Exam 2: practice questions
A nurse is teaching a client about terbutaline. Which of the following statements by the client indicates understanding of the teaching? A. this medication will stop my contractions B. this medication will prevent vaginal bleeding C. this medication will promote blood flow to my baby D. this medication will increase my prostaglandin production
A terbutaline blocks beta adrenergic receptors, which causes uterine smooth muscle relaxation
A nurse is caring for a client who is in active labor. The cervix is dilated to 5cm, and the membranes are intact. Based on the use of external electronic fetal monitoring, the nurse notes an FHR of 115 to 125/min with occasional increases up to 150 to 155/min that last for 25 seconds and have moderate variability. There is no slowing of the FHR from the baseline. This client is exhibiting manifestations of which of the following (SATA): A. Moderate variability B. FHR accelerations C. FHR decelerations D. Normal baseline FHR E. Fetal tachycardia
A, B, D *moderate variability of 20/min (expected reference range is 6-25/min) *FHR accelerations are present with increases up to 150-155/min lasting for 25 seconds *normal baseline FHR of 115-125, which is within the expected range of 110-160/min
A nurse is caring for a client who reports manifestations of preterm labor. Which of the following findings are risk factors of this condition? SATA A. Urinary tract infection B. multifetal pregnancy C. oligohydramnios D. diabetes mellitus E. uterine abnormalities
A, B, D, E polyhydramnios is a risk factor
The following are all associated with severe pre-eclampsia: (SATA) A. continuous headache B. photophobia C. tachycardia D. blood pressure of 160/100 E. urine output of 75 mL in 3 hours
A, B, D, E urine output should be 90 mL / 3 hrs
A nurse is to care for a client during the postpartum period. the client reports missing feedings due to her being too tired to feed the baby. What signs should a nurse look for to find out if the client is suffering from mastitis? SATA A. breast tenderness B. noted inflammation of the breast area C. breasts are soft to touch D. the client's oral temperature is 97.2 degrees F E. the client is experiencing chills
A, B, E
A nurse is caring for a client who has a new prescription for oxytocin to stimulate uterine contractions. Which of the following actions should the nurse take? SATA A. use an infusion pump for medication administration B. obtain vital signs frequently and with every dosage change C. stop infusion if uterine contractions occur every 4 min and last 45 seconds D. increase medication infusion rate rapidly E. monitor fetal HR continuously
A, B, E *oxytocin must be administered by an infusion pump to ensure precise dosage *vital signs are monitored to assess for hypertension, an adverse effect of oxytocin *continuous FHR monitoring is required to assess for fetal distress
A nurse is caring for a client who is at 42 weeks of gestation and is having an ultrasound. For which of the following conditions should the nurse plan for an amnio-infusion? (SATA) A. oligohydramnios B. hydramnios C. fetal cord compression D. hydration E. fetal immaturity
A, C inadequate amniotic fluid (oligohydramnios) can cause intrauterine growth restriction, restrict fetal movement & cause fetal distress during labor. it can also cause cord compression , which decreases fetal oxygenation
A nurse on the postpartum unit is assessing a client who is being admitted with suspected DVT. Which of the following clinical findings should the nurse expect? (SATA) A. calf tenderness to palpation B. mottling of the affected extremity C. elevated temperature D. area of warmth E. report of nausea
A, C, D
The nurse is caring for a mother who is requiring an intravenous magnesium sulfate continuous infusion. Which of these concerns the nurse that the mother may be experiencing magnesium sulfate toxicity? SATA A. serum magnesium level of 6.2 B. hourly urine output greater than 50 cc/hr C. the mother breathing at a respiratory rate of 10 RR D. mother's heart rate trending down from 92 to 56 E. mother's BP trending up from 120/56 to 167/72
A, C, D *mag sulfate should between 4-6
A nurse is caring for a client who is at 40 weeks of gestation and experiencing contractions every 3-5 minutes and becoming stronger. A vaginal exam reveals that the client's cervix is 3 cm dilated, 80% effaced and -1 station. The client asks for pain medication. Which of the following actions should the nurse take? (SATA) A. encourage use of patterned breathing techniques B. insert an indwelling urinary catheter C. administer opioid analgesic medication D. suggest application of cold E. provide ice chips
A, C, D *patterned breathing can help with pain mgmt *analgesics can be administered at this time *applying 'cold' is an appropriate non-pharmacological approach at this time
A nurse is caring for a client with a prescription for magnesium sulfate. The nurse should recognize that which of the following are contraindications for use of this medication? SATA A. fetal distress B. preterm labor C. vaginal bleeding D. cervical dilation greater than 6 cm E. severe gestational hypertension
