PrepU Questions (Midterm)

A nurse practitioner suspects that a child has scarlet fever based on which assessment finding?

Red, strawberry tongue

A primigravida 21-year-old client at 24 weeks' gestation has a 2-year history of HIV. As the nurse explains the various options for delivery, which factor should the nurse point out will influence the decision for a vaginal birth?

The viral load

Early in labor, a pregnant client asks why contractions hurt so much. Which answer should the nurse provide?

Lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels

The nurse should encourage a pregnant client who is taking short-acting insulin for her diabetes to avoid eating after self-administering the insulin.

False

A woman who is 42 weeks pregnant comes to the clinic. During the visit, which assessment should be prioritize?

Determining an accurate gestational age

The nurse is caring for a laboring client. The nurse observes that there are early decelerations. The fetal heart rate remains within normal limits with adequate variability. What is the nurse's best action?

Continue to monitor the client and the FHR

The nurse working on a pediatric floor understands the importance of promoting growth and development in all hospitalized patients. Which of the following activities would be an example of encouraging initiative in preschoolers?

Encouraging them to color in a medication schedule

The nurse is preparing to assist with a pudendal block. The nurse predicts the client is at which point in the labor process?

Just before birth

The nurse is admitting a client at 23 weeks' gestation in preparation for induction and delivery after it was determined the fetus had died secondary to trauma. When asked by the client to explain what went wrong, the nurse can point out which potential cause for this loss?

Placental abruption

A client in her second trimester of pregnancy arrives at a health care facility reporting heartburn. What instructions should the nurse offer to help the client deal with heartburn? Select all that apply.

Limit consumption of food before bedtime. Sleep in a semi-Fowler's position. Avoid overeating.

A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize?

Maternal hypotension and fetal bradycardia

During a difficult labor of an infant in the face presentation, the nurse notes the infant has a large amount of facial edema with bruising and ecchymosis. Which assessment would be the priority for this infant?

Patent airway

The nurse is correct to identify which psychological factor that often causes sleep deprivation while the client is in an acute care setting?

Separation anxiety

Which procedure is contraindicated in an antepartum client with bright red, painless bleeding?

Vaginal examination

The nurse has just administered morphine 2 mg IV to a laboring client. Which change in the fetal heart rate pattern would the nurse prioritize?

Decreased variability

A nurse assesses a client in labor and suspects hypotonic uterine dysfunction. Which intervention would the nurse expect to include in the plan of care for this client?

Administering oxytocin

What is a true statement regarding varicella zoster virus infection?

A complication of this infection includes secondary bacterial infections of the skin.

Which assessment findings indicate a distressed fetus? Select all that apply.

Absent accelerations Late deceleration patterns Persistent bradycardia

The nurse is analyzing the readout on the EFM and determines the FHR pattern is reassuring based on which recording?

Acceleration of at least 15 bpm for 15 seconds

The registered nurse has identified that the client's labor progress has slowed. Which nursing intervention, done by the practical nurse, is completed first?

Assess if the bladder is distended

The nurse is describing pregnancy danger signs to a pregnant woman who is in her first trimester. Which danger sign might occur at this point in her pregnancy?

Excessive vomiting

A nurse is caring for a pregnant client whose fetus has been diagnosed with macrosomia. When reviewing the client's history, which information would the nurse expect to find?

Gestational diabetes

A client in labor receiving epidural anesthesia develops hypotension. Which of the following would the nurse do first?

Give an intravenous bolus of fluid

Which nursing action is essential if the laboring client has the urge to push but she is not fully dilated?

Have the client pant and blow through the contraction

A pregnant client with sickle cell anemia is admitted in crisis. Which nursing intervention should the nurse prioritize?

I.V. fluids

Which nursing intervention offered in labor would probably be the most effective in applying the gate control theory for relief of labor pain?

Massage the woman's back.

A preschooler is hospitalized with asthma. His mother needs to leave to go home and check on her other children. It is close to dinner time and she plans on returning first thing in the morning. What should she tell her son before leaving to help in the transition?

Tell him she will be back after he wakes up tomorrow.

Which statement describes why hypertonic contractions tend to become very painful?

The myometrium becomes sensitive from the lack of relaxation and anoxia of uterine cells.

A pregnant client states, "I am only 6 weeks pregnant, but the morning sickness is awful. When is it going to stop?" What is the best response by the nurse?

"Usually after 12 weeks, when the placenta starts managing the production of progesterone, morning sickness ends."

A pregnant woman with type 2 diabetes is scheduled for a laboratory test of glycosylated hemoglobin (HbA1C). What does the nurse tell the client is a normal level for this test?

6%

When counseling a Japanese American about nutrition and diet in pregnancy, it would be important to include

A list of foods that contain calcium

A client has just received combined spinal epidural. Which nursing assessment should be performed first?

Assess vital signs

The health care provider and nurse are assisting the client in the delivery of the fetus. The mother has been pushing with little effect. As the nurse obtains the instruments to assist with delivery, which method is used for pain relief?

A pudendal block

A nurse is monitoring a client during the second stage of labor. Which finding in the mother should cause concern for the nurse?

A rise in systolic blood pressure of 30 mm Hg with each contraction

A young patient has been corrected by nurses numerous times for running in the hallway. Which is the best action to take to modify this behavior?

Allow the child to accompany nurses to obtain a wheelchair.

Which initial interview technique would be least effective in gathering information from a suspected abuse victim?

Ask the client to strip down and show you where she has been hurt.

Which documentation in the health record is most correct for the third stage of labor?

Begins with the time of delivery of the fetus and ends with the time of the delivery of the placenta

The fetus of a nulliparous woman is in a shoulder presentation. The nurse would prepare the client for which type of birth?

Cesarean

Which type of anesthesia is anticipated when the delivery of the fetus must be done quickly due to an emergency situation?

General

The nurse caring for children with fungal infections most often administers which of the following medications?

Griseofulvin

A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered?

Naloxone

Women who are obese in pregnancy are at higher risk for developing all of the following EXCEPT

Neural tube defects

The nurse is caring for a child hospitalized with pertussis. Which nursing intervention would be the highest priority for this child?

The nurse will administer oxygen.

A client asks her nurse what effleurage means. After instruction is given, the nurse determines learning has taken place when the client states:

"Effleurage is light abdominal massage used to displace pain."

What would be most important to include in the teaching plan for parents of a child with pinworm?

"Make sure the child washes his hands after using the bathroom."

The nurse is caring for a client in the transition phase of the labor process. Which client statement requires nursing action?

"My lips and fingers are tingling."

The health care provider approves a labor plan which includes analgesia. The client questions how analgesia will help her pain during labor. Which answer is best?

"The analgesia will reduce the sensation of pain for a limited period of time."

A woman at 41 weeks' gestation is progressing well in labor; however, the nurse notes the amniotic fluid is greenish in color. When questioned by the client for the reason for this, which explanation should the nurse provide?

"This is meconium-stained fluid from the baby."

A nurse is client teaching with a 30-year-old gravida 1 who has sickle cell anemia. Providing education on which topic is the highest nursing priority?

Avoidance of infection

The client is experiencing back labor and reporting intense pain in the lower back. The nurse should point out which intervention will be the most effective at this point?

Counterpressure against the sacrum

The nurse is monitoring a primipara who has been receiving oxytocin and is now in hypertonic labor. If the nurse notes the fetal heart rate has suddenly dropped, which action should the nurse prioritize?

Decrease the oxytocin drip rate

The nurse is caring for a laboring client who has been administered a regional block for pain management. What is the nurse's priority action?

Ensure that emergency equipment is readily available

Tinea cruris (jock itch) is a protozoan infection.

False

A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is:

Increasing birth weight

The nutritional needs of an adolescent pregnant patient are unique because

Owing to typical food choices, an adolescent is often lacking calcium, iron, and folic acid in the diet

The fetus of a woman in labor is determined to be in a persistent occiput posterior position. Which intervention would the nurse prioritize?

Pain relief measures

The nurse is caring for an adolescent diagnosed with syphilis. The drug of choice for treating syphilis is:

Penicillin

A nurse is completing a dressing change on a 5-month-old in a crib in the procedure room. The wrap needed to complete the care is just outside of arm's reach. What action should the nurse take?

Raise the side rail, then gather the needed supply

After 12 hours of active labor, a multipara patient at 39 weeks' gestation is only dilated 6 centimeters. Which of the following is a consideration for the nurse?

Reassess the fetal presentation and position.

The nurse is caring for a client in active labor. Which assessment finding should the nurse prioritize and report to the team?

Sudden shortness of breath

A nursing student correctly identifies which of the following as the main reason that hospitals have play rooms for children:

To continue development during hospitalization

You are doing client education with an obese woman who is trying to get pregnant. She confides in you that she is on a diet and trying to lose weight. Which of the following would you teach her?

Weight reduction should not be undertaken during pregnancy.

In the labor and delivery unit, which is the best way to prevent the spread of infection?

Complete hand hygiene

A client in week 38 of her pregnancy arrives at the emergency room reporting a sharp pain between her umbilicus and the iliac crest in her lower right abdomen that is increasing. She reports having experienced intense nausea and vomiting for the past 3 hours. Given these symptoms, the nurse suspects which of the following conditions?

Appendicitis

The identification band on a infant was removed for performance of a procedure. What is the priority nursing intervention?

Apply a new band after verifying identity using two identifiers

There has been much research done on pain and the perception of pain. What is the result of research done on levels of satisfaction with the control of labor pain?

Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience.

A pregnant client undergoing labor induction is receiving an oxytocin infusion. Which finding would require immediate intervention?

Urine output of 20 mL/hour

The nurse is assisting a primary care provider to attempt to manipulate the position of the fetus in utero from a breech to cephalic position. What does the nurse inform the client the procedure is called?

External version

The nurse is working with a client approaching her due date. Arrange the sequence of typical labor pain that the client may experience from onset to birth of the fetus. Use all options.

