position. Insert a gloved hand into the vagina to relieve pressure on the cord.

Insert a gloved hand into the vagina to relieve pressure on the cord.

A nurse is completing a health history for a client who is at 6 weeks of gestation. The client informs the nurse that she smokes one pack of cigarettes per day. The nurse should advise the client that smoking places the client's newborn at risk for which of the following complications? Hearing loss Intrauterine growth restriction Type 1 diabetes mellitus Congenital heart defects

Intrauterine growth restriction

A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rho (D) immunoglobulin. Which of the following should be included in the teaching? It prevents the formation of Rh antibodies in mothers who are Rh negative. It destroys Rh antibodies in mothers who are Rh negative. It destroys Rh antibodies in newborns who are Rh positive. It prevents the formation of Rh antibodies in newborns who are Rh positive.

It prevents the formation of Rh antibodies in mothers who are Rh negative.

A charge nurse observes a nurse checking fetal heart tones (FHT) for a client who is at 12 weeks of gestation. Which of the following actions by the nurse indicates a need for intervention by the charge nurse? Places a pillow under the client's head Counts the fetal heart rate for a full minute Auscultates above the symphysis pubis Listens with a fetoscope

Listens with a fetoscope

A nurse is preparing to administer oxygen via hood therapy to a newborn who was born at 30 weeks of gestation. Which of the following is an appropriate nursing action when providing care to this infant? Remove the hood every hour for 10 min to facilitate bonding. Insert an orogastric tube for decompression of the stomach. Place the newborn in Trendelenburg position. Maintain oxygen saturations between 93% to 95%.

Maintain oxygen saturations between 93% to 95%

A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant? Maintain the integrity of the sac. Promote maternal-infant bonding. Educate the parents about the defect. Provide age-appropriate stimulation.

Maintain the integrity of the sac.

A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn's plan of care? Monitor I&O. Monitor axillary temperature. Monitor blood glucose levels. Monitor weight.

Monitor blood glucose levels.

A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client's ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should be included in the newborn's plan of care? Observe for meconium in respiratory secretions. Monitor for hyperglycemia. Identify manifestations of anemia. Monitor for hyperthermia.

Observe for meconium in respiratory secretions.

A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take? Obtain blood glucose by heel stick. Initiate phototherapy. Monitor the newborn's blood pressure. Place the newborn in a radiant warmer.

Obtain blood glucose by heel stick.

A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform? Immediately report the situation to the client's provider and prepare the client for induction of labor. Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring. Offer the client a snack of orange juice and crackers. Turn the client onto her left side.

Offer the client a snack of orange juice and crackers.

A nurse is assessing a client for postpartum infection. Which of the following findings should indicate to the nurse that the client requires further evaluation for endometritis? Moderate amount of dark red lochia with a bloody odor A localized area of breast tenderness Pelvic pain Hematuria

Pelvic pain

A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first? Place the client in the lateral position. Increase the rate of maintenance IV infusion. Elevate the client's legs. Administer oxygen using a nonrebreather mask.

Place the client in the lateral position.

A nurse is planning care for a newborn who has spinal bifida. Which of the following actions should be included in the plan of care? Obtain rectal temperatures. Place the newborn in the prone position. Cover the lesion with a dry dressing. Apply snug, clean diapers.

Place the newborn in the prone position.

A nurse is caring for a client who is at 18 weeks of gestation. The client tells the nurse that she felt fluttering movements in her abdomen 3 days ago. The nurse should interpret this finding as which of the following? Ballottement Lightening Quickening Chloasma

Quickening

A nurse is caring a client who is 3 days postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis? Swelling in both breasts Cracked and bleeding nipples Red and painful area in one breast A white patch on a nipple

Red and painful area in one breast

A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding? Tachycardia Absence of clonus Polyuria Report of headache

Report of headache

A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client? Temperature Fetal Heart Rate (FHR) Bowel sounds Respiratory rate

Respiratory rate

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion? Diminished deep-tendon reflexes Respiratory rate of 16/min Urine output of 50 mL in 4hr Heart rate of 56/min

Respiratory rate of 16/min

A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones? Left lower Right lower Left upper Right upper

Right upper

A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make? The presenting part is 1 cm above the ischial spines. The presenting part is 1 cm below the ischial spines. The cervix is 1 cm dilated. The cervix is effaced 1 cm.

The presenting part is 1 cm above the ischial spines.

A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first? Palpate the client's uterus. Administer oxygen to the client. Increase the client's IV fluid infusion rate. Turn the client onto her side.

Turn the client onto her side.

A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis? Severe nausea and vomiting Large amount of vaginal bleeding Unilateral, cramp-like abdominal pain Uterine enlargement greater than expected for gestational age

Unilateral, cramp-like abdominal pain

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following? Uteroplacental insufficiency Maternal bradycardia Umbilical cord compression Fetal head compression

Uteroplacental insufficiency