A, C, D preterm labor and severe hypertension are indications of when mag sulfate SHOULD be used
The nurse is caring for a patient in the postpartum period. The nurse notices that there is blood pooling under the patient's buttocks and she is suspecting postpartum hemorrhage. Which of these are nursing interventions for a patient experiencing postpartum hemorrhage? SATA A. assess the amount of lochia and clots present B. begin the patient on a magnesium sulfate infusion C. firmly massage the fundus of the mother D. insert a foley catheter E. monitor the patient's VS
A, C, D, E *catheter, be sure she is voiding & a full bladder will prevent the uterus from contracting back down
A nurse is providing education to a client who is 2 hr postpartum and has perineal laceration. Which of the following information should the nurse include? (SATA) A. use a perineal squeeze bottle to cleanse the perineum B. Sit on the perineum while resting in bed C. Apply a topical anesthetic cream or spray to the perineum D. Wipe the perineum thoroughly with a back & forth motion E. Apply cold or ice packs to the perineum
A, C, E
The postpartum client is experiencing a postpartum hemorrhage. Which of the following medications would the nurse expect to administer? SATA A. carboprost tromethamine B. magnesium sulfate C. methylergonovine D. oxycodone E. misoprostol
A, C, E
A nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of nurses. Which of the following factors should the nurse include in the teaching? (SATA) A. precipitous labor B. obesity C. inversion of the uterus D. oligohydramnios E. retained placental fragments
A, C, E precipitous labor, retained placental fragments, inversion of the uterus
The nurse is preparing a class for a group of new parents on the psychological adaptations that occur after the birth. The nurse should include which signs and symptoms that might suggest postpartum blues? SATA A. the mother is feeling over-emotional B. the mother is experiencing uncontrollable crying C. the mother is experiencing ideas of hurting herself or the baby D. the mother is experiencing mood swings E. the mother is experiencing memory loss
A, D *uncontrollable crying is depression
A nurse is caring for a client in the third stage of labor. Which of the following findings indicate placental separation? (SATA) A. lengthening of the umbilical cord B. swift gush of clear amniotic fluid C. softening of the lower uterine segment D. Appearance of dark blood from the vagina E. Fundus firm upon palpation
A, D, E
A nurse is caring for a client who is in labor. Which of the following assessment findings should the nurse report to the provider? A. fetal HR baseline of 90 bpm B. maternal temperature of 37.8 C (100F) C. uterine relaxation for 1 min between contractions D. uterine contractions increasing in intensity
A, fetal heart rate of 90 bpm a FHR of 90 is considered bradycardia and should be reported to the provider. Fetal bradycardia is associated with fetal cardiac defects, maternal hypoglycemia and fetal viral infections
A nurse is monitoring a client who is receiving spinal anesthesia. The nurse should identify which of the following findings as a complication of the infusion? A. maternal hypotension B. fetal tachycardia C. increased fetal heart rate variability D. maternal hypothermia
A, maternal hypotension
A nurse is performing a fundal assessment for a client who is 2 days postpartum and observes the perineal pad for lochia. The pad is saturated approximately 12 cm with lochia that is bright red and contains small clots. Which of the following findings should the nurse document? A. moderate lochia rubra B. excessive lochia serosa C. light lochia rubra D. scant lochia serosa
A. the client has a moderate amount of lochia containing small clots which is an expected finding
A nurse on a postpartum unit is caring for four clients' which of the following clients should the nurse recognize as the greatest risk for development of a postpartum infection? A. a client who experienced a precipitous labor in less than 3 hrs B. a client who had premature rupture of membranes and prolonged labor C. a client who delivered a large for gestational age infant D. a client who had a boggy uterus that was not well contracted
B, PROM with prolonged labor poses the greatest risk fo developing postpartum infection because the birth canal was open allowing pathogens to enter
A nurse is caring for a client who has postpartum psychosis. Which of the following actions is the nurse's priority? A. Reinforce the need to take antipsychotics as prescribed B. As the client if they have thoughts of harming themselves or their infant C. monitor the infant for indications of failure to thrive D. Review the client's medical record for a history of bipolar disorder
B, identify that the greatest risk to the client and the infant is self harm or harm directed forward the infant .
