OB Final

A client who has just given birth to a healthy newborn required an episiotomy. Which action would the nurse implement immediately after birth to decrease the client's pain from the procedure? Apply an ice pack to the site. Offer warm blankets. Encourage the woman to void. Offer a warm sitz bath.

Apply an ice pack to the site.

A nurse is assisting in the care of a newborn shortly after birth. Which of the following actions should the nurse take to assist in the prevention of hyperbilirubinemia? Begin phototherapy. Initiate early feeding. Remove mucous with a bulb syringe. Administer phytonadione

Initiate early feeding.

A nurse is caring for a newborn who is formula fed. The newborn takes 0.5 oz of formula at 0800, 1 oz at 1100, 0.5 oz at 1300, 0.5 oz at 1600, and 0.5 oz at 1830. How many mL of formula should the nurse record as the client's intake for the shift? 80 mL 70 mL 100 mL 90 mL

90 mL

A client experienced prolonged labor with prolonged premature rupture of membranes. The nurse would be alert for which condition in the mother and the newborn? hemorrhage trauma infection hypovolemia

infection

A nurse is assisting a client with breastfeeding her newborn. The nurse should explain that which of the following reflexes will initiate sucking? Stepping Babinski Rooting Moro

rooting

A nurse is caring for a client who has unrelieved episiotomy pain 8 hr following delivery. Which of the following actions should the nurse take? Apply an ice pack to the perineum. Prepare a warm sitz bath. Place a soft pillow under the client's buttocks. Position a heating lamp toward the episiotomy.

Apply an ice pack to the perineum.

The nurse is caring for a client experiencing a prolonged second stage of labor. The nurse would place a priority on preparing the client for which intervention? Assisted delivery with forceps and/or vacuum A precipitous birth Artificial rupture of membranes A cesarean section

A cesarean section

The nurse is working with a group of community health members to develop a plan to address the special health needs of women. The group would design educational programs to address which condition as the priority? A. Heart disease B. Cancer C. Diabetes D. Smoking

A. Heart disease

The patient has an order in place for Lactulose 30 g via G-Tube to be administered BID. The nurse has available Lactulose 10 g/15 mL. How many mL will the nurse administer via the G-Tube? 10 mL 150 mL 45 mL 30 mL

45 mL

A nurse is caring for a client who is being evaluated for endometrial cancer. Which of the following findings should the nurse expect the client to report? A. Hot flashes B. Recurrent urinary tract infections C. Blood in the stool D. Abnormal vaginal bleeding

A. Hot flashes

The nurse is caring for a client after experiencing a placental abruption, Which findings the priority to report to the healthcare provider? 45mL urine output in 2 hours Hemoglobin of 13g/dL Hematocrit of 36% Platelet count of 150,000 mm

45mL urine output in 2 hours The nurse knows a placental abruption places a client at high risk of hemorrhage. A decreased urine output indicates decreased perfusion from blood loss.

A nurse is reinforcing teaching with a client who is in labor about why epidural anesthesia is not initiated until a good labor pattern has been established. Which of the following explanations should the nurse include? A."Given too soon, epidural anesthesia can cause fetal depression." B."Given too soon, epidural anesthesia will delay rupture of fetal membranes." C."Given too soon, epidural anesthesia can cause maternal hypertension." D. "Given too soon, epidural anesthesia can prolong labor."

"Given too soon, epidural anesthesia can prolong labor."

A nurse is reinforcing teaching about comfort measures for breast engorgement with a client who is postpartum and is bottle feeding her newborn. Which of the following statements by the client indicates a need for further teaching? "I will wear a snug fitting bra." "I should crush cabbage leaves and place them on my breast." "I will apply ice packs to my breasts." "I should stimulate my nipples by squeezing softly."

"I should stimulate my nipples by squeezing softly."

A nurse is assisting with the care of a client who is in labor and has the urge to push. Which of the following instructions should the nurse give the client? a. "I will let you know when you should push according to your contractions." b. "Take a deep, cleansing breath before and after each contraction." c. "You should push continuously throughout the entire contraction." d. "Hold your breath and push while I count to ten."

"I will let you know when you should push according to your contractions."

A postpartum client who is bottle feeding her newborn asks, "When should my period return?" Which response by the nurse would be the most appropriate? "It's difficult to say, but it will probably return in about 2 to 3 weeks." "You don't have to worry about it returning for at least 3 months." "You don't have to worry about that now, it will be quite a while." "It varies, but you can estimate it returning in about 7 to 9 weeks."

"It varies, but you can estimate it returning in about 7 to 9 weeks."

A nurse is reinforcing teaching about newborn care with a client who is 2 hr postpartum. Which of the following statements by the client indicates a need for further teaching? "I will place my baby on my stomach and cover her with a warm blanket." "My baby's bassinet should be kept away from fans and air conditioning." "My baby's temperature will be checked rectally every hour." "I should keep my baby's head covered."

"My baby's temperature will be checked rectally every hour."

A client who is breast-feeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate? "Your body is responding to the events of labor, just like after a tough workout." "Let me check your vaginal discharge just to make sure everything is fine." "The baby's sucking releases a hormone that causes the uterus to contract." "Your uterus is still shrinking in size; that's why you're feeling this pain."

"The baby's sucking releases a hormone that causes the uterus to contract."

A nurse is collecting data from a newborn 1 hr after delivery. Which of the following respiratory rates is within the expected reference range for a newborn? ​100/min ​48/min ​22/min ​110/min

48/min

A nurse is caring for a newborn who was delivered by vacuum extraction and has swelling on his head that crosses the suture line. The newborn's mother asks about the swelling on her newborn's head. Which of the following responses should the nurse make? "This is a cephalhematoma, which will resolve on its own in 3 to 5 days." "This is a Mongolian spot, which is found on many newborns." "This is erythema toxicum, which is a transient allergic reaction that causes edema in the skin." "This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor."

"This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor."

A primigravida is admitted to the labor and delivery unit. Her membranes have ruptured, she is 1 cm dilated, 20% effaced, and is not having contractions. She asks the nurse, "Do I get the epidural now? I really don't want any pain." The best response by the nurse is: (Select all that apply). "We can't give the epidural until you are well established in labor or it may slow your labor." "What can I do to help you relax? "I will call the anesthesiologist immediately and get started on it." "I can help you cope with the pain until the epidural is started." "You might as well accept you will have pain with labor and delivery."

"We can't give the epidural until you are well established in labor or it may slow your labor." "What can I do to help you relax?" "I can help you cope with the pain until the epidural is started."

A nurse is caring for a client who is postpartum. The client states, "I am concerned about my baby's hearing because my mother was born deaf." Which of the following statements should the nurse make? ​"Look at how she looks as you when you speak. That's a good sign." "The best way to determine if your baby can hear is to clap your hands loudly and see if she startles." "There is no need to worry about that. Most forms of hearing loss are not inherited." "We do routine hearing screenings on newborns. You'll know the results before you leave the hospital."

"We do routine hearing screenings on newborns. You'll know the results before you leave the hospital."

A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the baby's mouth, which of the following responses by the nurse is appropriate? "Babies know instinctively exactly how much of the nipple to take into their mouth." "Try to place the nipple, the entire areola, and some breast tissue beyond the areola into her mouth." "Your baby's mouth is rather small so she will only take part of the nipple." "You should place your nipple and some of the areola into her mouth."

"You should place your nipple and some of the areola into her mouth."

A nurse is reinforcing teaching about signs preceding the onset of labor with a client who is at 39 weeks of gestation. Which of the following statements should the nurse include? "You will have a decrease in vaginal discharge." "You will experience a surge of energy." "You will experience urinary retention." "You will have a weight gain of 0.5 to 1.5 kilograms."

"You will experience a surge of energy." Prior to the onset of labor, the pregnant client experiences a surge of energy.

A woman who gave birth 24 hours ago tells the nurse, "I've been urinating so much over the past several hours." Which response by the nurse would be most appropriate? "The anesthesia that you received is wearing off and your bladder is working again." "You must have an infection, so let me get a urine specimen." "Your uterus is not contracting as quickly as it should." "Your body is undergoing many changes that cause your bladder to fill quickly."

"Your body is undergoing many changes that cause your bladder to fill quickly."

The provider has ordered Morphine Sulfate 4 mg IV every 4 hours PRN for pain. The nurse has available Morphine Sulfate 10 mg/mL. How many mL will the nurse administer? 4 mL 2.5 mL 40 mL 0.4 mL

0.4 mL

The physician has ordered 100 ml D5W with 1000 mg of Ampicillin IVPB every 6 hours. The IV tubing delivers 10 gtts/ml. The instructions from the pharmacist state to infuse over 30 minutes. The rate of infusion will be how many gtts/min? 33 mL/hr 33 gtts/min 34 gtts/min 34 mL/hr

33 gtts/min

The physician writes an order for Heparin 700units/hr. The label on the I.V. bag reads: Heparin 10,000 units in 500 mL D5W. How many mL/hr will deliver the correct dose? 15 mL/hr 13 mL/hr 35 mL/hr 10 mL/hr

35 mL/hr

A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the RNimmediately? A client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions is tearful A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors A client who has preeclampsia has 2+ patellar reflexes and 2+ proteinuria A client who has preeclampsia and reports epigastric pain and unresolved headache

A client who has preeclampsia and reports epigastric pain and unresolved headache using the urgent vs nonurgent framework for nursing care, the nurse should report these findings to the charge nurse. These manifestations indicate that the client's condition is worsening and are manifestations of severe preeclampsia. Manifestations of severe preeclampsia include BP 160/100 mm Hg or greater; proteinuria 3 to 4+; oliguria; elevated serum creatinine greater than 1.2 mg/dL; cerebral or visual disturbances; hyperreflexia with possible ankle clonus; pulmonary, cardiac, or hepatic involvement, including elevated liver enzymes, nausea, vomiting, epigastric pain, and right upper-quadrant pain; extensive peripheral edema; and thrombocytopenia.

A nurse is caring for a client who is at 36 weeks of gestation and has suspected placenta previa. For which of the following findings should the nurse monitor the client? A. Abdominal pain with minimal red vaginal bleeding B. A large amount of bright red vaginal bleeding without pain C.Severe abdominal pain with increasing fundal height D.Intermittent abdominal pain following passage of bloody mucus

A large amount of bright red vaginal bleeding without pain With placenta previa, the placenta implants in the lower part of the uterus, partly or completely obstructing the cervical os, or outlet to the vagina. Clients who have placenta previa have sudden, painless vaginal bleeding, typically in the third trimester.

