Practice Questions
1. Prioritize the postpartum mother's needs 4 hours after giving birth by placing a number 1, 2, 3, or 4 in the blank before each need. Learn how to hold and cuddle the infant. Watch a baby bath demonstration given by the nurse. Sleep and rest without being disturbed for a few hours. Interaction time (first 30 minutes) with the infant to facilitate bonding.
1. Interaction time (first 30 minutes) with the infant to facilitate bonding. 2. Sleep and rest without being disturbed for a few hours. 3. Learn how to hold and cuddle the infant. 4. Watch a baby bath demonstration given by the nurse.
A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should take? A. Assist the client into the left-lateral position. B. Apply a fetal scalp electrode. C. Insert an IV catheter. D. Perform a vaginal exam.
A
A nurse in the labor and delivery unit is caring for a client who is in the second stage of labor. The client's labor has been progressing, and she is expected to deliver vaginally in 20 min. The provider is preparing to administer lidocaine (Xylocaine) for pain relief and perform an episiotomy. The nurse should know that the type of regional anesthetic block that is to be administered is which of the following? A. Pudendal block B. Epidural block C. Spinal block D. Paracervical block
A
A nurse is caring for a client having contractions every 8 minutes that are 30 to 40 seconds in duration. The client's cervix is 2m dilated, 50% effaced, and the fetus is at a -2 station with a FHR around 140/min. Which of the following stages and phases of labor is the client experiencing? a. First stage, latent phase b. First stage, active phase c. First stage, transition phase d. Second stage of labor
A
A nurse is caring for a client who has been in labor for 12 hours with intact membranes. The nurse performs a vaginal examination to ensure which of the following prior to the performance of the amniotomy? a. Fetal engagement b. Fetal lie c. Fetal attitude d. Fetal position
A
A nurse is caring for a client who has been in labor for 12 hr, and her membranes are intact. The provider has decided to perform an amniotomyin an effort to facilitate the progress of labor. The nurse performs a vaginal examination to ensure which of the following prior to the performance of the amniotomy? A. Fetal engagement B. Fetal lie C. Fetal attitude D. Fetal position
A
A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following antepartum complications should the nurse understand is a risk factor for this client? A. Preeclampsia B. Thrombophlebitis C. Placenta previa D. Hyperemesis gravidarum
A
A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following antepartum complications should the nurse understand is a risk factor for this condition? a. Preeclampsia b. Thrombophlebitis c. Placenta previa d. Hyperemesis gravidarum
A
A nurse is caring for a client who has mastitis. Which of the following is the typical causative agent of mastitis? A.Staphylococcus aureus B.Chlamydia trachomatis C.Klebsiellapneumonia D.Clostridium perfringens
A
A nurse is caring for a client who has mastitis. Which of the following is the typical causative agent of mastitis? a. Staphylococcus aureus b. Chlamydia trachomatis c. Klebsiella pneumonia d. Clostridium perfringens
A
A nurse is caring for a client who is in active labor and reports severe back pain. During assessment, the fetus is noted to be in the occiput posterior position. Which of the following maternal positions should the nurse suggest to the client to facilitate normal labor progress? A. Hands and knees B. Lithotomy C. Trendelenburg D. Supine with a rolled towel under one hip
A
A nurse is caring for a client who is in active labor and reports severe back pain. During assessment, the fetus is noted to be in the occiput posterior position. Which of the following maternal positions should the nurse suggest to the client to facilitate normal labor progress? a. Hands and knees b. Lithotomy c. Trendelenburg d. Supine with a rolled towel under one hip
A
A nurse educator in the labor and delivery unit is reviewing the use of chemical agents to promote cervical ripening with a group of newly licensed nurse. Which of the following statements by the nurse indicates understanding of the teaching? a. They are tablets administered vaginally. b. They act by absorbing fluid from tissues. c. They promote dilation of the os. d. They include an amniotomy.
A
A nurse in the labor and delivery unit is caring for a client in labor and applies an external fetal monitorandtocotransducer. The FHR is around 140/min. Contractions are every 8 min and 30 to 40 seconds induration. The nurse performs a vaginal exam and finds the cervix is 2 cm dilated, 50% effaced, and thefetus is at a -2 station. Which of the following stages and phases of labor is this client experiencing? A. The first stage, latent phase B. The first stage, active phase C. The first stage, transition phase D. The second stage of labor
A
A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should take? a. Assist the client into the left-lateral position b. Apply a fetal scalp electrode c. Insert an IV catheter d. Perform a vaginal exam
A
A nurse is caring for a client who is in the second stage of labor. The client's labor has been progressing and a vaginal delivery is expected in 20 minutes. The provider is preparing to administer lidocaine for pain relief and perform an episiotomy. The nurse should know that which of the following types of regional anesthetic block is to be administered? a. Pudendal b. Epidural c. Spinal d. Paracervical
A
A nurse is caring for a client who is postpartum. The nurse should identify which of the following findings as an early indicator of hypovolemia caused by hemorrhage? a. Increasing pulse and decreasing blood pressure b. Dizziness and increasing respiratory rate c. Cool, clammy skin, and pal mucous membranes d. Altered mental status and level of consciousness
A
A nurse is caring for a postpartum client. The nurse should understand that which of the following findings are the earliest indication of hypovolemia caused by hemorrhage? A. Increasing pulse and decreasing blood pressure B. Dizziness and increasing respiratory rate C. Cool, clammy skin, and pale mucous membranes D. Altered mental status and level of consciousness
A
A nurse is conducting a home visit for a client who is 1 week postpartum and breastfeeding. The client reports breast engorgement. Which of the following recommendations should the nurse make? a. Apply cold compresses between feedings b. Take a warm shower right after feedings c. Apply breast milk to the nipples and allow them to air dry d. Use the various infant positions for feedings
A
A nurse is conducting a home visit for a client who is 2 weeks postpartum and breastfeeding. The client reports breast engorgement. Which of the following recommendations should the nurse make? A. "Apply cold compresses between feedings." B. "Take a warm shower right after feedings." C. "Apply breast milk to the nipples and allow them to air dry." D. "Use the various infant positions for feedings."
A
A nurse is performing a fundal assessment for a client in her second postpartum day and observes the client's perineal pad for lochia. She notes the pad to be saturated approximately 12 cm with lochia that is bright red in color and contains small clots. The nurse knows that this finding is A. moderate lochia rubra. B. excessive lochia rubra. C. light lochia rubra. D. scant lochia serosa.