A nurse is caring for a client who is in labor and is experiencing incomplete uterine relaxation between hypertonic contractions. The nurse should identify that this contraction pattern increases the risk for which of the following complications? A. prolonged labor B. reduced fetal oxygen supply C. delayed cervical dilation D. increased maternal stress
B, inadequate uterine relaxation results in reduced oxygen supply to the fetus
A nurse is caring for a client who is 40 weeks of gestation and reports having a large gush of fluid from the vagina while walking from the bathroom. Which of the following actions should the nurse take first? A. examine the amniotic fluid for meconium B. check the FHR C. Dry the client and make them comfortable D. apply a tocotransducer
B, the greatest risk to the client and fetus is umbilical cord prolapse , leading to fetal distress following rupture of membranes. The first action to take is to check the FHR for clinical findings of distress
A nurse is caring for a client in active labor. When last examined 2 hr ago, the client's cervix was 3 cm dilated, 100 % effaced, membranes in tact and the fetus was at -2 station. The client suddenly states "my water broke". The monitor reveals a FHR of 80 to 85/min and the nurse performs a vaginal examination, noticing clear fluid and a pulsing loop of umbilical cord in the client's vagina. Which of the following actions should the nurse perform first? A. place the client in the Trendelenburgh position B. apply pressure to the presenting part with the fingers C. administer O2 @ 10 L/min via a facemask D. initiate IV fluids
B, apply pressure to the presenting part with the fingers
A nurse is assessing a client who is at 36 weeks of gestation. Which of the following manifestations should the nurse recognize as a potential prenatal complication and report to the provider? A. varicose veins B. double vision C. leukorrhea D. flatulence
B, double vision, blurry vision or visual disturbances are signs of potential complications associated with preeclampsia. The nurse should report this finding to the provider.
A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie? A. apply palms of both hands to sides of uterus B. Palpate the fundus of the uterus C. Grasp lower uterine segment between thumb & fingers D. stand facing client's feet with fingertips outlining cephalic prominence
B, palpating the fundus of the uterus identifies the fetal part that is present, indicating the fetal lie (longitudinal or transverse)
A nurse is caring for a client who is in active labor. The client reports lower back pain. The nurse suspects that this pain is related to a persistent occiput posterior fetal position. Which of the following non-pharmacological nursing interventions should the nurse recommend to the client? A. abdominal effleurage B. sacral counter-pressure C. showering if not contraindicated D. back rub and massage
B, sacral counter-pressure to the lower back relieves the pressure exerted on the pelvis and spinal nerves by the fetus
A nurse is caring for a client who is in the transition phase of labor and reports that they need to have a bowel movement with the peak of contractions. Which of the following actions should the nurse make? A. assist the client to the bathroom B. prepare for impending delivery C. prepare to remove fecal impaction D. encourage the client to take deep, cleansing breaths
B, the urge to have a bowel movement indicates fetal descent and complete dilation
Tocolytic therapy includes which of the following medications? SATA A. oxytocin B. terbutaline C. nifedipine D. carboprost tromethamine E. betamethasone
B, C, *betamethasone can / will be given, but it is not a tocolytic