A 36-week pregnant client presents to the OB department for a scheduled external cephalic version. The nurse understand the potential complications of an external cephalic version include: (Select all that apply). a) Twisting of the umbilical cord b) Placenta abruptio c) Brachial plexus injury d) Placenta accreta e) Rupture of amniotic membrane

A)Twisting of the umbilical cord B)Placenta abruptio C)Brachial plexus injury E)Rupture of amniotic membranes

A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority? A. hemorrhage B. jaundice C. infection D. edema

A. hemorrhage

A nurse is assisting with the care of a client who is in early labor with intact membranes and a temperature of 38.9° C (102° F). After notifying the provider, which of the following actions should the nurse take? a. Recheck the client's temperature in 2 hr. b. Administer acetaminophen orally. c. repare the client for placement of an intrauterine pressure catheter. d. Administer misoprostol vaginally.

Administer acetaminophen orally. The nurse should administer acetaminophen to lower the client's temperature and encourage her to drink sips of water. Acetaminophen is a pregnancy risk category B medication, so it is likely that the provider will prescribe it.

A nurse is assisting in the care of a client who is in active labor. The nurse notes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take first? a. Elevate the client's legs. b. Position the client on her side. c.Administer oxygen via face mask. ​d.Increase the infusion rate of the IV fluid

Administer oxygen via face mask. The nurse should administer oxygen to increase the oxygen concentration of the blood that reaches the placenta; however, there is another action that is the priority.

A nurse is assisting with the care of a client who is using pattern-paced breathing during the first stage of labor. The client says she feels lightheaded and her fingers are tingling.Which of the following actions should the nurse take? Administer oxygen via nasal cannula. Assist the client to breathe into a paper bag. Have the client tuck her chin to her chest. ​Instruct the client to maintain a breathing rate no less than twice the normal rate.

Administer oxygen via nasal cannula.

​A nurse is caring for a client who is 2 days postpartum, is breastfeeding, and reports nipple soreness. Which of the following measures should the nurse suggest to help lessen discomfort during breastfeeding? (Select all that apply.) Start breastfeeding with the nipple that is most sore. Let the newborn sleep for long periods so the nipples can heal. Alternate breasts at the beginning of each feeding. Apply breast milk to her nipples before each feeding. Change the infant's position on the nipples.

Alternate breasts at the beginning of each feeding. Apply breast milk to her nipples before each feeding. Change the infant's position on the nipples.

A patient suddenly begins having difficulty breathing, becomes confused, and is hypotensive. The nurse suspects what condition? Placenta abruption Uterine prolapse Placenta accreta Amniotic fluid embolism

Amniotic fluid embolism Amniotic fluid embolism signs and symptoms might include: Sudden shortness of breath Excess fluid in the lungs (pulmonary edema) Sudden low blood pressure Sudden failure of the heart to effectively pump blood (cardiovascular collapse) Life-threatening problems with blood clotting (disseminated intravascular coagulopathy) Bleeding from the uterus, cesarean incision or intravenous (IV) sites Altered mental status, such as anxiety or a sense of doom Chills Rapid heart rate or disturbances in the rhythm of the heart rate Fetal distress Seizures Loss of consciousness

A nurse is reinforcing teaching about a biophysical profile with a client who is at 40 weeks of gestation. The nurse should explain that this profile focuses on which of the following parameters? (Select all that apply.) a. Nuchal translucency b. Amniotic fluid volume c. Fetal breathing d. Fetal motion e. Fetal gender

Amniotic fluid volume Fetal breathing Fetal motion

A nurse is reinforcing teaching with a client who is scheduled for a nonstress test (NST). Which of the following information should the nurse include? a. The client will be asked to stimulate her nipples for 5 min during the test. b. An IV will be initiated prior to the test. c. An external fetal monitor will be used to monitor the FHR. d. The client will receive an ultrasound prior to the test.

An external fetal monitor will be used to monitor the FHR. During a nonstress test, the client is seated in a semi-reclining position. An external fetal monitor is applied to detect the FHR and uterine contractions. The FHR is monitored for 20 to 30 min. A reactive, or reassuring, FHR is determined to be the presence of two accelerations in a 20-min period, each lasting at least 15 seconds and peaking at least 15 beats/min above the FHR baseline.

A nurse is caring for a client who is at 34 weeks of gestation and has a suspected placenta previa. Which of the following actions should the nurse take? a. Apply ice to the perineal area. b. Complete a vaginal exam. c. Apply an external fetal monitor. d. Perform a rectal exam.

Apply an external fetal monitor. The nurse should immediately apply the fetal monitor to determine if the fetus is in distress.

​A nurse is collecting data from a client who is 3 days postpartum and is breastfeeding. Her fundus is three fingerbreadths below the umbilicus, and her lochia rubra is moderate. Her breasts feel hard and warm. Which of the following recommendations should the nurse give the client? Express milk from both breasts. Apply a heating pad to her breasts. Obtain a prescription for an antibiotic. Wear a nipple shield.

Apply a heating pad to her breasts.

A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7° C (100° F), pulse rate 88./min, respiratory rate 18/min. Which of the following actions should the nurse perform? Ask the client to empty her bladder. Increase IV fluids. encourage the client to nurse more frequently so her milk will come in. Report the client's temperature elevation.

Ask the client to empty her bladder.

A nurse is caring for a client who is 38 weeks gestation and has been diagnosed with chorioamnionitis. Which of the following nursing interventions is a priority? Administer oxytocin Monitor WBC count Assess temperature Assess amniotic fluid

Assess temperature

During a vaginal delivery, the physician states that a shoulder dystocia is occurring. Which intervention may be expected of the nurse? Prepare the vacuum extractor for the health-care provider to use. Call the laboratory for an immediate blood type and crossmatch Place the patient in Trendelenburg's position Assist the client to flex her thighs upon her abdomen.

Assist the client to flex her thighs upon her abdomen. CORRECT McRobert's manoeuvre - hyperflex maternal hips (knees to chest position) and tell the patient to stop pushing. This widens the pelvic outlet by flattening the sacral promontory and increasing the lumbosacral angle. This single manoeuvre has a success rate of about 90% and is even higher when combined with 'suprapubic pressure',

A client who is in labor presents with shoulder dystocia of the fetus. Which nursing intervention is a priority when managing care and preparing for delivery? Assisting in positioning the woman in a squatting position. Assess for reports of intense back pain in the first stage of labor. Anticipate possible use of forceps to rotate to anterior position at birth. Assess for prolonged second stage of labor with arrest of descent.

Assisting in positioning the woman in a squatting position. The nurse caring for the client in labor with shoulder dystocia of the fetus should assist with positioning the client in squatting position. The client can also be helped into the hands and knees position or lateral recumbent position for birth to free the shoulders. Assessing for intense back pain in the first stage of labor, anticipating possible use of forceps to rotate the anterior position at birth, and assessing for prolonged second stage of labor with arrest of descent are important interventions when caring for a client with persistent OP (occiput posterior) position of the fetus.

A nurse is caring for a client who is at 38 weeks of gestation who has a score of 10 on her biophysical profile (BPP). Which of the following actions should the nurse take? a.Assure the client that the score is within the expected range. b.Assist the client into a side-lying position. c.Administer oxygen and notify the provider. d.Offer the client orange juice and repeat the assessment in 1 hr.

Assure the client that the score is within the expected range.

A nurse is collecting data from a client who is 12 hr postpartum following a spontaneous vaginal delivery. The nurse should expect to find the uterine fundus at which of the following positions on the client's abdomen? ​One fingerbreadth above the symphysis pubis At the level of the umbilicus To the right of the umbilicus Three fingerbreadths above the umbilicus

At the level of the umbilicus

A nurse seeing Ariana walking down the hall and says, "Me la Pelas Ary." How bad "se la pela" la Ary? A. A little bit B. A SHIT TON C. 50/50 D. Ponte derechita Emy.

B D

A nurse is reviewing the laboratory results of a newborn that is 4 hr old. Which of the following findings should the nurse identify as the priority? Bilirubin 18 mg/dL Blood glucose 50 mg/dL Platelets 200,000/mm³ Hemoglobin 22 g/dL

Bilirubin 18 mg/dL

A nurse is reinforcing teaching with a new mother about the purpose of administering vitamin K to her newborn following delivery. The nurse should explain that the purpose of administering vitamin K is to prevent which of the following complications? Potassium deficiency Infection Hyperbilirubinemia Bleeding

Bleeding

​A nurse is caring for a newborn who is small for gestational age (SGA). Which of the following findings should the nurse expect? Decreased circulating RBC Blood glucose instability Well rounded abdomen Retinopathy

Blood glucose instability

A nurse is assisting with monitoring a client in labor who has preeclampsia and is receiving magnesium sulfate. The client's respiratory rate is 8/min. Which of the following should the nurse administer? Naloxone Protamine sulfate Flumazenil Calcium gluconate

Calcium gluconate The nurse should plan to administer calcium gluconate or calcium chloride as the reversal agent for a client who experiences magnesium sulfate toxicity.

A nurse is collecting data from a newborn and notes a swollen area on the head that does not cross the suture line. The nurse should document this finding as which of the following? Molding Cephalhematoma Nevus flammeus Caput succedaneum

Cephalhematoma

A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first? Feel for a full bladder. Measure the client's vital signs. Check the client's fundus. Request the provider perform a vaginal examination.

Check the client's fundus.

A nurse is assisting with the care of a newborn following a vaginal delivery. Which of the following actions should the nurse perform first? Clear the airway. Stimulate the infant to cry. Dry the infant off and cover the head. Clamp the umbilical cord.

Clear the airway.

A nurse is contributing to the plan of care for a preterm newborn. To help the newborn conserve energy, which of the following actions should the nurse recommend? Cluster the newborn's care activities. to prevent excessive stimulation. Place elbow restraints on the newborn. Allow opportunities for newborn massage. Change the newborn's position every 2 hr.

Cluster the newborn's care activities. to prevent excessive stimulation.

A nurse is caring for a newborn shortly after birth and places the newborn under a radiant warmer. Which of the following potential complications does this action help to prevent? Cold stress Shivering Brown fat production Thermogenesis

Cold stress

A nurse is collecting data from a newborn who is 12 hr old. His respiration rate is 44/min, shallow, with periods of apnea lasting up to 5 seconds. Which of the following actions should the nurse take? Continue routine monitoring. Request an order for supplemental oxygen. Activate respiratory arrest procedures. Report the observation to the charge nurse immediately.

Continue routine monitoring.

A nurse is assisting a nurse midwife in examining a client who is a primigravida at 42 weeks of gestation and states that she thinks she is in labor. Which of the following findings confirmthat the client is in labor? Cervical dilation Pain just above the navel Contractions every 3 to 4 min Amniotic fluid in the vaginal vault

Contractions every 3 to 4 min

A nurse is caring for a client who is experiencing shaking chills during the immediate postpartum period. Which of the following actions should the nurse take? Place the client on seizure precautions. Notify the charge nurse. Cover the client with warm blankets. Determine the client's temperature.

