Final Exam Practice B

A nurse is preparing to perform Leopold maneuvers for a client. identify the sequence the nurse should follow 1. identify the attitude of the head 2. palpate the fundus to identify the fetal part 3. determine the location of the fetal back 4. palpate for the fetal part presenting at the inlet

2. palpate the fundus to identify the fetal part 3. determine the location of the fetal back 4. palpate for the fetal part presenting part at the inlet 1. identify the attitude of the head

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? A. determine respiratory function B. increase the IV fluid rate C. access emergency medication from cart D. collect a maternal blood sample for coagulopathy studies

A. determine the respiratory function

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? A. emotional lability B. focusing phase C. cognitive restructuring D. Couvade syndrome

A. emotional lability

A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings in an indication for the administration of the medication? (Select all that apply) A. flaccid uterus B. cervical laceration C. excess vaginal bleeding D. increased afterbirth cramping E. increased maternal temperature

A. flaccid uterus C. excessive vaginal bleeding

A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching? A. i will eat foods that taste good instead of balancing my meals B. i will avoid having a snack before I go to bed each night C. i will have a cup of hot tea with each meal D. i will eliminate products that contain dairy from my diet

A. i will eat foods that taste good instead of balancing my meals

A nurse is calculating a client's expected date of birth using Nagele'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? A. september 3rd B. september 20th C. august 3rd D. august 20th

A. september 3rd

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? A. shortness of breath B. breakthrough bleeding C. vomiting D. breast tenderness

A. shortness of breath

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? A. swelling of the face B. varicose veins in the calves C. nonpitting 1+ ankle edema D. hyperpigmentation of the cheeks

A. swelling of the face

A nurse is performing a newborn assessment. Which of the following images should the nurse identify as an indication of spina bifida occulta A. tuft of hair on back just above buttocks B. large cyst on back of infant C. red open spot on back of child D. blueish bruise looking area over both buttocks

A. tuft of hair on back just above buttocks

A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching? A. you should take the medication within 72 hours following unprotected sexual intercourse B. you should avoid taking this medication if you are on an oral contraceptive C. if you don't start your period within 5 days of taking this medication, you will need a pregnancy test D. one dose of this medication will prevent you from becoming pregnant for 14 days after taking it.

A. you should take the medication within 72 hours following unprotected sexual intercourse

A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take? A. restrict hourly fluid intake to 150 ml/hr B. have calcium gluconate readily available C. assess deep tendon reflexes every 6 hours D. monitor intake and output every 4 hours

B. have calcium gluconate readily available

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? A. just above the umbilicus B. just above the symphysis pubis C. the right lower quadrant D. the left lower quadrant

B. just above the symphysis pubis

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? A. increased fetal movement B. leakage of fluid from the vagina C. upper abdominal discomfort D. urinary frequency

B. leakage of fluid from the vagina

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? A. place the shoulder harness in the slots above the newborn's shoulders B. place the retainer clip at the level of the newborn's armpits C. place the newborn at a 60 degree angle in the car seat D. place the newborn in a blanket before securing them in the car seat

B. place the retainer clip at the level of the newborn's armpits

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

B. transition

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? A. confirm the newborn's Apgar score B. verify the newborn's identification C. administer vitamin K to the newborn D. determine obstetrical risk factors

B. verify the newborn's identification

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? A. you should replace the diaphragm every 5 years B. you should leave the diaphragm in place for at least 6 hours after intercourse. C. you should use an oil based product as a lubricant when inserting the diaphragm D. you should insert the diaphragm when your bladder is full

B. you should leave the diaphragm in place for at least 6 hours after intercourse.

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? A. you will need to drink the glucose solution 2 hours prior to the test B. limit your carbohydrate intake for 3 days prior to the test C. a blood glucose of 130-140 is considered a positive screening result D. you will need to fast for 12 hours prior to the test

C. a blood glucose of 130-140 is considered a positive screening result

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? A. place the client in a supine position for 30 minutes following the first dose of anesthetic solution B. administer 1,000 ml of dextrose 5% in water prior to the first dose of anesthetic solution C. monitor the client's blood pressure every 5 min following the first dose of anesthetic solution D. ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose of anesthetic solution

C. monitor the client's blood pressure every 5 minutes following the first dose of anesthetic solution

A nurse is assessing a newborn who is 12 hours old. Which of the following manifestations requires intervention by the nurse? A. acrocyanosis of the extremities B. murmur at the left sternal border C. substernal chest retractions while sleeping D. positive babinski reflex

C. substernal chest retractions while sleeping

A nurse is providing discharge teaching to a client who is postpartum. For which of the following manifestation should the nurse instruct the client to monitor and report to the provider? A. persistent abdominal striae B. temperature 100F C. unilateral breast pain D. brownish red discharge on day 5

C. unilateral breast pain

A nurse is preparing to administer azithromycin to a client who is at 16 weeks 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?