A
A nurse is performing a fundal assessment for a client who is 2 days postpartum and observes the perineal pad for lochia. The pad is saturated approximately 12cm with lochia that is bright red and contains small clots. Which of the following findings should the nurse document? a. Moderate lochia rubra b. Excessive lochia serosa c. Light lochia rubra d. Scant lochia serosa
A
A nurse is providing discharge teaching for a nonlactating client. Which of the following instructions should the nurse include in the teaching? a. Wear a supportive bra continuously for the first 72 hours b. Pump your breasts every 4 hours to relieve discomfort c. Use breast shells throughout the day to decrease milk supply d. Apply warm compresses until milk suppression occurs
A
A postpartum woman reports hearing voices and says, "The voices are telling me to do bad things to my baby." The clinic nurse interprets these findings as suggesting postpartum a. psychosis. b. anxiety disorder. c. depression. d. blues.
A
After a vaginal examination, the nurse determines that the client's fetus is in an occiput posterior position. The nurse would anticipate that the client will have: a. Intense back pain b. Frequent leg cramps c. Nausea and vomiting d. A precipitous birth
A
Postpartum breast engorgement occurs 48 to 72 hours after giving birth. What physiologic change influences breast engorgement? a. An increase in blood and lymph supply to the breasts b. An increase in estrogen and progesterone levels c. Colostrum production increases dramatically d. Fluid retention in the breasts due to the intravenous fluids given during labor
A
The major purpose of the first postpartum homecare visit is to: a. Identify complications that require interventions b. Obtain a blood specimen for PKU testing c. Complete the official birth certificate d. Support the new parents in their parenting roles
A
When caring for a client during the active phase of labor without continuous electronic fetal monitoring, the nurse would intermittently assess FHR every: a. 15 to 30 minutes b. 5 to 10 minutes c. 45 to 60 minutes d. 60 to 75 minutes
A
When determing the frequency of contractions, the nurse would measure which of the following? a. Start of one contraction to the start of the next contraction b. Beginning of one contraction to the end of the same contraction c. Peak of one contraction to the peak of the next contraction End of one contraction to the beginning of the next contraction
A
Which of the following practices would not be included in a physiologic birth? a. Early induction of labor <39 weeks' gestation b. Freedom of movement for the laboring woman c. Continuous presence and support throughout labor d. Encouraging spontaneous pushing when urge felt
A
Which of the following would the nurse assess as indicating positive bonding between the parents and their newborn? a. Holding the infant close to the body b. Having visitors hold the infant c. Buying expensive infant clothes d. Requesting that the nurses care for the infant
A
A nurse is caring for a client who is 1 hrfollowing a vaginal birth and experiencing uncontrollable shaking. The nurse should understand that the shaking is due to which of the following? (Select all that apply.) A. A change in body fluids B. The metabolic effort of labor C. Diaphoresis D. A decrease in body temperature E. A decrease in prolactin levels
A, B
Interventions that are underutilized in promoting a normal birth. Select all that apply. a. Oral nutrition and fluids in labor b. Open glottis pushing in the second stage of labor c. Skin-to-skin contact after birth for infant bonding d. Routine artificial rupture of membranes (amniotomy) e. Labor induction with Pitocin given intravenously f. Routine episiotomy to shorten labor length
A, B, C
A nurse is discussing risk factors for urinary tract infections with a newly licensed nurse. Which of the following conditions should the nurse include include in the teaching? Select all that apply. a. Epidural anesthesia b. Urinary bladder catheterization c. Frequent pelvic examinations d. History of UTIs e. Vaginal birth
A, B, C, D
A nurse on the postpartum unit is performing a physical assessment of a client who is being admitted with a suspected deep-vein thrombosis (DVT). Which of the following clinical findings should the nurse anticipate the client will exhibit? (Select all that apply.) A. Calf tenderness to palpation B. Swelling of the extremity C. Elevated temperature D. Area of warmth E. Report of nausea
A, B, C, D
A nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of nurses. Which of the following should be included in the discussion? (Select all that apply.) A. Precipitous delivery B. Lacerations C. Inversion of the uterus D. Oligohydramnios E. Retained placental fragments
A, B, C, E
A nurse is caring for a client who is in active labor. The cervix is dilated to 5cm, and the membranes are intact. Based on the use of external electronic fetal monitoring, the nurse notes a FHR of 115 to 125/min with occasional increases up to 150 to 155/min that lasts 25 seconds and have moderate variability. There is no slowing of the FHR from the baseline. This client is exhibiting manifestations of which of the following? Select all that apply. a. Moderate variability b. FHR accelerations c. FHR decelerations d. Normal baseline FHR e. Fetal tachycardia
A, B, D
A nurse is caring for a postpartum client who delivered their third infant 2 days ago. Which of the following manifestations could indicate postpartum depression? Select all that apply. a. Fatigue b. Insomnia c. Euphoria d. Flat affect e. Delusions
A, B, D
A nurse is providing care for a client who is in active labor. Her cervix is dilated to 5 cm, and her membranes are intact. Based on the use of external electronic fetal monitoring, the nurse notes a FHR of 115 to 125/min with occasional increases up to 150 to 155/min that last for 25 seconds, and have beat‑to‑beat variability of 20/min. There is no slowing of FHR from the baseline. The nurse should recognize that this client is exhibiting signs of which of the following? (Select all that apply.) A. Moderate variability B. FHR accelerations C. FHR decelerations D. Normal baseline FHR E. Fetal tachycardia
A, B, D
A nurse is caring for a postpartum client who delivered her third infant 2 days ago. The nurse recognizes that which of the following findings are suggestive of postpartum depression? (Select all that apply.) A. Fatigue B. Insomnia C. Euphoria D. Flat affect E. Crying
A, B, D, E
A nurse is caring for a client who is 1 day postpartum. The nurse is assessing for maternal adaptation and mother-infant bonding. Which of the following behaviors by the client indicates a need for the nurse to intervene? (Select all that apply.) A. Demonstrates apathy when the infant cries B. Touches the infant and maintains close physical proximity C. Views the infant's behavior as uncooperative during diaper changing D. Identifies and relates infant's characteristics to those of family members E. Interprets the infant's behavior as meaningful and a way of expressing needs
A, C
A nurse is caring for a client who is 1 day postpartum. The nurse is assessing for maternal adaptation and parent-infant bonding. Which of the following behaviors by the client indicates a need for the nurse to intervene? Select all that apply. a. Demonstrates apathy when the newborn cries b. Touches the newborn and maintains close physical proximity c. Views the newborn's behaviors as uncooperative during diaper changing d. Identifies and relates newborn's characteristics to those of family members e. Interprets the newborn's behavior as meaningful and a way of expressing needs
A, C
A nurse is caring for a client who is 42 weeks of gestation and is having an ultrasound. For which of the following conditions should the nurse plan for an amniotransfusion? Select all that apply. a. Oligohydramnios b. Hydraminos c. Fetal cord compression d. Hydration e. Fetal immaturity
A, C
A nurse is caring for a client who is at 42 weeks of gestation and is admitted to the labor and delivery unit. During an ultrasound, it is noted that the fetus is large for gestational age. The nurse reviews the prescription from the provider to begin an amnioinfusion. The nurse should know that an amnioinfusion is indicated for which of the following reasons? (Select all that apply.) A. Oligohydramnios B.Hydramnios C. Fetal cord compression D. Hydration E. Fetal immaturity
A, C
A nurse is caring for a client at 40 weeks of gestation who is experiencing contractions every 3 to 5 minand becoming stronger. A vaginal exam reveals that the client's cervix is 3 cm dilated, 80% effaced, and-1 station. The client asks for pain medication. Which of the following actions should the nurse take at this time? (Select all that apply.) A. Encourage the use of patterned breathing techniques. B. Insert an indwelling urinary catheter. C. Administer opioid analgesic medication as prescribed. D. Suggest application of cold. E. Provide ice chips.