Cramping in the lower abdomen Pain noted in the lower back, buttocks and thighs Intense contractions resulting in fetal movement Burning in the perineum

When needed, total parenteral nutrition (TPN) is often administered at home to reduce health care costs. When teaching a patient how to safely administer TPN, the home care nurse emphasizes

Testing blood glucose every 6 hours

The pain of labor is influenced by many factors. What is one of these factors?

The woman is prepared for labor and birth.

A woman entering her third trimester of pregnancy asks the nurse how much weight she should gain during this trimester. What is the nurse's best answer?

1 lb/week

A woman relates to the nurse that she understands that dietary fat is bad for her and that she should avoid it during pregnancy. How should the nurse respond?

Fats are essential during pregnancy, and vegetable oils are a good source.

When assessing cervical effacement of a client in labor, the nurse assesses which characteristic?

Degree of thinning

Assessment of a woman in labor reveals that the fetus is in a cephalic presentation and engagement has occurred. The nurse interprets this finding to indicate that the presenting part is at which station?

0

The recommended weight gain during the first trimester for a woman who was in the normal weight range prepregnancy is 2 to 4 pounds. After the first trimester, what is the recommended weekly weight gain for a woman who was considered normal weight prepregnancy?

1 pound

A woman with type 2 diabetes is considering becoming pregnant and asks the nurse whether she will be able to continue taking her current oral hypoglycemics. The nurse's response will point out which factor?

Have been shown to be effective and safe in recent short term studies.

The nurse is instructing on maternal hormones which may impact the onset of labor. Which hormones are included in the discussion? Select all that apply.

Oxytocin Progesterone Prostaglandins

Which client statement is anticipated after immediately receiving an intrathecal injection of pain medication?

"I have no pain now."

A client is scheduled for a cesarean section under spinal anesthesia. After instruction is given by the anesthesiologist, the nurse determines the client has understood the instructions when the client states:

"I may end up with a severe headache from the spinal anesthesia."

When collecting data to devise a labor plan for a multiparous woman, which question best allows the nurse to develop individualized strategies?

"Tell me how you handled labor pain in your past deliveries."

Vitamin B12 deficiency is most likely to be found in which patient?

A vegan

A pregnant client mentions to the nurse that a friend has given her a variety of herbs to use during her upcoming labor to help manage pain. Specifically, she gave her chamomile tea, raspberry leaf tea, skullcap, catnip, jasmine, lavender, and black cohosh. Which of these should the nurse encourage the client not to take because of the risk of acute toxic effects such as cerebrovascular accident?

Black cohosh

A child is diagnosed with an enterovirus infection. Which type of infection control precaution would be most important for the nurse to use?

Contact

A nurse assesses a primigravida client in the eighth week of gestation. The client reports nausea and vomiting in the mornings. The client tells the nurse, "I'm not able to keep liquids down and I'm eating like a bird." The client also expresses concerns about hormonal changes and how the pregnancy will affect her physical appearance. Which client problem should the nurse assess first?

Deficient fluid volume

A client in preterm labor is receiving magnesium sulfate IV and appears to be responding well. Which finding on assessment should the nurse prioritize?

Depressed deep tendons reflexes

A client in the first trimester reports having nausea and vomiting, especially in the morning. Which instruction would be most appropriate to help prevent or reduce the client's compliant?

Eat dry crackers or toast before rising.

Nutritional requirements generally go up during pregnancy. Which nutritional requirement proportionally increases the most during pregnancy?

Iron

The nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8oF, contractions every 4 to 5 minutes lasting 30 seconds, and greenish-color fluid in the vaginal vault. Which finding should the nurse prioritize?

Meconium in the fluid

A child is diagnosed with giardiasis. The physician prescribes medication to treat the infection. Which of the following would the nurse anticipate being prescribed?

Metronidazole

A child is brought to the emergency department by his parents. The parents report that he stepped on a rusty nail about a week and a half ago. The child is complaining of cramping in his jaw and some difficulty swallowing. The nurse suspects tetanus. When assessing the child, the nurse would be alert to which muscle groups being affected next?

Neck

When caring for a client requiring a forceps-assisted birth, the nurse would be alert for:

Potential lacerations and bleeding

A nursing instructor is teaching students about high-risk pregnancies. Some circumstances that may cause a pregnancy to be labeled as high-risk include which of the following? (Select all that apply.)

Poverty Lack of support people Genetic inheritance Past history of pregnancy complications

The nurse is caring for a 16-year-old child with a diagnosis of acquired immunodeficiency syndrome (AIDS). What treatment goal has the highest priority for this child?

Preventing spread of infection

A woman who had preterm labor and preterm PROM successfully halted has reached week 36 of pregnancy and is doing well on home care. Which of the following nursing diagnoses should the nurse prioritize for this client?

Risk for fetal infection related to early rupture of membranes

The most common complication of varicella is:

Secondary bacterial infections.

Which nursing intervention will help reduce a child's anxiety about hospitalization?

Show the child all equipment to be used, including sounds

Parents of a child who has been diagnosed with tinea capitis ask how the child got the infection. Which of the following would the nurse explain as the most likely cause?

Using a friend's comb

Megadoses of which vitamin can cause congenital anomalies?

Vitamin A

How can the nurse best counsel a patient with pyrosis?

"Avoid lying down 2 hours after eating."

A group of nursing students are on the L & D unit where there is a woman having very intense contractions with a resting uterine tone >20 mm Hg. The woman is screaming out every time she has a contraction. The preceptor asks the students, "What is the highest priority fetal assessment we [the nursing staff] should focus on at this time?

Look for late decelerations on monitor which is associated with fetal anoxia.

The nurse is monitoring a client who just received IV sedation. Which instruction should the nurse prioritize with the client and her partner?

Ambulate only with assistance from the nurse or caregiver.

A delivery room nurse notes that after the provider attempts to remove the placenta, a ball of tissue appears in the woman's vagina accompanied by massive amount of gushing blood. Immediately the woman's vital signs reveal: BP 70/48, pulse rate 150, mucous membranes are pale. Which interventions should be the priority for the delivery room nurse? Select all that apply.

Apply oxygen mask at 10 L/min. Discontinue the IV oxytocin infusion.

When interviewing a pregnant woman, how can the nurse best assess the patient's dietary intake?

Ask the woman to recall what she ate in the last 24 hours.

The nurse is caring for a 2-year-old boy who has been admitted to the hospital. Which of the following should she do to ensure a safe environment for this child?

Check that side rails of the boy's crib are in good repair and raised

The nurse identifies increased stress in the pediatric client and family prior to an upcoming surgery. Which suggestion is most helpful to decrease the level of stress in parents?

Choosing an ambulatory surgery site.

A woman who is obese comes to the clinic because she thinks that she is pregnant. The pregnancy is confirmed. The nurse is developing a teaching plan for this woman about pregnancy and challenges associated with it related to obesity. The nurse would most likely plan to address which condition as being an increased risk?

Gestational diabetes Large for gestational age (LGA) infant Difficult vaginal delivery

A nurse caring for a hospitalized 3 week old finds the infant's name band on the floor. Which is the nurse's best action?

Get two more name bands and place one on the infant's arm and the other on the infant's leg.

Shoulder dystocia is a true medical emergency that can cause fetal demise because the baby cannot be born. Stuck in the birth canal, the infant cannot take its first breath. Which maneuver is first attempted to deliver an infant with shoulder dystocia?

McRoberts maneuver

A woman at 32 weeks' gestation just experienced rupture of her membranes. She asks the nurse what could cause this to happen and the nurse's explanation would include which risk factors? Select all that apply.

Cigarette smoking Multifetal pregnancies Amniocentesis

A young woman in her first trimester confesses to the nurse when questioned that she is probably not consuming enough calories. The nurse should explain to this client that deficient nutrition can hinder the baby's growth, which at this point in her pregnancy is primarily via an increase in the number of cells formed. This type of growth is known as which of the following?

Hyperplasia

A G3P2 woman at 39 weeks' gestation presents highly agitated, reporting something "came out" when her membranes just ruptured. Which action should the nurse prioritize after noting the umbilical cord is hanging out of the vagina?

Put her in bed immediately, call for help, and hold the presenting part of the cord.

A multipara woman is experiencing a prolonged descent while trying to rest and increase her fluid intake. The nurse suggests that she change position. Which positions are most effective for pushing to speed up the descent? Select all that apply.

Semi-Fowler's position

A 5-year-old girl was brought to the emergency room following a car wreck in which she sustained a head injury. She has been thoroughly assessed, including having a skull x-ray, which showed no signs of fracture. The child is conscious and demonstrates no signs of neurologic injury. Which of the following actions should the nurse anticipate performing next?

Teaching the parents of the child how to evaluate consciousness and assess for signs of intracranial pressure for the next 24 hours at home

At which time in a client's labor process would the nurse encourage effleurage?

During the early labor phase

The nurse is preparing to teach a pregnant client with iron deficiency anemia about the various iron-rich foods to include in her diet. Which food should the nurse point out will help increase the absorption of her iron supplement?

Orange juice

A woman is in the first stage of labor. The nurse would encourage her to assume which position to facilitate the progress of labor?

Upright

Which interventions will the nurse include when caring for a child with an infectious disorder? Select all that apply.

Ensure immunization status is current. Use appropriate personal protective equipment. Provide information about disease transmission. Educate the child and family about infection control.

A pregnant woman comes to the clinic and reports redness and swelling in her right calf as well as pain, even when resting. The nurse suspects a deep vein thrombosis (DVT). Which of the following does the nurse diagnose as the biggest danger for this patient?

Pulmonary embolism

The nurse is discussing options to provide relief of labor pain when the client states, "Why can't the health care provider provide a sedative during labor?" Which disadvantages are common with providing a sedative as pain management? Select all that apply.

Sedatives will not provide pain relief. The sedation effect can cross to the fetus. Sedatives are only used in early labor

Sensory deprivation occurs when children receive more stimulation than they can tolerate or process.