4

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? A. you can miss your period for several other reasons. Describe your typical menstrual cycle. B. if you have been sexually active and haven't used protection, it is likely that you are pregnant C. let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet? D. because you have missed your period, you should try taking a home pregnancy test before you start worrying.

A. you can miss your period for several other reasons. Describe your typical menstrual cycle.

A nurse is caring for a client who is experiencing preterm labor at 29 weeks gestation and has a prescription for betamethasone. Which of the following statements should the nurse make about the indication for medication administration? A. this medication will stop your labor B. this medication stimulates fetal lung maturity C. this medication will decrease your risk for uterine infections D. this medication will increase your baby's weight

B. this medication stimulates fetal lung maturity

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? A. Left upper quadrant B. Right upper quadrant C. Left lower quadrant D. Right lower quadrant

C. left lower quadrant

A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects? A. client reports nausea B. urinary output of 40 ml/hr C. respiratory rate 10/min D. client reports feeling flushed

C. respiratory rate 10/min

A nurse is caring for a client who is in active labor and has had no cervical change in the last 4 hours. Which of the following statements should the nurse make? A. let me help you into a comfortable pushing position so you can begin bearing down. B. i am going to call the doctor to get a prescription for medication to ripen your cervix. C. i will give you some IV pain medicine to strengthen your contractions D. your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions.

D. your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions.

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? A. apply sacral counterpressure B. perform TENS C. initiate slow-paced breathing D. assist with biofeedback

A. apply sacral counterpressure

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) A. cholecystitis B. hypertension C. human papillomavirus D. migraine headaches E. anxiety disorder

A. cholecystitis B. hypertension D. migraine headaches

A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take? A. cover the newborn's eyes while under the phototherapy light B. keep the newborn in a shirt while under the phototherapy light C. apply a light moisturizing lotion to the newborn's skin D. turn and reposition the newborn every 4 hr while undergoing phototherapy.

A. cover the newborn's eyes while under the phototherapy light

A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura. Which of the following findings should the nurse expect? A. decreased platelet count B. increased ESR C. decreased megakaryocytes D. increased WBC

A. decreased platelet count

A nurse is reviewing the laboratory results for a client who is at 10 weeks of gestation. Which of the following laboratory findings should the nurse report to the provider? A. hemoglobin 10 B. WBC count 15,000 C. RBC count 5.8 D. hematocrit 34%

A. hemoglobin 10

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? A. place a rolled towel beneath one of the client's hips. B. apply internal upward pressure to the presenting part using two gloved fingers C. administer oxygen to the client via a nonrebreather mask at 10L/min D. increase the IV infusion rate

B. Apply internal upward pressure to the presenting part using two gloved fingers.

A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority? A. a client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL B. a client who is at 34 weeks of gestation and reports epigastric pain C. a client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL D. a client who is at 39 weeks of gestation and reports urinary frequency and dysuria

B. a client who is at 34 weeks of gestation and reports epigastric pain

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? A. place warm, moist packs on the breasts B. apply cabbage leaves to the breasts C. wear a loose fitting bra D. put green tea bags on the breasts

B. apply cabbage leaves to the breasts

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? A. decreased HR B. chin quivering C. pinpoint pupils D. slowed respiration

B. chin quivering

A nurse is speaking with a client who is trying to make a decision about tubal ligation. The client asks, "what effects will this procedure have on my sex life?" Which of the following responses should the nurse make? A. i think that is something you should discuss with your doctor B. this procedure should have no effect on your sexual performance or adequacy C. you'll be fine. i can't imagine you and your partner will have any problems with sexual function D. if this concerns you, perhaps you should reconsider and use another form of contraception

B. this procedure should have no effect on your sexual performance or adequacy

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. A. percutaneous umbilical blood sampling B. amniofusion C. BPP D. chorionic villus sampling

C. BPP

A nurse is teaching a client who has pregestational type 1 DM about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? A. i should have a goal of maintaining my fasting blood glucose between 100-120 B. i should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater C. i will continue taking my insulin if i experience nausea and vomiting D. i will ensure that my bedtime snack is high in refined sugar

C. I will continue taking my insulin if i experience nausea and vomiting

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? A. calcium B. vitamin E C. Iron D. Vitamin D

C. Iron

A nurse is teaching a client who is 36 weeks of gestation and has a prescription for a nonstress test. Which of the following statements should the nurse include in the teaching? A. You will receive IV fluids prior to this test B. The procedure will take approximately 10 to 15 minutes C. You will be offered orange juice to drink during the test D. You will need to sign an informed consent form each time you have this test.

