RN Maternal Newborn Online Practice 2019 B with NGN

A nurse is calculating a client's expected date of birth using Nägele's rule. The client tells the nurse that her last menstrual cycle started on November 27th. Which of the following dates is the client's expected date of birth?

ANSWER: September 3rd RATIONALE: When using Nägele's rule to calculate the estimated date of birth for a client, the nurse should subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. November 27th minus 3 months equals August 27th. August 27th plus 7 days equals September 3rd.

A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's secretions. Which of the following instructions should the nurse include?

ANSWER: Stop suctioning when the newborn's cry sounds clear. RATIONALE: The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds like it is coming through a bubble of fluid or mucus.

A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?

ANSWER: Swelling of the face RATIONALE: Swelling of the face, sacral area, and fingers can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema.

A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?

ANSWER: Temperature RATIONALE: The greatest risk for a client following amniotomy is infection. Therefore, the nurse should identify that the priority assessment is the client's temperature.

A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?

ANSWER: Verify the newborn's identification. RATIONALE: When using the safety/risk reduction approach to client care, the first action the nurse should take is to verify the newborn's identity upon arrival to the nursery.

A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?

ANSWER: Oligohydramnios RATIONALE: The nurse should identify that oligohydramnios requires further fetal assessment using electronic fetal monitoring. Other conditions that require further assessment include hypertension, diabetes, intrauterine growth restriction, renal disease, decreased fetal movement, previous fetal death, post-term pregnancy, systemic lupus erythematosus, and intrahepatic cholestasis.

A nurse is providing discharge teaching to the parents of a newborn about car seat safety. Which of the following instructions should the nurse include?

ANSWER: Place the retainer clip at the level of the newborn's armpits. RATIONALE: The nurse should instruct the parents to place the newborn in a federally approved car seat with the retainer clip snugly at the level of the newborn's armpits.

A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?

ANSWER: Platelets 50,000/mm3 RATIONALE: A platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. The nurse should report this result to the provider.

A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones (FHT)?

CORRECT: Just above the symphysis pubis RATIONALE: At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHT just above the symphysis pubis.

A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has determined the fetal position as left occipital anterior. To which of the following areas of the client's abdomen should the nurse apply the ultrasound transducer to assess the point of maximum intensity of the fetal heart?

CORRECT: Left lower quadrant RATIONALE: The fetal heart tones of a fetus in the left occipital anterior position are best heard in the left lower quadrant.

A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take?

CORRECT: Massage the client's fundus. RATIONALE: The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is to massage the client's fundus to expel clots and promote contractions.

A nurse at a provider's office is caring for a client who is 28 years of age. The nurse is preparing the client for surgery. Which of the following actions should the nurse take? Select all that apply.

ANSWER: Inform the client to be NPO prior to surgery is correct. Administer Rho D immune globulin prior to surgery is incorrect. Prepare to administer AB positive blood products if needed is incorrect. Insert an 18-gauge peripheral IV prior to surgery is correct. Explain the surgical procedure to the client is incorrect. Obtain a complete blood count is correct. Verify a consent form is signed by the client is correct RATIONALE: Inform the client to be NPO prior to surgery is correct. The nurse should inform the client to be NPO prior to surgery. This will prevent aspiration during surgery. Administer Rho D immune globulin prior to surgery is incorrect. The nurse should administer Rho D immune globulin after surgery. The client is Rh negative and could develop antibody formation if exposed to Rh positive blood. Prepare to administer AB positive blood products if needed is incorrect. The nurse should only administer O or B negative blood products if the client requires a blood transfusion. Any other blood types are incompatible and can cause a reaction. Insert an 18-gauge peripheral IV prior to surgery is correct. The nurse should provide IV access prior to surgery by inserting a larger bore IV such as an 18- or 20-gauge. An IV is used to administer IV fluids or blood products during surgery. Explain the surgical procedure to the client is incorrect. The provider is responsible for explaining the procedure to the client. The nurse is responsible for ensuring that the client is fully informed about the surgery. Obtain a complete blood count is correct. The nurse should obtain a complete blood count to establish baseline data prior to surgery. Verify a consent form is signed by the client is correct. The nurse should verify that the client has signed a consent form for surgery. This is mandatory prior to any surgical pro

A nurse at a provider's office is caring for a client who is 28 years of age. The nurse is collaborating with another nurse about the client's plan of care. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