A nurse is assessing a client who has postpartum depression. The nurse should expect which of the following manifestations? (SATA) A. paranoia that their infant will be harmed B. concerns about lack of income to pay bills C. anxiety about assuming a new role as a parent D. Rapid decline in estrogen and progesterone E. feeling of inadequacy with the new role as a parent
B, C, D, E
A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? SATA A. breastfeeding needs to be stopped for 3 months B. pregnancy needs to be avoided for 1-3 months C. the vaccine is administered by the subcutaneous route D. exposure to immunosuppressed individuals needs to be avoided E. a hypersensitivity reaction can occur if the client has an allergy to eggs F. the area of the injection needs to be covered with a sterile gauze for 1 week
B, C, D, E
Which of these are considered risks for the infant who is born to a diabetic mother? SATA A. microsomia B. polyhydramnios C. congenital anomalies D. hyperglycemia E. shoulder dystocia
B, C, E *MACROsomia is a risk
A nurse is teaching a client about the benefits of internal fetal heart monitoring. Which of the following statements should the nurse include? (SATA) A. It is considered a non invasive procedure B. It can detect abnormal fetal heart tones early C. It can determine the amount of amniotic fluid you have D. It allows for accurate readings with maternal movement
B, D *it IS an invasive procedure *it CANNOT determine the amount of amniotic fluid
A nurse receives a report for a client who is in labor and is experiencing contractions that are 4 min apart. Which of the following patterns should the nurse expect on the fetal monitor? A. contractions that last for 60 seconds each with a 4 min rest between contractions B. contractions that last for 60 seconds each with a 3 min rest between contractions C. A contraction that lasts for 4 min followed by a period of relaxation D. Contractions that last for 45 seconds each with a 3 min rest between contractions
B, contractions that last for 60 seconds each with a 3 min rest between contractions
A nurse is providing postpartum discharge teaching to a client who is non-lactating about breast discomfort relief measures. Which of the following pieces of information should the nurse include? A. wear a loose-fitting bra to alleviate breast discomfort B. Place fresh cabbage leaves on your breasts C. Apply warm, moist compresses to your breasts D. Express small amounts of milk from your breasts frequently
B, place fresh cabbage leaves on your breasts fresh cabbage leaves can be applied to engorged breasts to help relieve discomfort. The coolness of the leaves and the phytoestrogens exert a therapeutic effect on engorged breasts. Leaves should be replaced when they become wilted
A nurse is teaching a client who is pregnant about toxoplasmosis. Which of the following instructions should the nurse include? A. to prevent toxoplasmosis, you will need to receive a MMR vaccination during your pregnancy B. You should avoid gardening during your pregnancy to decrease your risk of contracting toxoplasmosis C. You will get a body rash if you are infected with toxoplasmosis D. Toxoplasmosis is transmitted through a bite from an infected mosquito
B. toxoplasmosis infection is potentially teratogenic to the fetus. It can be transmitted through contact with cat feces, which can be found in garden areas. It can also be transmitted through contact in uncooked meat
A nurse is providing discharge teaching for a non-lactating client. Which of the following instructions should the nurse include in the teaching? A. Wear a supportive bra continuously for the first 72 hours B. Pump your breast every 4 hours to receive discomfort C. Use breast shells throughout the day to decrease milk supply D. Apply warm compresses until milk suppression occurs