Cover the client with warm blankets.

During a vaginal exam, the nurse notes that the lower uterine segment is softened. The nurse documents this finding as: A. Ortolans's sign. B. Goodall's sign. C. Chadwick's sign. D. Hagar's sign.

D. Hagar's sign.

A nurse is assisting with the admission of a client who is at 38 weeks of gestation and has severe preeclampsia. When collecting data from the client, the nurse should expect which of the following findings? A. Tachycardia B. Diplopia C. Polyuria D. Headache

D. Headache

A nurse is collecting data from a client who is postpartum 2 hr following delivery of a healthy newborn. Which of the following findings indicates the client's bladder is distended? Heart rate 52/min ​Increased uterine contractions Decreased lochia Elevated fundus level

Elevated fundus level

Which compound would the nurse have readily available for a client who is receiving magnesium sulfate to treat severe preeclampsia? A. calcium carbonate B. ferrous sulfate C. potassium chloride D. calcium gluconate

D. calcium gluconate

A nurse is preparing to examine a post-term newborn immediately following delivery. Which of the following findings should she expect to observe? (Select all that apply.) Easy heel to ear movability. Lanugo covering shoulders and back. Deep plantar creases. Vernix in the folds and creases Cracked, peeling skin

Deep plantar creases. Cracked, peeling skin

A nurse is collecting data from an infant who has hydrocephalus. Which of the following findings should the nurse expect? Proteinuria Soft and flat fontanels Hypertension Dilated scalp veins

Dilated scalp veins

​A nurse on the postpartum unit is collecting data from a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize this client is at risk for which of the following postpartum complications? a. Preeclampsia b. Puerperal infection c. Disseminated intravascular coagulation (DIC) d. Amniotic fluid embolism

Disseminated intravascular coagulation (DIC)

A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 66 beats per minute. Which of these actions should the nurse take? Contact the primary care provider, as it indicates early DIC. Obtain an order for a CBC, as it suggests postpartum anemia. Document the finding, as it is a normal finding at this time. Contact the primary care provider, as it is a first sign of postpartum eclampsia.

Document the finding, as it is a normal finding at this time.

A nurse is collecting data from a newborn and finds an apical pulse of 130/min. Which of the following actions should the nurse take? Document this as an expected finding. Prepare the newborn for transport to the NICU. Ask another nurse to verify the heart rate. Call the neonatologist to assess the newborn.

Document this as an expected finding.

A nurse is caring for a newborn immediately following delivery. After assuring the airway is patent, which of the following actions should be the nurse's priority? Administer Vitamin K. Document the Apgar score. Dry the newborn. Apply identification bands.

Dry the newborn.

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

Drying the newborn's skin thoroughly

A nurse is caring for a client who is pregnant and undergoing a non-stress test. The nurse records the FHR as 130 to 150/min, with no fetal movement for 15 min. Which of the following actions should the nurse take? a.Encourage the client to walk around and then resume monitoring. b. Apply vibroacoustic stimulation to the woman's abdomen. c. Report the findings to the provider and prepare the client for induction of labor. d. Turn the client onto her left side.

Encourage the client to walk around and then resume monitoring.

A nurse is updating the plan of care for a newborn who is undergoing phototherapy. Which of the following actions should the nurse include in the plan? Maintain the newborn in a prone position. Encourage the newborn to breastfeed every 2 hr. Apply lotion to the newborn's skin twice per day. Monitor the newborn's blood glucose level hourly.

Encourage the newborn to breastfeed every 2 hr.

A nurse is caring for a client who is 12 hr postpartum. The nurse recognizes the client is in the dependent, taking-in phase of maternal postpartum adjustment. Which of the following is an expected finding during this period? Expressions of excitement Focus on the family unit and its members Lack of appetite Eagerness to learn newborn care skills

Expressions of excitement

A nurse is monitoring a client with premature rupture of membranes (PROM) who is in labor and observes meconium in the amniotic fluid. What does this indicate? Fetal distress related to hypoxia Infection Central Nervous System (CNS) impairment Cord compression

Fetal distress related to hypoxia CORRECT. When meconium is present in the amniotic fluid, it typically indicates fetal distress related to hypoxia. Meconium stains the fluid yellow to greenish-brown, depending on the amount present. A decreased amount of amniotic fluid reduces the cushioning effect, thereby making cord compression a possibility. A foul odor of amniotic fluid indicates infection.

A nurse is assisting with the care of a client who is in labor. Which of the following findings should the nurse report to the provider? a. Contraction resting period 35 seconds b. Contraction lasting 85 seconds c. Answer Fetal heart rate 100/min for a 10-min period d. Four contractions in a 10-min period

Fetal heart rate 100/min for a 10-min period

A nurse is caring for a client who is 1 day postpartum following a cesarean birth. To prevent thrombophlebitis, the nurse should contribute which of the following interventions to the client's plan of care? Have the client ambulate frequently in the hallway. Keep the client on bed rest. Place pillows under the client's knees while she is resting in bed. Apply warm, moist soaks to the client's lower legs.

Have the client ambulate frequently in the hallway.

A nurse is assisting with the care of a client who is multigravid and in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following is the appropriatenursing response? Assist the client into a comfortable position. Assess the perineum for signs of crowning. Have the client pant during the next few contractions. Help the client to the bathroom to empty her bladder.

Have the client pant during the next few contractions. Panting is fast, continuous, shallow breathing. It helps a client in labor refrain from pushing before her cervix reaches full dilation.

A nurse is assisting to collect data for a gestational age assessment on a newborn. Which of the following should the nurse check during a neuromuscular assessment? (Select all that apply.) Moro reflex Heel to ear Scarf sign Arm recoil Popliteal angle

Heel to ear Scarf sign Arm recoil Popliteal angle

A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse expect to administer? (Select all that apply.) Haemophilus influenzae type b vaccine (Hib) Hepatitis B immunization Phytonadione injection Lidocaine gel to the umbilical stump Antibiotic ophthalmic ointment

Hepatitis B immunization Phytonadione injection Antibiotic ophthalmic ointment

A nurse is collecting data from a newborn who weighs 5,160 g (11 lb, 6 oz) and whose mother has diabetes mellitus. For which of the following data should the nurse monitor? Hypoglycemia Hypobilirubinemia Hypercalcemia Decreased RBC

Hypoglycemia

A nurse is caring for several newborn clients. For which of the following findings should the nurse notify the charge nurse? Jaundice in an infant who is 4-hr old A blood glucose fingerstick of 40 mg/dL for an infant who is 1-hr old Acrocyanosis in an infant who is 2-hr old A hematocrit of 60% in an infant who is 8-hr old

Jaundice in an infant who is 4-hr old

A nurse in a prenatal client is caring for a client who is at 38 weeks of gestation and has heavy, red vaginal bleeding, without contractions, that started spontaneously. She is in no distress and states that she can "feel the baby moving." The client should undergo an ultrasound to determine which of the following findings? a.Location of the placenta b.Fetal lung maturity c.Frequency and duration of contractions d.Rh incompatibility

Location of the placenta Painless, spontaneous vaginal bleeding might be an indication of placenta previa. With the ultrasound, the provider can identify the location of the placenta and urgency of the delivery.

A nurse is caring for a newborn who has a myelomeningocele and is admitted to the newborn intensive care unit (NICU) to await surgery. Which of the following nursing goals is priority in the care of this infant? Maintain integrity of the sac. Educate the parents about the defect. Provide age-appropriate stimulation. Promote maternal-infant bonding.

Maintain integrity of the sac.

A nurse is assisting with the care of a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain? Administering prescribed analgesic medication Encouraging the client to rest between contractions Massaging the client's back ​Turning the client onto her left side

Massaging the client's back

A nurse is reinforcing teaching with a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse recognizes that which of the following is the most common risk factor for a placental abruption? a. Maternal cocaine use b. Maternal hypertension ​​c. Maternal battering d. Maternal cigarette smoking

Maternal hypertension Maternal hypertension is the most common risk factor for placental abruption.

A nurse is admitting a term newborn to the nursery following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following? Physiologic jaundice Absence of vitamin K ​Maternal cocaine abuse Maternal/newborn blood group incompatibility

Maternal/newborn blood group incompatibility

A nurse is reinforcing teaching with a newly licensed nurse about the complications associated with maternal gestational diabetes. Which of the following complications should the nurse include? a. Small for gestational age newborn b. Oligohydramnios c. Placenta previa d. Newborn hypoglycemia

Newborn hypoglycemia

A nurse is collecting data from a newborn. Which of the following anatomical landmarks should the nurse use to measure chest circumference? Axillae ​Sternal notch Nipple line Lower ribcage border

Nipple line

A nurse is collecting data about reflexes from a newborn. Which of the following actions should the nurse take to elicit the newborn's Moro reflex? Perform a sharp hand clap near the infant. Place a finger at the base of the newborn's toes. Hold the newborn vertically, allowing one foot to touch the crib surface. Turn the newborn's head quickly to one side.

Perform a sharp hand clap near the infant.

A nurse is reinforcing teaching about reducing the risk of perineal infection with a client who had a vaginal birth. Which of the following information should the nurse include in the teaching? (Select all that apply.) Perform hand hygiene before and after voiding Apply ice packs to the perineal area several times daily. Blot the perineal area dry after voiding. Sit on a pillow to protect the perineum. Clean the perineal area from front to back.

Perform hand hygiene before and after voiding Blot the perineal area dry after voiding. Clean the perineal area from front to back.

A nurse is assisting with the care of a client who had an epidural anesthesia block during the early stages of labor. The client's blood pressure is 80/40 mm Hg and the fetal heart recording is 140/min. Which of the following actions should the nurse take first? a. Elevate the legs. b. Increase IV fluid rate. c. Notify the provide. d. Place the client in a lateral position.

Place the client in a lateral position

A nurse is assisting with the care of a newborn who needs a gestational age assessment. Which of the following findings should the nurse record as a part of this assessment? crocyanosis of hands and feet Plantar creases cover 2⁄3 of sole Anterior fontanel soft and level Vernix caseosa in inguinal creases

Plantar creases cover 2⁄3 of sole

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hr ago. The nurse should identify that which of the following findings places the client at risk for a postpartum hemorrhage? Two-vessel umbilical cord Small for gestational age newborn Gestational hypertension Precipitous birth

Precipitous birth

A nurse is assisting with the admission of a client who is at 39 weeks of gestation and has heavy vaginal bleeding. Which of the following actions should the nurse take immediately? a. Request the RN perform a cervical examination. b. Administer antibiotics. c. Initiate an IV infusion of magnesium sulfate. d. Prepare for cesarean birth.