ANSWER: Transvaginal ultrasound is indicated Meperidine IM is contraindicated. Repeat quantitative β-hCG level is anticipated. Methotrexate IM is anticipated Blood typing is anticipated RATIONALE: Transvaginal ultrasound is indicated. The nurse should anticipate a prescription for a transvaginal ultrasound. A transvaginal ultrasound is useful in determining the location of the ectopic pregnancy. Meperidine IM is contraindicated. Clients who receive methotrexate for an ectopic pregnancy should not take analgesics stronger than acetaminophen, because these medications can mask the manifestations of tubal rupture. Repeat quantitative β-hCG level is anticipated. The quantitative β-hCG level should be repeated within 48 hr to see if the level has changed from last recording. If increased levels are identified with no intrauterine pregnancy on ultrasound, this is indicative of ectopic pregnancy. Methotrexate IM is anticipated. The nurse should anticipate a prescription for methotrexate IM administration to prevent further embryonic cell reproduction. Blood typing is anticipated. The nurse should also anticipate potential surgical intervention for the client; therefore, blood typing is indicated. EXHIBIT 1: History and Physical Day 1 at 1000: Gravida 3, Para 2, Abortion 1 Asthma (managed with levalbuterol inhaler as needed) Pelvic inflammatory disease (PID) Spontaneous vaginal delivery X 2 (hypertension with first pregnancy at 20 years of age) Voluntary termination of pregnancy (3rd pregnancy) EXHIBIT 2: Nurses' Notes Day 1 at 1000: Client presents to the office with concerns of late menses, abdominal pain, and scant dark red vaginal spotting. Client reports menstrual period is usually regular and is 2 weeks late. Last menstrual period: 2/20/XX. Client reports occasional dull abdominal pain and rates it as 2 on a 0 to

A nurse at a provider's office is caring for a client who is 28 years of age. Complete the following sentence by using the list of options. The nurse should first address the client's ... followed by the client's ..... .

ANSWER: Dropdown 1 Heart rate is correct. Dropdown 2 Vaginal spotting is correct. RATIONALE: Dropdown 1 Heart rate is correct. The nurse should first address the client's heart rate, which is above the expected reference range, to establish a baseline for continued monitoring. Lung sounds and bowel sounds are incorrect. The nurse should address these unexpected findings because they require further assessment by the nurse; however, there is another finding the nurse should address first. Dropdown 2 Vaginal spotting is correct. The nurse should next address the amount and characteristics of the client's vaginal spotting to establish a baseline for continued monitoring. Hemoglobin level and anxiety are incorrect. The nurse should address these unexpected findings because they require further assessment by the nurse; however, there is another finding the nurse should address first. EXHIBIT 1: History and Physical Day 1 at 1000: Gravida 3, Para 2, Abortion 1 Asthma (managed with levalbuterol inhaler as needed) Pelvic inflammatory disease (PID) Spontaneous vaginal delivery X 2 (hypertension with first pregnancy at 20 years of age) Voluntary termination of pregnancy (3rd pregnancy) EXHIBIT 2: Nurses' Notes Day 1 at 1000: Client presents to the office with concerns of late menses, abdominal pain, and scant dark red vaginal spotting. Client reports menstrual period is usually regular and is 2 weeks late. Last menstrual period: 2/20/XX. Client reports occasional dull abdominal pain and rates it as 2 on a 0 to 10 pain scale. Client is alert and oriented, appears anxious. Speech clear. Skin warm and dry to touch. Heart rate regular at 90/min. Respirations even and non-labored. Lungs slight inspiratory wheezes. Bowel sounds hyperactive in all four quadrants. Abdomen tender to touch right lower quadrant. Perineal pad with sca

A nurse is teaching a client who is at 24 weeks of gestation regarding a 1-hr glucose tolerance test. Which of the following statements should the nurse include in the teaching?

ANSWER: "A blood glucose of 130 to 140 is considered a positive screening result." RATIONALE: The nurse should instruct the client that a blood glucose level of 130 to 140 mg/dL is considered a positive screening. If the client receives a positive result, she will need to undergo a 3-hr glucose tolerance test to confirm if she has gestational diabetes mellitus.

A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

ANSWER: "I will continue taking my insulin if I experience nausea and vomiting." RATIONALE: The nurse should teach the client to continue to take her insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes.

A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching?

ANSWER: "I will have blood tests because my potassium might decrease." RATIONALE: An adverse effect of terbutaline is hypokalemia.

A nurse is teaching a new parent about newborn safety. Which of the following instructions should the nurse include in the teaching?

ANSWER: "You can share your room with your baby for the next few weeks." RATIONALE: The nurse should recommend room-sharing during the first few weeks. This allows the parent to be readily available to the newborn and learn the newborn's cues. However, the nurse should instruct the parent to avoid placing the newborn in their bed as it increases the risk for sudden infant death syndrome.

A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?

ANSWER: "You should take the medication within 72 hours following unprotected sexual intercourse." RATIONALE: Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception. The nurse should instruct the adolescent to take this medication as soon as possible within 72 hr after unprotected sexual intercourse.

A nurse is preparing to administer azithromycin to a client who is at 16 weeks of gestation and has a positive chlamydia culture. The prescription states "Administer azithromycin 1 g orally now." Available is 250 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

ANSWER: 4 TABLETS RATIONALE: 250MG = .25G 1G/.25G = 4

A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect?