False

A nurse is assessing a pregnant woman in her last trimester. Which question would be most appropriate to use to gather information about weight gain and fluid retention?

"How swollen do your ankles appear before you go to bed?

The nurse is caring for a primipara with PROM who appears extremely anxious and reveals that she is scared her birthing process will be extremely painful because it will be "dry". Which is the best response from the nurse?

"No birth is ever really dry, because amniotic fluid continues to be manufactured."

A 6-year-old boy is scheduled to have surgery to repair a congenital defect in his heart in about a week. The parents tell the nurse that they are nervous about telling him about the surgery in advance because they fear that he will just worry about it. On the other hand, they also feel that they should prepare him mentally for the surgery. Which of the following should the nurse recommend to the parents?

"Tell him about the surgery about 6 days ahead of time so that he knows what to expect; at his age that would be best."

The nurse is admitting a primigravida client who has just presented to the unit in early labor. Which response should the nurse prioritize to assist the client in remaining calm and cooperative during birth?

"The baby is coming. I'll explain what's happening and guide you."

A nurse is conducting a program at women's health clinic about nutritional needs and women during pregnancy. When discussing dietary intake, which information would the nurse include?

A woman with twins should gain approximately 1 pound a week for a total of 40 to 45 lbs.

The coach of a client in labor is holding the client's hand and appears to be intentionally applying pressure to the space between the first finger and thumb on the back of the hand. The nurse recognizes this as which form of therapy?

Acupressure

Which of the following statements regarding weight and pregnancy is correct?

An underweight woman should increase her caloric intake by 500 to 1000 calories a day.

A pregnant woman with a history of mitral stenosis is to be prescribed medication as treatment. Which of the following medication classes would the nurse expect the patient to begin taking?

Anticoagulant

The client and her partner have prepared for a natural birth and bring a picture of a sunset over the ocean with them. The nurse predicts they will be using which techniuqe during labor?

Attention focusing

Erin, a 19-year-old first-time mother in the second stage of labor who has been given an epidural, reports severe, unrelenting abdominal pain and rates it as 10 on a scale of 0 to 10. What should the nurse do?

Call the obstetrician; severe unrelenting abdominal pain could indicate placental abruption, uterine rupture, or other undiagnosed complication.

A nurse is teaching a 32-year-old primigravida woman about nutrition during pregnancy. Which information would the nurse include in the teaching plan? Select all that apply:

Caloric intake should be increased 300 cal/day. Protein intake should be increased by more than 30 g/day. Intake of all minerals, especially iron, should be increased.

The nurse is admitting a woman at 32 weeks' gestation in preterm labor. The nurse should question the order for magnesium sulfate after noting which assessment finding?

Cervical dilation of 5 cm

There are four essential components of labor. The first is the passageway. It is composed of the bony pelvis and soft tissues. What is one component of the passageway?

Cervix

A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture?

Clear to straw-colored fluid

Which intervention would be most important when caring for the client with breech presentation confirmed by ultrasound?

Continuing to monitor maternal and fetal status

The nursing instructor is illustrating the various positions the fetus may utilize during the passage through the vaginal canal at birth. The instructor determines the session is successful when the students correctly identify the ROA position, indicating which presentation by the fetus?

Facing the right anterior pelvic quadrant

Pica is a symptom of which nutritional deficiency?

Iron deficiency

The appearance of which hallmark clinical manifestation occurs in measles?

Koplik spots

A nursing instructor is describing the progression of signs and symptoms associated with varicella from earliest to latest. Place the signs and symptoms below in the sequence that the instructor would describe them.

Low-grade fever Macular rash Papular rash Vesicle formation Crusting

A nurse is preparing a presentation for parents about common childhood infectious diseases. What conditions would the nurse include as being caused by a tick bite? Select all that apply.

Lyme disease Rocky Mountain spotted fever

A nursing instructor is teaching students about childhood infectious diseases. Which of the following would the instructor identify as the cause of warts in children?

Papilloma virus

The nurse is assessing a woman who had a forceps-assisted birth for complications. Which condition would the nurse assess in the fetus?

Caput succedaneum

A client is giving birth when shoulder dystocia occurs in the fetus. The nurse recognizes that which condition in the client is likely to increase the risk for shoulder dystocia?

Diabetes

Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia?

Difficulty breathing

Which vitamin is essential for the mother to consume daily to help prevent birth anomalies such as neural tube defects in a developing fetus?

Folic acid

Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in:

Latent phase of the first stage.

A nurse informs a pregnant woman with cardiac disease that she will need two rest periods each day and a full night's sleep. The nurse further instructs the client that which position for this rest is best?

Left lateral recumbent

A client who has been in prolonged labor reports extreme back pain. She asks why her back hurts so much. What would be the best response by the nurse?

"Different fetal positions can cause prolonged labor and back pain."

The nursing student demonstrates an understanding of dystocia with which statement?

"Dystocia is diagnosed after labor has progressed for a time."

A mother is talking to the nurse and is concerned about managing her asthma while she is pregnant. Which response to the nurse's teaching indicates that the woman needs further instruction?

"I need to begin taking allergy shots like my friend to prevent me from having an allergic reaction this spring."

A pregnant client with a history of asthma since childhood presents for a prenatal visit. What statement by the client would the nurse prioritize?

"I sometimes get a bit wheezy."

A nurse is talking to a newly pregnant woman who had a mitral valve replacement in the past. Which statement by the client reveals an understanding about the preexisting condition?

"I understand that my fetus and I both are at risk for complications."

A 32-year-old woman with epilepsy mentions to the nurse during a routine well-visit that she would like to have children and asks the nurse for advice. Which response is most appropriate from the nurse?

"I'll let the doctor know so you can discuss your medications. In the meantime, I'll give you a list of folate-rich foods you can add to your diet."

A 22-year-old female is 25 weeks pregnant. She explains that she is having difficulty getting an adequate amount of protein into her diet because she is a vegetarian. How can the nurse best counsel this patient?

"In addition to getting protein from eating dairy, eat complementary proteins such as beans and rice together, or beans and wheat together."

A nurse recommends to a client in labor to try concentrating intently on a photo of her family as a means of managing pain. The woman looks skeptical and asks, "How would that stop my pain?" Which explanation should the nurse give?

"It distracts your brain from the sensations of pain."

A woman's baby is HIV positive at birth. She asks the nurse if this means the baby will develop AIDS. Which statement would be the nurse's best answer?

"The antibodies may be those transferred across the placenta; the baby may not develop AIDS."

A primigravidia client at 38 weeks' gestation calls the clinic and reports, "My baby is lower and it is more difficult to walk." Which response should the nurse prioritize?

"The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks."

A 33-year-old P2002 is 6 weeks pregnant. She always felt nauseous in the early part of her previous pregnancies, and she is concerned about her dietary intake at the beginning of this pregnancy because she has just begun to feel nauseous. How can the nurse best counsel this patient?

"Try eating fruit in the morning and having small, frequent meals throughout the day as opposed to three large meals."

The nurse is providing teaching to the parents of a child with varicella. Which statement indicates that the parents have understood the instructions?

"We need to make sure that he washes his hands frequently."

The nurse is preparing a 4-year-old patient for surgery. According to hospital policy, the surgical site must be marked prior to entering the operating room. The patient shies away from the nurse when approached with a black marker. Which is the best approach for the nurse to take?

"Would you like your mother or me to draw a smiley face on your arm?"

A woman, who has been in labor for a few hours, is now complaining of being hungry. Which response by the nurse would be best if the client asks for some food to eat?

"You could have some hard candy to suck on."

When a client is counseled about the advantages of epidural anesthesia, which statement made by the counselor would indicate the need for further teaching?

"You have no trouble walking around and using the bathroom after you receive the epidural."

A pregnant woman who has been taking penicillin prophylactically because she had rheumatic fever as a child tells the nurse that she wants to stop taking it now that she is pregnant. Which of the following is the best response by the nurse?

"You should continue taking this drug, because penicillin is not known to be a fetal teratogen."

A pregnant single mom living alone tells the nurse she is considering getting a cat for her 2-year-old daughter. Which is the best response by the nurse?

"You should wait until after you give birth to obtain the cat for your daughter."

The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth?

+4

A client gave birth to a child 3 hours ago and noticed a triangular-shaped gap in the bones at the back of the head of her newborn. The attending nurse informs the client that it is the posterior fontanelle. The client is anxious to know when the posterior fontanelle will close. Which time span is the normal duration for the closure of the posterior fontanelle?

8 to 12 weeks

A nursing student correctly identifies an older infant who fixes the eyes on a new caregiver, becomes restless, thrashes arms and legs, and begins to cry as likely experiencing which of the following?

8-month anxiety

The nurse is caring for a pregnant woman is determined to be at high risk for gestational diabetes. The nurse prepares to rescreen this client at which time frame?

24 to 28 weeks

A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is:

5

The nurse manager is reviewing all the L & D clients on the unit in order to prepare assignments to the nursing staff. For which clients would augmentation of labor with oxytocin be considered contraindicated or used cautiously? Select all that apply.

44 year old primipara diagnosed with gestational diabetes in active labor for the past 6 hours. 33 year old female who is 32 weeks gestation in labor with twins. A 30 year old multipara woman who has experienced premature rupture of membranes 5 days ago but just now reporting it to provider.

The nurse is caring for a client in the transition stage of labor. In which scenario would the nurse predict the use of forceps may be used to assist in delivery?

Abnormal position of the fetal head

The nurse is assessing a laboring client and notes: 5 cm dilated, 80% effaced, zero station, contractions every 2 to 3 minutes, lasting 50 seconds, becoming increasingly uncomfortable, and apprehensive but appropriate and focused on breathing and relaxation. The nurse determines which nursing diagnosis is most appropriate for this client?

Acute pain related to uterine contractions

The nurse is caring for an adolescent diagnosed with genital herpes. The drug of choice for treating genital herpes is:

Acyclovir

A nurse is meeting the family of a child scheduled for surgery at a reception area. Which of the following approaches should the nurse take while admitting the child to the hospital?