Prepare for cesarean birth. The nurse should begin preparing for a cesarean birth for a client who is full term and has heavy vaginal bleeding. A client who has heavy vaginal bleeding is at risk for hemorrhage and subsequent fetal compromise. Therefore, immediate delivery via cesarean section will likely be advised.

A nurse is admitting a client who is 42 weeks gestation to the health care facility. The client is suspected of having cephalopelvic disproportion (CPD). Which should the nurse do next? Administer oxytocin intravenously at 4mL/min. Prepare the client for a cesarean birth. Place the client in lithotomy position for birth. Perform artificial rupture of membranes.

Prepare the client for a cesarean birth. CORRECT. Cephalopelvic disproportion is associated with post-term pregnancy. This client will not be able to vaginally deliver and should be prepared for a cesarean birth. Lithotomy position, AROM (artificial rupture of membranes, and oxytocin are indicated for a vaginal birth.

A nurse is caring for a client who is at 38 weeks of gestation and has a positive contraction stress test. Which of the following actions should the nurse take? Repeat the contraction stress test in 24 hr. Prepare the client for admission to the hospital Document the findings as expected in the client records. Check the client's cervix for dilation.

Prepare the client for admission to the hospital. Answer Rationale:A positive contraction stress test indicates fetal distress and needs further evaluation. The nurse should prepare the client to be admitted to the hospital.

A nurse is caring for a client in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse take first? A. Place the client in a knee-chest or Trendelenburg position. b.Prepare the client for an emergency cesarean birth. c.Cover the cord with a sterile, moist saline dressing. d.Explain to the client what is happening.

Prepare the client for an emergency cesarean birth.

A pregnant client is brought to the health care facility with signs of premature rupture of membranes. Which conditions and complications are associated with PROM? Select all that apply. Prolapsed cord Abruptio placenta Spontaneous abortion Placenta previa Preterm labor Infection

Prolapsed cord Abruptio placenta Spontaneous abortion Preterm labor Infection

A nurse is assisting with the care of a newborn immediately following a cesarean delivery. The nurse's highest priority is to monitor the newborn for which of the following? Kernicterus Renal impairment ABO incompatibility Respiratory distress

Respiratory distress

A nurse is assisting with the care of 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? a. Heart rate of 60/min b.Respiratory rate of 16/min c. Diminished deep-tendon reflexes d. Urine output of 50 mL in 4 hr

Respiratory rate of 16/min The client's respiratory rate should be at least 12/min as a precaution against excessive depression of impulses at the myoneural junction. Based on this finding, the nurse can continue the infusion.

A nurse is reinforcing discharge teaching with a client who is 2 days postpartum and has a history of postpartum depression. Which of the following instructions should the nurse include? Contact a crisis counselor once a week. Stay home until one week after delivery. Sleep as much as possible. Return to work two weeks after delivery.

Return to work two weeks after delivery.

A nurse is assisting with the care of a client who is at 37 weeks of gestation and has placenta previa. Which of the following risks is the primary reason the nurse should avoid performing a pelvic examination? a. Infection b. Preterm labor c. Profound bleeding d. Rupture of the fetal membranes

Rupture of the fetal membranes

A nurse is preparing a sitz bath for a client who is 1 day postpartum. Which of the following actions should the nurse take? Check on the client every 30 min during the bath. Set the water temperature to 40° C (104° F). Instruct the client to relax her gluteal muscles when entering the bath. Fill the bath ¾ full of water.

Set the water temperature to 40° C (104° F).

A nurse is collecting data from a newborn who has respiratory distress syndrome and is experiencing respiratory acidosis. Which of the following risk factors predisposes the newborn to respiratory difficulties? Small for gestational age Maternal history of asthma Cesarean birth Ventricular septal defect

Small for gestational age

A nurse is assisting in the care of a newborn immediately following birth. The nurse notes mucus bubbling out of the newborn's mouth and nose. Which of the following actions should the nurse take first? Suction the newborn's mouth with a bulb syringe. Administer saline drops into the newborn's nares. Perform deep suctioning of the newborn's trachea with an endotracheal tube. Place the newborn in Trendelenburg position.

Suction the newborn's mouth with a bulb syringe.

A nurse is reinforcing teaching about strategies to calm a newborn with a client who is postpartum. Which of the following suggestions should the nurse make? (Select all that apply.) Allow the newborn to continue crying until she falls asleep. ​Take the newborn for a ride in the car. Keep the newborn in the center of a large crib. ​Carry the newborn in a front or back pack. Swaddle the newborn in a receiving blanket.

Take the newborn for a ride in the car. Carry the newborn in a front or back pack. Swaddle the newborn in a receiving blanket.

A nurse is assisting in the care of a client who is in labor. The doctor documents the vaginal examination as: 3 cm, 30%, and -1. The nurse evaluates this documentation to mean which of the following? a. The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm above the ischial spines. b. The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm above the ischial spines. c. The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm below the ischial spines. d. ​The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 1 cm below the ischial spines.

The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm above the ischial spines. Answer Rationale: ​Dilation of the cervix is measured from closed to 10 cm; effacement, or thinning and shortening of the cervix, is measured from 0% to 100%; and station is the relation of the presenting part to the ischial spines of the maternal pelvis and is measured in centimeters above, below, or at the level of the spines. If the station is -1, then the presenting part is 1 cm above the ischial spine.

A nurse is caring for a client who is postpartum. Which of the following findings is an indication for the nurse to administer Rho(D) immune globulin? The client is Rh positive and the newborn is Rh positive. The client is Rh negative and the newborn is Rh positive. The client is Rh positive and the newborn is Rh negative. The client is Rh negative and the newborn is Rh negative.

The client is Rh negative and the newborn is Rh positive.

A nurse is caring for a newborn who is at 34 weeks of gestation, weighs 1,550 g, and has nasal flaring, intercostal retractions, expiratory grunting, and mild cyanosis. The nurse should place the newborn in an incubator for which of the following reasons? The newborn's temperature control mechanism is immature. The newborn has a small body surface for his weight. Heat increases the flow of oxygen to the newborn's extremities. Heat facilitates the drainage of mucus for a premature newborn.

The newborn's temperature control mechanism is immature.

A nurse is caring for a client who is breastfeeding and tells the nurse that she is concerned about her newborn's hydration. Which of the following nursing observations is appropriate to use in evaluating the adequacy of the newborn's hydration? The fit of the newborn's clothes The newborn's skin turgor How often the newborn cries The number of wet diapers per day

The number of wet diapers per day

A nurse is reinforcing teaching about umbilical cord care with a client who is postpartum. Which of the following instructions should the nurse include? Cleanse the area around the cord with baby oil each day. Do not immerse the newborn's abdomen in water until the cord is dry. Protect the cord by covering it with the newborn's diaper. The stump should fall off in 10 to 14 days.

The stump should fall off in 10 to 14 days.

A nurse is reinforcing teaching with a newly licensed nurse about a biophysical profile. Which of the following information should the nurse include in the teaching? a. This test determines the estimated date of birth. b.The client will need to be NPO for 8 hr prior to the test. c. The test predicts fetal well-being in the third trimester d. The nurse will initiate an IV prior to this test.

The test predicts fetal well-being in the third trimester.

A nurse is caring for a newborn. How many blood vessels should the nurse expect to observe in the newborn's umbilical cord? Two arteries and one vein Two veins and one artery Two arteries and two veins One artery and one vein

Two arteries and one vein

A nurse is assisting in the care of a client who is in active labor. The nurse notes variable decelerations of the FHR. The nurse should identify which of the following as a cause of variable decelerations? a. Umbilical cord compression b.Fetal head compression c. Polyhydramnios d. Maternal fever

Umbilical cord compression The nurse should identify that variable decelerations are caused by compression of the umbilical cord.

A nurse is caring for a postpartum client following a vaginal birth of a newborn weighing 4252 g (9 lb 6 oz). The nurse should identify that this client is at risk for which of the following postpartum complications? Postpartum infection Retained placental fragments Thrombophlebitis Uterine atony

Uterine atony

A nurse is assisting in the care of a client who is in the second stage of labor. Which of the following findings should the nurse report to the provider? a. Bloody show from the vagina b. Uterine contraction lasting 2 min c. Pelvic pressure with contractions d. Early decelerations in the FHR

Uterine contraction lasting 2 min.

A nurse is preparing to administer vitamin K IM to a newborn. Into which of the following muscles should the nurse inject the medication? ​Vastus lateralis Deltoid Dorsogluteal Ventrogluteal

Vastus lateralis

A nurse reinforcing teaching about vitamin K with a client who is postpartum. Which of the following statements should the nurse include? Vitamin K decreases the newborn's risk of jaundice. Vitamin K decreases the newborn's risk of hemorrhagic disorders. Vitamin K decreases the newborn's risk of complications from the Hepatitis B vaccine. Vitamin K decreases the newborn's risk of health care-associated infections.

Vitamin K decreases the newborn's risk of hemorrhagic disorders.

A nurse is caring for a client who is at 28 weeks of gestation and has received terbutaline. Which of the following findings should the nurse expect? Enhanced fetal lung surfactant Maternal glucose 63 mL/dL Fetal heart rate 100/min Weakened uterine contractions

Weakened uterine contractions Terbutaline is a beta2-adrenergic agonist that acts to relax the uterus. Terbutaline is used to stop a contraction pattern in a client who is at preterm gestation.

A nurse is caring for a newborn who is small for gestational age. Which of the following findings is associated with this condition? Gray umbilical cord Moist skin Wide skull sutures Protruding abdomen

Wide skull sutures

A nurse is caring for a client who is postpartum and asks, "When will my breast milk come in?" Which of the following responses should the nurse make? In about 10 days after delivery. You have colostrum now and your supply will increase ​In 3 to 5 days after delivery. Within 2 days after delivery ​In 6 to 8 days after delivery.

You have colostrum now and your supply will increase ​In 3 to 5 days after delivery.

A nurse is reviewing information about maternal and paternal adaptations to the birth of a newborn. The nurse observes the parents interacting with their newborn physically and emotionally. The nurse documents this as: attachment. engrossment. lactation. puerperium.

attachment.

The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which finding would the nurse expect when assessing the client's fundus? cannot be palpated 6 cm below the umbilicus 10 cm below the umbilicus 2 cm below the umbilicus

cannot be palpated

On a follow up visit to the clinic, a nurse suspects that a postpartum client is experiencing postpartum psychosis. Which finding would most likely lead the nurse to suspect this condition? delusional beliefs insomnia sadness feelings of anxiety

delusional beliefs

The nurse administers Rho(D) immune globulin to an Rh-negative client after delivery of an Rh-positive newborn based on the understanding that this drug will prevent her from: developing AB antigens in her blood. becoming pregnant with an Rh-positive fetus. becoming Rh positive. developing Rh sensitivity.

developing Rh sensitivity.