CORRECT: Jitteriness RATIONALE: Jitteriness, tachypnea, retractions, nasal flaring, lethargy, temperature instability, apnea, abnormal cry, poor feeding, and seizures are expected findings of hypoglycemia. Newborns who are small or large for gestational age and late preterm newborns are at an increased risk for hypoglycemia.

A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take next?

ANSWER: Apply internal upward pressure to the presenting part using two gloved fingers. RATIONALE: Using evidence-based practice, the first action the nurse should take is to apply internal upward pressure to the presenting part. Prolapse of the umbilical cord during labor can result in decreased perfusion to the fetus, which can lead to hypoxia. After calling for assistance, the nurse should relieve the compression on the umbilical cord by applying upward internal pressure on the presenting part with two gloved fingers. The nurse should not move their hand.

A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take?

ANSWER: Apply sacral counterpressure. RATIONALE: The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position.

A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates her uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?

ANSWER: Assist the client to empty her bladder. RATIONALE: The nurse should assist the client to empty her bladder because the assessment findings indicate that the client's bladder is distended. This can prevent the uterus from contracting, resulting in increased vaginal bleeding or postpartum hemorrhage.

A nurse is reviewing laboratory results of a newborn who is 4 hr old. Which of the following findings should the nurse report to the provider?

ANSWER: Bilirubin 9 mg/dL RATIONALE: A bilirubin level of 9 mg/dL is above the expected reference range for a newborn who is 4 hr old. The expected reference range for a newborn who is less than 24 hr old is 2 to 6 mg/dL. The nurse should report this finding to the provider.

A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?

ANSWER: Biophysical profile (BPP) RATIONALE: The nurse should prepare the client for a BPP to further assess fetal well-being. A positive contraction stress test indicates there is potential uteroplacental insufficiency. A BPP uses a real time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli.

A nurse is reviewing the laboratory report of a newborn who is 24 hr old. Which of the following results should the nurse report to the provider?

ANSWER: Blood glucose 30 mg/dL RATIONALE: Newborns less than 24 hr old should have a blood glucose of 40 to 45 mg/dL. A blood glucose level of 30 mg/dL is below the expected reference range for a newborn who is 24 hr old and should be reported to the provider.

A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?

ANSWER: Chin quivering RATIONALE: Behavioral responses to a newborn's pain include facial expressions such as chin quivering, grimacing, and furrowing of the brow.

A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take?

ANSWER: Cover the newborn's eyes while under the phototherapy light. RATIONALE: Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherapy light.

A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment?

ANSWER: Demonstrate to the client how to perform a newborn bath. RATIONALE: Demonstrating to the client how to perform a newborn bath occurs during the taking-hold phase. The new parent moves from being passively dependent to taking a stronger interest in her new role as a mother. She is now focusing on the care her newborn and acquiring parenting skills. The nurse should provide positive reinforcement during this phase to give the new parent confidence and promote maternal adjustment.

A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take?

ANSWER: Explain to the client this is an expected occurrence. RATIONALE: Chloasma, also referred to as the mask of pregnancy, is a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forehead. It is seen most often in dark-skinned women and is caused by an increase in melanotropin during pregnancy. This condition appears after 16 weeks of gestation and increases gradually until delivery for 50 to 70% of women. Therefore, the nurse should reassure the client that this is an expected occurrence which usually fades after delivery.

A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?

ANSWER: Instruct the client to press the provided button each time fetal movement is detected. RATIONALE: Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to press the button when she detects fetal movement will ensure that the fetal movement is noted.

A nurse in a women's health clinic is providing teaching about nutritional intake to a client who is at 8 weeks of gestation. The nurse should instruct the client to increase her daily intake of which of the following nutrients?

ANSWER: Iron RATIONALE: The recommendation for iron intake during pregnancy is higher than that for women who are not pregnant. For women who are pregnant, it is 27 mg/day. For women who are not pregnant, it is 15 mg/day for women younger than 19 years old and 18 mg/day for women between the ages of 19 and 50 years old.

A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?

ANSWER: Leakage of fluid from the vagina RATIONALE: Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the provider.

A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?

CORRECT: Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution. RATIONALE: The nurse should plan to obtain a baseline blood pressure prior to the initiation of anesthetic solution. The nurse should then continue to monitor the client's blood pressure every 5 to 10 min to assess for maternal hypotension caused by the anesthetic solution.

A nurse is teaching a postpartum client about the steps the nurse will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make?

CORRECT: "Staff members who take care of your baby will be wearing a photo identification badge." RATIONALE: The nurse should instruct the client that all staff members that care for newborns are required to wear a photo identification badge so that the client will be reassured of the newborn's safety. Some units' staff members wear special badges or a specific color scrubs.

A nurse is caring for a client who is experiencing preterm labor at 29 weeks of gestation and has a prescription for betamethasone. Which of the following statements should the nurse make about the indication for medication administration?