A. wear a supportive bra continuously for the first 72 hours.
During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On assessment, a RN finds the clients uterus to be firm and midline & at the level of the umbilicus. The nurse interprets this finding as being: A. evidence of a possible vaginal hematoma B. an indication of cervical or perineal laceration C. a normal discharge of lochia D. abnormally excessive lochia rubra flow
C. a normal discharge of lochia
A nurse is providing discharge instructions to a postpartum client following a cesarean birth. The client reports leaking urine every time they sneeze or cough. Which of the following interventions should the nurse suggest? A. sit-ups B. pelvic tilt exercises C. kegel exercises D. abdominal crunches
C. kegel exercises
A nurse is providing discharge instructions for a client. At 4 weeks postpartum, the client should contact the provider for which of the following client findings? A. scant, non-odorous white vaginal discharge B. Uterine cramping during breastfeeding C. Sore nipples with cracks and fissures D. Decreased response with sexual activity
C. sore nipples with cracks and fissures. this can be the start of mastitis
A client calls a providers office and reports having contractions for 2 hrs that increased with activity and did not decrease with rest and hydration. The client denies leaking of vaginal fluid but did notice blood when wiping after voiding. Which of the following manifestations is the client experiencing? A. Braxton Hicks contractions B. Rupture of membranes C. Fetal descent D. True contractions
D true contractions do not go away with hydration or walking. They are regular in frequency, duration and intensity and become stronger with walking.
A nurse is reviewing discharge teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following instructions should the nurse include in the teaching? A. use a condom with sexual intercourse B. avoid bubble bath solution when taking a tub bath C. wipe from back to front when performing perineal hygiene D. keep a daily record of fetal kick counts
D,
A nurse is caring for a client who is in labor. With the use of Leopold maneuvers, it is noted that the fetus is in a breech presentation. For which of the following possible complications should the nurse observe? A. precipitous labor B. premature rupture of membranes C. post maturity syndrome D. prolapsed umbilical cord
D, a prolapsed umbilical cord is a potential complication for a fetus in a breech presentation
A nurse is planning care for a client who is postpartum and has thrombophlebitis. Which of the following nursing interventions should the nurse include in the plan of care? A. apply cold compresses to the affected extremity B. massage the affected extremity C. allow the client to ambulate D. measure leg circumference
D, plan to measure the circumference of the leg to assess for changes in the client's condition
A nurse is caring for a client who is using patterned breathing during labor. The client reports numbness and tingling of the fingers. Which of the following actions should the nurse take? A. administer O2 via nasal cannula @ 2L/min B. apply a warm blanket C. assist the client to a side-lying position D. place an O2 mask over the client's mouth and nose
D, the client is experiencing hyperventilation caused by low blood levels of PCO2. Placing an O2 mask over the client's nose and mouth or having the client breathe into a paper bag will reduce the intake of O2, allowing the PCO2 to rise and alleviate the numbness & tingling
A nurse is reviewing the electronic monitor tracing of a client who is in active labor. A fetus receives more oxygen when which of the following appears on the tracing? A. peak of uterine contraction B. moderate variability C. FHR acceleration D. relaxation between uterine contractions
D, a fetus is most oxygenated during the relaxation period between contractions. During the contractions, the arteries to the utero-placental intervillous spaces are compressed, resulting in a decrease in fetal circulation
A nurse is caring for a client who is in the first stage of labor and is encouraging the client to void every 2 hrs. Which of the following statements should the nurse make? A. a full bladder increases the risk of fetal trauma B. a full bladder increases the risk for bladder infections C. a distended bladder will be traumatized by frequent pelvic exams D. a distended bladder reduces pelvic space needed for birth
D, a distended bladder reduces pelvic space, impedes fetal descent, and places the bladder at risk for trauma during the labor process
A nurse is teaching a client who is postpartum and breastfeeding. Which of the following statements should the nurse include? A. you will need to wait 3 months before resuming sexual intercourse B. you don't need to use contraception until you are 4 months postpartum C. As long as you breastfeed, you will experience an overproduction of vaginal lubrication D. A reduction in sexual interest could indicate a postpartum depression