Admit the family as a single entity

Which facility policy enhances family-centered care?

Allowing family presence during procedures

A woman in week 40 of her pregnancy has developed a urinary tract infection (UTI). The nurse anticipates that medication would be safe and appropriate to use with this client? Select all that apply.

Amoxicillin Ampicillin Cephalosporins

Mrs. Carter is admitted to the labor and birth unit. The lab results of her cervical culture for group B streptococcal were positive. What priority intervention will be initiated?

Ampicillin or cefazolin intravenous is given before delivery.

Which child will the nurse identify as at greatest risk for developing a urinary tract infection?

An 8-month-old bottle-fed female with HIV

A pregnant client is screened for tuberculosis during her first prenatal visit. An intradermal injection of purified protein derivative (PPD) of the tuberculin bacilli is given. Which sign would indicate a positive test result?

An indurated wheal over 10 mm in diameter appears in 48 to 72 hours.

A 10-year-old child will require daily shots for a new diagnosis of diabetes. Which equipment should be included when planning for therapeutic play?

An insulin syringe, an alcohol pad and fluid filled vial

A woman's obstetrician prescribes vitamin K supplements for a client who is on antiepileptic medications beginning at 36 weeks' gestation. The mother asks the nurse why she is taking this medication. The nurse's best response would be:

Antiepileptic therapy can lead to vitamin K-deficient hemorrhage of the newborn.

A primigravida client has just arrived in early labor and is showing signs of extreme anxiety over the birthing process. Why should the nurse prioritize helping the client relax?

Anxiety can slow down labor and decrease oxygen to the fetus.

The nurse identifies a nursing diagnosis of risk for injury related to possible effects of oxytocin therapy. Which action would the nurse perform to ensure a positive outcome for the client?

Assess contractions by using external monitor.

The nurse is reviewing the medication administration record (MAR) of a client at 39 weeks' gestation and notes that she is ordered an opioid for pain relief. Which is an assessment priority after administering?

Assess fetal heart rate.

The nurse is completing an admission assessment on a patient in an acute care setting. Which of the following approaches is the most effective for the nurse?

Be certain the parents are present during the admission assessment.

A 38-year-old woman comes into the obstetrician's office for prenatal care, stating that she is about 12 weeks pregnant with her first child. What questions would the nurse ask this client, considering her age and potential sensitivity to being labeled an "older" primipara?

Be non-judgmental in your history gathering and offer her pregnancy resources to read and explore.

A 13-year-old boy who recently immigrated to the United States from India is found to be infected by a strain of the poliovirus. After initial symptoms of fever, headache, nausea, vomiting and abdominal pain subside, the virus proceeds to his central nervous system. Which of the following would be the best intervention for this client at this point?

Bed rest, analgesia, and application of moist hot packs

The nurse is doing meal planning with a pregnant woman with iron-deficiency anemia. What dietary recommendations would the nurse make to enhance the woman's intake of iron? Select all that apply.

Drink orange juice with the iron supplement. Increase intake of dried beans and green leafy vegetables. Cook food in an iron skillet, if possible.

The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding?

Duration

The client in active labor overhears the nurse state the fetus is ROA. The nurse should explain this refers to which component when the client becomes concerned?

Fetal position

The nurse is admitting a client who is in early labor. After determining that the birth is not imminent, which assessment should the nurse perform next?

Fetal status

The student nurse is preparing to assess the fetal heart rate (FHR). She has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's:

Left lower quadrant

A young client arrives at the clinic with a rash on the trunk and flexor surfaces of the extremities. The mother informs the nurse that the rash started a day before on the exterior surfaces of the extremities; 2 days before, the child had a really bad rash on the face. The physician diagnoses the child with erythema infectiosum. The nurse tells the mother that this is also known as:

Fifth disease

A pregnant woman with sickle cell anemia is very concerned her infant will also develop the disease and questions the nurse about that possibility. Which is the best response from the nurse?

Both parents have to carry the trait.

A 28-year-old primigravida client presents to the unit in early labor. The record reveals the client is 5 ft (1.5 m) tall, 95 lbs (43 kg), and has gained 25 lbs (11.3 kg) over a normal, uneventful pregnancy. The nurse predicts this client will have which type of pelvis upon assessment?

Cannot be determined

A 38-year-old client, G4P3, at 10 weeks' gestation with an unplanned pregnancy, has concerns the fetus may have a genetic defect. The nurse should point out which test would be the best current choice to investigate the possibility of a chromosomal abnormality?

Chorionic villus sampling

A pregnant client with a history of heart disease has been admitted to a health care center reporting breathlessness. The client also reports shortness of breath and easy fatigue when doing ordinary activity. The client's condition is markedly compromised. The nurse would document the client's condition using the New York Heart Association (NYHA) classification system as which class?

Class III

When providing nutritional counseling to a pregnant woman with diabetes, the nurse would urge the client to obtain most of her calories from which source?

Complex carbohydrates

A nurse studying high-risk pregnancies correctly identifies which of the following as causes for such a label? (Select all that apply.)

Concurrent disorder Pregnancy-related complication External factor that jeopardizes both the health of the woman and fetus External factor that jeopardizes the health of the woman or the fetus

Between her regularly scheduled visits, a woman in her first trimester of pregnancy who is taking iron supplements for anemia calls the nurse at her obstetrician's office reporting constipation. She reports that she has never had this problem before and asks for some advice about how to get relief. What is the best advice the nurse can give her?

Continue taking iron supplements but increase fluids and high-fiber foods; exercise more.

The nurse is admitting a client who is in labor who reports her husband and doula will be arriving shortly. Which action should the nurse prioritize in response?

Continue with the admission assessment

A pregnant client in her first trimester visits the health care facility for regular checkups. The nurse instructs the client to increase her dietary intake of folic acid based on the understanding that folic acid is important for which action?

Decreasing incidence of birth defects

Which nursing intervention would be most appropriate for a 9-year-old hospitalized for shoulder dislocation?

Developing a collaborative plan for activities

A young woman recently gave birth to a healthy 7 lb, 6 oz (3,304 g) baby girl. There were no complications during the birth, and the mother appears to be well. Which of the following should the nurse do to assess this client's psychological state after the pregnancy?

Encourage the client to talk about her birthing experience with the nurse and others.

A 3-year-old is admitted to the hospital for pneumonia. Which intervention would be most effective in reducing separation anxiety?

Encouraging rooming-in

The nursing instructor is preparing a group of nursing students for their clinical phase and is questioning them on the various assessment skills they will need. The instructor determines the session is successful when the students correctly choose which time interval to assess the fetal heart rate of clients who are in the active phase of labor?

Every 15 to 30 minutes

A G2P1 woman with type 1 diabetes is determined to be at 8 weeks' gestation by her health care provider. The nurse should point out which factor will help the client maintain glycemic control?

Exercise

All of the following are physical signs of protein deficiency in pregnancy EXCEPT

Fissures at the corner of the mouth or pale mucous membranes

A woman comes to the clinic for an exam and says that she is considering trying to become pregnant in the next few months. What would the nurse encourage the client to begin taking now?

Folic acid

The nursing instructor is teaching a group of nursing students about the uniqueness of pain involved with the birthing process. The instructor determines the session is successful when the students correctly choose which pain factor to be related to psychosocial influences?

Fear of pain during labor

A nursing student learning about childhood infectious diseases correctly identifies which of the following as the disease related to chickenpox, which tends to occur in older children or young adults?

Herpes zoster

At 31 weeks' gestation, a 37-year-old woman with a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Assessment reveals cervix 2.1 cm long; fetal fibronectin in cervical secretions, and cervix dilated 3 to 4 cm. Which interactions should the nurse prepare to assist with?

Hospitalization, tocolytic, and corticosteroids

In providing culturally competent care to a laboring woman, which is a priority?

Identify how the client expresses labor pain.

A pregnant woman diagnosed with cardiac disease 4 years ago is told that her pregnancy is a high-risk pregnancy. The nurse then explains that the danger occurs primarily because of the increase in circulatory volume. The nurse informs the client that the most dangerous time for her is when?

In weeks 28 to 32

The nurse is assisting a client through labor, monitoring her closely now that she has received an epidural. Which finding should the nurse prioritize to the anesthesiologist?

Inability to push

The nurse is teaching a prenatal class on the difference between true and false labor contractions. The nurse determines the session is successful when the class correctly chooses which factor as an indication of true labor contraction?

Increase even if relaxing and taking a shower

A client who requested "no drugs" in labor asks the nurse what other options are available for pain relief. The nurse reviews several options for nonpharmacologic pain relief, and the client thinks effleurage may help her manage the pain. This indicates that the nurse will:

Instruct the client or her partner to perform light fingertip repetitive abdominal massage.

A nursing instructor is teaching students about anemia during pregnancy. Which type of anemia does the instructor teach students is most prevalent during pregnancy?

Iron-deficiency anemia

After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position?

Knee-chest

A nursing student has learned that precipitous labor is when the uterus contracts so frequently and with such intensity that a very rapid birth will take place. This means the labor will be completed in which span of time?

Less than 3 hours

The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. How should the nurse document this finding?

Lie

A nurse is caring for a family whose child has been admitted to the hospital for orthopedic surgery. Which of the following should the nurse do to promote a positive hospital stay for the child and the family?

Limit diagnostic procedures to only those necessary to minimize the length of the hospital stay

Nausea and vomiting are common reports during pregnancy. What nutritional action can be used to lessen nausea and vomiting?

Limiting intake of heavy, greasy foods

A nurse is assisting a client in active labor whose diabetes has been poorly controlled. Which assessment of the neonate should be prioritize after its birth?

Macrosomia

A client in labor has been given an epidural anesthetic. Which nursing assessment finding is most important immediately following the administration of epidural anesthesia?

Maternal blood pressure decreases from 130/70 to 98/50 mm Hg.