A, C, D
A nurse is caring for a client who is at 40 weeks of gestation and experiencing contractions every 3 to 5 minutes and becoming stronger. A vaginal exam reveals that the client's cervix is 3cm dilated, 80% effaced, and -1 station. The client asks for pain medication. Which of the following actions should the nurse take? Select all that apply. a. Encourage use of patterned breathing techniques b. Insert an indwelling urinary catheter c. Administer opioid analgesic medication d. Suggest application of cold e. Provide ice chips
A, C, D
A nurse on the postpartum unit is assessing a client who is being admitted with a suspected deep-vein thrombosis (DVT). Which of the following clinical findings should the nurse expect? Select all that apply. a. Calf tenderness to palpation b. Mottling of the affected extremity c. Elevated temperature d. Area of warmth e. Report of nausea
A, C, D
A nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of nurses. Which of the following factors should the nurse include in the teaching? Select all that apply. a. Precipitous delivery b. Obesity c. Inversion of the uterus d. Oligohydramnios e. Retained placental fragments
A, C, E
A nurse is providing education to a client who is 2 hours postpartum and has perineal laceration. Which of the following information should the nurse include? Select all that apply. a. Use a perineal squeeze bottle to cleanse the perineum b. Sit on the perineum while resting in bed c. Apply a topical anesthetic cream or spray to the perineum d. Wipe the perineum thoroughly with a back-and-forth motion Apply cold or ice packs to the perineum
A, C, E
A nurse is caring for a client in the third stage of labor. Which of the following findings indicate placental separation? Select all that apply. a. Lengthening of the umbilical cord b. Swift gush of clear amniotic fluid c. Softening of the lower uterine segment d. Appearance of dark blood from the vagina e. Fundus firm upon palpation
A, D, E
A nurse is caring for a client in the third stage of labor. Which of the following findings indicate that placental separation has occurred? (Select all that apply.) A. Lengthening of the umbilical cord. B. Swift gush of clear amniotic fluid. C. Softening of the lower uterine segment. D. Appearance of dark blood from the vagina. E. Fundus is firm upon palpation.
A, D, E
A nurse is reviewing the electronic monitor tracing of a client who is in active labor. A fetus receives more oxygen when which of the following appears on the tracing? a. Peak of the uterine contraction b. Moderate variability c. FHR acceleration d. Relaxation between uterine contractions
D
A client experiences a large gush of fluid from her vagina while walking in the hallway of the birthing unit. The nurse's first nursing action after establishing that the fluid is amniotic fluid should be to A. assess the amniotic fluid for meconium. B. monitor the FHR for distress. C. dry the client and make her comfortable. D. monitor the client's uterine contractions.
B
A client in the early postpartum period is very excited and talkative. She is repeatedly telling the nurse every detail of her labor and birth. Because the client will not stop talking, the nurse is having difficulty completing the postpartum assessments. The appropriate action by the nurse is to A. come back later when the client is more cooperative. B. give the client time to express her feelings. C. tell the client she needs to be quiet so the assessment can be completed. D. redirect the client's focus so that she will become quiet.
B
A client in the early postpartum period is very excited and talkative. They repeatedly tell the nurse every detail of the labor and birth. Because the client will not stop talking, the nurse is having difficulty completing the postpartum assessments. Which of the following action should the nurse take? a. Come back later when the client is more cooperative b. Give the client time to express feelings c. Tell the client they need to be quiet so the assessment can be completed d. Redirect the client's focus so that they will become quiet
B
A home-health nurse is conducting a visit to the home of a client who has a 2-month-old infant and a 4-year-old son. The client expresses frustration about the behavior of the 4-year-old who was previously toilet trained and is now frequently wetting himself. The nurse should provide education and explains to the client that A. her son was probably not ready for toilet training and should wear training pants. B. her son is showing an adverse sibling response. C. this indicates the child requires counseling. D. this can be resolved by sending the child to preschool.
B
A nurse caring for a client who is in labor and experiencing incomplete uterine relaxation between hypertonic contractions. The nurse should identify that this contraction pattern increases the risk for which of the following complications? a. Prolonged labor b. Reduced fetal oxygen supply c. Delayed cervical dilation d. Increased maternal stress
B
A nurse in labor and delivery is completing an admission history for a client who is at 39 weeks of gestation. The client reports that she has been leaking fluid from her vagina for 2 days. The nurse knowsthat this client is at risk for A. cord prolapse. B. infection. C. postpartum hemorrhage. D.hydramnios.
