Questions I Got Wrong
the breathing technique that the mother should be instructed to use as the fetus' head is crowning is: A Blowing B Slow chest C Shallow D Accelerated-decelerated
A
When assessing an 18-month old, the nurse notes a characteristics protruding abdomen. Which of the following would explain the rationale for this findings? A Bowlegged posture B Linear growth curve CIncreased food intake owing to age D Underdeveloped abdominal muscles
D
When discussing a seven month old infant's mother regarding the motor skill development, the nurse should explain that by age seven months, an infant most likely will be able to... A Eat with a spoon. B Walk with support. C Stand while holding unto a furniture D Sit alone using the hands for support
D
While the client is in active labor with twins and the cervix is 5 cm dilates, the nurse observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the following would be the nurse's most appropriate action? A Notify the physician immediately B Administer oxygen at 6 liters by mask C Have the client pant-blow during the contractions D Note FHR ptatterns
A
A client is admitted to the birthing suite in early active labor. The priority nursing intervention on admission of this client would be: A Auscultating the fetal heart B Taking an obstetric history C Asking the client when she last ate D Ascertaining whether the membranes were ruptured
A
A client who's admitted to labor and delivery has the following assessment findings: gravida 2 para 1, estimated 40 weeks' gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which of the following would be the priority at this time? A Preparing for immediate delivery. B Checking for ruptured membranes. C Placing the client in bed to begin fetal monitoring. D Providing comfort measures.
A
A client with group AB blood whose husband has group O has just given birth. The major sign of ABO blood incompatibility in the neonate is which complication or test result? A Jaundice within the first 24 hours of life B Jaundice after the first 24 hours of life C Bleeding from the nose and ear D Negative Coombs test
A
A nurse is assessing a newborn infant following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions would be most appropriate? A Document the findings B Reinforce the dressing C Circle the amount of bloody drainage on the dressing and reassess in 30 minutes D Contact the physician
A
A nurse is monitoring a client in labor who is receiving Pitocin and notes that the client is experiencing hypertonic uterine contractions. List in order of priority the actions that the nurse takes. A Stop of Pitocin infusion B Perform a vaginal examination C Reposition the client D Check the client's blood pressure and heart rate E Administer oxygen by face mask at 8 to 10 L/min A A, D, B, E, C B A, B, D, E, C A A, D, B, C, E D A, D, C, E, B
A
The nursing intervention to relieve pain in breast engorgement while the mother continues to breastfeed is A Apply warm compress on the engorged breast B Massage the breast C Apply cold compress on the engorged breast D Apply analgesic ointment
A
Which change would the nurse identify as a progressive physiological change in postpartum period? A Lactation B Diuresis C Lochia D Uterine involution
A
A mother brings her one month old infant to the clinic for check-up. Which of the following developmental achievements would the nurse assess for? A Smiling and laughing out loud. B Turning the head from side to side. C Holding a rattle briefly. D Rolling from back to side.
B
A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the following signs, if noted in the mother, would be an early sign of excessive blood loss? A A temperature of 100.4ºF B An increase in the pulse from 88 to 102 BPM C An increase in the respiratory rate from 18 to 22 breaths per minute D A blood pressure change from 130/88 to 124/80 mm Hg
B
During the period of induction of labor, a client should be observed carefully for signs of: A Severe pain B Uterine tetany C Hypoglycemia D Umbilical cord prolapse
B
In placenta praevia marginalis, the placenta is found at the: A Internal cervical os partly covering the opening B Lower segment of the uterus with the edges near the internal cervical os C External cervical os slightly covering the opening D Lower portion of the uterus completely covering the cervix
B
The nurse should anticipate that hemorrhage related to uterine atony may occur postpartally if this condition was present during the delivery: A Placental delivery occurred within thirty minutes after the baby was born B The labor and delivery lasted for 12 hours C An episiotomy had to be done to facilitate delivery of the head D Excessive analgesia was given to the mother
D
Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1 1/2 to 2 minutes. The nurse's immediate action would be to: A Change the woman's position B Stop the Pitocin C Elevate the woman's legs D Administer oxygen via a tight mask at 8 to 10 liters/minute
B
Nurse Roy is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first? A Check for placenta previa. B Change the client's position. C Prepare for emergency cesarean section. D Administer oxygen.
B
When examining the fetal monitor strip after rupture of the membranes in a laboring client, the nurse notes variable decelerations in the fetal heart rate. The nurse should: A Stop the oxytocin infusion B Change the client's position C Prepare for immediate delivery D Take the client's blood pressure
B
Which of the following abilities would a nurse expect a 4 month old infant to perform? A Responding to pleasure with smiles. B Sitting up without support. C Turning from either side to the back. D Grasping a rattle when it is offered
B
A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100% effaced, and she is dilated to 3 cm. Her fetus is at +1 station. The nurse is aware that the fetus' head is: A Not yet engaged B Entering the pelvic inlet C Below the ischial spines D Visible at the vaginal opening
C
A client with type 1 diabetes mellitus who's a multigravida visits the clinic at 27 weeks gestation. The nurse should instruct the client that for most pregnant women with type 1 diabetes mellitus: A Contraction stress testing is performed weekly. B Induction of labor is begun at 34 weeks' gestation. C Nonstress testing is performed weekly until 32 weeks' gestation D Weekly fetal movement counts are made by the mother.