A postpartum client has a fourth-degree perineal laceration. The nurse would expect which medication to be ordered? bromocriptine ducosate methylergonovine ferrous sulfate

ducosate

A nurse is making a home visit to a postpartum woman who delivered a healthy newborn 4 days ago. The woman's breasts are swollen, hard, and tender to the touch. The nurse documents this finding as: engrossment. mastitis. involution. engorgement.

engorgement.

A woman who delivered a healthy newborn several hours ago asks the nurse, "Why am I perspiring so much?" The nurse integrates knowledge that a decrease in which hormone plays a role in this occurrence? estrogen progesterone hCG testosterone

estrogen

After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention? frequent, scant voidings. presence of lochia serosa. fundus firm, below umbilicus. milk filling in both breasts.

frequent, scant voidings.

A woman who is 2 weeks postpartum calls the clinic and says, "My left breast hurts." After further assessment on the phone, the nurse suspects the woman has mastitis. In addition to pain, the nurse would question the woman about which symptom? an inverted nipple on the affected breast. an ecchymotic area on the affected breast. hardening of an area in the affected breast. no breast milk in the affected breast.

hardening of an area in the affected breast.

Assessment of a postpartum client reveals a firm uterus with bright-red bleeding and a localized bluish bulging area just under the skin at the perineum. The woman also is complaining of significant pelvic pain and is experiencing problems with voiding. The nurse suspects which condition? bladder distention. uterine atony. laceration. hematoma.

hematoma

A nurse is teaching a postpartum client how to do muscle-clenching exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response? alleviates perineal pain improves pelvic floor tone reduces lochia promotes uterine involution

improves pelvic floor tone

When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be: about the same as after a vaginal delivery. less than after a vaginal delivery. greater than after a vaginal delivery. saturated with clots and mucus.

less than after a vaginal delivery.

The nurse is assessing a postpartum client's lochia and finds that there is about a 4-inch stain on the perineal pad. The nurse documents this finding as which description? light moderate scant large

light

A postpartum client is experiencing subinvolution. When reviewing the woman's labor and birth history, which contributor would the nurse identify as being significant to this condition? no anesthetics (drug-free) used in labor. early ambulation. long duration of labor. breastfeeding.

long duration of labor.

Which method would be the most effective in evaluating the parents' understanding about their newborn care? observe the parents perform the care after demonstration by the nurse. allow the parents to state the steps of the care. demonstrate all infant care procedures. routinely assess the newborn for cleanliness.

observe the parents perform the care after demonstration by the nurse.

A nurse is reviewing the policies of a facility related to bonding and attachment with newborns. Which practice would the nurse identify as needing to be changed? offering around-the-clock nursery care for all infants. allowing unlimited visiting hours on maternity units. promoting rooming-in. encouraging infant contact immediately after birth.

offering around-the-clock nursery care for all infants.

A nurse is teaching a new mother about breast-feeding. The nurse determines that the teaching was successful when the woman identifies which hormone as responsible for milk let-down? oxytocin prolactin estrogen progesterone

oxytocin

A nurse is collecting data from a client who gave birth one week ago. Which of the following findings should the nurse identify as a manifestation of endometritis? Bradycardia Pink lochia ​Pelvic pain Hematuria

pelvic pain

A nurse is visiting a postpartum woman who delivered a healthy newborn 5 days ago. Which finding would the nurse expect? creamy white discharge deep red mucus-like discharge bright red discharge pinkish brown discharge

pinkish brown discharge

A postpartum woman is having difficulty voiding for the first time after giving birth. Which action would be least effective in helping to stimulate voiding? placing her hand in a basin of cool water. having her hear the sound of running water nearby. standing her in the shower with the warm water on. pouring warm water over her perineum.

placing her hand in a basin of cool water.

The nurse is assisting a postpartum woman out of bed to the bathroom for a sitz bath. Which action would be a priority? placing the call light within her reach prior to leaving the bathroom. teaching her how the sitz bath works. telling her to use the sitz bath for 30 minutes. cleaning the perineum with the peri-bottle.

placing the call light within her reach prior to leaving the bathroom.

A nurse is assessing a postpartum woman. Which finding would lead the nurse to suspect that a postpartum woman is having a problem? increased levels of clotting factors elevated white blood cell count slightly increased hematocrit pulse rate of 110 beats/minute

pulse rate of 110 beats/minute

A postpartum client comes to the clinic for her 6-week postpartum check-up. When assessing the client's cervix, the nurse would expect the external cervical os to appear: triangular. slit-like. shapeless. circular.

slit-like.

Review of a primiparous woman's labor and birth record reveals a prolonged second stage of labor and extended time in the stirrups. Based on an interpretation of these findings, the nurse would be especially alert for which condition? retained placental fragments thrombophlebitis hypertension uterine subinvolutio

thrombophlebitis

A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus and documents which finding as normal? two fingerbreadths below the umbilicus. at the level of the umbilicus. four fingerbreadths below the umbilicus. two fingerbreadths above the umbilicus.

two finger breadths below the umbilicus.

A nurse is reinforcing teaching about crib safety with the parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? "I should place the crib near a window to provide adequate sunlight and fresh air." "I should place my baby's stuffed animals between the mattress and side of the crib." ​"I will place my baby on his back when he is sleeping." "I will place my baby on his stomach when he is sleeping."

​"I will place my baby on his back when he is sleeping."

​A home health care nurse is reinforcing teaching about breast engorgement with a client who is postpartum and is breastfeeding her newborn. Which of the following client statements indicates an understanding of the teaching? ​"I won't wear a bra during the daytime." ​"I'll feed my baby every 2 hours." ​"I'll apply cold compresses 20 min before each feeding." "I will stop breastfeeding until I am done with the antibiotics."

​"I'll feed my baby every 2 hours."

A nurse is reinforcing teaching about Kegel exercises with a client who is two days postpartum.. Which of the following statements by the client indicates an understanding of the teaching? ​"These exercises will help prevent bladder infections." ​"These exercises will help my pelvic muscles stretch when I give birth." "These exercises will help lessen my back aches." "These exercises will prevent further stretch marks."

​"These exercises will help my pelvic muscles stretch when I give birth."

A nurse is caring for a client during a nonstress test (NST). The nurse observes two decelerations of 15/min in the fetal heart rate during a period of fetal movement. Each deceleration lasts 20 seconds. Which of the following results are indicated by these findings? a. A negative test b. ​A nonreactive test c. A positive test d. ​A reactive test

​A nonreactive test

A nurse is assisting in the care of a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse take? Maintain the client in the lithotomy position. Check the client's temperature every 4 hr. Remind the client to bear down with each contraction. ​Encourage the client to empty the bladder every 2 hr.

​Encourage the client to empty the bladder every 2 hr.

A nurse is assisting with the care of a client who is in labor. The client's labor is difficult and prolonged and she reports a severe backache. Which of the following factors is a contributing cause of difficult, prolonged labor? a. Maternal pelvis is gynecoid. b. ​Fetal position is persistent occiput posterior. c. ​Fetal attitude is in general flexion. d. Fetal lie is longitudinal.

​Fetal position is persistent occiput posterior. Answer Rationale: The persistent occiput posterior position of the fetus is a common cause of prolonged, difficult labor with severe back pain.

A nurse is assisting with the admission of a client who is at 38 weeks of gestation and has severe preeclampsia. When collecting data from the client, the nurse should expect which of the following findings? Tachycardia Hypotension ​Headache ​Polyuria

​Headache

A nurse is reinforcing teaching with the mother of a newborn who is small for gestational age. Which of the following should the nurse include as a cause of this condition? ​Placental insufficiency Maternal obesity Perinatal asphyxia Primipara

​Placental insufficiency

​A nurse is preparing to auscultate fetal heart tones for a client who is pregnant. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundal portion of the uterus and a long, smooth surface on the mother's right side. In which of the following maternal quadrants should the nurse auscultate fetal heart tones? a. Left lower quadrant b. Right lower quadrant c. Left upper quadrant d. Right upper quadrant

​Right upper quadrant Answer Rationale: Fetal heart tones are best auscultated directly over the location of the fetal back, which, in this breech presentation, is in the right upper quadrant.

A nurse is assisting with the care of a client who presents to a labor and delivery unit with rapidly progressing labor. Which of the following actions is the priority for the nurse to take? Cutting the umbilical cord Supporting the infant during the birth Preventing the perineum from tearing Promoting delivery of the placenta

​Supporting the infant during the birth The most important intervention is preventing injury to the infant during the delivery, which is achieved by supporting the infant during birth. Fetal complications from precipitous labor include hypoxia, caused by decreased periods of uterine relaxation between contractions. A change in pressure from a rapid delivery of the fetal head can cause neurologic damage, such as increased intracranial pressure and dural or subdural tearing. Rapid birth can also cause maternal injury, such as vaginal or perineal lacerations. Precipitous labor is defined as labor that lasts less than 3 hr from the onset of contractions to the time of birth. Precipitous labor can result from hypertonic uterine contractions, which can increase the risk for abruptio placentae.

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

​​Obtain blood glucose by heel stick.

A client who has come to the clinic is diagnosed with endometriosis. What would the nurse expect the primary care provider to prescribe as a first-line treatment? A. Antiestrogens B. Progestins C.Gonadotropin-releasing hormone analogues D. NSAIDs

D. NSAIDs

A client reports that she has multiple sex partners and has a lengthy history of carious pelvic infections. She would like to know if there is any temporary contraceptive method that would suit her condition. Which should the nurse suggest for this client? A. Condoms B. Tubal ligation C. Intrauterine device (IUD) D. Oral contraceptives

A. Condoms

Parents who recently experienced the death of their unborn child ask the nurse, "What is a fetal death?" What is the nurse's best response? A. "Fetal deaths occur later in pregnancy after 20 weeks' gestation." B."It refers to the intrauterine fetal death at any time during pregnancy." C."Fetal deaths occur earlier in pregnancy before 20 weeks' gestation." D. "Fetal death occurs only at the birth of the newborn."

A. "Fetal deaths occur later in pregnancy after 20 weeks' gestation."

A couple comes to the clinic for a fertility evaluation. The male partner is to undergo a semen analysis. After teaching the partner about this test, which client statement indicates that the client has understood the instructions? A. "I have to abstain from sexual activity for about 1 to 2 days before the sample." B. "I will withdraw before I ejaculate during sex to collect the specimen. C. "I will place the specimen in a special plastic bag to transport it." D. "I need to bring the specimen to the lab the day after collecting it."