B
A nurse is assessing a postpartum client for fundal height, location, and consistency. The fundus is found to be displaced laterally to the right, and there is uterine atony. Which of the following is the cause of the uterine atony? A. Poor involution B. Urinary retention C. Hemorrhage D. Infection
B
A nurse is assessing a postpartum client for fundal height, location, and consistency. The fundus is noted to be displaced laterally to the right, and there is uterine atony. The nurse should identify which of the following conditions as the cause of the uterine atony? a. Poor involution b. Urinary retention c. Hemorrhage d. Infection
B
A nurse is caring for a client in active labor. When last examined 2 hours ago, the client's cervix was 3cm dilated, 100% effaced, membranes intact and the fetus was at a -2 station. The client suddenly states, "My water broke." The monitor reveals a FHR of 80 to 85/min, and the nurse performs a vaginal examination, noticing clear fluid and a pulsing loop of umbilical cord in the client's vagina. Which of the following actions should the nurse perform first? a. Place the client in the Trendelenburg position b. Apply pressure to the presenting part with the fingers c. Administer oxygen at 10L/min via a face mask d. Initiate IV fluids
B
A nurse is caring for a client who has postpartum psychosis. Which of the following actions is the nurse's priority? a. Reinforce the need to take antipsychotics as prescribed b. Ask the client if they have thoughts of harming themselves or their infant c. Monitor the infant for indications of failure to thrive d. Review the client's medical record for a history of bipolar disorder
B
A nurse is caring for a client who is 2 days postpartum. The client states, "My 4-year old son was toilet trained and now he is frequently wetting himself." Which of the following statements should the nurse provide to the client? a. Your son was probably not ready for toilet training and should wear training pants. b. Your son is showing an adverse sibling response. c. Your son may need counseling. d. You should try sending your son to preschool to resolve the behavior.
B
A nurse is caring for a client who is 40 weeks of gestation and reports having large gush of fluid from the vagina while walking to the bathroom. Which of the following actions should the nurse take first? a. Examine the amniotic fluid for meconium b. Check the FHR c. Dry the client and make them comfortable d. Apply a tocotransducer
B
A nurse is caring for a client who is having an induction of labor. Based on the use of external electronic fetal monitoring, the nurse notes that the FHR variability is decreased and resembles a straight line. The client has not received pain medication. Which of the following should occur first before the nurse can apply an internal scalp electrode? A. Dilation B. Rupture of the membranes C. Effacement D. Engagement
B
A nurse is caring for a client who is in active labor. The client reports lower back pain. The nurse suspects that this pain is related to a persistent occiput posterior fetal position. Which of the following nonpharmacological nursing interventions is appropriate? A. Abdominal effleurage B. Sacral counterpressure C. Showering if not contraindicated D. Back rub and massage
B
A nurse is caring for a client who is in active labor. The client reports lower-back pain. The nurse suspects that this pain is related to persistent occiput posterior fetal position. Which of the following nonpharmacological nursing interventions should the nurse recommend to the client? a. Abdominal effleurage b. Sacral counterpressure c. Showering if not contraindicated Back rub and massage
B
A nurse is caring for a client who is in labor and experiencing incomplete uterine relaxation between hypertonic contractions. The nurse recognizes the adverse effect of this contraction pattern is A. prolonged labor. B. reduced fetal oxygen supply. C. delayed cervical dilation. D. increased maternal stress.
B
A nurse is caring for a client who is in the transition phase of labor and reports that she needs to have a bowel movement with the peak of contractions. Which of the following is an appropriate nursing intervention? A. Assist the client to the bathroom. B. Prepare for an impending delivery. C. Prepare to remove a fecal impaction. D. Encourage the client to take deep, cleansing breaths.
B
A nurse is caring for a client who is in the transition phase of labor and reports that they need to have a bowel movement with the peak of contractions. Which of the following actions should the nurse make? a. Assist the client to the bathroom b. Prepare for an impending delivery c. Prepare to remove a fecal impaction d. Encourage the client to take deep, cleansing breaths
B
A nurse is caring for a client who is receiving oxytocin (Pitocin) for induction of labor and has an intrauterine pressure catheter (IUPC) placed to monitor uterine contractions. For which of the following contraction patterns should the nurse discontinue the infusion of oxytocin? A. Frequency of every 2 min B. Duration of 90 to 120 seconds C. Intensity of 60 to 90 mm Hg D. Resting tone of 15 mm Hg
B
A nurse is caring for a client who is receiving oxytocin for induction of labor and has an intrauterine pressure catheter (IUPC) placed to monitor uterine contractions. For which of the following contraction patterns should the nurse discontinue the infusion of oxytocin? a. Frequency of every 2 minutes b. Duration of 90 to 120 seconds c. Intensity of 60 to 90 mmHg d. Resting tone of 15mmHg
B
A nurse is completing an admission assessment for a client who is 39 weeks of gestation and reports leaking from the vagina for 2 days. Which of the following conditions is the client at risk for developing? a. Cord prolapse b. Infection c. Postpartum hemorrhage d. Hydramnios
B
A nurse is completing postpartum discharge teaching to a client who had no immunity to varicella and was given varicella vaccine. Which of the following statements by the client indicates understanding of the teaching? A. "I will need to use contraception for 3 months before considering pregnancy." B. "I need a second vaccination at my postpartum visit." C. "I was given the vaccine because my baby is O-positive." D. "I will be tested in 3 months to see if I have developed immunity."
B
A nurse is completing postpartum discharge teaching to a client who had no immunity to varicella and was given to varicella vaccine. Which of the following statements by the client indicates understanding of the teaching? a. I will need to use contraceptives for 3 months before considering pregnancy. b. I need a second vaccination at my postpartum visit. c. I was given the vaccine because my baby is O-positive. d. I will be tested in 3 months to see if I have developed immunity.
B
A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie? A. Apply palms of both hands to sides of uterus. B. Palpate the fundus of the uterus. C. Grasp lower uterine segment between thumb and fingers. D. Stand facing client's feet with fingertips outlining cephalic prominence.