CORRECT: "This medication stimulates fetal lung maturity." RATIONALE: The nurse should inform the client that betamethasone is a glucocorticoid that enhances fetal lung maturity by promoting the release of enzymes that release lung surfactant.

A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make?

CORRECT: "You can miss your period for several other reasons. Describe your typical menstrual cycle." RATIONALE: Amenorrhea is a presumptive sign of pregnancy, not a positive sign. Therefore, the nurse should explore the client's menstrual cycle to determine other necessary interventions.

A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse include in the teaching?

CORRECT: "You should leave the diaphragm in place for at least 6 hours after intercourse." RATIONALE: The client should keep the diaphragm in place for at least 6 hr after intercourse to provide protection against pregnancy.

A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?

CORRECT: Active RATIONALE: The nurse should identify that the client is in the active phase of labor. This phase is characterized by a cervical dilatation of 6 to 10 cm and contractions every 1.5 to 5 min, each lasting 40 to 90 seconds.

A nurse is planning discharge for a client who is 3 days postpartum. Which of the following nonpharmacological interventions should the nurse include in the plan of care for lactation suppression?

CORRECT: Apply cabbage leaves to the breasts. RATIONALE: Plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort caused by breast engorgement.

A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?

CORRECT: Decreased platelet count RATIONALE: A client who has ITP has an autoimmune response that results in a decreased platelet count.

A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?

CORRECT: Determine respiratory function. RATIONALE: The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to determine respiratory function and the need for cardiopulmonary resuscitation.

A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, "happy one minute and crying the next." The nurse should interpret the client's statement as an indication of which of the following?

CORRECT: Emotional lability RATIONALE: The nurse should recognize and interpret the client's statement as an indication of emotional lability. Many clients experience rapid and unpredictable changes in mood during pregnancy. Intense hormonal changes may be responsible for mood changes that occur during pregnancy. Tears and anger alternate with feelings of joy or cheerfulness for little or no reason.

A nurse is teaching a client who is Rh negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?

CORRECT: I will need this medication if I have an amniocentesis." RATIONALE: Rho(D) immune globulin is given to clients who are Rh negative following an amniocentesis because of the potential of fetal RBCs entering the maternal circulation.

A nurse is teaching a client who has a new prescription for combined oral contraceptives about potential adverse effects of the medication. For which of the following findings should the nurse instruct the client to notify the provider?

CORRECT: Shortness of breath RATIONALE: The nurse should instruct the client to notify the provider immediately of any shortness of breath. Shortness of breath and chest pain can indicate a pulmonary embolus or myocardial infarction. Also, the nurse should instruct the client to notify the provider of other adverse effects that can indicate potential complications, including abdominal pain, sudden or persistent headaches, blurred vision, and severe leg pain.

A nurse is assessing a newborn who is 12hr old. Which of the following manifestations requires intervention by the nurse?

CORRECT: Substernal chest retractions while sleeping RATIONALE: Substernal chest retractions can indicate respiratory distress syndrome in the newborn. This manifestation requires further assessment and intervention by the nurse.

A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?

CORRECT: Vomiting RATIONALE: Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days.

A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's history should the nurse recognize as a contraindication to oral contraceptives? (Select all that apply.)

Cholecystitis is correct. A history of gallbladder disease is a contraindication for the use of oral contraceptives. Hypertension is correct. Hypertension is a contraindication for the use of oral contraceptives. Human papillomavirus is incorrect. The presence of human papillomavirus is not a contraindication for the use of oral contraceptives. Migraine headaches is correct. A history of migraine headaches is a contraindication for the use of oral contraceptives. Anxiety disorder is incorrect. The presence of an anxiety disorder is not a contraindication for the use of oral contraceptives.

A nurse at a provider's office is caring for a client who is 28 years of age. Select the 3 findings that require immediate follow-up.

EXHIBIT 1: History and Physical Day 1 at 1000: Gravida 3, Para 2, Abortion 1 Asthma (managed with levalbuterol inhaler as needed) Pelvic inflammatory disease (PID) Spontaneous vaginal delivery X 2 (hypertension with first pregnancy at 20 years of age) Voluntary termination of pregnancy (3rd pregnancy) EXHIBIT 2: Nurses' Notes Day 1 at 1000: Client presents to the office with concerns of late menses, abdominal pain, and scant dark red vaginal spotting. Client reports menstrual period is usually regular and is 2 weeks late. Last menstrual period: 2/20/XX. Client reports occasional dull abdominal pain and rates it as 2 on a 0 to 10 pain scale. Client is alert and oriented, appears anxious. Speech clear. Skin warm and dry to touch. Heart rate regular at 90/min. Respirations even and non-labored. Lungs slight inspiratory wheezes. Bowel sounds hyperactive in all four quadrants. Abdomen tender to touch right lower quadrant. Perineal pad with scant amount of dark red vaginal spotting. EXHIBIT 3: Vital Signs Day 1 at 1000: Temperature 37.2° C (98.9° F) Heart rate 90/min Respirations 16/min Blood pressure 120/74 mm Hg Oxygen saturation 97% room air ANSWER: Abdomen assessment is CORRECT. Vaginal spotting is CORRECT Menstrual period is CORRECT RATIONALE: Heart rate is incorrect. The client's heart rate is regular and within the expected reference range; therefore, this finding does not require immediate follow up. Abdomen assessment is CORRECT. The client reports dull abdominal pain and rates it as 2 on 0 to 10 pain scale. The nurse noted right lower quadrant abdominal tenderness during their assessment, which is an unexpected finding that requires immediate follow up. Respiratory assessment is incorrect. The client has a history of asthma, which causes wheezing. The client's respirations are regular, non-labored, and their