D, manifestations of postpartum depression include decreased libido, feelings of sadness or anxiety, difficulty sleeping or loss of appetite. *lactation can cause vaginal dryness and breastfeeding mothers often benefit from the use of a water soluble gel during intercourse
A nurse is assessing a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite and a feeling of letdown. Which of the following conditions are associated with these manifestations? A. postpartum fatigue B. postpartum psychosis C. letting go phase D. postpartum blues
D, postpartum blues
A nurse is planning care for a newly admitted client who reports "I am in labor and have had vaginal bleeding for 2 weeks". Which of the following should the nurse include in the plan of care? A. inspect the introitus for a prolapsed cord B. Perform a test to identify the ferning pattern C. Monitor station of the presenting part D. Defer vaginal examinations
D, vaginal examinations should not be performed until placenta previa or abruptio has been ruled out as the cause of vaginal bleeding
A nurse is teaching a client who had a vacuum-assisted vaginal delivery. Which of the following statements should the nurse identify as an indication that the client understands the information? A. my baby's head will be cone shaped for about 2 months B. My doctor performed this procedure because I didn't dilate passed 6 cm C. The doctor performed this procedure because my hemoglobin was low D. My baby has a higher risk of developing jaundice
D. My baby has a higher risk of developing jaundice a vacuum assisted birth increases the risk of jaundice as the bruises caused by the device dissipate. this procedure results in a cone shaped head that resolves in 3-4 days
A nurse is reviewing a new prescription for terbutaline with a client who has a history of preterm labor. Which of the following client statements indicates understanding of the teaching? A. I can increase my activity now that I've started on this medication B. I will increase my daily fluid intake to 3 quarts C. I will report increasing intensity of contractions to my doctor D. I am glad this will prevent preterm labor
C the client should report increasing intensity, frequency or duration of contractions to the provider because these are manifestations of preterm labor *The action of terbutaline is to relax uterine smooth muscle. Clients taking this medication are instructed to limit activity, which stimulates smooth muscle to delay preterm labor *terbutaline delays preterm labor, it does not stop it *fluids should be limited to 2,400 ml/day
A nurse is caring for a client following the administration of an epidural block and is preparing to administer an IV fluid bolus. The client's partner asks about the purpose of the IV fluids. Which of the following statements should the nurse make? A. it is needed to promote increased urine output B. it is needed to counteract the respiratory depression C. It is needed to counteract hypotension D. it is needed to prevent oligohydramnios
C maternal hypotension can occur following an epidural block and can be offset by administering an IV fluid bolus
A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate IV continuous infusion. Which of the following findings should the nurse report to the provider? A. 2+ DTR B. 2+ pedal edema C. 24 ml/hr urinary output D. respirations 12/min
C urine output less than 25-30 mL/hr is associated with magnesium sulfate toxicity & should be reported to the provider RR less than 12 should be reported
A nurse is teaching a client who is breastfeeding and has mastitis. Which of the following responses should the nurse make? A. limit the amount of time the infant nurses on each breast B. nurse the infant only on the in affected breast until resolved C. completely empty each breast at each feeding or use a pump D. wear a tight fitting bra until lactation has ceased
C, instruct the client to completely empty each breast at each feeding to prevent milk stasis, which will provide a medium for bacterial growth
A nurse is caring for a client who is at 42 weeks of gestation and in active labor. Which of the following findings is the fetus at risk for developing? A. intrauterine growth restriction B. hyperglycemia C. meconium aspiration D. polyhydramnios
C, post-term neonates are at risk for aspiration of meconium
A nurse is caring for a client who is in active labor, irritable and reports the urge to have a bowel movement. The client vomits and states, I've had enough. I can't do this anymore". Which of the following stages of labor is the client experiencing? A. second stage B. fourth stage C. transition phase D. latent phase
C, the transition phase of labor occurs when the client becomes irritable, feels rectal pressure, similar to the need to have a bowel movement, and can become nauseous with emesis