B
A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie? a. Apply palms of both hands to sides of uterus b. Palpate the fundus of the uterus c. Grasp lower uterine segment between thumb and fingers d. Stand facing client's feet with fingertips outlining cephalic prominence
B
A nurse is providing care to four clients on the postpartum unit. Which of the following clients is at greatest risk for developing postpartum infection? a. A client who has an episiotomy that is erythematous and has extended into a third-degree laceration b. A client who does not wash their hands between perineal care and breastfeeding c. A client who is not breastfeeding and is using measures to suppress lactation A client who has a cesarean incision that is well-approximated with no drainage
B
A nurse is providing care to multiple clients on the postpartum unit. Which of the following clients is at greatest risk for developing a puerperal infection? A. A client who has an episiotomy that is erythematous and has extended into a third-degree laceration B. A client who does not wash her hands between perineal care and breastfeeding C. A client who is not breastfeeding and is using measures to suppress lactation D. A client who has a cesarean incision that is well-approximated with no drainage
B
A nurse on the postpartum unit is caring for four clients. Which of the following clients should the nurse recognize as the greatest risk for development of postpartum infection? a. A client who experienced a precipitous labor less than 3 hours in duration b. A client who had premature rupture of membranes and prolonged labor c. A client who delivered a large for gestational age infant d. A client who had a boggy uterus that was not well-contracted
B
A nurse on the postpartum unit is caring for several clients. The nurse should recognize that the greatest risk for development of a postpartum infection is the client who A. experienced a precipitous labor less than 3 hrin duration. B. had premature rupture of membranes and prolonged labor. C. delivered a large for gestational age infant. D. had a boggy uterus that was not well-contracted.
B
As the nurse is explaining the difference between true versus false labor to her childbirth class, she states that the major difference between them is: a. Discomfort level is greater with false labor b. Progressive cervical changes occur in true labor c. There is a feeling of nausea with false labor d. There is more fetal movement with true labor
B
During the fourth stage of labor, the nurse assesses the woman at frequent intervals after giving childbirth. What assessment data would cause the nurse the most concern? a. Moderate amount of dark red lochia drainage on peripad b. Uterine fundus palpated to the right of the umbilicus c. An oral temperature reading of 100.6F d. Perineal area bruised and edematous beneath her ice pack
B
Immediately after childbirth in the recovery area, the nurse observes the mother's partner's fascination and interest in the new son. This behavior is often termed: a. Attachment b. Engrossment c. Bonding d. Temperament
B
Physiologic preparation for labor would be demonstrated by: a. Decrease in Braxton Hicks contractions felt by mother b. Weight gain and an increase in appetite by mother c. Lightening, whereby the fetus drops into true pelvis d. Fetal heart rate acceleration and increased movements
C
The nurse is caring for a woman experiencing hypertonic uterine dystocia. The woman's contractions are erratic in their frequency, duration, and of high intensity. The priority nursing intervention would be to: a. Encourage ambulation every 30 minutes b. Provide pain relief measures c. Monitor the Pitocin infusion rate closely d. Prepare the woman for an amniotomy
B
The nurse is instructing the postpartum client who plans to bottle-feed her newborn about measures to prevent breast engorgement when she is discharged. Which of the following measures should the nurse include in the teaching plan? a. Decreasing her fluid intake for the first week at home b. Wearing a tight-fitting supportive bra 24 hours' daily c. Take a diuretic to release the extra fluid in the breasts d. Manually express the milk that is accumulating
B
The nurse would anticipate a cesarean birth for a client who has which active infection present at the onset of labor? a. Hepatitis b. Herpes simplex virus c. Toxoplasmosis d. Human papillomavirus
B
The nurse would expect a postpartum woman to demonstrate lochia in which sequence? a. Rubra, alba, serosa b. Rubra, serosa, alba c. Serosa, alba, rubra d. Alba, rubra, serosa
B
The shortest but most intense phase of labor is the: a. Latent phase b. Active phase c. Transition phase d. Placental expulsion phase
B
Which fetal lie is most conducive to a spontaneous vaginal birth? a. Transverse b. Longitudinal c. Perpendicular d. Oblique
B
Which of the following factors in a postpartum woman's history would lead the nurse to monitor the woman closely for an infection? a. Hemoglobin of 12 mg/dL b. Manually extracted placenta c. Labor of 10 hours' length Multiparty of 5 pregnancies
B
Which of the following suggestions would be most appropriate to include in the teaching plan for a postpartum woman who needs to lose weight? a. Increase fluid intake and acid-producing foods in her diet. b. Avoid empty-calorie foods, breast-feed, increase exercise. c. Start a high-protein, low carbohydrate diet and restrict fluids. d. Eat no snacks or carbohydrates after dinner.
B
A nurse is assessing a client who has postpartum depression. The nurse should expect which of the following manifestations? Select all that apply. a. Paranoia that their infant will be harmed b. Concerns about lack of income to pay bills c. Anxiety about assuming a new role as a parent d. Rapid decline in estrogen and progesterone e. Feeling of inadequacy with the new role as a parent
B, C, D, E
A nurse is caring for a client who has postpartum depression. Which of the following are expected findings? (Select all that apply.) A. Disappointment in the characteristics of the infant B. Concerns about lack of income to pay bills C. Anxiety about assuming a new role as a mother D. Rapid decline in estrogen and progesterone E. Postpartum physical discomfort and/or pain
B, C, D, E
A nurse is reviewing discharge teaching with a client who has a urinary tract infection. Which of the following statements by the client indicates understanding of the teaching? (Select all that apply.) A. "I will perform pericare and apply a perineal pad in a back-to-front direction." B. "I will drink cranberry and prune juices to make my urine more acidic." C. "I will drink large amounts of fluids to flush the bacteria from my urinary tract." D. "I will go back to breastfeeding after I have finished taking the antibiotic." E. "I will take Tylenol for any discomfort."
B, C, E
A nurse is teaching a client about the benefits of internal fetal heart monitoring. Which of the following statements should the nurse include? Select all that apply. a. It is considered a noninvasive procedure. b. It can detect abnormal fetal heart tones early. c. It can determine the amount of amniotic fluid you have. d. It allows for accurate readings with maternal movement. e. It can measure uterine contraction intensity.
B, D, E
A client who was in active labor and whose cervix has dilated to 4cm experiences a weakening in the intensity and frequency of her contractions and exhibits no further progress in labor. The nurse interprets this as a sign of: a. Hypertonic labor b. Precipitate labor c. Hypotonic labor d. Dysfunctional labor
C
A nurse is caring for a client and her partner during the second stage of labor. The client's partner asks the nurse to explain how he will know when crowning occurs. Which of the following is an appropriate response by the nurse? A. "The placenta will protrude from the vagina." B. "Your partner will report a decrease in the intensity of contractions." C. "The vaginal area will bulge as the baby's head appears." D. "Your partner will report less rectal pressure."
C
A nurse is caring for a client and partner during the second stage of labor. The client's partner asks the nurse to explain how to know when crowning occurs. Which of the following responses should the nurse make? a. The placenta will protrude from the vagina. b. Your partner will report a decrease in the intensity of contractions. c. The vaginal area will bulge and the baby's head appears. d. Your partner will report less rectal pressure.