A. "I have to abstain from sexual activity for about 1 to 2 days before the sample."

A nurse is conducting an in-service program for a group of nurses on the health of women and their families, incorporating information from Healthy People 2020. The nurse determines that additional discussion and clarification is needed when the group makes which statement? A. "Immunizations may be the cause of some illnesses being seen currently." B."Maintaining a physically active lifestyle is strongly encouraged" C. "Environmental quality is directly related to health care." D."Obesity, drug use, and smoking are major problems."

A. "Immunizations may be the cause of some illnesses being seen currently."

A pregnant woman in the 36th week of gestation reports that her feet are quite swollen at the end of the day. After careful assessment, the nurse determines that this is an expected finding at this stage of pregnancy. Which intervention is appropriate for the nurse to suggest? A. "Try elevating your legs when you sit." B. "Wear spandex-type full-length pants." C. "Eliminate salt from your diet." D. "Limit your intake of fluids."

A. "Try elevating your legs when you sit."

A nurse is providing prenatal care to a pregnancy client. At which time would the nurse expect to screen the client for group B streptococcus infection? A. 36 weeks' gestation B. 28 week' gestation C. 16 weeks' gestation D. 32 weeks' gestation

A. 36 weeks' gestation

A nurse is reviewing contraception options for four clients. The nurse should identify which of the following clients as having a contraindication to oral contraceptives? A. A client who has a blood pressure of 140/90 mm Hg B. A client who has a menstrual cycle every 14 days C.A client who has a hematocrit of 39% D. A 15-year old client who has acne

A. A client who has a blood pressure of 140/90 mm Hg

A nurse is preparing for a health promotion presentation for new mothers. Which topics would be appropriate for the nurse to include in the presentation? Select all that apply. A. Breastfeeding encouragement B. Proper infant sleep position C. Infants in smoke-free environments D. How to swaddle their infants E. How to bed share with their infants

A. Breastfeeding encouragement B. Proper infant sleep position C. Infants in smoke-free environments D. How to swaddle their infants

On the first prenatal visit, examination of the woman's internal genitalia reveals a bluish coloration of the cervix and vaginal mucosa. The nurse documents this finding as: A. Chadwick's sign. B. Hagar's sign. C. Homans' sign. D. Goodall's sign.

A. Chadwick's sign.

A nurse is preparing a class for a group of young adult women about emergency contraceptives (ECs). What information would the nurse need to stress to the group? Select all that apply. A. ECs induce an abortion-like reaction. B. ECs provide some protection against STIs. C. ECs are birth control pills in higher, more frequent doses. D.ECs are not to be used in place of regular birth control. E. ECs provide little protection for future pregnancies.

A. ECs induce an abortion-like reaction. C. ECs are birth control pills in higher, more frequent doses. D.ECs are not to be used in place of regular birth control. E. ECs provide little protection for future pregnancies.

The nurse would recommend the use of which supplement as a primary prevention strategy to prevent neural tube defects in the future offspring of pregnant women? A. Folic Acid B.Calcium C. Vitamin D D. Iron

A. Folic Acid

After teaching a pregnant woman about the hormones produced by the placenta, the nurse determines that the teaching was successful when the woman identifies which hormone produced as being the basis for pregnancy tests? A. Human chorionic gonadotropin (hCG) B. Human placental lactogen (hPL) C. Progesterone (progestin) D. Estrogen (estriol)

A. Human chorionic gonadotropin (hCG)

A nurse is preparing a class discussion on cardiovascular disease in women. When discussing the priority risk factors for this disease, which would the nurse leastlikely include? Select all that apply. A. Menopause B. Diabetes diagnosis C. Weight cycling D. Gender E. Age

A. Menopause D. Gender E. Age

A client comes to the prenatal clinic for her first visit. When determining the client's estimated due date, the nurse understands what which method is the mostaccurate? A. Nagele's rule B. gestational wheel C. birth calculator D. ultrasound

A. Nagele's rule

A pregnant client and her husband have had a session with a genetic specialist. What is the role of the nurse after the client has seen a specialist? A. Review what has been discussed with the specialist. B. Refer the client to another specialist for a second opinion. C. . Identify the best decision to be taken by the client. D. Refer the client for further diagnostic and screening tests.

A. Review what has been discussed with the specialist.

Assessment of a pregnant woman and her fetus reveals tachycardia and hypertension. There is also evidence suggesting vasoconstriction. The nurse would question the woman about use of which substance? A. cocaine B. alcohol C. marijuana D. heroin

A. cocaine

A nurse is teaching a pregnant client in her first trimester about discomforts that she may experience. The nurse determines that the teaching was successful when the woman identifies which discomfort as common during the first trimester? Select all that apply. A. cravings B. backache C. breast tenderness D. leg cramps E. urinary frequency

A. cravings C. breast tenderness E. urinary frequency

A nurse suspects that a client is developing HELLP syndrome. The nurse notifies the health care provider based on which finding? A. elevated liver enzymes B. elevated platelet count C. disseminated intravascular coagulopathy (DIC) D. hyperglycemia

A. elevated liver enzymes

Which change in the musculoskeletal system would the nurse mention when teaching a group of pregnant women about the physiologic changes of pregnancy? A. increased lordosis B. joint contraction C. decreased swayback D. ligament tightening

A. increased lordosis

A pregnant client in her second trimester has a hemoglobin level of 11 g/dL. The nurse interprets this as indicating: A. iron-deficiency anemia. B. a multiple gestation pregnancy. C. greater-than-expected weight gain. D. hemodilution of pregnancy.

A. iron-deficiency anemia.

A nurse strongly encourages a pregnant client to avoid eating swordfish and tilefish because these fish contain which component? A. mercury, which could harm the developing fetus if eaten in large amounts B. lactose, which leads to abdominal discomfort, gas, and diarrhea C. excess folic acid, which could increase the risk for neural tube defects D. low-quality protein that does not meet the woman's requirements

A. mercury, which could harm the developing fetus if eaten in large amounts

A nurse is assessing a client who may be pregnant. The nurse reviews the client's history for presumptive signs. Which sign would the nurse most likely note? Select all that apply. A. nausea B. abdominal enlargement C. fetal heart sounds D. amenorrhea E. Braxton-Hicks contractions

A. nausea D. amenorrhea

The nurse working in a prenatal clinic recognizes that the primary hormone responsible for sustaining pregnancy is what? A. progesterone B. leteinizing hormone C. testosterone D. estrogen

A. progesterone

A woman comes to the prenatal clinic suspecting that she is pregnant, and assessment reveals probable signs of pregnancy. Which finding would the nurse most likely assess? Select all that apply. A. softening of the cervix B. positive pregnancy test C. absence of menstruation D. ballottement E. auscultation of a fetal heart beat F. ultrasound visualization of the fetus

A. softening of the cervix B. positive pregnancy test D. ballottement

A nurse is describing the various birth methods to pregnant couples. Which information would the nurse include as part of the Lamaze method? A. use of specific breathing and relaxation techniques B. interruption of the fear-tension-pain cycle C. concentration on sensations while turning on to own bodies D. focus on the pleasurable sensations of childbirth

A. use of specific breathing and relaxation techniques

A client at a prenatal class requests information on how the gender of a baby is determined. Which statement made by the nurse would be most accurate? A. "Gender is determined at conception and depends on whether the ovum is fertilized by a Y-bearing or an X-bearing sperm." B. "Gender is determined by week 20 of gestation and depends on whether the ovum is fertilized by a Y-bearing or an X-bearing sperm." C ."Gender is determined as the embryo is fertilized by a Y-bearing or an X-bearing sperm." D. "Gender is determined at conception and depends on whether the sperm is fertilized by a Y-bearing or X-bearing ovum."

A."Gender is determined at conception and depends on whether the ovum is fertilized by a Y-bearing or an X-bearing sperm."

A 24-year-old client who is planning to become pregnant comes to the clinic for an evaluation. When assessing the client, which finding would alert the nurse to implement measures to reduce the client's risk for problems during pregnancy? Select all that apply. A.drinks wine 3 to 4 times/week B.quit smoking 4 years ago C. follows a vegetarian diet D. has a BMI of 22 E. uses ibuprofen daily

A.drinks wine 3 to 4 times/week C. follows a vegetarian diet E. uses ibuprofen daily

After teaching a pregnant woman with iron deficiency anemia about her prescribed iron supplement, which statement indicates successful teaching? A. "I should take my iron with milk." B. "I need to eat foods high in fiber." C. "I'll call the primary care provider if my stool is black and tarry." D. "I should avoid drinking orange juice."

B. "I need to eat foods high in fiber."

A client comes to the clinic with abdominal pain. Based on her history the nurse suspects endometriosis. The nurse expects to prepare the client for which evaluatory method to confirm this suspicion? A. Pelvic Exam B. Transvaginal ultrasound C. Laparoscopy D. Hysterosalpingogram

B. Transvaginal ultrasound

A nurse is obtaining a genetic history of a pregnant client by eliciting historical information about her family members. Which question is the most appropriate for the nurse to ask? A. "Were there any instances of premature birth in the family?" B. "Is there a family history of drinking or drug abuse?" C. "What was the cause and age of death for deceased family members?" D. "Were there any instances of depression during pregnancy?"

B. "Is there a family history of drinking or drug abuse?"

A woman in her second trimester comes for a follow-up visit and says to the nurse, "I feel like I'm on an emotional roller-coaster." Which response by the nurse would be most appropriate? A. "Have you been experiencing any thoughts of harming yourself?" B. "Mood swings are completely normal during pregnancy." C. "How often has this been happening to you?" D. "Maybe you need some medication to level things out."

B. "Mood swings are completely normal during pregnancy."

The nurse is teaching a pregnant woman with a prepregnancy body mass index of 26 about recommended weight gain. The nurse determines that the teaching was successful when the woman states that she should gain approximately how much during pregnancy? A. 28 to 40 pounds B. 15 to 25 pounds C. 35 to 40 pounds D. 25 to 35 pounds

B. 15 to 25 pounds

At a prenatal class, the participants ask the nurse who would benefit from genetic counseling. Which responses by the nurse are correct? Select all that apply. A. "A woman who is a grand multigravida." B. A woman whose husband is age 50 years or older." C. "A woman who has been exposed to teratogens." D. "A young teenager experiencing her first pregnancy." E. "A woman who receives an abnormal alpha-fetoprotein result."