A laboring client has been pushing without delivering the fetal shoulders. The primary care provider determines the fetus is experiencing shoulder dystocia. What intervention can the nurse assist with to help with the birth?

McRoberts maneuver

The nurse determines that it is necessary to implement airborne precautions for children with which infection?

Measles

The skull is the most important factor in relation to the labor and birth processes. The fetal skull must be small enough to travel through the bony pelvis. What feature of the fetal skull helps to make this passage possible?

Molding

A nurse counsels a pregnant woman regarding her recommended daily allowance of calories. She advises her to obtain her carbohydrate calories from complex carbohydrates rather than simple carbohydrates. What is the best rationale for this guidance?

More consistent regulation of glucose and insulin

A 15-year-old boy visits his primary care physician's office with fever, headache, and malaise, along with complaints of pain on chewing and pain in the jawline just in front of the ear lobe. The boy asks his mother to leave the exam room for a minute and then tells the nurse that he is also experiencing testicular pain and swelling. The nurse recognizes that this client most likely has which condition?

Mumps

A child in the clinic has a fever and reports a sore neck. Upon assessment the nurse finds a swollen parotid gland. The nurse suspects which infectious disease?

Mumps

A 29-year-old client comes to the clinic because she has not had a menstrual period for two months and thinks she is pregnant. The nurse would assess the client for which of the following?

Nausea and vomiting that fades as the day goes on

After teaching a class on the role of white blood cells in infection, the instructor determines that the teaching was successful when the class identifies which type of white blood cells as important in combating bacterial infections?

Neutrophils

When caring for a client in the third stage of labor, the nurse notices that the expulsion of the placenta has not occurred within 5 minutes after birth of the infant. What should the nurse do?

Nothing. Normal time for stage three is 5 to 30 minutes.

A nurse is assessing a client in her seventh month of pregnancy who has an artificial valve prosthesis. The client is taking an oral anticoagulant to prevent the formation of clots at the valve site. Which of the following nursing interventions is most appropriate in this situation?

Observe the client for signs of petechiae and premature separation of the placenta

A nurse is trying to maintain the healthy nutritional intake of a 7-year-old girl who has been admitted to the hospital for surgery. Which of the following should the nurse do encourage proper fluid intake in this child?

Offer the child popsicles

The nurse is preparing an educational event for pregnant women on the topic of labor pain and birth. The nurse understands the need to include the origin of labor pain for each stage of labor. What information will the nurse present for the first stage of labor?

Pain originates from the cervix and lower uterine segment.

A woman with known cardiac disease from childhood presents at the obstetrician's office 6 weeks' pregnant. What recommendations would the nurse make to the client to address the known cardiac problems for this pregnancy? Select all that apply.

Plan periods of rest into the workday. Receive pneumococcal and influenza vaccines. Let the physician know if you become short of breath or have a nighttime cough.

A 17-year-old primigravida with type 1 diabetes is at 37 weeks gestation comes to the clinic for an evaluation. The nurse notes her blood sugar has been poorly controlled and the health care provider is suspecting the fetus has macrosomia. The nurse predicts which step will be completed next?

Preparing for amniocentesis and fetal lung maturity assessment

During a routine prenatal check up, the nurse interviews a pregnant client to identify possible risk factors for developing gestational diabetes. Which factor would the nurse identify as increasing the woman's risk? Select all that apply.

Previous history of spontaneous abortion Maternal obesity with body mass index more than 35

A young hospitalized patient whose parents have just left for a few hours begins to cry uncontrollably, thrashes about, and will not allow the nurse to provide comfort. This patient is exhibiting which stage of separation anxiety?

Protest

A nurse is caring for an infant who has been admitted the hospital for surgery. Which of the following interventions should the nurse implement to ensure the continued growth and development of the infant during his stay?

Provide a singular room for the child and family in the neonatal intensive care unit

A school-aged child is scheduled for surgery. Which of the following would be most helpful to reduce stress and anxiety?

Provide a tour of the surgery unit and allow the child to see hear and feel equipment that will be used during his stay

A pediatric nurse observes signs of separation anxiety and suggests rooming- in. The goal of rooming-in is to prevent which?

Separation anxiety for both pediatric client and caregiver

Which assessment finding in a client reporting uterine contractions would be most consistent as an indicator of approaching labor?

Rupture of amniotic membranes

Which finding would the nurse expect in a neonate who is born with the assistance of a vacuum extractor?

Scalp edema

A patient comes to the birthing suite and informs the nurse that "the baby is coming" and "I feel like I have to have a bowel movement." It is likely that the woman is which of the following stages of labor?

Second stage

A nurse is providing education to a woman at 28 weeks' gestation who has tested positive for gestational diabetes mellitus (GDM). What would be important for the nurse to include in the client teaching?

She is at increased risk for type 2 diabetes mellitus after her baby is born.

A patient is concerned about the mercury levels in fish and asks the nurse which fish are safe to eat. The best response is

Shrimp, canned tuna, pollack, and catfish

The nurse identifies from a client's prenatal record that she has a documented gynecoid pelvis. Upon the client entering the labor and delivery department, which nursing action is best?

Take no extra measures; prepare for a standard labor.

A woman with active tuberculosis in her sixth month of pregnancy is taking ethambutol hydrochloride. Which assessment would be most important for the nurse to complete for this woman?

Test for color recognition using Snellen eye chart

When planning a labor experience for a primigravid, understanding which characteristic of labor pain is most helpful?

The characteristics of labor pain follow a pattern.

A nurse is promoting vaccine administration. When instructing on the physiological changes, which statement best explains what occurs in the child when vaccines are administered?

The child develops an active immunity.

Which client outcome during active and transitional labor is best?

The client will practice breathing techniques during contractions.

The nurse is caring for a client at 39 weeks' gestation and whose fetal station is noted as a 0 (zero). The nurse is correct to document which?

The fetus is in the true pelvis and engaged.

The nurse caring for a patient in an acute care setting utilizes a family-centered approach to the patient's care. Which of the following is a good example of this approach?

The nurse asks the parents which activities of daily living they would like to participate in.

The nursing instructor is teaching the students the basics of the labor and delivery process. The instructor determines the session is successful when the students correctly choose which action will best help to prevent infections in their clients?

Thoroughly wash the hands before and after client contact.

The nurse is caring for a child admitted to the hospital for sepsis. Which assessment finding is the most concerning?

Urine output of 10 ml over 3 hours

A laboring client is experiencing dysfunctional labor or dystocia due to the malfunction of one or more of the "four Ps" of labor. Which scenario best illustrates a power problem?

Uterine contractions are weak and ineffective.

A G2P1 woman is in labor attempting a VBAC, when she suddenly complains of light-headedness and dizziness. An increase in pulse and decrease in blood pressure is noted as a change from the vital signs obtained 15 minutes prior. The nurse should investigate further for additional signs or symptoms of which complication?

Uterine rupture

A woman in active labor with a history of two previous C-sections is being monitored frequently as she tries to have a vaginal birth. Suddenly, the woman grabs the nurse's hand and states, "Something inside me is ripping/tearing." The RN notes her BP is 80/50, pulse rate is 130 and weak, skin is cool and clammy and the fetal monitor shows bradycardia. The nurse activates the code team because the nurse suspects the client may be experiencing which complication?

Uterine rupture

When the nurse is instructing on disease transmission, which is noted as the smallest infectious agent known?

Virus

After teaching nursing students about childhood exanthems, the instructor determines that the teaching was successful when the students identify what as the primary cause?

Viruses

A pregnant client has been diagnosed as having a urinary tract infection (UTI). Which of the following instructions regarding control of the infection should the nurse provide the client?

Wear cotton underwear

Parents bring their 9-year-old child to the clinic for a well-child visit. They are concerned because several children in the neighborhood have developed Lyme disease and ask for suggestions on what to do to reduce their child's risk. What would be appropriate for the nurse to suggest? Select all that apply.

Wearing protective clothing when playing in wooded areas. Inspecting the skin closely for ticks after the child plays in wooded areas. Contacting the health care provider if there is any area of inflammation that might be a bite.

At what time is the laboring client encouraged to push?

When the cervix is fully dilated

A client in her fifth month of pregnancy is having a routine clinic visit. The nurse should assess the client for which common second trimester condition?

Physiological anemia

A nursing instructor is teaching students about preexisting illnesses and how they can complicate a pregnancy. The instructor recognizes a need for further education when one of the students makes which statement?

"A pregnant woman does not have to worry about contracting new illnesses during pregnancy."

You have just admitted a 32-year-old female in active labor to the delivery suite. During the admission assessment she says, "I am so afraid that my asthma will get out of control during labor and my baby will be harmed." Which response by the nurse would be most appropriate?

"Actually, asthma symptoms tend to diminish during labor."

The nurse is assessing a pregnant client who has a long history of asthma. She states, "I'm trying not to use my asthma medications because I certainly don't want my baby exposed to them." What is the nurse's best response?

"Actually, having uncontrolled asthma is much riskier for your baby than the medication."

A pregnant client with cystic fibrosis (CF) comes to the office for a prenatal visit. She asks the nurse for information on breast-feeding. The best response by the nurse is:

"Breast-feeding is not a good idea. Because your breast milk is high in sodium due to CF, there is a risk of the infant receiving too much sodium."

The nurse is explaining to a 4-year-old about a CT scan with contrast. Which explanation by the nurse is most appropriate?

"I am going to give you some medicine through the tube in your arm so we can take a picture inside your belly."

A pregnant client is diagnosed with syphilis. Which interviewing question would demonstrate respect for the client and therapeutic communication?

"I am sure it is frightening to you to be diagnosed with a disease that can affect your baby."

A pregnant client with diabetes in the hospital reports waking up with shakiness and diaphoresis. Which action should the nurse prioritize after discovering the client's fasting blood sugar is 60 mg/dL?

Provide the client some milk to drink.

A 4-year-old is ordered to bedrest. Which activity would be most appropriate for promoting play?