C
A nurse is caring for a client following the administration of an epidural block and is preparing to administer a prescribed IV fluid bolus. The client's partner asks about the purpose of the IV fluids. Which of the following is an appropriate response by the nurse? A. "It is needed to promote increased urine output." B. "It is needed to counteract respiratory depression." C. "It is needed to counteract hypotension." D. "It is needed to prevent oligohydramnios."
C
A nurse is caring for a client following the administration of an epidural block and is preparing to administer an IV fluid bolus. The client's partner asks about the purpose of the IV fluids. Which of the following statements should the nurse make? a. It is needed to promote increased urine output. b. It is needed to counteract respiratory depression. c. It is needed to counteract hypotension. d. It is needed to prevent oligohydramnios.
C
A nurse is caring for a client who had no prenatal care, is Rh-negative, and will undergo an external version at 38 weeks of gestation. Which of the following medications should the nurse plan to administer prior to the version? a. Prostaglandin gel b. Magnesium sulfate c. Rho(D) immune globulin d. Oxytocin
C
A nurse is caring for a client who is at 42 weeks of gestation and in active labor. The nurse should understand that the fetus is at risk for which of the following? A. Intrauterine growth restriction B. Hyperglycemia C. Meconium aspiration D. Polyhydramnios
C
A nurse is caring for a client who is at 42 weeks of gestation and in active labor. Which of the following findings is the fetus at risk for developing? a. Intrauterine growth restriction b. Hyperglycemia c. Meconium aspiration d. Polyhydramnios
C
A nurse is caring for a client who is in active labor and becomes nauseous and vomits. The client isvery irritable and feels the urge to have a bowel movement. She states, "I've had enough. I can't do this anymore. I want to go home right now." The nurse knows that these signs indicate the client is in the A. second stage of labor. B. fourth stage of labor. C. transition phase of labor. D. latent phase of labor.
C
A nurse is caring for a client who is in active labor, irritable, and reports the urge to have a bowel movement. The client vomits and states, "I've had enough. I can't do this anymore." Which of the following stages of labor is the client experiencing? a. Second stage b. Fourth stage c. Transition phase d. Latent phase
C
A nurse is caring for client who had no prenatal care, is Rh-negative and will undergo an external version at 37 weeks of gestation. The nurse anticipates a prescription for which of the following medications to be administered prior to the version? A. Prostaglandin gel (Cervidil) B. Magnesium sulfate C.RhO(D) immune globulin (RhoGAM) D. Oxytocin (Pitocin)
C
A nurse is providing discharge instructions for a client. At 4 weeks postpartum, the client should contact her provider for which of the following client findings? A. Scant, nonodorouswhite vaginal discharge B. Uterine cramping during breastfeeding C. Sore nipple with cracks and fissures D. Decreased response with sexual activity
C
A nurse is providing discharge instructions for a client. At 4 weeks postpartum, the client should contact the provider for which of the following client findings? a. Scant, nonodorous white vaginal discharge b. Uterine cramping during breastfeeding c. Sore nipple with cracks and fissures d. Decreased response with sexual activity
C
A nurse is providing discharge instructions to a postpartum client following a cesarean birth. The client reports leaking urine every time she sneezes or coughs. Which of the following should the nurse suggest? A. Performing sit-ups B. Performing pelvic tilt exercises C. Doing Kegel exercises D. Doing abdominal crunches
C
A nurse is providing discharge instructions to a postpartum client following a cesarean birth. The client reports leaking urine every time they sneeze or cough. Which of the following interventions should the nurse suggest? a. Sit-ups b. Pelvic tilt exercises c. Kegel exercises d. Abdominal crunches
C
A nurse is teaching a client who is breastfeeding and has mastitis. Which of the following is an appropriate statement by the nurse? A. "Limit the amount of time the infant nurses on each breast." B. "Nurse the infant only on the unaffected breast until resolved." C. "Completely empty each breast at each feeding or use a pump." D. "Wear a tight-fitting bra until lactation has ceased."
C
A nurse is teaching a client who is breastfeeding and has mastitis. Which of the following responses should the nurse make? a. Limit the amount of time the infant nurses on each breast b. Nurse the infant only on the unaffected breast until resolved c. Completely empty each breast at each feeding or use a pump d. Wear a tight-fitting bra until lactation has ceased
C
A postpartum mother appears very pale and states she is bleeding heavily. The nurse should first: a. Call the client's health care provider immediately b. Immediately set up an intravenous infusion of magnesium sulfate c. Assess the fundus and ask her about her voiding status d. Reassure the mother that this is a normal finding after childbirth
C
After teaching a group of breast-feeding women about nutritional needs, the nurse determines that the teaching was successful when the women state that they need to increase their intake of which nutrients? a. Carbohydrates and fiber b. Fats and vitamins c. Calories and protein d. Iron-rich foods and minerals
C
By the end of the second stage of labor, the nurse would expect which of the following events? The a. Cervix is fully dilated and effaced b. Placenta is detached and expelled c. Fetus is born and on mother's chest d. Woman to request pain medication
C
During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On assessment, a nurse finds the client's uterus to be firm and midline and at the level of the umbilicus. The nurse interprets this finding as A. evidence of a possible vaginal hematoma. B. an indication of a cervical or perineal laceration. C. a normal postural discharge of lochia. D. abnormally excessive lochia rubraflow.