A nurse is caring for a client and partner during the second stage of labor. The client's partner asks the nurse to explain how to know when crowning occurs Which of the following responses should the nurse make? A. the placenta will protrude from the vagina B. your partner will report a decrease in the intensity of contractions C. the vaginal area will bulge as the baby's head appears D. Your partner will report less rectal pressure
C, crowing is bulging of the perineum and the appearance of the fetal head
The nurse suspects that the client is experiencing magnesium sulfate toxicity due to the following symptoms: A. RR 14/min B. Hyperreflexia C. urine output of 20 mL / 1 hr D. Serum Magnesium level of 7.5 E. maternal BP of 90/60 from 126/82
C, D *hyporeflexia indicates toxicity *a significant drop in BP can also indicate toxicity
A nurse is reviewing discharge teaching with a client who has a urinary tract infection. Which of the following statements by the client indicates understanding of the teaching (SATA)? A. I will perform perineal care and apply a perineal pad in a back to front direction B. I will drink grape juice to make my urine more acidic C. I will drink large amounts of fluids to flush the bacteria from my urinary tract D. I will go back to breastfeeding after I have finished taking the antibiotics E. I will take Tylenol for any discomfort
C, E
A nurse is caring for a client having contractions every 8 min that are 30 to 40 seconds in duration. The client's cervix is 2 cm dilated, 50% effaced, and the fetus is at -2 station with a FHR around 140/min. Which of the following stages and phases of labor is this client experiencing? A. first stage, latent phase B. first stage, active phase C. first stage, transition phase D. second stage of labor
A, in stage 1, latent phase the cervix dilates from 0 to 3 cm, and contraction duration ranges from 30 to 45 seconds
A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following antepartum complications should the nurse understand is a risk factor for this condition? A. preeclampsia B. thrombophlebitis C. placenta previa D. hyperemesis gravidarum
A, DIC can occur secondary in a client who has preeclampsia
A nurse is caring for a client who is in the second stage of labor. The client's labor has been progressing, and a vaginal delivery is expected in 20 min. The provider is preparing to administer lidocaine for pain relief and perform an episiotomy. The nurse should know that which of the following types of regional anesthetic blocks is to be administered? A. pudendal B. epidural C. spinal D. para-cervical
A, a pudendal block is a trans-vaginal injection of local anesthetic that anesthetizes the perineal area for the episiotomy & repair, and the expulsion of the fetus
A nurse is caring for a client who is postpartum. The nurse should identify which of the following findings as an early indicator of hypovolemia caused by hemorrhage? A. increasing pulse & decreasing blood pressure B. dizziness & increasing respiratory rate C. cool, clammy skin and pale mucous membranes D. Altered mental status and LOC
A, a rising pulse rate and decreasing B are often the first indications of inadequate blood volume
A nurse educator in the L&D unit is reviewing the use of chemical agents to promote cervical ripening with a group of newly licensed nurses. Which of the following statements indicates understanding of the teaching? A. they are tablets administered vaginally B. they act by absorbing fluid from tissues C. they promote dilation of the OS D. they include an amniotomy
A, chemical agents that promote cervical ripening include medications administered vaginally
A nurse is caring for a client who is in active labor and reports severe back pain. During assessment, the fetus is noted to be in the occiput posterior position. Which of the following maternal positions should the nurse suggest to the client to facilitate normal labor progress? A. Hands and knees B. lithotomy C. trendelenburgh D. supine with a rolled towel under one hip
A, having the client assume a position on both hands and knees can help the fetus rotate from a posterior to an anterior position
A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should take? A. assist the client into the left-lateral position B. apply a fetal scalp electrode C. insert an IV catheter D. Perform a vaginal exam
A, the greatest risk to the fetus during late decelerations is utero-placental insufficiency. The initial nursing action should be to place the client into the left lateral position to increase utero-placental perfusion
A nurse is caring for a client who is in labor and is receiving oxytocin. The nurse should monitor the client for which of the following as complications of oxytocin? SATA A. uterine rupture B. uterine tachystole C. placental abruption D. hyponatremia E. placenta previa
A, B, C, D uterine rupture: oxytocin increases the force of uterine contractions uterine tachystole: (excessively frequent uterine contractions) oxytocin increases the frequency of contractions placental abruption: this is a potential complication of oxytocin hyponatremia: this is a potential complication because oxytocin can cause water intoxication