Providing a basin with water and toys while bathing the child

A nursing student is learning tips when caring for children. The instructor informs students that they should not call children "honey." What explanation for avoiding this term is the best reason the nurse would give?

"Honey" can cause children to worry that they have been confused with another child.

After teaching a pregnant woman with iron deficiency anemia about her prescribed iron supplement, which statement indicates successful teaching?

"I need to eat foods high in fiber."

The nurse is caring for a 10-year-old child dying of leukemia. The mother requests that the nurse allow her to bathe the child. The child has multiple IV lines, electrodes, oxygen tubing, and an NG tube. Which of the following is the best response by the nurse?

"I think that would be a great idea. Would you like some help with all the tubes?"

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?

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

A nurse is interviewing a primigravida woman about nutrition during pregnancy. During the interview, the woman asks the nurse about consuming caffeine. Which information would the nurse include when teaching the woman about caffeine intake during pregnancy? Select all that apply.

"Pregnant women should not consume more than 300 mg of caffeine a day. An 8 oz cup of coffee has approximately 120 mg of caffeine." "Although it includes significantly smaller amounts, chocolate also contains caffeine."

Nursing students are learning about the body's response to infection. Which of the following statements made by a student indicates an understanding of the job of pus in an infection?

"Pus indicates that phagocytosis is occurring."

The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out zero station refers to which sign?

"The presenting part is at the true pelvis and is engaged."

A nursing student is learning about fetal presentation. The nursing instructor realizes a need for further instruction when the student makes which of the following statements?

"Transverse lie is the same as when the fetal buttocks present to the birth canal."

A child is diagnosed with group A streptococcal pharyngitis. The nurse would teach the parents to be alert for signs and symptoms of:

Scarlet fever.

A nurse is preparing a 6-year-old boy for an emergency appendectomy. The boy is in a lot of pain and also scared. Which statement would be best to explain this surgery to him?

"We are going to fix the part that hurts down there so that it doesn't hurt anymore."

A 43-year-old, physically fit, healthy woman who is newly married tells the nurse that she and her husband would like to have a child. What is an appropriate first response?

"Well, I'm sure you know there are some risks involved so it's helpful that you've been taking such good care of yourself."

A woman is to undergo an amnioinfusion. Which statement would be most appropriate to include when teaching the woman about this procedure?

"You'll need to stay in bed while you're having this procedure."

The nurse is caring for a 12-year-old patient with neuroblastoma. The nurse enters the room to hang a new bag of IV fluid. The mom looks up and states she feels helpless and there is nothing she can do for her child. Which of the following is the best response for the nurse to make?

"Your presence here is very important to your child. Is there some part of his daily care that you would like to do yourself?"

Which order by the health care provider would the nurse question if given in the active stage of labor?

Secobarbital for relaxation

A nurse is assessing a client's nutritional intake during pregnancy. What is the best method for accomplishing this?

Enacting a 24-hour nutrition recall

A nurse is caring for a young client with pneumonia who has slight nausea and does not feel like eating. The client is sipping on fluids. The child's mother says that she is worried and wants the nurse to make the child eat. What is the best nursing action?

Encourage but do not force the child to eat.

Which intervention would be least effective in caring for a woman who is in the transition phase of labor?

Encouraging the woman to ambulate

A patient of normal weight and new to the obstetric clinic asks the nurse how much weight to gain during pregnancy. What is the best response the nurse can give?

10 lbs over the first 20 weeks; 1 lb per week after that

A low-risk client is in the active phase of labor. The nurse evaluates the fetal monitor strip at 10:00 a.m. and notes the following: moderate variability, FHR in the 130s, occasional accelerations, and no decelerations. At what time should the nurse reevaluate the FHR?

10:30 am

The nurse is assessing a new client who presents in early labor. The nurse determines the fetus has an acceptable heart rate if found within which range?

110 to 160 bpm

The nurse is monitoring the uterine contractions of a woman in labor. The nurse determines the woman is experiencing hypertonic uterine dysfunction based on which contraction finding?

Erratic

The nurse is caring for a patient in an acute care setting. Which of the following is true regarding activities of daily living (ADLs) for this patient?

Greater cooperation can be achieved if ADLs mimic home routines.

A teenage patient active on the high school football team comes to the clinic with a cut on his leg that looks infected. The culture report returns information that leads to a diagnosis of MRSA. What should the nurse use as preventive measures in this case?

Handwashing Contact precautions Gloves

A client in her second trimester of pregnancy complains to the nurse of heartburn. Which of the following should the nurse suggest to the client as a preventative measure?

Have small frequent meals

A nurse is providing care to several pregnant women at different weeks of gestation. The nurse would expect to screen for group B streptococcus infection in the client who is at:

36 weeks' gestation.

Assessment of pregnant woman reveals that the woman has a BMI of 31. The woman is pregnant with one fetus. The nurse would most likely recommend a total weight gain of no greater than which amount?

20 pounds

A woman is admitted to the L & D unit for prostaglandin insertion along with IV oxytocin induction to begin 12 hours afterward. The nurse, preparing to insert the prostaglandin, questions this order for which of the women on the unit who have a history of which disease? Select all that apply.

24 year old female with a history of asthma, diagnosed at age 9. 30 year old female who developed diabetes at age 5 and currently is in pre-renal failure.

A pregnant client of normal weight is concerned about excessive weight gain during her pregnancy. She states, "I don't want to get fat!" The nurse should inform her that she can expect to gain how much weight during her pregnancy?

25 to 30 pounds

You are discussing weight gain with a group of pregnant women at the clinic. One woman is very thin and her prepregnancy weight falls below the normal weight range for her height. What is her recommended weight gain during her pregnancy?

28 to 40 pounds

A nurse is serving as a doula to a client who is now in labor at an alternative birthing center. The client has opted for a water birth, and the nurse is now drawing the water into a large tub. What temperature should the nurse keep the water at?

37 C

A client is 33 weeks pregnant and has had diabetes since age 21. When checking her fasting blood glucose level, which value would indicate the client's disease is controlled?

85 mg/dL

The nurse is assessing the external fetal monitor and notes the following: FHR of 175 bpm, decrease in variability, and late decelerations. Which action should the nurse prioritize at this time?

Have the woman change her position.

The nurse is noting a collection of blood under the scalp on a newborn being discharged to home. The nurse is correct to prepare teaching instructions of which topic?

A cephalohematoma

The obstetrician is examining a woman who is in early labor to determine the positioning of the fetus. The nurse knows that which of the following fetal attitudes would be the most advantageous for birth?

Head flexed forward so much that the chin touches the sternum

A client in active labor is given spinal anesthesia. Which information would the nurse include when discussing with the client and family about the disadvantages of spinal anesthesia?

Headache following anesthesia

Which of the following is true regarding problems that commonly affect nutritional health in pregnancy?

50% of women report pyrosis at some point in pregnancy.

A woman whose body mass index (BMI) is 32 has just learned that she is pregnant. Which of the following should the nurse advise her regarding her weight over the course of her entire pregnancy?

She should gain 11 to 20 lb

Which neonate is at highest risk for developing neonatal herpes following birth?

A newborn who was a vaginal delivery to a mother who had her initial outbreak during the third trimester of pregnancy and has active lesions

The nurse recognizes which person as needing further education?

A nursing assistant who is obtaining vital signs in the playroom

A client states that "she thinks" her water has broken. Which best provides confirmation of the rupture of membranes?

A positive Nitrazine test

A nurse is reviewing the medical records of several women who come to the prenatal clinic for care. The nurse plans to increase the number of teaching sessions on nutrition for the women at risk for poor nutritional status. Which woman would the nurse most likely identify as needing the additional sessions. Select all that apply.

A woman who is 42-years of age A woman whose prepartum weight was less 85% of ideal weight. A woman who shows a weight gain of 2 or more pounds per week.

The nursing instructor is pointing out the various complcations which can occur during pregnancy in women with diabetes mellitus. The instructor determines the session is successful after the students correctly choose which complication that can occur if the diabetes is not kept under control?

Hydramnios

The student nurse is learning about normal labor. The teacher reviews the cardinal movements of labor and determines the instruction has been effective when the student correctly states the order of the cardinal movements as follows:

Descent, flexion, internal rotation, extension, external rotation, expulsion.

During a prenatal visit, the physician determines that the fetal heart beat is too fast. What drug would the nurse expect the physician to order for the mother to treat the fetal tachycardia?

Digoxin

The nurse is monitoring a client in the first stage of labor. The nurse determines the client's uterine contractions are effective and progressing well based on which finding?

Dilation of cervix

A woman in her 20s explains to the nurse that she would like to eat more healthy foods during her pregnancy but complains about the high cost of food. She confides that she just makes minimum wage at her job and that things are tight for her financially. What would be the most appropriate intervention for the nurse to make?

Discuss the WIC program with the client.

A G4P3 client with a history of controlled asthma is upset her initial prenatal appointment is taking too long, making her late for another appointment. What is the nurse's best response when the client insists she knows how to handle her asthma and needs to leave?

Acknowledge her need to leave but ask her to demonstrate the use of inhaler and peak flow meter before she goes; remind her to take regular medications.

Which nursing action is applied throughout all stages of labor?

Do not allow the client to lay flat on her back for long periods.

A client has just had an epidural placed. Before the procedure, her vital signs were as follows: BP 120/70, P90 bmp, R18 per min, and O2 sat 98%. Now, 3 minutes after the procedure, the client says she feels lightheaded and nauseous. Her vital signs are BP 80/40, P100 bmp, R20 per min, and O2 sat 96%. Which interventions should the nurse perform?

Assist the client to semi-Fowler's position, assess the fetal heart rate, start an IV bolus of 500 mL, and administer oxygen via face mask.

Which changes in pregnancy would the nurse identify as a contributing factor for arterial thrombosis, especially for the woman with atrial fibrillation

Hypercoagulable state

Infants admitted to the hospital need toys in their cribs, such as mobiles, blocks, soft toys, and rattles.