C
During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On assessment, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus. Which of the following findings should the nurse interpret this data as being? a. Evidence of a possible vagina hematoma b. An indication of a cervical or perineal laceration c. A normal postural discharge of lochia d. Abnormally excessive lochia rubra flow
C
In the taking-in maternal role phase described by Rubin (1984), the nurse would expect the woman's behavior to be characterized as which of the following? a. Gaining self-confidence b. Adjusting to her new relationships c. Being passive and dependent d. Resuming control over her life
C
The nurse is assessing Ms. Smith, who gave birth to her first child 5 days ago. What findings by the nurse would be expected? a. Cream-colored lochia; uterus above the umbilicus b. Bright-red lochia with clots; uterus 2 fingerbreadths below umbilicus c. Light pink or brown lochia; uterus 4 to 5 fingerbreadths below umbilicus d. Yellow, mucousy lochia; uterus at the level of the umbilicus
C
The nurse is developing a plan of care for a woman experiencing dystocia. Which of the following interventions would be the nurse's highest priority? a. Changing the woman's position frequently b. Providing comfort measures to the woman c. Monitoring the fetal heart rate patterns Keeping the couple informed of the labor progress
C
The nurse notes the presence of transient fetal accelerations on the fetal monitoring strip. Which intervention would be most appropriate? a. Reposition the client on the left side b. Begin 100% oxygen via face mask c. Document this as indicating a normal pattern d. Call the health care provider immediately
C
When assessing a postpartum woman, which of the following would lead the nurse to suspect postpartum blues? a. Panic attacks and suicidal thoughts b. Anger toward self and infant c. Periodic crying and insomnia d. Obsessive thoughts and hallucinations
C
When managing a client's pain during labor, nurses should: a. Make sure the agents given do not prolong labor b. Know that all pain relief measures are similar c. Support the client's decisions and requests d. Not recommend nonpharamcologic methods
C
Which activity would the nurse include in the teaching plan for parents with a newborn and an older child to reduce sibling rivalry when the newborn is brought home? a. Punishing the older child for bedwetting behavior b. Sending the sibling to the grandparents' house c. Planning a daily "special time" for the older sibling d. Allowing the sibling to share a room with the infant
C
Which assessment would indicate that a woman is in true labor? a. Membranes are ruptured and fluid is clear b. Presenting part is engaged and not floating c. Cervix is 4cm dilated, 90% effaced d. Contractions last 30 seconds, every 5 to 10 minutes
C
Which of the following observations would suggest that placental separation is occurring? a. Uterus stops contracting altogether b. Umbilical cord pulsations stop c. Uterine shape changes to globular d. Maternal blood pressure drops
C
Which of the following would the nurse expect to include in the plan of care for a woman with mastitis who is receiving antibiotic therapy? a. Stop breast-feeding and apply lanolin. b. Administer analgesics and bind both breasts. c. Apply warm or cold compresses and administer analgesics. d. Remove the nursing bra and expose the breast to fresh air.
C
While assessing a postpartum multiparous woman, the nurse detects a boggy uterus midline 2 cm above the umbilicus. Which intervention would be the priority? a. Assessing vital signs immediately b. Measuring her next urinary output c. Massaging her fundus d. Notifying the woman's obstetrician
C
A nurse is reviewing discharge teaching with a client who has a urinary tract infection. Which of the following statements by the client indicates understanding of the teaching? Select all that apply. a. I will perform perineal care and apply a perineal pad in a back-to-front direction b. I will drink grape juice to make my urine more acidic c. I will drink large amounts of fluid to flush the bacteria from my urinary tract d. I will go back to breastfeeding after I have finished taking the antibiotic I will take Tylenol for any discomfort
C, E
A client calls a provider's office and reports having contractions for 2 hours that increased with activity and did not decrease with rest and hydration. The client denies leaking of vaginal fluid but did notice blood when wiping after voiding. Which of the following manifestations is the client experiencing? a. Braxton Hicks contractions b. Rupture of membranes c. Fetal descent d. True contractions
D
A new mother was brought to the postpartum unit who gave birth 12 hours ago. Because this is her first child, which of the following goals by the nurse is most appropriate? a. Early discharge for the mother and newborn b. Rapid transition into her role of being a parent/caretaker c. Minimal need for expression of her feelings now d. Effective education of both parents before discharge
D
A nurse concludes that the father of an infant is not showing positive signs of parent-infant bonding and appears to be very anxious and nervous when the infant's mother asks him to bring her the infant. Which of the following is an appropriate nursing intervention to promote father-infant bonding? A. Hand the father the infant, and suggest that he change the diaper. B. Ask the father why he is so anxious and nervous. C. Tell the father that he will grow accustomed to the infant. D. Provide education about infant care when the father is present.
D
A nurse concludes that the parent of a newborn is not showing positive indications of parent-infant bonding. The parent appears very anxious and nervous when asked to bring the newborn to the other parent. Which of the following actions should the nurse use to promote parent-infant bonding? a. Hand the parent the newborn, and suggest that they change the diaper b. Ask the parent why they are so anxious and nervous c. Tell the parent that they will grow accustomed to the newborn d. Provide education about infant care when the parent is present
D
A nurse is reviewing the electronic monitor tracing of a client who is in active labor. The nurse knows that a fetus receives more oxygen when which of the following appears on the tracing? A. Peak of the uterine contraction B. Moderate variability C. FHR acceleration D. Relaxation between uterine contractions
D
A nurse in labor and delivery is planning care for a newly admitted client who reports she is in labor and has been having vaginal bleeding for 2 weeks. Which of the following should the nurse include in the plan of care? A. Inspect the introitusfor a prolapsed cord. B. Perform a test to identify the ferningpattern. C. Monitor station of the presenting part. D. Defer vaginal examinations.
D
A nurse in the delivery room is planning to promote maternal-infant bonding for a client who just delivered. Which of the following is the priority action by the nurse? A. Encourage the parents to touch and explore the neonate's features. B. Limit noise and interruption in the delivery room. C. Place the neonate at the client's breast. D. Place the neonate skin-to-skin on the client's chest.
D
A nurse in the delivery room is planning to promote parent-infant bonding for a client who just delivered. Which of the following is the priority action by the nurse? a. Encourage the parents to touch and explore the neonate's features b. Limit noise and interruption in the delivery room c. Place to neonate at the client's breast d. Position the neonates skin-to-skin on the client's chest
D
A nurse in the labor and delivery unit is caring for a client who is using patterned breathing during labor. The client reports numbness and tingling of the fingers. Which of the following actions should the nurse take? A. Administer oxygen via nasal cannula at 2 L/min. B. Apply a warm blanket. C. Assist the client to a side-lying position. D. Place an oxygen mask over the client's nose and mouth.
D
A nurse in the labor and delivery unit receives a phone call from a client who reports that hercontractions started about 2 hrago, did not go away when she had two glasses of water and rested, andbecame stronger since she started walking. Her contractions occur every 10 min and last about 30 seconds.She hasn't had any fluid leak from her vagina. However, she saw some blood when she wiped aftervoiding. Based on this report, the nurse should recognize that the client is experiencing? A. Braxton Hicks contractions. B. rupture of membranes. C. fetal descent. D. true contractions.
D
A nurse is assessing a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown. The nurse knows these findings are characteristics of A. postpartum fatigue. B. postpartum psychosis. C. the letting-go phase. D. postpartum depression.