A nurse is discussing risk factors for urinary tract infections with a newly licensed nurse. Which of the following conditions should the nurse include in the teaching? (SATA) A. epidural anesthesia B. urinary bladder catheterization C. frequent pelvic examinations D. history of UTI's E. vaginal birth
A, B, C, D cesarean birth places a client at risk for development
Which of the following interventions are indicated for the patient experiencing a postpartum hemorrhage? (SATA) A. massage fundus B. place patient in Trendelenburg position C. assess amount of lochia, clots D. assess for bladder distention E. administer oxygen at 2-3 liters via non-rebreather mask
A, B, C, D, O2 should be given at 10-12 liters
A nurse is administering magnesium sulfate IV for seizure prophylaxis to a client who has severe preeclampsia. Which of the following indicates magnesium sulfate toxicity? A. respirations less than 12/min B. urinary output less than 25 mL/hr C. hyper-reflexic deep tendon reflexes D. decreased LOC E. flushing & sweating
A, B, D
A nurse is caring for postpartum client who delivered their third infant 2 days ago. Which of the following manifestations could indicate postpartum depression? (SATA) A. fatigue B. insomnia C. euphoria D. flat affect E. delusions
A, B, D
A nurse is assessing a postpartum client for fundal height, location and consistency. The fundus is noted to be displaced laterally to the right and there is uterine atony. The nurse should identify which f the following conditions as the cause of the uterine atony? A. poor involution B. Urinary retention C. Hemorrhage D. Infection
B. urinary retention
A nurse is completing postpartum discharge teaching to a client who had no immunity to varicella and was given the varicella vaccine. Which of the following statements by the client indicates an understanding of the teaching? A. I will need to use contraception for 3 months before considering pregnancy B. I need a second vaccination at my postpartum visit C. I was given the vaccine because my baby is O positive D. I will be tested in 3 months to see if I have developed immunity
B. I need a second vaccination at my postpartum visit clients receiving RUBELLA vaccination need to use contraception for 3 months after
A nurse is providing care to 4 clients on the post partum unit. Which of the following clients is at greatest risk for developing a postpartum infection? A. a client who has an episiotomy that is erythematous and has extended into a third degree laceration B. A client who does not wash their hands between perineal care and breastfeeding C. A client who is not breastfeeding and is using measures to suppress lactation D. a client who has a cesarean incision that is well approximated with no drainage
B. a client who does not wash their hands between perineal care and breastfeeding
A nurse is caring for a newborn immediately following delivery. Which of the following actions should the nurse perform? A. perform a detailed physical assessment B. place the newborn directly on the client's chest C. give the newborn an IM vitamin K D. Administer erythromycin ophthalmic ointment
B. place the newborn directly on the client's chest
A nurse is conducting a home visit for a client who is 1 week postpartum and breastfeeding. The client reports breast engorgement. Which of the following recommendations should the nurse make? A. apply cold compress between feedings B. take a warm shower right after feedings C. apply breast milk to the nipples and allow them to air dry D. use the various positions for feedings
B. take a warm shower right after feedings
A nurse is caring for a client who is postpartum and is having difficulty voiding. Which of the following actions should the nurse take first? A. place the client's hands in warm water B. administer an analgesic to the client C. pour water from a squeeze bottle over the client's perineum D. assist the client to the bathroom
D. assist the client to the bathroom the greatest risk to this client is an injury from a distended bladder; therefore the first action the nurse should take is to assist the client to the bathroom to encourage spontaneous voiding. If this is unsuccessful, the nurse can try other techniques to promote voiding
A nurse is caring for a client who is receiving IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if magnesium sulfate toxicity is suspected? A. Nifedipine B. Pyridoxine C. Ferrous sulfate D. Calcium gluconate
D. calcium gluconate
A nurse is reviewing the providers admission orders for a client who is at 37 weeks of gestation and is HIV positive. Which of the following orders should the nurse clarify with the provider? A. intermittent auscultation B. Biophysical profile C. non-stress test D. fetal scalp electrode
D. fetal scalp electrode the placement of a fetal scalp electrode is an invasive procedure that requires ruptured membranes. The electrode is inserted into the fetal scalp, which will increase the fetus's exposure to HIV and is contraindicated
What is a therapeutic usage of methylergonovine?
prevents postpartum hemorrhage