A nurse at a provider's office is caring for a client who is 28 years of age. Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

EXHIBIT 1: History and Physical Day 1 at 1000: Gravida 3, Para 2, Abortion 1 Asthma (managed with levalbuterol inhaler as needed) Pelvic inflammatory disease (PID) Spontaneous vaginal delivery X 2 (hypertension with first pregnancy at 20 years of age) Voluntary termination of pregnancy (3rd pregnancy) EXHIBIT 2: Nurses' Notes Day 1 at 1000: Client presents to the office with concerns of late menses, abdominal pain, and scant dark red vaginal spotting. Client reports menstrual period is usually regular and is 2 weeks late. Last menstrual period: 2/20/XX. Client reports occasional dull abdominal pain and rates it as 2 on a 0 to 10 pain scale. Client is alert and oriented, appears anxious. Speech clear. Skin warm and dry to touch. Heart rate regular at 90/min. Respirations even and non-labored. Lungs slight inspiratory wheezes. Bowel sounds hyperactive in all four quadrants. Abdomen tender to touch right lower quadrant. Perineal pad with scant amount of dark red vaginal spotting. EXHIBIT 3: Vital Signs Day 1 at 1000: Temperature 37.2° C (98.9° F) Heart rate 90/min Respirations 16/min Blood pressure 120/74 mm Hg Oxygen saturation 97% room air EXHIBIT 4: Diagnostic Results Day 1 at 1015: Urine human chorionic gonadotropin (HCG) positive (negative) QUESTION: After reviewing the client's current assessment findings, the nurse should identify that the client is experiencing "Condition" as evidenced by "Findings". ANSWER: Dropdown 1 Ectopic pregnancy is correct. Dropdown 2 Right lower quadrant abdominal tenderness is correct. RATIONALE: Dropdown 1 Ectopic pregnancy is correct. The client reports late menses, abdominal pain, and scant dark red vaginal spotting. The assessment findings reveal right lower quadrant abdominal tenderness and scant dark red vaginal spotting on perineal pad, which are associated with ectopic

The nurse is reviewing the postpartum client's medical record. The nurse is reviewing the client's electronic medical record. Which of the following actions should the nurse take? Select the 5 actions that the nurse should perform.

EXHIBIT 1: History and Physical Delivered at 38 weeks of gestation via cesarean delivery 48 hr ago 42 years old Gravida 2, Para 1 History of hypertension History of asthma No antihypertensive medications during pregnancy. Treatment plan included diet and exercise. EXIBIT 2: Nurses' Notes 1730: Client is awake and alert. Fundus is firm, midline, and 2 cm below the umbilicus. Incision is intact, light amount of lochia rubra observed.+2 pitting edema observed to bilateral lower extremities. Reports headache pain as 3 on a scale of 0 to 10. Reports headache and heartburn began about 1 hr ago. EXHIBIT 3: Vital Signs 1730: Blood pressure 152/105 mm Hg Temperature 37.8° C (100° F) Pulse 70/min Respiratory rate 20/min Oxygen saturation 98% EXHIBIT 4: Diagnostic Results Admission laboratory values (48 hr ago): Hgb 11 g/dL (greater than 11 g/dL) Platelets 150,000/mm³ (150,000 to 400,000/mm³) BUN 19 mg/dL (10 to 20 mg/dL) Creatinine 1 mg/dL (0.5 to 1 mg/dL) Aspartate aminotransferase (AST) 33 units/L (0 to 35 units/L) Alanine aminotransferase (ALT) 32 units/L (4 to 36 units/L) Urinalysis: Color: pink-tinged pH 6.2 mg/dL (4.6 to 8 mg/dL) Specific gravity 1.022 (1.010 to 1.025) Leukocyte esterase Negative (Negative) Nitrite negative (Negative) Protein 0 mg/dL (0 to 8 mg/dL) Glucose negative (Negative) Ketones none (None) Bilirubin none (None) Red blood cells: >20 (≤2) ANSWER: Place on seizure precautions is CORRECT. The nurse should place the client on seizure precautions because the client has preeclampsia and is receiving magnesium sulfate. Administer magnesium sulfate IV bolus as prescribed is CORRECT. The nurse should administer magnesium sulfate IV bolus as prescribed because this medication helps to prevent the client from progressing to eclampsia. Monitor the client's blood pressure every hour is INCORRECT. The