B. A woman whose husband is age 50 years or older." E. "A woman who receives an abnormal alpha-fetoprotein result."

After discussing various methods of contraception with a client and her partner, the nurse determines that the teaching was successful when they identify which contraceptive method as providing protection against sexually transmitted infections (STIs)? A. Intrauterine system B. Condoms C. tubal ligation D. oral contraceptives

B. Condoms

When teaching a pregnant client about the physiologic changes of pregnancy, the nurse reviews the effect of pregnancy on glucose metabolism. Which underlying reason for the effect would the nurse include? A. Pancreatic function is affected by pregnancy. B. Glucose is utilized more rapidly during a pregnancy. C. The pregnant woman increases her dietary intake. D. Glucose moves through the placenta to assist the fetus.

B. Glucose is utilized more rapidly during a pregnancy.

A prenatal nurse is conducting a class on healthy pregnancy and explains the role of placental hormones. Which statements would the nurse make? Select all that apply. A. Relaxin causes enlargement of a woman's breasts, uterus, and external genitalia. B. Human chorionic gonadatropin is the basis for pregnancy tests C. Human placental lactogen participates in the development of maternal breasts for lactation. D. Thyroxin modulates fetal and maternal metabolism. E. Progesterone stimulates maternal metabolism and breast development. F. Estrogen causes enlargement of a woman's breasts.

B. Human chorionic gonadatropin is the basis for pregnancy tests C. Human placental lactogen participates in the development of maternal breasts for lactation. E. Progesterone stimulates maternal metabolism and breast development. F. Estrogen causes enlargement of a woman's breasts.

After reviewing a client's history, which factor would the nurse identify as placing her at risk for gestational hypertension? A. This is the client's second pregnancy. B. Mother had gestational hypertension during pregnancy. C. Client has a twin sister. D. Sister-in-law had gestational hypertension.

B. Mother had gestational hypertension during pregnancy.

When describing perinatal education to a pregnant woman and her partner, the nurse emphasizes which goal as the primary one? A. Equip a couple with the knowledge to experience a pain-free childbirth. B. Provide knowledge and skills to actively participate in birth and parenting. C. Empower the couple to totally control the birth process. D. Eliminate anxiety so that they can have an uncomplicated birth.

B. Provide knowledge and skills to actively participate in birth and parenting.

A nurse in a provider's office is collecting data for a 45-year-old client who is having manifestations associated with perimenopause. Which of the following findings should the nurse expect? A. Report of urinary retention B. Report of dryness with vaginal intercourse C. Elevated blood pressure above 140/90 D. Elevated body temperature above 37.8° C (100° F)

B. Report of dryness with vaginal intercourse

It is determined that a client's blood Rh is negative and her partner's is positive. To help prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time? A. at 32 weeks' gestation and immediately before discharge B. at 28 weeks' gestation and again within 72 hours after delivery C. 24 hours before delivery and 24 hours after delivery D. in the first trimester and within 2 hours of delivery

B. at 28 weeks' gestation and again within 72 hours after delivery

A nurse is assessing a pregnant woman on a routine checkup. When assessing the woman's gastrointestinal tract, what would the nurse expect to find? Select all that apply. A. increased peristalsis B. complaints of bloating C. hyperemic gums D. nausea E. heartburn

B. complaints of bloating C. hyperemic gums D. nausea E. heartburn

A nurse is conducting a program for pregnant women with gestational diabetes about reducing complications. The nurse determines that the teaching was successful when the group identifies which factor as being most important in helping to reduce complications associated with pregnancy and diabetes? A. control of blood urea nitrogen (BUN) levels for optimal kidney function B. degree of blood glucose control achieved during the pregnancy C. stability of the woman's emotional and psychological status D. reduction in retinopathy risk by frequent ophthalmologic evaluations

B. degree of blood glucose control achieved during the pregnancy

A nurse is conducting a class for pregnant women with diabetes. Which factor would the nurse emphasize as being most important in helping to reduce the maternal/fetal/neonatal complications associated with pregnancy and diabetes? A. evaluation of retinopathy by an ophthalmologist B. degree of glycemic control achieved during the pregnancy C. blood urea nitrogen level (BUN) within normal limits D. stability of the woman's emotional and psychological status

B. degree of glycemic control achieved during the pregnancy

A woman at 10 weeks gestation comes to the clinic for an evaluation. Which finding might lead the nurse to suspect gestational trophoblastic disease? A. report of frequent mild nausea B. fundal height measurement of 18 cm C. blood pressure of 120/84 mm Hg D. history of bright red spotting 6 weeks ago

B. fundal height measurement of 18 cm

A pregnant client whose diabetes has been poorly controlled throughout her pregnancy is in labor. The nurse would assess the neonate closely at birth for which condition? A. macrosomia B. hyperglycemia C. low birthweight D. hypobilirubinemia

B. hyperglycemia

A woman is diagnosed with a vaginal infection. After teaching the client about measures to reduce her risk, the nurse determines that the client needs additional teaching when she states which factor as increasing her risk? A. use of feminine hygiene sprays B. menstruation C. douching D.antibiotic therapy

B. menstruation

A woman has opted to use the basal body temperature method for contraception. The nurse instructs the client that a rise in basal body temperature indicates which event? A. pregnancy B. ovulation C. onset of menses D. safe period for intercourse

B. ovulation

A nurse is reviewing the medical record of a pregnant woman and notes that she is gravid II. The nurse interprets this to indicate the number of: A. preterm births. B. pregnancies. C. spontaneous abortions. D. births.

B. pregnancies.

A nurse is conducting a review class for a group of perinatal nurses working at the local clinic. The clinic sees a high population of women who are HIV positive. After discussing the recommendations for antiretroviral therapy with the group, the nurse determines that the teaching was successful when the group identifies which rationale as the underlying principle for the therapy? A. can cure acute HIV/AIDS infections B. reduction in viral loads in the blood C. treatment of opportunistic infections D. adjunct therapy to radiation and chemotherapy

B. reduction in viral loads in the blood

A nurse is collecting data from a client who requests a prescription for a diaphragm. Which of the following findings should the nurse identify as a contraindication to the client's use of a diaphragm? A. The client is 42 years old. B.The client has more than one sex partner. C.The client smokes cigarettes. D. The client had a vaginal birth 6 months ago.

B.The client has more than one sex partner.

A woman comes to the clinic because she has been unable to conceive. When reviewing the woman's history, the nurse would least likely identify which factor as a possible risk? A. diabetes since age 15 years B.age of 25 years C.weight below standard for height and age D. history of smoking

B.age of 25 years

The nurse is reviewing the laboratory test results of a client with dysfunctional uterine bleeding (DUB). Which finding would be of concern? A. serum cholesterol of 140 mg/dL B.hemoglobin level of 10.1 g/dL C.prothrombin time of 60 seconds D.negative pregnancy test

B.hemoglobin level of 10.1 g/dL

A nurse is working with a woman who is a victim of violence. Which intervention would be most important for this client? A. providing for the client's safety B.reassuring her she is not alone C.documenting the abuse D. educating about the cycle of violence

B.reassuring her she is not alone

A client who is HIV-positive is in her second trimester and remains asymptomatic. She voices concern about her newborn's risk for the infection. Which statement by the nurse would be most appropriate? A. "Antibodies cross the placenta and provide immunity to the newborn." B. "You'll probably have a cesarean birth to prevent exposing your newborn." C. "Antiretroviral medications are available to help reduce the risk of transmission." D. "Wait until after the infant is born, and then something can be done."

C. "Antiretroviral medications are available to help reduce the risk of transmission."

A gravida 2 para 1 client in the 10th week of her pregnancy says to the nurse, "I've never urinated as often as I have for the past three weeks." Which response would be most appropriate for the nurse to make? A. "You shouldn't be urinating this frequently now; it usually stops by the time you're eight weeks pregnant. Is there anything else bothering you?" B. "Women having their second child generally don't have frequent urination. Are you experiencing any burning sensations?" C. "By the time you are 12 weeks pregnant, this frequent urination should really decrease, but it is likely to return toward the end of your pregnancy." D. "Having to urinate so often is annoying. I suggest that you watch how much fluid you are drinking and limit it."

C. "By the time you are 12 weeks pregnant, this frequent urination should really decrease, but it is likely to return toward the end of your pregnancy."

When the nurse is alone with a client, the client says, "It was all my fault. The house was so messy when he got home, and I know he hates that." Which response would be most appropriate? A. "What else did you do to make him so angry with you?" B. "Remember, he works hard and you need to meet his needs." C. "It is not your fault. No one deserves to be hurt." D. "You need to start to clean the house early in the day."

C. "It is not your fault. No one deserves to be hurt."

The nurse is teaching a pregnant woman with type 1 diabetes about her diet during pregnancy. Which client statement indicates that the nurse's teaching was successful? A. "Because I need extra protein, I'll have to increase my intake of milk and meat." B. "I'll basically follow the same diet that I was following before I became pregnant." C. "Pregnancy affects insulin production, so I'll need to make adjustments in my diet." D. "I'll adjust my diet and insulin based on the results of my urine tests for glucose."

C. "Pregnancy affects insulin production, so I'll need to make adjustments in my diet."

A nurse measures a pregnant woman's fundal height and finds it to be 28 cm. The nurse interprets this to indicate that the client is at how many weeks' gestation? A. 36 weeks' gestation B. 14 weeks' gestation C. 28 weeks' gestation D. 20 weeks' gestation

C. 28 weeks' gestation

A pregnant woman with gestational diabetes comes to the clinic for a fasting blood glucose level. When reviewing the results, the nurse determines that which result indicates good glucose control? A. 120 mg/dL B. 100 mg/dL C. 88 mg/dL D. 110 mg/dL

C. 88 mg/dL

A nurse is providing information regarding ovulation to a couple who want to have a baby. Which should the nurse tell the clients? A. A rise in estrogen occurs at ovulation B. The lifespan of the ovum is only about 48 hours C. At ovulation, a mature follicle ruptures, releasing an ovum. D. Ovulation takes place 10 days before menstruation.

C. At ovulation, a mature follicle ruptures, releasing an ovum.

A nurse is planning a continuum of care for a client during pregnancy, labor, and childbirth. What is the most important factor in enhancing the birthing experience? A. Involving a pediatric physician B. Adhering to strict specific routines C. Educating the client about the importance of a support person D. Assigning several nurses as a support team

C. Educating the client about the importance of a support person

A client has been informed that her pregnancy test indicates that she is 3 weeks pregnant. Which instructions should the nurse give the client in regard to her condition? A. Avoid exercise during pregnancy. B. Wear comfortable clothes that are not tight or restrictive. C. Stop using drugs, alcohol, and tobacco D. Discontinue intercourse until after the baby is born.