C. You will be offered orange juice to drink during the test

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? A. reassess the client in 2 hr B. administer simethicone C. assist the client to empty her bladder D. instruct the client to lie on her right side

C. assist the client to empty her bladder

A nurse is reviewing the laboratory report of a newborn who is 24 hours old. Which of the following results should the nurse report to the provider? A. hgb 20 B. total bilirubin 5 C. blood glucose 30 D. WBC count 20,000

C. blood glucose 30

A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include? A. shortness of breath when climbing stairs B. swelling of feet and ankles at the end of the day C. headache that is unrelieved by analgesia D. braxton hicks contractions

C. headache that is unrelieved by analgesia

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? A. I will get injections of the medication once daily until my labor stops B. my blood sugar may be low while I'm on this medication C. I will have blood tests because my potassium might decrease D. my blood pressure may increase while I'm on this medication.

C. i will have blood tests because my potassium might decrease

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. A. discuss contraceptive options with the client and her partner B. repeat information to ensure client understanding C. listen to the client and her partner as they reflect upon the birth experience D. demonstrate to the client how to perform a newborn bath.

D. demonstrate to the client how to perform a newborn bath

A nurse is teaching a client who is Rh negative about RhoGam. Which of the following statements by the client indicates an understanding of the teaching? A. i will receive this medication if my baby is Rh-negative B. i will receive this medication when i am in labor C. i will need a second dose of this medication when my baby is 6 weeks old D. i will need this medication if i have an amniocentesis

D. i will need this medication if i have an amniocentesis

A nurse is caring for a client who is at 35 weeks of gestation and has placenta previa. Which of the following actions should the nurse take? A. perform a vaginal exam to determine cervical dilation every 2 hour B. instruct the client to ambulate in the hallway once every 4 hour C. administer betamethasone to the client via IM injection D. initiate continuous external fetal monitoring

D. initiate continuous external fetal monitoring

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? A. maintain the client NPO throughout the procedure B. place the client in a supine position C. instruct the client to massage the abdomen to stimulate fetal movement D. instruct the client to press the provided button each time fetal movement is detected

D. instruct the client to press the provided button each time fetal movement is detected

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? A. Hct 39% B. serum albumin 4.5 C. WBC 9,000 D. platelets 50,000

D. platelets 50,000

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? A. bilirubin 9mg/dL B. Hemoglobin 18g/dL C. Platelets 175,000 mm D. hematocrit 45%

A. bilirubin 9mg/dL

A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect? A. jitteriness B. hypertonia C. abdominal distention D. mottling

A. jitteriness

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 next? A. massage the client's fundus B. insert an indwelling urinary catheter C. administer oxygen at 10L/min D. elevate the client's right hip

A. massage the client's fundus

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? A. oligohydramnios B. hyperemesis gravidarum C. leukorrhea D. periodic tingling of the fingers

A. oligohydramnios

A nurse is teaching a new parent about newborn safety. Which of the following instructions should the nurse include in the teaching? A. you can share your room with your baby for the next few weeks B. cover your baby with a light blanket while sleeping C. check the temperature of your baby's bath water with your hand D. your baby can nap in the car seat during the daytime

A. you can share your room with your baby for the next few weeks

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 notify as a priority? A. O2 saturation B. temperature C. blood pressure D. urinary output

B. temperature

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? A. tell the client to follow up with a dermatologist B. explain to the client this is an expected occurrence C. instruct the client to increase her intake of vitamin D D. inform the client she might have an allergy to her skin care products.

B. explain to the client this is an expected occurrence

A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make? A. the nurse will carry your newborn to the nursery for procedures B. we will document the relationship of visitors in your medical record C. your baby will stay in the nursery while you are asleep D. staff members who take care of your baby will be wearing a photo identification badge

D. staff members who take care of your baby will be wearing a photo identification badge

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? A. insert the syringe tip before compressing the bulb B. suction each of the nares before suctioning the mouth. C. insert the tip of the syringe into the center of the newborn's mouth. D. stop suctioning when the newborn's cry sounds clear.

D. stop suctioning when the newborn's cry sounds clear

A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI? A. large for gestational age B. hyperglycemia C. bradypnea D. vomiting

D. vomiting