True

The nurse is assessing a pregnant client with a known history of congestive heart failure who is in her third trimester. Which assessment findings should the nurse prioritize?

Dyspnea, crackles, and irregular weak pulse

A client in labor has received a spinal epidural block. Which nursing intervention should the nurse prioritize after assessing maternal hypotension and changes in the fetal heart rate (FHR)?

Administer supplemental oxygen.

A client has opted to receive epidural anesthesia during labor. Which of the following interventions should the nurse implement to reduce the risk of a significant complication associated with this type of pain management?

Administration of 500 mL of IV Ringer's lactate

A client in labor has requested the administration of narcotics to reduce pain. At 2 cm cervical dilatation, she says that she is managing the pain well at this point but does not want it to get ahead of her. What should the nurse do?

Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor.

After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical?

Amniotomy

A woman who is 8 months pregnant comes to the clinic with urinary frequency and pain on urination. The client is diagnosed with a urinary tract infection (UTI). Which of the following medications would the nurse anticipate the physician will order?

Amoxicillin

The clinic nurse teaches a pregestational type 1 diabetic client that constant insulin levels are very important during pregnancy. The nurse tells the client that the best way to maintain a constant insulin level is to use:

An insulin pump.

Which statement is true regarding analgesia versus anesthesia?

Analgesia only reduces pain, but anesthesia partially or totally blocks all pain in a particular area.

A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client?

Assess fetal heart sounds.

A client has been in labor for 10 hours and is 6 cm dilated. She has already expressed a desire to use nonpharmacologic pain management techniques. For the past hour, she has been lying in bed with her doula rubbing her back. Now, she has begun to moan loudly, grit her teeth, and bear down with each contraction. She rates her pain as 8 out of 10 with each contraction. What should the nurse do first?

Assess for labor progression

Which action is a priority when caring for a woman during the fourth stage of labor?

Assessing the uterine fundus

A client states, "I think my water broke! I felt this gush of fluid between my legs." The nurse tests the fluid with a nitrazine swab and confirms membrane rupture if the swab turns:

Blue

A woman with a positive history of genital herpes is in active labor. Assessment reveals vesicles in the perineum area, membranes are ruptured, dilated 5 cm, and effaced 70%. The nurse should prepare the client for which type of birth?

Cesarean

The nurse is preparing a birthing care plan for a pregnant client. Which factor should the nurse prioritize to achieve adequate pain relief during the birthing process?

Client priorities and preferences are incorporated into the plan.

A pregnant woman with diabetes at 10 weeks' gestation has a glycosylated hemoglobin (HbA1c) level of 13%. At this time the nurse should be most concerned about which possible fetal outcome?

Congenital anomalies

A nursing instructor is teaching the students about the standard and transmission-based precautions. What type of precautions require placing a client in an isolated room with limited access, wearing gloves during contact with the client and all body fluids or contaminated items, wearing two layers of protective clothing, and avoiding sharing equipment between clients?

Contact precautions

The nursing instructor is preparing a class discussing the role of the nurse during the labor and birthing process. Which intervention should the instructor point out has the greatest effect on relieving anxiety for the client?

Continuous labor support

Which finding would lead the nurse to suspect that the fetus of a woman in labor is in hypertonic uterine dysfuction?

Contractions most forceful in the middle of uterus rather than the fundus

A pregnant client in her 20th week of gestation, having systemic lupus erythematosus (SLE), is admitted to the healthcare unit for management of the exacerbation of SLE. Which of the following would be most appropriate to treat the client's condition?

Corticosteriods

A woman with cardiac disease at 32 weeks' gestation reports she has been having spells of light-headedness and dizziness every few days. Which instruction should the nurse prioritize?

Decrease activity and rest more often.

A woman in labor has received a pudendal block. The nurse would assess the woman for which condition?

Decrease in maternal blood pressure

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?

Degree of blood glucose control achieved during the pregnancy

A toddler who is vomiting and has diarrhea is seen in the clinic. The child's mother states that these symptoms started in the last 6 to 8 hours. Which of the following would the nurse expect from these symptoms?

Dehydration

Which cardinal movement of delivery is the nurse correct to document by station?

Descent

The nurse assesses that the fetus of a woman is in an occiput posterior position. The nurse predicts the client will experience which situation related to this assessment?

Experience of additional back pain

A client in week 38 of her pregnancy has an ultrasound performed at a routine office visit and learns that her fetus has not moved out of a breech position. Which intervention does the nurse anticipate for this client?

External cephalic version

When stimulating the fetus via an acoustic vibrator, which action indicates fetal well-being?

Fetal heart rate acceleration occurs

A client at 35 weeks' gestation is now in stable condition after being admitted for vaginal bleeding. Which assessment should the nurse prioritize?

Fetal heart tones

A pregnant client with deep vein thrombosis has been diagnosed as having systemic lupus erythematosus (SLE). The nurse would monitor the client closely for the development of which complication?

Fetal malnutrition

A primigravida whose labor was initially progressing normally is now experiencing a decrease in the frequency and intensity of her contractions. The nurse would assess the woman for which condition?

Fetopelvic disproportion

One vitamin has been identified as helping to prevent neural tube defects when consumed in adequate amounts before conception through the early weeks of pregnancy. Which vitamin is it?

Folic acid

A nurse is listening to a patient's heart and determines that there is a change since the last normal prenatal visit. The patient has no history of heart disease, so which of the following should the nurse expect has developed?

Functional murmur

The nurse is caring for a child diagnosed with Hepatitis B. Which system is most likely to have complications from this diagnosis?

Gastrointestinal

A 3-year-old admitted to the hospital for pneumonia starts wetting the bed. The parents are visibly upset. Which action by the nurse is most appropriate?

Give reassurance that regression can happen when children are sick

Which nursing action is required before a client in labor receives an epidural?

Giving a fluid bolus of 500 ml

A nurse explains to a pregnant woman the importance of consuming adequate iodine in her diet. Which of the following conditions can a deficiency in iodine lead to?

Goiter

Nursing students are learning about the infectious process. They correctly identify the first stage of an infectious disease to be the:

Incubation period

Put the following stages of infectious disease in correct order:

Incubation period Prodromal period Illness Convalescent period

A woman calls the obstetrician's office to inquire how long she needs to wait to get pregnant following a seizure she had last week. The nurse would tell her to wait how long?

It is recommended that she wait 6 months after seizures are under control before getting pregnant.

The nurse is assessing a mother who just delivered a 7 lb (3136 g) baby via cesarean delivery. Which assessment finding should the nurse prioritize if the mother has a history of controlled atrial fibrillation?

Jugular distention

In women with cardiac failure, the maternal blood pressure becomes insufficient to provide an adequate supply of blood to the placenta. The infant will likely experience some undesired effects, including which of the following?

Low birth weight

The immune system works to destroy pathogens by helping the body get rid of or resist the invasion of foreign materials The blood cells that surround, ingest and neutralize the pathogens are which of the following?

Macrophages

The nurse is preparing information for a client who has just been diagnosed with gestational diabetes. Which instruction should the nurse prioritize in this information?

Maintain a daily blood glucose log

The nurse is caring for a 6-month-old patient who has been hospitalized since birth. Which of the following nursing interventions is the most beneficial to this patient's psychosocial health?

Maintain consistent caregivers to promote trust and attachment.

The nurse is assessing a client in labor for pain and notes she is currently not doing well handling the increased pain. Which opioid can the nurse offer to the client to assist with pain control?

Meperidine

A woman calls the health care facility stating that she is in labor. The nurse would urge the client to come to the facility if the client reports which symptom?

Moderately strong contractions every 4 minutes, lasting about 1 minute

A woman has been in labor for the past 8 hours and she has progressed to the second stage of labor. However, after 2 hours with no further descent the provider diagnoses an "arrested descent." The woman asks, "Why is this happening." Which response by the nurse is the best answer to this question?

More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal.

A 7-year-old with an earache comes to the clinic. The child's mother reports that 1 day ago her child had a fever and headache and did not want to play. When the nurse asks where it hurts, the child points to the jawline in front of the earlobe. What does the nurse expect the diagnosis to be for this child?

Mumps

A 13 month old who has recurrent illnesses is having difficulty sleeping at night. In considering therapeutic interventions, the pediatric nurse correctly identifies which stage of sleep that allows the body to rest and restore function?

NREM

A full-term neonate delivered an hour after the mother received IV meperidine is showing signs of respiratory depression. The nurse should be prepared to administer which medication?

Naloxone

The nurse is discussing medications to be given to a child who has been diagnosed with candidiasis. Which of the following medications would most likely be prescribed for the child?

Nystatin

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting?

Occiput

A woman presents at Labor and Delivery very upset. She reports that she has not felt her baby moving for the last 6 hours. The nurse listens for a fetal heart rate and cannot find a heartbeat. An ultrasound confirms fetal death and labor induction is started. What intervention by the nurse would be appropriate for this mother at this time?

Offer to take pictures and footprints of the infant once it is delivered.

A pregnant client has developed iron-deficiency anemia and has been prescribed 200 mg of elemental iron per day. The nurse should encourage the client to take this medication with which substance?

Orange juice

A nurse is educating a group of nursing students about the etiology of labor. Which of the following should the nurse explain as the hormone produced by the posterior pituitary?

Oxytocin

A child is diagnosed with scarlet fever. The nurse is reviewing the child's medical record, expecting which medication to be prescribed for this child?

Penicillin V

The nurse notices that the 6-year-old sibling of a hospitalized child has a runny nose and is coughing. What action should be taken by the nurse?

Perform a screening for communicable diseases

A mother brings her 8-year-old son for evaluation because of a rash on his lower leg. Which finding would support the suspicion that the child has Lyme disease?

Playing in the woods about a week ago

A young woman with scoliosis has just learned that she is pregnant. Several years ago, she had stainless-steel rods surgically implanted on both sides of her vertebrae to strengthen and straighten her spine. However, her pelvis is unaffected by the condition. Which of the following does the nurse anticipate in this woman's pregnancy?