D
A nurse is assessing a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown. Which of the following conditions are associated with these manifestations? a. Postpartum fatigue b. Postpartum psychosis c. Letting-go phase d. Postpartum blues
D
A nurse is caring for a client in active labor. When last examined 2 hrago, the client's cervix was 3 cm dilated, 100% effaced, membranes intact, and the fetus was at a -2 station. The client suddenly states "my water broke." The monitor reveals a FHR of 80 to 85/min, and the nurse performs a vaginal examination, noticing clear fluid and a pulsing loop of umbilical cord in the client's vagina. Which of the following actions should the nurse perform first? A. Place the client in the Trendelenburg position. B. Apply pressure to the presenting part with her fingers. C. Administer oxygen at 10 L/min via a face mask. D. Call for assistance.
D
A nurse is caring for a client who is admitted to the labor and delivery unit. With the use of Leopold maneuvers, it is noted that the fetus is in a breech presentation. For which of the following possible complications should the nurse observe? A. Precipitous labor B. Premature rupture of membranes C.Postmaturitysyndrome D. Prolapsed umbilical cord
D
A nurse is caring for a client who is in labor. With the use of Leopold maneuvers, it is noted that the fetus is in a breech presentation. For which of the following possible complications should the nurse observe? a. Precipitous labor b. Premature rupture of membranes c. Postmaturity syndrome d. Prolapsed umbilical cord
D
A nurse is caring for a client who is in the first stage of labor and encourages the client to void every 2 hr. The nurse explains that a A. full bladder increases the risk for fetal trauma. B. full bladder increases the risk for bladder infections. C. distended bladder will be traumatized by frequent pelvic exams. D. distended bladder reduces pelvic space needed for birth.
D
A nurse is caring for a client who is in the first stage of labor and is encouraging the client to void every 2 hours. Which of the following statements should the nurse make? a. A full bladder increases the risk for fetal trauma. b. A full bladder increases the risk for bladder infections. c. A distended bladder will be traumatized by frequent pelvic exams. d. A distended bladder reduces pelvic space needed for birth.
D
A nurse is caring for a client who is using patterned breathing during labor. The client reports numbness and tingling of the fingers. Which of the following actions should the nurse take? a. Administer oxygen via nasal cannula at 2 L/min b. Apply a warm blanket c. Assis the client to a side-lying position d. Place an oxygen mask over the client's nose and mouth
D
A nurse is conducting a home visit with a client who is 3 months postpartum and breastfeeding. Menses has not yet resumed. The client is discussing contraception with the nurse, stating that she does not want to have another child for a couple of years. The nurse understands that this client needs further instruction if the client makes which of the following statements? A. "I have already started using the mini pill for protection." B. "Because of our beliefs, we are going to use the rhythm method." C. "I am being refitted for a diaphragm by my doctor next week." D. "I will begin using birth control when I stop breastfeeding."
D
A nurse is planning care for a client who is postpartum and has thrombophlebitis. Which of the following nursing interventions should the nurse include in the plan of care? a. Apply cold compresses to the affected extremity b. Massage the affected extremity c. Allow the client to ambulate d. Measure leg circumferences
D
A nurse is planning care for a newly admitted client who reports, "I am in labor and I have been having vaginal bleeding for 2 weeks." Which of the following should the nurse include in the plan of care? a. Inspect the introitus fro a prolapsed cord b. Perform a test to identify the ferning pattern c. Monitor station of the presenting part d. Defer vaginal examinations
D
A nurse on the postpartum unit is planning care for a client who has thrombophlebitis. Which of the following nursing interventions should the nurse include in the plan of care? A. Apply cold compresses to the affected extremity. B. Massage the affected extremity. C. Allow the client to ambulate. D. Measure leg circumferences.
D
After the nurse provides instructions to a postpartum woman about postpartum blues, which statement would indicate understanding of it? I will a. "Need to take medication daily to treat the anxiety and sadness." b. "Call the OB support line only if I start to hear voices." c. "Contact my doctor if I become dizzy and fell nauseated." d. "Feel like laughing 1 minute and crying the next minute."
D
Methergine has been ordered for a postpartum woman because of excessive bleeding. The nurse should question this order if which of the following is present? a. Mild abdominal cramping b. Tender inflamed breasts c. Pulse rate of 68 beats per minute d. Blood pressure of 158/96 mmHg
D
The nurse is explaining to a postpartum woman 48 hours after her giving childbirth that the after pains she is experiencing can be the result of which of the following? a. Abdominal cramping is a sign of endometriosis. b. A small infant weighing less than 8 pounds c. Pregnancies that were too closely spaced d. Contractions of the uterus after birth
D
The rationale for using a prostaglandin gel for a client prior to the induction of labor is to: a. Stimulate uterine contractions b. Numb cervical pain receptors c. Prevent cervical lacerations Soften and efface the cervix
D
When a client in labor is fully dilated, which instruction would be most effective to assist her in encouraging effective pushing? a. Hold your breath and push through entire contraction b. Use chest-breathing with the contraction c. Pant and blow during each contraction d. Wait until you feel the urge to push
D
When assessing the following women, which would the nurse identify as being the greatest risk for preterm labor? a. Woman who had twins in a previous pregnancy b. Client living in a large city close to the subway c. Woman working full time as a computer programmer d. Client with a history of previous preterm labor
D
When implementing the plan of care for a multigravida postpartum woman who gave birth just a few hours ago, the nurse vigilantly monitors the client for which complication? a. Deep venous thrombosis b. Postpartum psychosis c. Uterine infection d. Postpartum hemorrhage
D
When reviewing the medical record of a client, the nurse notes that the woman has a condition in which the fetus cannot physically pass through the maternal pelvis. The nurse interprets this as: a. Cervical insufficiency b. Contracted pelvis c. Maternal disproportion d. Fetopelvic disproportion
D
Which of the following findings would lead the nurse to suspect that a woman is developing a postpartum complication? a. Moderate lochia rubra for the first 24 hours b. Clear lung sounds upon auscultation c. Temperature of 100 degrees F d. Chest pain experienced when ambulating
D
Which of the following would lead the nurse to suspect that a postpartum woman was developing a complication? a. Fatigue and irritability b. Perineal discomfort and pink discharge c. Pulse rate of 60 bpm d. Swollen, tender, hot area on breast
D
Which of these activities would best help the postpartum nurse to provide culturally sensitive care for the childbearing family? a. Taking a transcultural course b. Caring for only families of his or her cultural origin c. Teaching Western beliefs to culturally diverse families d. Educating himself or herself about diverse cultural practices
D