The nurse is reviewing the postpartum client's medical record. The nurse is planning care for the postpartum client. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

EXHIBIT 1: History and Physical Delivered at 38 weeks of gestation via cesarean delivery 48 hr ago 42 years old Gravida 2, Para 1 History of hypertension History of asthma No antihypertensive medications during pregnancy. Treatment plan included diet and exercise. EXIBIT 2: Nurses' Notes 1730: Client is awake and alert. Fundus is firm, midline, and 2 cm below the umbilicus. Incision is intact, light amount of lochia rubra observed.+2 pitting edema observed to bilateral lower extremities. Reports headache pain as 3 on a scale of 0 to 10. Reports headache and heartburn began about 1 hr ago. EXHIBIT 3: Vital Signs 1730: Blood pressure 152/105 mm Hg Temperature 37.8° C (100° F) Pulse 70/min Respiratory rate 20/min Oxygen saturation 98% EXHIBIT 4: Diagnostic Results Admission laboratory values (48 hr ago): Hgb 11 g/dL (greater than 11 g/dL) Platelets 150,000/mm³ (150,000 to 400,000/mm³) BUN 19 mg/dL (10 to 20 mg/dL) Creatinine 1 mg/dL (0.5 to 1 mg/dL) Aspartate aminotransferase (AST) 33 units/L (0 to 35 units/L) Alanine aminotransferase (ALT) 32 units/L (4 to 36 units/L) Urinalysis: Color: pink-tinged pH 6.2 mg/dL (4.6 to 8 mg/dL) Specific gravity 1.022 (1.010 to 1.025) Leukocyte esterase Negative (Negative) Nitrite negative (Negative) Protein 0 mg/dL (0 to 8 mg/dL) Glucose negative (Negative) Ketones none (None) Bilirubin none (None) Red blood cells: >20 (≤2) ANSWER: Urinalysis is ANTICIPATED. The nurse should anticipate a prescription for a urinalysis. A urinalysis will reveal the presence of increased levels of protein in the urine, which might be indicative of preeclampsia. Monitor intake and output is ANTICIPATED. The nurse should anticipate a prescription for monitoring the client's intake and output. Although the client is in the postpartum period, some clients do not develop manifestations of preeclamps

A nurse is caring for a postpartum client. A nurse is performing an assessment on the client. Which of the following findings should the nurse report to the provider? Select all that apply.

EXHIBIT 1: History and Physical Delivered at 38 weeks of gestation via cesarean delivery 48 hr ago 42 years old Gravida 2, Para 1 History of hypertension History of asthma No antihypertensive medications during pregnancy. Treatment plan included diet and exercise. EXIBIT 2: Nurses' Notes 1730: Client is awake and alert. Fundus is firm, midline, and 2 cm below the umbilicus. Incision is intact, light amount of lochia rubra observed.+2 pitting edema observed to bilateral lower extremities. Reports headache pain as 3 on a scale of 0 to 10. Reports headache and heartburn began about 1 hr ago. EXHIBIT 3: Vital Signs 1730: Blood pressure 152/105 mm Hg Temperature 37.8° C (100° F) Pulse 70/min Respiratory rate 20/min Oxygen saturation 98% EXHIBIT 4: Diagnostic Results Admission laboratory values (48 hr ago): Hgb 11 g/dL (greater than 11 g/dL) Platelets 150,000/mm³ (150,000 to 400,000/mm³) BUN 19 mg/dL (10 to 20 mg/dL) Creatinine 1 mg/dL (0.5 to 1 mg/dL) Aspartate aminotransferase (AST) 33 units/L (0 to 35 units/L) Alanine aminotransferase (ALT) 32 units/L (4 to 36 units/L) Urinalysis: Color: pink-tinged pH 6.2 mg/dL (4.6 to 8 mg/dL) Specific gravity 1.022 (1.010 to 1.025) Leukocyte esterase Negative (Negative) Nitrite negative (Negative) Protein 0 mg/dL (0 to 8 mg/dL) Glucose negative (Negative) Ketones none (None) Bilirubin none (None) Red blood cells: >20 (≤2) ANSWER: Fundus 2 cm below the umbilicus is incorrect. The client's fundus is 2 cm below the umbilicus, which is within the expected reference range. The fundus descends at approximately 1 cm each day until it is no longer palpable; therefore, the nurse should not report this finding to the provider. Blood pressure 152/110 mm Hg is CORRECT. The client's blood pressure is above the expected reference range. An elevated blood pressure can be an indication o