C
A new mother received epidural anesthesia during labor and had a forceps delivery after pushing 2 hours. At 6 hours PP, her systolic blood pressure has dropped 20 points, her diastolic BP has dropped 10 points, and her pulse is 120 beats per minute. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider, the nurse immediately plans to: A Monitor fundal height B Apply perineal pressure C Prepare the client for surgery. D Reassure the client
C
A nurse is caring for a PP woman who has received epidural anesthesia and is monitoring the woman for the presence of a vulva hematoma. Which of the following assessment findings would best indicate the presence of a hematoma? A Complaints of a tearing sensation B Complaints of intense pain C Changes in vital signs D Signs of heavy bruisin
C
The nurse teaches a pregnant woman to avoid lying on her back. The nurse has based this statement on the knowledge that the supine position can: A Interfere with free movement of the coccyx B Lead to transient episodes of hypotension C Unduly prolong labor D Cause decreased placental perfusion
D
An expected cardiopulmonary adaptation experienced by most pregnant women is: A Tachycardia B Dyspnea at rest C Shortness of breath on exertion D Progression of dependent edema
C
An infant is observed to be competent in the following developmental skills: stares at an object, place her hands to the mouth and takes it off, coos and gargles when talk to and sustains part of her own weight when held to in a standing position. The nurse correctly assessed infant's age as... A Eight months. B Six months C Four months D Two months
C
By keeping the nursery temperature warm and wrapping the neonate in blankets, the nurse is preventing which type of heat loss? A Radiation B Conduction C Convection D Evaporation
C
The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest but most difficult part of this stage? A Complete phase B Latent phase C Transitional phase D Active phase
C
To ensure adequate lactation the nurse should teach the mother to: A Feed the baby every 3-4 hours following a strict schedule B Breastfeed when the breast are engorged to ensure adequate supply C Breast feed the baby on self-demand day and night D Feed primarily during the day and allow the baby to sleep through the night
C
While assessing a primipara during the immediate postpartum period, the nurse in charge plans to use both hands to assess the client's fundus to: A Determine the size of the fundus B Promote uterine involution C Prevent uterine inversion DHasten the puerperium period
C
A nurse is developing a plan of care for a PP woman with a small vulvar hematoma. The nurse includes which specific intervention in the plan during the first 12 hours following the delivery of this client? A Assess vital signs every 4 hours B Inform health care provider of assessment findings C Measure fundal height every 4 hours D Prepare an ice pack for application to the area.
D
A pregnant client is admitted to the labor room. An assessment is performed, and the nurse notes that the client's hemoglobin and hematocrit levels are low, indicating anemia. The nurse determines that the client is at risk for which of the following? A A loud mouth B Low self-esteem C Hemorrhage D Postpartum infection
D
A primigravida patient is admitted to the labor delivery area. Assessment reveals that she is in early part of the first stage of labor. Her pain is likely to be most intense: A Around the pelvic girdle and in the upper arms B At the perineum C Around the pelvic girdle and at the perineum D Around the pelvic girdle
D
After expulsion of the placenta in a client who has six living children, an infusion of lactated ringer's solution with 10 units of pitocin is ordered. The nurse understands that this is indicated for this client because: A She had a precipitate birth B This was an extramural birth C Retained placental fragments must be expelled D Multigravidas are at increased risk for uterine atony.
D
At 38 weeks gestation, a client is having late decelerations. The fetal pulse oximeter shows 75% to 85%. The nurse should: A Discontinue the catheter, if the reading is not above 80% B Discontinue the catheter, if the reading does not go below 30% C Advance the catheter until the reading is above 90% and continue monitoring D Reposition the catheter, recheck the reading, and if it is 55%, keep monitoring
D
During a prenatal examination, the nurse draws blood from a young Rh negative client and explain that an indirect Coombs test will be performed to predict whether the fetus is at risk for: A Physiologic hyperbilirubinemia B Respiratory distress syndrome C Protein metabolic deficiency D Acute hemolytic disease
D
Five hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to prevent hypothermia. What is a common source of radiant heat loss? A Cold weight scale B Cool room temperature C Low room humidity D Cools incubator walls
D
Following a precipitous delivery, examination of the client's vagina reveals a fourth-degree laceration. Which of the following would be contraindicated when caring for this client? A Instructing the client on the use of sitz baths if ordered B Instructing the client about the importance of perineal (Kegel) exercises C Applying cold to limit edema during the first 12 to 24 hours D Instructing the client to use two or more peripads to cushion the area
D
Gravida refers to which of the following descriptions? A Number of children a female has delivered B A serious pregnancy C Number of term pregnancies a female has had. D Number of times a female has been pregnant
D
Postpartum Period: The fundus of the uterus is expected to go down normally postpartally about __ cm per day. A 3.0 cm B 2.5 cm C 2.0 cm D 1.0 cm
D
The fetal heart rate is checked following rupture of the bag of waters in order to: A Determine if there is utero-placental insufficiency B Check if the fetus is suffering from head compression C Check if fetal presenting part has adequately descended following the rupture D Determine if cord compression followed the rupture
D
The nurse in charge is caring for a postpartum client who had a vaginal delivery with a midline episiotomy. Which nursing diagnosis takes priority for this client? A Pain related to the type of incision B Risk for infection related to the type of delivery C Urinary retention related to periurethral edema D Risk for deficient fluid volume related to hemorrhage
D