Potential for greater than usual back pain

A client has presented in the early phase of labor, experiencing abdominal pain and signs of growing anxiety about the pain. Which pain management technique should the nurse prioritize at this stage?

Practicing effleurage on the abdomen

A 17-year-old is diagnosed with infectious mononucleosis. The nurse should discuss which intervention with the teenager's caregiver to best assure an uncomplicated recovery?

Precautions to avoid secondary infections

A nurse is conducting a class for a group of pregnant women about nutritional needs during pregnancy. Which statement would the nurse include when describing a woman's mineral needs in pregnancy?

Pregnant women should drink fluoridated water.

The nurse is admitting a client in labor. The care provider determines that the fetus is in a transverse lie and not responsive to Leopold maneuvers. What intervention should the nurse provide for the client?

Prepare the client for a cesarean birth.

The nurse is monitoring a client in labor who has had a previous cesarean section and is trying a vaginal birth with an epidural. The nurse observes a sudden drop in blood pressure, increased heart rate, and deep variable deceleration on the fetal monitor. The client reports severe pain in her abdomen and shoulder. What should the nurse prepare to do?

Prepare the client for a cesarean birth.

The nurse is assessing a multipara woman who presents to the hospital after approximately 2 hours of labor and notes the fetus is in a transverse lie. After notifiying the RN and primary care provider, which action should the LPN prioritize?

Prepare to assist with external version

A maternity nurse is aware that the fetal head is the presenting part in complete extension position. Which type of birth should the maternity nurse anticipate?

Prolonged labor and possible cesarean birth

When describing perinatal education to a pregnant woman and her partner, the nurse emphasizes which goal as the primary one?

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

A 15-year-old admitted for asthma exacerbation is nearing discharge and is requesting to take a shower. Which nursing intervention is most appropriate?

Provide privacy and needed supplies

A nurse is coaching a woman during the second stage of labor. Which action should the nurse encourage the client to do at this time?

Push with contractions and rest between them.

A 23-year-old client who's 27 weeks pregnant arrives at her physician's office with complaints of fever, nausea, vomiting, malaise, unilateral flank pain, and costovertebral angle tenderness. Which condition would the nurse most likely suspect?

Pyelonephritis

A 32-year-old woman presents to the labor and birth suite in active labor. She is multigravida, relaxed, and talking with her husband. When examined by the nurse, the fetus is found to be in a cephalic presentation. His occiput is facing toward the front and slightly to the right of the mother's pelvis, and he is exhibiting a flexed attitude. How does the nurse document the position of the fetus?

ROA

A pregnant woman comes to the emergency department stating she thinks she is in labor. Which assessment finding concerning the pain will the nurse interpret as confirmation that this client is in true labor?

Radiates from the back to the front

A 33-year-old client has been progressing slowly through an unusually long labor. The nurse assesses the fetal scalp pH and determines it is 7.26. How should the nurse explain this result to the client when asked what it means?

Reassuring; it is associated with normal acid-base balance.

The nurse is doing an in-service training on clinical manifestations seen in communicable diseases. Which skin condition best describes erythema?

Redness of the skin produced by congestion of the capillaries

A nurse is teaching a group of pregnant women who are in their first trimester about nutrition during pregnancy. When describing the caloric needs, which information would the nurse incorporate into the teaching plan? Select all that apply.

Regardless of weight or BMI, a woman should never consume less than 1500 calories a day. Recommended total caloric intake in pregnancy is 2500 or 3000 calories a day. It is better to obtain calories from complex carbohydrates (cereals and grains) than from simple carbohydrates (sugars and fruits). The best approach in evaluating a woman's caloric intake is to evaluate the weight that she is gaining.

What information should be included in the teaching plan for a child with varicella?

Remind the child not to scratch the lesions.

A client is diagnosed with peripartum cardiomyopathy (PPCM). Which therapy would the nurse expect to administer to the client?

Restricted sodium intake

The nurse is performing a physical examination on a 9-year-old boy who has experienced a tick bite on his lower leg and is suspected of having Lyme disease. Which assessment finding would the nurse expect to find?

Ring-like rash on lower leg

A 6-year-old child is brought to the clinic by his parents. The parents state, "He had a sore throat for a couple of days and now his temperature is over 102° F (38.9° C). He has this rash on his face and chest that looks like sunburn but feels really rough." What would the nurse suspect?

Scarlet fever

Which physical characteristic of the neonate is typically present in the neonate of a primigravid mother?

Significant head molding

A primigravida is 1 cm dilated, in early latent labor, and interested in avoiding epidural anesthesia. After asking about which nonpharmacologic options for pain relief she can use at this time, which options should tne nurse point out to the client? Select all that apply.

Simple breathing exercises Effleurage Walking and then using a birthing ball

A nurse is providing care to an infant who develops roseola during hospitalization. The nurse would institute which infection control precaution?

Standard

A nurse precepting a student in labor and delivery informs the student that the incidence of venous thromboembolic disease increases during pregnancy. What does the nurse tell the student contributes to this increased risk? (Select all that apply.)

Stasis of blood in lower extremities Hypercoagulability

A woman receiving an oxytocin infusion for labor induction develops contractions that occur every minute and last 75 seconds. Uterine resting tone remains at 20 mm Hg. Which action would be most appropriate?

Stop the infusion immediately.

A client and her husband have prepared for a natural birth; however, as the client progresses to 8 cm dilation, she can no longer endure the pain and begs the nurse for an epidural. What is the nurse's best response?

Support the client's decision and call the obstetrician.

The nurse is performing a physical examination of an 8-year-old girl who was bitten by her kitten. Which assessment would lead the nurse to suspect cat-scratch disease?

Swollen lymph nodes

An adolescent girl and her caregiver present at the pediatrician's office. The adolescent reports severe abdominal pain. A diagnosis of pelvic inflammatory disease (PID) is made. The nurse notes in the child's chart that this is the third time she has been treated for PID. Which action by the nurse would be most appropriate?

Take the child to a private room and interview her regarding her sexual history and partners.

A client with hyperemesis gravidarum is on a clear liquid diet. Which foods would be appropriate for the nurse to serve? Select all that apply:

Tea and gelatin Ginger ale and apple juice Cranberry juice and chicken broth

A 39-year-old multigravida with diabetes presents at 32 weeks' gestation reporting she has not felt movement of her fetus. Assessment reveals the fetus has died. The nurse shares with the mother that the institution takes pictures after the birth and asks if she would like one. What is the best response if the mother angerily says no and starts crying?

Tell her that the hospital will keep the photos for her in case she changes her mind.

When developing a labor plan with the client, which outcome is the priority?

The client will direct her pain management techniques.

The nurse is assisting a client in labor and delivery and notes the placenta is now delivered. Which documentation should the nurse prioritize?

The completion of the third stage of labor

A woman in active labor suddenly experiences a sharp, excruciating low abdominal pain, which the nurse suspects may be a uterine rupture since the shape of the abdomen has changed. The nurse calls a code, and a C-section is performed stat, but the infant does not survive the trauma. A few hours later, after the woman has stabilized, she asks to hold and touch her infant, and the nurse arranges this. Later, the nurse's documentation should include which outcome statement?

The parents are beginning to demonstrate positive grieving behaviors.

A woman arrives at the prenatal clinic and is accompanied by her partner. Which behaviors would be suggestive of intimate partner violence (IPV)? Select all that apply.

The partner answers questions for the pregnant client. The partner is overly protective of the pregnant client. Poor weight gain during the pregnancy and low birth weight infant

The nurse is caring for a client who has an irregular pattern of uterine contraction. As a result, the nurse anticipates a problem with which?

The powers

The nurse instructs the client about skin massage and the gate control theory of pain. Which statement would be appropriate for the nurse to include for client understanding of the nonpharmacologic pain relief methods?

These methods are a technique to prevent the painful stimuli from entering the brain.

The client in labor at 3 cm dilation and 25% effaced is asking the nurse for analgesia. Which explanation should the nurse provide when explaining why it is too early to administer an analgesic?

This may prolong labor and increase complications

Which of the following infections is often contracted by having contact with an infected dog or cat?

Tinea corporis

A client has not received any medication during her labor. She is having frequent contractions every 1 to 2 minutes and has become irritable with her coach and no longer will allow the nurse to palpate her fundus during contractions. Her cervix is 8 cm dilated and 90% effaced. The nurse interprets these findings as indicating:

Transition phase of the first stage of labor

The nurse is assessing a primigravida woman who reports vaginal itching, a great deal of foamy yellow-green discharge, and pain during intercourse. The nurse suspects the woman has contracted which disorder?

Trichomoniasis

In vasa previa, the umbilical vessels of a velamentous cord insertion cross the cervical os and therefore deliver before the fetus.

True

A pregnant woman at term is in the obstetrics unit for induction in the morning. Her membranes rupture, and the external fetal monitor shows deep variable decelerations. For what should the nurse immediately check the patient?

Umbilical cord prolapse

Which nursing intervention stimulates therapeutic play in a hospitalized child?

Uninterrupted role playing of a surgical procedure

A woman with a history of crack cocaine abuse is admitted to the labor and birth area. While caring for the client, the nurse notes a sudden onset of fetal bradycardia. Inspection of the abdomen reveals an irregular wall contour. The client also reports acute abdominal pain that is continuous. Which condition would the nurse suspect?

Uterine rupture

A woman in labor is experiencing hypotonic uterine dysfunction. Assessment reveals no fetopelvic disproportion. Which group of medications would the nurse expect to administer?

Uterine stimulants

Which method does the nurse use to determine fetal presentation, position and attitude?

Utilize Leopold maneuvers

The nurse is caring for a client who prefers resting on her back during the labor process. To facilitate client wishes, which nursing action is required?

Utilize a wedge under one hip

Which changes in the female body occur to allow the passage of the fetus down the birth canal? Select all that apply.

Vaginal rugae stretch and smooth out The cervix dilates to 10 cm The cervix softens