C. Stop using drugs, alcohol, and tobacco

The nurse working in a maternity clinic suspects that a client and her children are in an abusive relationship. While waiting for test results, the nurse decides to teach the client about partner abuse. What would be the best rationale for the nurse's decision? A.The nurse knows that the woman may be weak and controlled by her partner. B. The nurse has a legal responsibility to protect clients. C. The nurse understands there is an ethical responsibility to protect clients. D. The nurse knows that children exposed to family violence are likely to be abused.

C. The nurse understands there is an ethical responsibility to protect clients.

When assessing a family for possible barriers to health care, the mother reports several problems she has been having when coming to her local clinic. The nurse would consider which reported problem as having the greatest impact on this family's health care? A. Language barrier B. Health care workers' attitudes C. Transportation to the clinic D. Family finances

C. Transportation to the clinic

A nurse is describing the cycle of violence to a community group. When explaining the first phase, the nurse would most likely include which description? A. associated with loss of physical and emotional control B. somehow triggered by the victim's behavior C. characterized by tension-building and minor battery D. like a honeymoon that lulls the victim

C. characterized by tension-building and minor battery

A nurse is monitoring a client's hCG levels because she has had a previous ectopic pregnancy and one spontaneous abortion. Which finding would the nurse interpret as indicating that the pregnancy is progressing appropriately? A. plateauing of the level at 7 days B. abruptly declining levels after 60 days C. doubling of the level every 2 to 3 days D. gradually increasing levels every month

C. doubling of the level every 2 to 3 days

A nurse is conducting an assessment of a woman who has experienced PROM. Which finding would lead the nurse to suspect infection as the cause of a client's PROM? A. blue color on Nitrazine testing B. yellow-green fluid C. foul odor D. ferning

C. foul odor

During a routine prenatal visit, a client, 36 weeks pregnant, states she has difficulty breathing and feels like her pulse rate is really fast. The nurse finds her pulse to be 100 beats per minute (increased from baseline readings of 70 to 74 beats per minute) and irregular, with bilateral crackles in the lower lung bases. The nurse would develop a plan of care identifying interventions to promote which area as the priority? A. anxiety B. activity C. gas exchange D. tissue perfusion

C. gas exchange

A woman in the 34th week of pregnancy says to the nurse, "I still feel like having intercourse with my husband." The woman's pregnancy has been uneventful. The nurse responds based on the understanding that: A. intercourse at this time is likely to cause rupture of membranes. B. there are other ways that the couple can satisfy their needs. C. it is safe to have intercourse at this time. D. intercourse at this time is likely to result in premature labor.

C. it is safe to have intercourse at this time.

A nurse is counseling a pregnant woman with rheumatoid arthritis about medications that can be used during pregnancy. Which drug would the nurse emphasize as being contraindicated at this time? A. glucocorticoid B. nonsteroidal anti-inflammatory drugs C. methotrexate D. hydroxychloroquine

C. methotrexate

Assessment of a pregnant woman reveals that she compulsively craves ice. The nurse documents this finding as: A. ballottement. B. linea nigra. C. pica D. quickening.

C. pica

In a client's seventh month of pregnancy, she reports feeling "dizzy, like I'm going to pass out, when I lie down flat on my back." The nurse explains that this is due to: A. pressure of the presenting fetal part on the diaphragm. B. physiologic anemia due to hemoglobin decrease. C. pressure of the gravid uterus on the vena cava. D. a 50% increase in blood volume.

C. pressure of the gravid uterus on the vena cava.

After teaching a group of pregnant women about breastfeeding, the nurse determines that the teaching was successful when the group identifies which hormone as important for the production of breast milk after birth? A. gonadotropin-releasing hormone B. placental estrogen C. prolactin D. progesterone

C. prolactin

While talking with a pregnant woman who has undergone genetic testing, the woman informs the nurse that her baby will be born with Down syndrome. The nurse understands that Down syndrome is an example of: A. multifactorial inheritance. B. chromosomal deletion. C. trisomy numeric abnormality. D. X-linked recessive inheritance.

C. trisomy numeric abnormality.

A primiparous client is being seen in the clinic for her first prenatal visit. It is determined that she is 11 weeks pregnant. The nurse develops a teaching plan to educate the client about what she will most likely experience during this period. Which possible effect would the nurse include? A. hemorrhoids B. backache C. urinary frequency D. ankle edema

C. urinary frequency

During a prenatal visit, a pregnant woman says, "I know the amniotic fluid is important, but can you tell me more about it?" When describing amniotic fluid to a pregnant woman, which description would the nurse most likely include? A. "The amount of fluid remains fairly constant throughout the pregnancy." B."The fluid is mostly protein to provide nourishment to your baby." C."This fluid acts as a cushion to help to protect your baby from injury." D. "This fluid acts as transport mechanism for oxygen and nutrients."

C."This fluid acts as a cushion to help to protect your baby from injury."

A pregnant client tells her nurse that she is interested in arranging a home birth. After educating the client on the advantages and disadvantages of a home birth, which statement would indicate that the client understood the information? A."I like having the privacy, but it might be too expensive for me to set up in my home." B. "The midwife is trained to resolve any emergency, and she can bring any pain meds." C. "It is safer because I will have a midwife." D. "I want to have more control, but I am concerned if an emergency would arise."

D. "I want to have more control, but I am concerned if an emergency would arise."

A nurse is reinforcing teaching with a client who has genital herpes. Which of the following client statements should the nurse identify as understanding of the teaching? A. "The provider can do weekly treatment to remove the lesions." B. "I should use condoms during the prodromal phase of infection." C. "I am not contagious if no lesions are present." D. "The lesions can spread to other areas of my body."

D. "The lesions can spread to other areas of my body."

A nurse is preparing an in-service program for a group of newly hired nurses about trends in care for pregnant women. When describing events of the past decade, the nurse would state that the average length of stay in the hospital for vaginal births is: A. 72 to 96 hours or less. B. 96 to 120 hours or less. C. 48 to 72 hours or less. D. 24 to 48 hours or less.

D. 24 to 48 hours or less.

A couple comes to the clinic for preconception counseling and care. As part of the visit, the nurse teaches the couple about fertilization and initial development, stating that the zygote formed by the union of the ovum and sperm consists of how many chromosomes? A. 23 B.22 C.44 D.46

D. 46

A nurse is reinforcing teaching with a client who is pregnant and has a new prescription for ferrous sulfate due to iron-deficiency anemia. The nurse should instruct the client to take this medication with which of the following? A. Milk B. Orange juice C. Scrambled eggs D. A high-fiber meal

D. A high-fiber meal

Which approach would be most appropriate when counseling a woman who is a suspected victim of violence? A. Call her at home to ask her some questions about her marriage. B. Wait until she comes in a few more times to make a better assessment. C. Offer her a pamphlet about the local battered women's shelter. D. Ask, "Have you ever been physically hurt by your partner?"

D. Ask, "Have you ever been physically hurt by your partner?"

When preparing a teaching plan for a group of women during their first pregnancy, the nurse reviews how maternity care has changed over the years. Which information would the nurse include when discussing events occurring in the 20th century? A. Epidemics of puerperal fever B. Performance of the first cesarean birth C. X-ray developed to assess pelvic size D. Development of free-standing birth centers

D. Development of free-standing birth centers

The nurse is explaining fetal circulation to a pregnant woman during an early prenatal visit. The nurse emphasizes the difference in her baby's circulation from the woman's circulation. The nurse determines that the teaching was successful when the woman describes which reason for the difference? A. Fetal blood is thicker than that of adults and needs different pathways. B. Fetal circulation carries rich, oxygenated blood to vital areas first. C. Fetal blood has a higher concentration of oxygen and circulates more slowly. D. Fetal heart rates are rapid and circulation time is double that of adults.

D. Fetal heart rates are rapid and circulation time is double that of adults.

When describing gender determination at a prenatal class, the nurse would include which statement? A. Gender is determined when the sperm and the oocyte undergo the process of mitosis. B. Gender is determined when the ovum and the spermatozoon undergo the process of meiosis. C. Gender is determined when the primary oocyte completes its first mitotic division. D. Gender is determined at fertilization when the ovum is fertilized.

D. Gender is determined at fertilization when the ovum is fertilized.

A client is trying to have a baby and wants to know the best time to have intercourse to increase the chance of pregnancy. Which time for intercourse is ideal to increase her chance of conceiving? A. Any time during the week before ovulation. B. One week after ovulation. C. Any time after ovulation. D. One or two days prior to ovulation.

D. One or two days prior to ovulation.

A nurse is conducting an orientation program for a group of newly hired nurses. As part of the program, the nurse is reviewing the issue of informed consent. The nurse determines that the teaching was effective when the group identifies which situation as a violation of informed consent? A. Getting verbal consent over the phone for an emergency procedure from the spouse of a unconscious woman B. Asking whether the client understands what she is signing following receiving education C. Serving as a witness to the signature process on an operative permit D. Performing a procedure on a 15-year-old without parental consent

D. Performing a procedure on a 15-year-old without parental consent

A woman is at 20 weeks' gestation. The nurse would expect to find the fundus at which area? A. midway between the umbilicus and xiphoid process B. midway between the pubis and umbilicus C. just above the symphysis pubis D. at the level of the umbilicus

D. at the level of the umbilicus

Which finding would the nurse interpret as suggesting a diagnosis of gestational trophoblastic disease? A. elevated hCG levels, enlarged abdomen, quickening B. vaginal bleeding, absence of FHR, decreased hPL levels C. visible fetal skeleton on ultrasound, absence of quickening, enlarged abdomen D. gestational hypertension, hyperemesis gravidarum, absence of FHR

D. gestational hypertension, hyperemesis gravidarum, absence of FHR

Assessment of a pregnant woman reveals a pigmented line down the middle of her abdomen. The nurse documents this as which finding? A. melasma B. striae gravidarum C. vascular spiders D. linea nigra

D. linea nigra

When teaching a class of pregnant women about the effects of substance abuse during pregnancy, the nurse would most likely include which effect? A. higher pain tolerance B. longer gestational periods C. excessive weight gain D. low-birthweight infants

D. low-birthweight infants

After teaching a group of adolescent girls about female reproductive development, the nurse determines that teaching was successful when the girls state that menarche is defined as a woman's first: A. sign of breast development. B. sexual experience. C. full hormonal cycle. D. menstrual period.

D. menstrual period.

Which information on a client's health history would the nurse identify as contributing to the client's risk for an ectopic pregnancy? A. use of oral contraceptives for 5 years B. heavy, irregular menses C. ovarian cyst 2 years ago D. recurrent pelvic infections

D. recurrent pelvic infections

A pregnant woman comes to the clinic and tells the nurse that she has been having a whitish vaginal discharge. The nurse suspects vulvovaginal candidiasis based on which assessment finding? A. urinary frequency B. fever C. incontinence D. vaginal itching

D. vaginal itching