A nurse is caring for a postpartum client. Based on the nurse's assessment findings, which of the following conditions is the client at greatest risk for developing? Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

EXHIBIT 1: History and Physical Delivered at 38 weeks of gestation via cesarean delivery 48 hr ago 42 years old Gravida 2, Para 1 History of hypertension History of asthma No antihypertensive medications during pregnancy. Treatment plan included diet and exercise. EXIBIT 2: Nurses' Notes 1730: Client is awake and alert. Fundus is firm, midline, and 2 cm below the umbilicus. Incision is intact, light amount of lochia rubra observed.+2 pitting edema observed to bilateral lower extremities. Reports headache pain as 3 on a scale of 0 to 10. Reports headache and heartburn began about 1 hr ago. EXHIBIT 3: Vital Signs 1730: Blood pressure 152/105 mm Hg Temperature 37.8° C (100° F) Pulse 70/min Respiratory rate 20/min Oxygen saturation 98% EXHIBIT 4: Diagnostic Results Admission laboratory values (48 hr ago): Hgb 11 g/dL (greater than 11 g/dL) Platelets 150,000/mm³ (150,000 to 400,000/mm³) BUN 19 mg/dL (10 to 20 mg/dL) Creatinine 1 mg/dL (0.5 to 1 mg/dL) Aspartate aminotransferase (AST) 33 units/L (0 to 35 units/L) Alanine aminotransferase (ALT) 32 units/L (4 to 36 units/L) Urinalysis: Color: pink-tinged pH 6.2 mg/dL (4.6 to 8 mg/dL) Specific gravity 1.022 (1.010 to 1.025) Leukocyte esterase Negative (Negative) Nitrite negative (Negative) Protein 0 mg/dL (0 to 8 mg/dL) Glucose negative (Negative) Ketones none (None) Bilirubin none (None) Red blood cells: >20 (≤2) ANSWER: The client is at greatest risk for developing "Preeclampsia " as evidenced by "Increased blood pressure" RATIONALE: BOX 1: Preeclampsia is CORRECT. The client has an increased blood pressure of 152/105 mm Hg, which is above the expected reference range. Some clients do not develop manifestations of preeclampsia until they are in the postpartum period. The client is also experiencing a headache and epigastric pain, along with an elevated blood

A nurse is caring for a postpartum client. Complete the following sentence by using the list of options.

EXHIBIT 1: History and Physical Delivered at 38 weeks of gestation via cesarean delivery 48 hr ago 42 years old Gravida 2, Para 1 History of hypertension History of asthma No antihypertensive medications during pregnancy. Treatment plan included diet and exercise. EXIBIT 2: Nurses' Notes 1730: Client is awake and alert. Fundus is firm, midline, and 2 cm below the umbilicus. Incision is intact, light amount of lochia rubra observed.+2 pitting edema observed to bilateral lower extremities. Reports headache pain as 3 on a scale of 0 to 10. Reports headache and heartburn began about 1 hr ago. EXHIBIT 3: Vital Signs 1730: Blood pressure 152/105 mm Hg Temperature 37.8° C (100° F) Pulse 70/min Respiratory rate 20/min Oxygen saturation 98% EXHIBIT 4: Diagnostic Results Admission laboratory values (48 hr ago): Hgb 11 g/dL (greater than 11 g/dL) Platelets 150,000/mm³ (150,000 to 400,000/mm³) BUN 19 mg/dL (10 to 20 mg/dL) Creatinine 1 mg/dL (0.5 to 1 mg/dL) Aspartate aminotransferase (AST) 33 units/L (0 to 35 units/L) Alanine aminotransferase (ALT) 32 units/L (4 to 36 units/L) Urinalysis: Color: pink-tinged pH 6.2 mg/dL (4.6 to 8 mg/dL) Specific gravity 1.022 (1.010 to 1.025) Leukocyte esterase Negative (Negative) Nitrite negative (Negative) Protein 0 mg/dL (0 to 8 mg/dL) Glucose negative (Negative) Ketones none (None) Bilirubin none (None) Red blood cells: >20 (≤2) ANSWER: The priority intervention the nurse should perform is "Assess the client's deep tendon reflexes (DTRs)" followed by "Assess the client for visual disturbances" RATIONALE: Dropdown 1 Assess the client's deep tendon reflexes (DTRs) is correct. The priority intervention for the nurse is to assess the client's DTRs to check the reflex irritability. According to evidence-based practice, increased DTR reflex irritability places the client at a greater

The nurse is reviewing the client's medical record. The nurse has reviewed the recent Nurse's Notes and the Diagnostic Results. Click to highlight the findings that indicate the client's condition is not improving. To deselect a finding, click on the finding again.

EXHIBIT 1: History and Physical Delivered at 38 weeks of gestation via cesarean delivery 48 hr ago 42 years old Gravida 2, Para 1 History of hypertension History of asthma No antihypertensive medications during pregnancy. Treatment plan included diet and exercise. EXIBIT 2: Nurses' Notes 1730: Client is awake and alert. Fundus is firm, midline, and 2 cm below the umbilicus. Incision is intact, light amount of lochia rubra observed.+2 pitting edema observed to bilateral lower extremities. Reports headache pain as 3 on a scale of 0 to 10. Reports headache and heartburn began about 1 hr ago. EXHIBIT 3: Vital Signs 1730: Blood pressure 152/105 mm Hg Temperature 37.8° C (100° F) Pulse 70/min Respiratory rate 20/min Oxygen saturation 98% EXHIBIT 4: Diagnostic Results Admission laboratory values (48 hr ago): Hgb 11 g/dL (greater than 11 g/dL) Platelets 150,000/mm³ (150,000 to 400,000/mm³) BUN 19 mg/dL (10 to 20 mg/dL) Creatinine 1 mg/dL (0.5 to 1 mg/dL) Aspartate aminotransferase (AST) 33 units/L (0 to 35 units/L) Alanine aminotransferase (ALT) 32 units/L (4 to 36 units/L) Urinalysis: Color: pink-tinged pH 6.2 mg/dL (4.6 to 8 mg/dL) Specific gravity 1.022 (1.010 to 1.025) Leukocyte esterase Negative (Negative) Nitrite negative (Negative) Protein 0 mg/dL (0 to 8 mg/dL) Glucose negative (Negative) Ketones none (None) Bilirubin none (None) Red blood cells: >20 (≤2) Nurse's Notes 1810: "Clonus positive. DTRs 4+" Resting, lights dim, environment quiet. Lochia small, fundus 1 cm below umbilicus, midline. 1840: Resting, "reports headache as 4 on a 0 to 10 pain scale." Edema +2 pitting to bilateral lower extremities. Diagnostic Results 1800: "Hgb 11 g/dL (>11 g/dL)" "Platelets 95,000/mm³ (150,000 to 400,000/mm³)" BUN: 20 mg/dL (10 to20 mg/dL) "Creatinine 0.9 mg/dL (0.5 to 1 mg/dL)" "Aspartate aminotransferase (AST) 60

A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)

Flaccid uterus is CORRECT. Oxytocin increases the contractility of the uterus. Cervical laceration is incorrect. Bleeding resulting from a cervical laceration continues even when the uterus is contracted and firm. It will require repair by the provider. Excess vaginal bleeding is CORRECT. Oxytocin enhances uterine contractility, decreasing vaginal bleeding. Increased afterbirth cramping is incorrect. The use of oxytocin will increase, rather than decrease, afterbirth cramping. Increased maternal temperature is incorrect. The use of oxytocin will have no effect on maternal temperature.

A nurse at a provider's office is caring for a client who is 28 years of age. A nurse is evaluating the client following surgery. Which of the following findings indicate that the client is experiencing a potential complication of surgery that requires immediate follow-up? Click to highlight the findings below.

Neurological findings of drowsiness and easy arousal are expected postoperatively; therefore, no follow up is required by the nurse. The client's temperature is below the expected reference range, which can be an indication of hypothermia. The client's oxygen saturation is below the expected reference range which can be an indication of decreasing oxygen levels associated with anesthesia. The client's blood pressure is below the expected reference range which can be a result of anesthesia or the client's low temperature. The client's temperature, oxygen saturation, and blood pressure all require immediate follow-up by the nurse. An integumentary finding of moist, cool skin is unexpected and requires follow up by the nurse. This finding might indicate hypothermia. A cardiopulmonary finding of +1 pedal pulses bilaterally requires follow up by the nurse. This indicates decreased circulation and perfusion. EXHIBIT 1: History and Physical Day 1 at 1000: Gravida 3, Para 2, Abortion 1 Asthma (managed with levalbuterol inhaler as needed) Pelvic inflammatory disease (PID) Spontaneous vaginal delivery X 2 (hypertension with first pregnancy at 20 years of age) Voluntary termination of pregnancy (3rd pregnancy) EXHIBIT 2: Nurses' Notes Day 1 at 1000: Client presents to the office with concerns of late menses, abdominal pain, and scant dark red vaginal spotting. Client reports menstrual period is usually regular and is 2 weeks late. Last menstrual period: 2/20/XX. Client reports occasional dull abdominal pain and rates it as 2 on a 0 to 10 pain scale. Client is alert and oriented, appears anxious. Speech clear. Skin warm and dry to touch. Heart rate regular at 90/min. Respirations even and non-labored. Lungs slight inspiratory wheezes. Bowel sounds hyperactive in all four quadrants. Abdomen tender to touch right lower quadrant.

A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

The first step the nurse should take when performing Leopold maneuvers is to palpate the client's fundus to identify the fetal part. Second, the nurse should determine the location of the fetal back. Third, the nurse should palpate for the fetal part presenting at the inlet. Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head.